Mary Ann Hogan RN Questions and rationals

413 MCSA An infant born to a mother known to be infected with human immunodeficiency virus (HIV) has also been diagnosed as HIV positive. While assessing the psychosocial support for the family, the nurse should ask: 1. "Does the family belong to a support group?" 2. "Are there neighbors nearby?" 3. "What type of insurance does the family have?" 4. "Does mother have a car?"

1 Emotional support for families of HIV+ clients can be challenging. Families who have already dealt with the problems associated with the disease process are most likely to be receptive to the discussion and able to offer emotional support. Application Psychosocial Integrity Nursing Process: Assessment Child Health Knowledge of the need for psychosocial support for families with children who are diagnosed with chronic conditions will aid in choosing the correct answer. 0

323 MCSA A child is exposed to a playmate that contracted chickenpox. Two days later the child is admitted to the 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? 1. Five to 10 days 2. 14 to 21 days 3. 21 to 25 days 4. One month

2 The upper respiratory symptoms may be early prodromal symptoms of chickenpox. The incubation period of chickenpox is 14 to 21 days. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Assessment Child Health Recognize that upper respiratory symptoms relate to the onset of chickenpox, and consider the prodromal period. 0

150 MCSA The partner of a client who has dissociative identity disorder with several alters is puzzled about why the children are included in family therapy. Which of the following would be the best explanation for the nurse to offer? 1. "Children need to have their experiences confirmed—and to learn to deal with the different personalities." 2. "There is probably a mistake in the referral; your partner is the one who has the problem." 3. "You and your partner should be seen, but it could be traumatizing to the children." 4. "It would be best to ask the children if they would like to participate, and bring them if they want."

1 All family members are affected by dissociative identity disorder. Children must also find ways to understand and deal with what is occurring to a parent, rather than denying what is obvious or proceeding on incorrect assumptions that are not challenged by accurate information. Analysis Psychosocial Integrity Communication and Documentation Mental Health 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. 0

325 MCSA Parents report that their small child stiffens when being held and does not smile or make eye contact with them. Based on this initial information, the nurse suspects that the child may have which disorder? 1. Autism 2. Attention deficit hyperactivity disorder 3. Mental retardation 4. Down syndrome

1 Although a thorough examination and assessment is necessary to diagnose autism, it can be suspected based on the information provided. These symptoms are not normally associated with the other disorders listed. Analysis Psychosocial Integrity Nursing Process: Analysis Child Health Recall that lack of interaction with others is a primary feature of autism. 0

461 MCSA The difficulty in assessing clients who are HIV-positive after exposure, but who have a negative ELISA test, is that the symptoms are: 1. Flu-like and vague. 2. Specific and similar to tuberculosis. 3. Often ignored. 4. Attributed to other illnesses.

1 Although options 2, 3, and 4 are sometimes the case, the flu-like symptoms are rather vague. Most individuals do not rush to a physician with flu-like symptoms unless they are not getting any better. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological Use the process of elimination to determine the correct answer. 0

288 MCSA The nurse follows the instructions of the AED for three analyses, with no shock indicated. The adult client remains unconscious and pulseless, and is not breathing. What would be the nurse's next intervention? 1. Leave the AED pads on and perform CPR for one minute, then re-analyze. 2. Remove the AED pads and continue CPR. 3. Recycle the AED to analyze again for three more intervals. 4. Perform two rescue breaths and then recycle the AED to analyze the rhythm.

1 BLS guidelines for AED use is to perform three analyses and, if no shock is indicated and there is still no sign of circulation, perform CPR for one minute before checking circulation and cycling the AED to analyze the rhythm again. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Fundamentals 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. 0

249 MCSA The client was taught calf-pumping exercises prior to surgery to decrease the possibility of thrombophlebitis developing postoperatively. The nurse observes the client performing the procedure and notes that the client correctly understands the technique when the client is observed doing which of the following? 1. Alternately contracting and relaxing the leg muscles 2. Alternately flexing and extending the knees 3. Raising and lowering the legs 4. Alternately dorsiflexing and plantar flexing the feet

1 Calf pumping exercises involve contracting and then relaxing the leg muscles in an alternating fashion. Options 2, 3, and 4 do not exercise the calf muscles, including the gastrocnemius muscles. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Evaluation Fundamentals 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. 0

185 MCSA In planning care for a client with an axis II personality disorder, the nurse anticipates that the client will differ from clients with axis I disorders in that the client will: 1. Tend to experience symptoms as ego-syntonic. 2. Usually display clinical symptoms. 3. Tend to experience symptoms as ego-dystonic. 4. Seldom experience addictive behaviors.

1 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 ego-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. Application Psychosocial Integrity Nursing Process: Analysis Mental Health 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. 0

255 MCSA The nurse should assess carefully a 79-year-old client who has been frequently sedated with haloperidol (Haldol) for signs of which of the following? 1. Tardive dyskinesia 2. Fecal impaction 3. Respiratory depression 4. Restlessness

1 Elderly clients have slower metabolism and elimination of drugs, causing an increased susceptibility to side effects. Extrapyramidal side effects are most common with haloperidol, a 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. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Assessment Mental Health 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. 0

444 MCSA A child with asthma caused by allergies would be expected to have which of the following findings on a complete blood count (CBC) report? 1. Eosinophils 21.9 2. WBC 10.9 3. Monocytes 4.0 4. Neutrophils 85.7

1 Eosinophils are usually elevated in an allergic response. The WBC in option 2 is barely above normal. The monocytes are normal in option 3 and the elevated neutrophils indicate an acute infection (option 4). Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological This question requires knowledge about the CBC. 0

467 MCSA An example of a type I hypersensitivity immune response includes which of the following? 1. Hay fever 2. Transplant rejection 3. Transfusion reaction 4. Serum sickness

1 Hay fever is an atopic type I reaction that is local instead of systemic. Transplant rejection is a type IV; transfusion reaction is a type II and serum sickness is a type III. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological Use the process of elimination to correctly answer this question. 0

390 MCSA The nurse would assess for which of the following electrolyte imbalances as a common finding in a client with AIDS? 1. Hyponatremia 2. Hypernatremia 3. Hyperkalemia 4. Hypocalcemia

1 Hyponatremia is a common finding in clients with AIDS. The incidence of opportunistic infections may contribute to this decrease in sodium. Hypernatremia, hyperkalemia, and hypocalcemia are not usually seen in clients who have AIDS. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological 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. 0

152 MCSA In a child with acute renal failure, the nurse would help to prevent hyperkalemia by limiting which of the following foods in the diet? 1. Potatoes, tomatoes, and oranges. 2. Grains, cheese, and citrus fruits. 3. Cereals, processed sugars, and wheat. 4. Rice, leafy green vegetables, and carbonated beverages.

1 Potatoes, tomatoes, and oranges have a high level of potassium content. The others have lesser amounts of potassium in them, when considering the groupings of foods in each option. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Child Health 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. 0

392 MCSA The nurse teaches a client that which of the following factors might increase risk of developing an exacerbation of systemic lupus erythematosus (SLE)? 1. Pregnancy 2. Hypotension 3. Fever 4. GI upset

1 Pregnancy can be associated with an exacerbation because of increased estrogen levels. Hypotension, fever, and GI upset do not exacerbate SLE. Application Physiological Integrity: Physiological Adaptation Teaching and Learning Adult Health: Immunological 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. 0

489 MCSA The nurse would assess for which one of the following findings that is consistent with clinical manifestations of systemic sclerosis? 1. Raynaud's phenomenon 2. Conjunctivitis 3. Photophobia 4. Splenomegaly

1 Raynaud's phenomenon is one of the most common findings associated with systemic sclerosis. Conjunctivitis, photophobia, and splenomegaly can all be seen in clients who experience the effects of systemic lupus erythematosus. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological This question requires knowledge about systemic sclerosis. 0

438 MCSA A client who has recently been diagnosed with diabetes mellitus (DM) Type 1 asks the nurse how she developed this because no one in her family is a diabetic. The nurse's best response is, "DM is an autoimmune disease characterized by:" 1. "Failure of the immune system to recognize self." 2. "Exacerbations and remissions." 3. "Accelerated production of killer T-cells." 4. "Immunosuppression and altered cortisol levels."

1 Recognition of self as foreign is the definition of any autoimmune disease. Further explanation may be needed to explain that the immune system usually recognizes self and identifies what is foreign, targets foreign cells, and destroys them. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Immunological This question requires knowledge about diabetes. 0

123 MCSA A nurse is discussing the home maintenance regimen with a client who has irritable bowel syndrome. Which of the following statements indicates client understanding? 1. "I'll take a walk after dinner each evening." 2. "I'll have a cigarette after meals to relax." 3. "I'll chew gum between meals to curb my appetite." 4. "I'll eat a lot of fresh vegetables and fruits."

1 Regular exercise can help to normalize bowel function. Cigarette smoking and gum chewing increase swallowed air; fresh vegetables are gas-producing. Analysis Physiological Integrity: Basic Care and Comfort Nursing Process: Evaluation Adult Health: Gastrointestinal 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. 0

218 MCSA A client with acquired immunodeficiency syndrome (AIDS) who has <i>Pneumocystis carinii</i> is being admitted to the nursing unit. The nurse should institute which of the following? 1. Standard precautions 2. Airborne precautions 3. Droplet precautions 4. Contact precautions

1 Standard precautions are used with all clients, regardless of the medical diagnosis. Clients with AIDS or <i>Pneumocystis carinii</i> pneumonia are not contagious and do not require transmission-based precautions. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Fundamentals Use the process of elimination based on nursing knowledge of standard precautions and the route of transmission for AIDS. 0

276 MCMA An adult client arrives to the Emergency Department with complaints of chest pain, and shortness of breath. The nurse concludes that which of the following points, if present in the client's history, would indicate that this pain may be related to cardiac disease? Select all that apply. 1. History of diabetes mellitus 2. Pain worsens with a deep breath 3. Pain increases with activity 4. Client smokes a pack of cigarettes per day 5. Client is diaphoretic during pain episode

1, 3, 4, 5 An awareness of the risk factors for cardiovascular disease and associated symptoms can assist the nurse in analyzing the origin of chest pain and prioritizing and implementing appropriate care. Diabetes (option 1), smoking (option 4), and hypertension are known modifiable and non-modifiable risk factors. Chest pain that occurs during activity (option 3) may indicate cardiac ischemia due to the increased oxygen demand. The associated symptom 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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Cardiovascular 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. 0

327 MCSA A teenager has been diagnosed with asthma, and cromolyn sodium (Intal) has been ordered for this child. Which statement by the child indicates a correct understanding of this drug? 1. "I should take this drug at the first sign of an asthma attack." 2. "This drug won't stop an asthma attack but may prevent a future attack." 3. "Cromolyn sodium is a form of corticosteroid." 4. "After taking one dose, I should wait 15 minutes and then take a second dose if my wheezing hasn't stopped."

2 Cromolyn sodium is an aerosol taken daily to prevent an attack. All of the other answers are incorrect. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Evaluation Child Health 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. 0

137 MCSA A nurse from the pediatric intensive care unit has floated to the cardiovascular intermediate care unit for the shift. Which of the following clients would the nurse assign to the float nurse for the shift? 1. A client who experienced myocardial infarction 36 hours ago 2. A client in heart failure receiving digoxin (Lanoxin) and bumetanide (Bumex) 3. A client who just underwent coronary atherectomy 4. A client scheduled for cardiac stent placement later in the day

2 The pediatric intensive care nurse is more likely to have experience working with heart failure, since children can experience heart failure secondary to cardiac defects. Myocardial infarction, stent placement, and coronary atherectomy are problems and procedures done for adult clients. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management Note the critical words <i>pediatric intensive care</i> in the stem of the question. Then determine which client has the health problem that could also be experienced in the pediatric population. 0

451 MCSA Of the following people who is at increased risk of acquiring HIV? 1. A police officer who works the streets and responds to emergencies 2. A sexually active teenager 3. A school nurse who exams children 4. A nurse working on a telemetry unit

2 The police officer and nurse on the telemetry unit should be using standard precautions 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. Application Health Promotion and Maintenance Nursing Process: Assessment Adult Health: Immunological This question requires knowledge about HIV. 0

377 MCSA Which of the following is correct concerning viral infections? 1. Most viral infections have specific antiviral agents that kill the virus. 2. Viruses may remain in a latent, non-replicating form for months or even years 3. Lymphocytes are usually decreased 4. Viruses have strands of both DNA and RNA

2 The viral replication cycle can range from minutes to days. Some viruses remain latent for long periods of time without replicating. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological Eliminate options 1, 3, and 4 as being untrue regarding virus. 0

274 MCSA The long-term care nurse has been called to the aid of a resident who has become unconscious after choking in the dining room. After positioning the client on the back, which of the following actions should the nurse take next? 1. Attempt to ventilate the client 2. Observe the oral cavity; carry out a finger sweep of the mouth 3. Perform five abdominal thrusts 4. Perform five chest thrusts

2 There is a specific sequence of actions that is performed as part of basic life support when a client is choking. After positioning the client on the back, the nurse would observe the oral cavity to detect any foreign body that may be removed immediately. Next, the nurse would open the airway and attempt to ventilate (option 1). If unsuccessful, this process would be 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. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Cardiovascular Remember the ABCs of life support to answer this question. Choose the option that attempts to clear the airway before taking any other actions. 0

244 MCSA The nurse doing health promotion in an ambulatory women's health clinic would plan to teach Kegel exercises to a woman with which of the following conditions? 1. Menopause 2. Uterine prolapse 3. Urinary tract infection 4. Premenstrual syndrome

2 Uterine prolapse is caused by weakened pelvic muscles, which can be strengthened by Kegel exercises. The other conditions are not treated with Kegel exercises. Application Health Promotion and Maintenance Nursing Process: Planning Adult Health: Renal and Genitourinary 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. 0

497 MCSA A client receives a polio vaccine during a clinic visit. The nurse explains that this will provide what type of immunity to the client? 1. Active natural immunity 2. Active artificial immunity 3. Passive natural immunity 4. Passive artificial immunity

2 Vaccines are administered to the client to promote the development of specific antibodies to afford protection. This is an example of active artificial immunity. Active natural immunity 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. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Analysis Adult Health: Immunological Use the rule of opposites to answer this question. 0

406 MCSA A 4-year-old child is having scratch tests for allergies. In teaching the family about the planned tests, the nurse should include the information that: 1. This test allows us to rule out one or two specific antigens. 2. The scratch test is the most sensitive allergy test. 3. Results can be obtained in 30 minutes. 4. The scratch test involves drawing a small amount of blood from the client.

3 A scratch test tests many allergens at once. It is of low sensitivity, but many allergens can be tested at once and the results can be obtained in 30 minutes. Application Physiological Integrity: Reduction of Risk Potential Teaching and Learning Child Health Note that the term "scratch" test should give some information necessary to respond to this question. 0

328 MCSA A client has an opportunistic respiratory infection. Which of the following is most likely correct? 1. The client has consumed contaminated food or water. 2. The client has encountered an extremely virulent microorganism. 3. The client's immune system is compromised. 4. The client has likely become infected in a healthcare facility

3 An opportunistic infection is one in which an individual develops a disease from an organism that does not cause disease in healthy individuals. This occurs with compromised immunity. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological Note the use of the word compromised. Select the option that matches the definition of opportunistic infection. 0

171 MCSA A client is advised to take an antiemetic to prevent nausea and vomiting. The nurse explains that anticipatory dosing should be done how long prior to activities that generally cause nausea? 1. 24 hours 2. 3 to 5 hours 3. 1/2 to 1 hour 4. 12 hours

3 Anticipatory prevention of nausea with antiemetics is effective if medication is taken 30 to 60 minutes before any activity causing nausea. The other options indicate incorrect timeframes. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Assessment Pharmacology 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. 0

156 MCSA The nurse writes on the worksheet for the shift to assess a client taking cholestyramine (Questran) for signs of possible deficiency of which vitamins? 1. Niacin and thiamine 2. Folic acid and Vitamin C 3. Vitamins A and D 4. Thiamine and cyanocobalamin

3 Clients who are taking cholestyramine (which is a bile resin) should be monitored for fat-soluble vitamin deficiencies (Vitamins A, D, E, and K), as the gastrointestinal side effects of the 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. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Assessment Pharmacology 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. 0

348 MCSA Which of the following substances is useful in inhibiting viral and bacterial growth in the body? 1. Leukocidin 2. Coagulase 3. Cytokines 4. Adherins

3 Cytokines serve as mediators of inflammation, while leukocidin, adherins, and coagulase enhance bacterial resistance to body defenses. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This item requires application of factual knowledge. 0

456 MCSA In assessing the lung sounds of a client in anaphylaxis, the nurse would expect to hear which of the following sounds? 1. Gurgles 2. Coarse sounds 3. Wheezing 4. Friction rub

3 Edema and bronchoconstriction are the clinical manifestations involving the respiratory system in anaphylaxis and usually produce diminished lung sounds, wheezing and stridor (which does not require a stethoscope). Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological This question requires knowledge about anaphylaxis. 0

270 MCSA The nurse who is doing the documentation during a code blue on an adult client observes an unlicensed assistive personnel (UAP) doing CPR. The nurse 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 2. 2 to 2.5 3. 1.5 to 2 4. 1 to 2

3 On an adult client, chest compressions should be done to a depth of 1.5 to 2 inches to be effective. Options 2 and 4 are excessively deep and could lead to injury, while option 4 is not deep enough to provide effective circulation. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Cardiovascular 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. 0

430 MCSA An infant is born with microcephaly. Part of the infant's assessment includes a TORCH test. In providing client education, the nurse explains to the mother that the TORCH test will assess for: 1. Presence of the TORCH virus. 2. Complications of pregnancy. 3. Presence of one or more specific viruses. 4. Evidence of thalidomide poisoning.

3 The acronym TORCH stands for toxoplasmosis, other (syphilis, hepatitis), rubella, cytomegalovirus, and herpes simplex virus. It is a study of common viruses that cause significant fetal damage. Application Physiological Integrity: Physiological Adaptation Teaching and Learning Child Health Recall the meaning of the acronym TORCH to answer this question correctly. 0

298 MCSA A 2-year-old child with rubeola (measles) is brought to the hospital with a rash covering the entire body, photophobia, and stuffy nose that interferes with breathing. The nurse utilizes which of the following nursing diagnoses as a priority for care when administering care to this child? 1. Impaired skin integrity 2. Disturbed body image 3. Risk for impaired gas exchange 4. Risk for disturbed sleep pattern

3 The child has a stuffy nose, which can impair air exchange. Nursing care involves use of a cool-mist vaporizer and gentle suctioning of the nose. The rash does not cause skin impairment. A 2-year-old will not have a disturbed body image. Disturbed sleep pattern would have less priority than gas exchange if this problem developed. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Planning Child Health 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. 0

271 MCSA The nurse is performing CPR on a 10-month-old infant. The nurse times the rate of compressions to achieve a total number of approximately how many compressions per minute? 1. 180 2. 120 3. 100 4. 80

3 The rate of compressions for an infant during CPR is at least 100 per minute. Options 1 and 2 are higher than the minimum number of compressions per minute, while option 4 does not deliver a sufficient number of compressions per minute. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Child Health 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. 0

200 MCSA A client is diagnosed with paranoid personality disorder. Which of the following assessment data does the nurse conclude are consistent with this diagnosis? 1. Delusions and hallucinations 2. Passivity and compliance with rules 3. Jealousy and secretiveness 4. Respect for authority

3 These characteristics are reflected in DSM-IV diagnostic criteria for paranoid personality disorder. They must be considered in planning and implementing care. Delusions and 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. Application Psychosocial Integrity Nursing Process: Assessment Mental Health 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 <i>paranoid</i> in the stem and <i>secretiveness</i> in the correct option to help make an association between the two. 0

373 MCSA A child with suspected toxoplasmosis is experiencing signs and symptoms of fatigue, fever, and lymphadenitis. Which of the following would be most important in obtaining a nursing history? 1. Determine any recent contact with ticks or fleas 2. Assess for prior streptococcal infections 3. Inquire about the presence of cats in the home 4. Inquire about recent trips out of the country

3 Toxoplasmosis is spread through contact with cat feces. Ticks carry the threat of Lyme disease or rickettsial infections. Protozoal infections can be found all over the world. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Child Health Recall that toxoplasmosis is associated with contact with cat feces. Select the only option that refers to cats. 0

481 MCSA A client receives a skin prick test for determination of allergies. Besides the wheals and erythema present, another symptom that will most likely be exhibited by the client with a positive test would be: 1. Dyspnea. 2. Hypertension. 3. Itching. 4. Rash over entire body.

3 Wheals, erythema, and itching are common after a skin prick test, which is conducted by placing a drop of a specific allergen to the skin and pricking the skin at the site of the drop. A response should occur in 15 to 20 minutes. Dyspnea would indicate an anaphylactic reaction and usually hypotension occurs. A rash usually doesn't occur over the entire body. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about allergy testing. 0

170 MCSA The nurse concludes that client education about dissociation is effective when the dissociative client states: 1. "When I want to get out of a situation, I choose to space out." 2. "When I have to cope with problems, I imagine I am somewhere else." 3. "When I'm under stress, I have a tendency to dissociate." 4. "When I think about my life, I pretend I am someone else."

3 When the client realizes the connection between stress, anxiety, and dissociation, he becomes able to modify his stressors or his response to them, thus preventing the dissociative process. The other responses in options 1, 2, and 4 do not reflect this concept. Analysis Psychosocial Integrity Nursing Process: Evaluation Mental Health 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. 0

423 MCSA An infant with numerous congenital defects and a diagnosis of rule out TORCH syndrome is admitted from the birth hospital directly to the pediatric 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? 1. Risk for caregiver role strain 2. Situational low self-esteem 3. Risk for impaired parent/infant attachment 4. Parental role conflict

3 With the birth of a less-than-expected infant, the parents may have difficulty accepting the child. In addition, the anticipated longer hospitalization and separation from the parents inhibit bonding, which could lead to altered attachment. Analysis Psychosocial Integrity Nursing Process: Planning Child Health 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. 0

449 MCSA Which of the following symptoms would be expected in an anaphylactic reaction? 1. Hypertension 2. Bradycardia 3. Rales 4. Stridor

4 A barking cough, wheezing, and stridor are clinical manifestations of the bronchoconstriction and edema that accompanies anaphylaxis. The blood pressure is usually low (hypotension) and the pulse fast (tachycardia). Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological This question requires knowledge about anaphylactic reactions. 0

419 MCSA A child is admitted to the hospital with an allergic reaction. The physician orders a complete blood count (CBC) with differential. The nurse would expect to see an elevation in the level of: 1. Red blood cells (RBCs). 2. Hemoglobin. 3. Leukocytes. 4. Eosinophils.

4 Eosinophils are the type of white blood cell that is associated with allergic reactions. Hemoglobin is present in red blood cells (RBCs), and RBCs carry oxygen to tissues. Leukocytes fight infection. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Analysis Child Health 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. 0

112 MCSA A client with a history of heart failure suddenly exhibits shortness of breath, a respiratory rate of 30, crackles auscultated bilaterally, and frothy sputum. After telephoning the physician for medical orders, which action should the nurse delegate to the Licensed Practical/Vocational Nurse (LPN/LVN)? 1. Start an intravenous line and cap it with a saline lock. 2. Monitor vital signs every 15 minutes. 3. Administer morphine sulfate 2 mg IV push immediately. 4. Insert a urinary catheter.

4 In a client whose condition is deteriorating, the RN should delegate the task that is most procedural in nature (in this case the urinary catheter). The LPN is able to collect data to report to the RN, but in a client whose acuity is changing, it is better for the RN to make the assessments (option 2). The RN should also insert the IV line and immediately administer the IV medication. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Adult Health: Cardiovascular 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. 0

230 MCSA A client with schizophrenia is admitted to the psychiatric unit. As the nurse approaches the client with medication, he refuses it, accusing the nurse of trying to poison him. The nurse's <i>best</i> response would be to tell him that: 1. "It is not poison, and you must take the medication." 2. "If you won't take this, I will give you an injection." 3. "I'm sorry you think that this medication is poison. You don't have to take it right now if you don't want to." 4. "You may decide if you want to take the medication by mouth or injection, but this medication will help you."

4 Option 4 provides the client with the choice of how he would like to take the medication, while being firm that he must take it; the choice gives the client a sense of control and helps to reduce the power struggle. Simply telling the client that the medication is not poison (option 1) would do little to persuade him to adhere. Option 2 provides no choice and implies punishment. The client must take the medication; therefore, option 3 would be inappropriate. Analysis Psychosocial Integrity Communication and Documentation Mental Health 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. 0

286 MCSA While performing cardiopulmonary resuscitation (CPR) on an adult visitor in a shopping mall, the mall security guard arrives with an automatic external defibrillator (AED) device. What actions would the nurse at the scene take at this time? 1. Continue CPR for one minute, then apply the AED. 2. Provide rescue breathing during the AED analysis and shock. 3. Wait until EMS is available to apply cardiac monitoring before using the AED. 4. Stop CPR, apply the AED, and follow the instructions provided.

4 The most common cause of sudden cardiac arrest is an abnormal heart rhythm called ventricular fibrillation. Therefore, delivering a shock via the AED can restore normal cardiac rhythm. An AED warrants use immediately when it becomes available. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Fundamentals 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. 0

308 MCSA The child is receiving an intravenous antibiotic that has a known side effect of ototoxicity. The nurse administering the dose should: 1. Dilute the dose as much as possible. 2. Infuse the dose over one hour. 3. Decrease the dose by 50%. 4. Monitor the child for ringing in the ears and dizziness

4 The nurse's responsibility involves early recognition of side effects from a drug. Therefore, the nurse would monitor the child for symptoms of ototoxicity. Diluting the dose and slowing 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. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Child Health Recognize that ototoxicity is damage to the ears and look for options that refer to ears and ear function. 0

453 MCSA The second child (who is Rh+) of an Rh- mother may develop problems because of: 1. Antigens passed to the child by the mother. 2. Hemolysis of white blood cells in the child. 3. Low hemoglobin level. 4. Antibodies passed to the child by the mother.

4 To answer this question correctly, you must understand that transfusion reactions (in this 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. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about Rh factor. 0

307 FIB The nurse is providing health teaching to a group of high school students regarding infectious mononucleosis. When discussing the incubation period as part of disease transmission, the nurse explains that the incubation period for this infection is ____ weeks. Write in a numerical answer.

6 The incubation period for infectious mononucleosis is up to 6 weeks (with a minimum of 4 weeks). This has important implications for the nurse and the client, since the source of the exposure may be difficult to determine after several weeks. Analysis Safe Effective Care Environment: Safety and Infection Control Teaching and Learning Adult Health: Communicable Disease 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. 0

65 HOTSPOT A client is scheduled to have a transverse colostomy performed. While doing client teaching, the nurse points to which stoma on the diagram to show the client the location of the stoma? Select the correct stoma. COMP_TEST_AAHBDMQ0.gif

<map name="65" id="65"><area shape="circle" coords="118,65,12" href="#" /></map> The correct area is the proximal stoma, not the distal one that is nearer to the distal colon and rectum. Coming from the small bowel in the center of the diagram, the stomas represent, in anatomical order, an ileostomy, cecostomy, ascending colostomy, transverse colostomy, descending colostomy, and sigmoidoscopy. Analysis Physiological Integrity: Basic Care and Comfort Teaching and Learning Adult Health: Gastrointestinal 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 <i>trans</i> means <i>across</i>. This might help you select the stoma that is halfway across the abdomen. 0

315 MCMA In caring for an adolescent with suspected narcotic abuse, the nurse would monitor the adolescent for which of the following? Select all that apply. 1. Constricted pupils 2. Euphoria 3. Hyperactivity 4. Aggressive behavior 5. Respiratory depression

1, 2, 5 Typical symptoms of narcotic abuse include constricted pupils, euphoria, and respiratory depression. Options 3 and 4 do not apply. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Child Health 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. 0

374 MCSA Which of the following clients would most likely acquire <i>Mycobacterium avium-intracellulare</i>? 1. Child 2. Homeless adult 3. HIV-positive individual 4. Teenager

3 <i>M. avium-intracellulare</i> is a mycobacterial infection (an opportunistic infection) that has been identified in those who are HIV-positive or have AIDS. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological Select the option that reflects the immunocompromised individual. 0

354 MCSA Pneumocystis carinii pneumonia is caused by: 1. Viral infection. 2. Bacterial infection. 3. Protozoal infection. 4. Rickettsial infection.

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. Knowledge Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological Eliminate options 1, 2, and 4 as this is a protozoal infection. 0

4 MCMA The clinic nurse is conducting health screenings. Which of the following client assessment findings indicates that client teaching is needed about the risk for stroke? Select all that apply. 1. Weight 205 lbs and height 5 feet 4 inches 2. Blood pressure 164/92 mmHg 3. Eats bran for breakfast daily 4. Smokes 1/2 pack cigarettes per day 5. Serum cholesterol level is 172 mg/dL

1, 2, 4 Obesity, hypertension, and smoking are modifiable risk factors for stroke. Hypercholesterolemia (cholesterol level greater than 200 mg) would also be a risk factor, but this client's level is less than 200 mg/dL. Eating a diet containing fiber helps keep cholesterol levels low and is not a risk factor for stroke. Analysis Health Promotion and Maintenance Nursing Process: Assessment Adult Health: Cardiovascular 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.

46 MCSA The nurse is assessing a 30-year-old client with a prior history of smoking who takes theophylline (Theo-Dur) for chronic obstructive pulmonary disease. Additional diagnoses include liver disease and congestive heart failure. The client is experiencing tremors, dizziness, tachycardia, and nausea. The nurse explains to the client that these symptoms may be the result of: 1. A history of smoking cigarettes. 2. Liver disease. 3. The client's age. 4. The client's weight.

2 Theophylline is a xanthine that causes bronchial dilation due to smooth muscle relaxation. Increased levels of theophylline occur with liver disease and congestive heart failure. Option 3 is incorrect because the client is young and therefore the age is insignificant. The smoking history (option 1) is not an issue; in fact, smokers metabolize theophylline more quickly and may need increased doses. There is no data about the client's weight (option 4) in the stem. Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Analysis Pharmacology 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.

21 MCSA A 60-year-old client has been prescribed rabeprazole (Aciphex) for symptoms of gastroesophageal reflux disease (GERD). He has trouble swallowing pills. What alternate medication should the nurse plan to request for this client? 1. Omeprazole (Prilosec) 2. Pantoprazole (Protonix) 3. Lansoprazole (Prevacid) 4. There is no substitute for Aciphex

3 Omeprazole, pantoprazole, and rabeprazole must be swallowed whole. Lansoprazole and esomeprazole capsules may be opened and sprinkled on applesauce or dissolved in 40 mL of juice. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Planning Pharmacology 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.

94 MCSA The nurse would encourage the new mother to use which breast-feeding position to enable the mother to have optimal control of the newborn's head while giving the mother a full view of the infant's cheeks and jaw? 1. Lying-down position 2. Cradle position 3. Clutch (football) position 4. Across-the-lap position

3 The football, or clutch, position provides the mother with more control of the newborn's head and full view of face. The lying-down position is usually done in bed (option 1). The cradle position often causes the newborn's head to wobble around on the mother's arm (option 2). Options 1, 2, and 4 do not allow full view of the infant's face. Application Health Promotion and Maintenance Nursing Process: Implementation Maternal-Newborn Visualize each of the options and systematically eliminate those that do not promote visualization of the face while maintaining control of the head. 0

262 MCSA The nurse concludes client teaching about infection control measures has been effective when a client with tuberculosis states, 1. "I need to wear a particulate respiratory mask when I go to x-ray." 2. "Nurse, can you give me some gloves so I can blow my nose?" 3. "I will need to use paper plates and cups to eat." 4. "I will flush the toilet twice after urinating."

1 A client with tuberculosis must wear a particulate respiratory mask if transportation to another hospital department is unavoidable. This is an element of airborne precautions 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. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Fundamentals 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. 0

125 MCSA The mother of an infant who underwent surgery to repair hypospadias asks the nurse why the infant is diapered as shown. The nurse would respond that this method of diapering will help to: 1. Protect the urinary stent that has been put in place. 2. Adequately measure the urinary output. 3. Provide for maximum absorption of urine. 4. Provide optimal protection of perineal skin from infected urine.

1 A double-diapering technique will help to protect a urinary stent following repair of hypospadias or epispadias. The inner diaper collects the infant's stool, while the outer one collects urine. Application Physiological Integrity: Physiological Adaptation Teaching and Learning Child Health 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. 0

350 MCSA Which of the following has been associated with chlamydial infection? 1. Myocarditis 2. Rheumatic fever 3. Arthritis 4. Liver abscess

1 A surface peptide found in chlamydia is similar to one in heart myosin and may trigger T-cells to attack both chlamydia and the heart. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological This item requires application of learned information about chlamydia. 0

229 MCSA The nurse is preparing a client for surgery. Prior to completing the skin preparation, the nurse assesses the surgical site for which of the following? 1. Presence of pustules or abrasions 2. Absence of hair growth 3. Presence of lanugo 4. Absence of pulsation

1 Abrasions, pustules, or other skin conditions have to be assessed and documented because these may interfere with wound healing. Hair growth—lack of it 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. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Assessment Fundamentals 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. 0

434 MCSA A child who contracts chicken pox at age 5 has developed which type of immunity? 1. Active acquired, natural 2. Passive acquired, natural 3. Passive acquired, artificial 4. Active acquired, artificial

1 Active acquired immunity occurs when the body produces antibodies or develops immune 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. Comprehension Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological Use the rule of opposites to answer this question. 0

122 MCSA The nurse is taking a nursing history from the mother of a child being admitted with flare-up of celiac disease. What piece of information would the nurse expect the mother to report? 1. Steatorrhea 2. Increased appetite 3. Cheerful behavior 4. Soft, formed stools

1 Acute episodes are characterized by bulky, frothy stools and steatorrhea because of malabsorption, anorexia, and irritability. The client would not exhibit increased appetite (option 2), cheerful behavior (option 3), or soft, formed stools (option 4). Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Child Health 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. 0

458 MCSA A client, who received a skin graft 2 months ago because of extensive burns, reports to the clinic with complaints of redness, swelling, fever, and tenderness over the graft site. This client is exhibiting: 1. Acute tissue rejection. 2. Hyperactive tissue rejection. 3. Chronic tissue rejection. 4. Graft-versus-host disease.

1 Acute tissue rejection is common and usually occurs between 4 days and 3 months after transplant. The manifestations are caused by the inflammatory process. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological This question requires knowledge about acute and chronic reactions. 0

355 MCSA Which of the following is correct concerning Hepatitis A? 1. Treatment with immune globulins can prevent disease if exposed. 2. It is transmitted through blood and body fluids. 3. Jaundice is rare in this form of hepatitis. 4. It usually becomes a chronic disease condition.

1 Administration of immune globulins can provide passive short-term immunity to the disease if administered within 7 days of exposure. Hepatitis A is transmitted through food feces and is usually not chronic. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological Recognize that options 2, 3, and 4 can be eliminated as they describe hepatitis B. 0

165 MCSA A client admitted with exacerbation of chronic obstructive pulmonary disease (COPD) has a respiratory rate of 18, a dry cough, and arterial blood gases that reveal a pH of 7.29, CO₂ of 50 mmHg, and O₂ of 72 mmHg. The nurse identifies which nursing diagnosis as the priority? 1. Impaired gas exchange 2. Activity intolerance 3. Risk for infection related to impaired respiratory defenses 4. Ineffective breathing pattern

1 All of these nursing diagnoses are appropriate for the client with COPD; however, the primary alteration is related to impaired gas exchange because of the abnormal blood gas results. The breathing pattern is satisfactory because the rate is within normal limits, and there is no data to support activity intolerance, although it is plausible. The client is at risk for infection but actual problems take priority over potential ones. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Planning Adult Health: Respiratory Compare the data in the question and use that as a means of selecting the priority nursing diagnosis. 1

473 MCSA A client with seasonal allergies has just recovered from a severe case of rhinitis and an increased incidence of asthma attacks. The nurse would expect to see an increase in which of the following? 1. IgE 2. IgG 3. IgA 4. IgM

1 Allergic rhinitis is a type I or IgE-mediated hypersensitivity where an allergen interacts with IgE that is bound to mast cells and basophils. A radio allergy sorbent test (RAST) will determine the presence of IgE. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological This question requires knowledge about immunity. 0

289 MCSA A nurse dining at a restaurant is summoned to assist with a choking adult who is markedly obese. The 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? 1. Attempt chest thrusts with the client in either a standing or sitting position. 2. Wait until the client becomes unconscious, lower him to the floor, and perform abdominal thrusts. 3. Attempt a finger sweep to remove the foreign body. 4. Ask the client to lie down to perform chest thrusts.

1 An alternate position with the obese client is using the chest thrusts while the individual is in a standing or sitting position. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Fundamentals 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. 0

126 MCSA Following the administration of a diphtheria/pertussis/tetanus (DPT) immunization the nurse notes that the infant has inspiratory stridor. The nurse should take which of the following actions? 1. Administer epinephrine as per protocol orders. 2. Evaluate for pulmonary edema. 3. Inspect for periorbital edema. 4. Assess the baby again in 15 minutes.

1 An inspiratory stridor is indicative of a hypersensitivity reaction to the DPT immunization and epinephrine should be administered to counteract the symptoms of the allergic response. Options 2 and 3 are irrelevant, and option 4 places the infant at risk for injury or death. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology 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. 0

119 MCSA A female client states that she will not undergo any invasive testing for her "stomach pain." The nurse explains that which of the following tests could be completed to assess the abdomen and still meet the client's wishes? 1. Abdominal ultrasound 2. Barium swallow 3. Colonoscopy 4. CT scan with contrast

1 An ultrasound is the only noninvasive procedure listed. The others require swallowing (option 2) or injecting (option 4) contrast, or insertion of an endoscope (option 3). Application Physiological Integrity: Reduction of Risk Potential Teaching and Learning Adult Health: Gastrointestinal 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 <i>swallow</i> in option 2, <i>-oscopy</i> in option 3, and <i>contrast</i> in option 4. These all imply that the test will be intrusive to the body. 0

237 MCSA Which of these statements if made by a client receiving dietary instruction for atherosclerosis would indicate a need for further discussion? 1. "Margarine has less fat than butter, so I will no longer use butter." 2. "I will steam, bake, or broil my foods." 3. "American cheese has 76 percent fat calories." 4. "I will increase my consumption of fruits and vegetables."

1 Atherosclerosis indicates the need to adopt a low-fat diet. Both butter and margarine have 4 grams of fat per serving, making the client's statement incorrect and in need of further clarification. The responses in the other options are correct. Analysis Health Promotion and Maintenance Nursing Process: Evaluation Adult Health: Cardiovascular The critical words in the question are <i>further discussion</i>. With this in mind, evaluate each of the options in terms of how they relate to a low-fat diet. 0

318 MCSA The mother of a newborn is concerned her infant has been exposed to a communicable disease. She states the doctor says the baby is protected because of some kind of immunity, but is unsure of the type. The nurse would identify the type of immunity as: 1. Nonspecific immunity. 2. Active immunity. 3. Specific immune response. 4. Immunizations.

1 Babies are born with nonspecific immunity. Active immunity and specific immune response are developed over time with exposure to an organism. Immunizations are inactivated substances or weakened organisms given to promote the development of immunity. Application Health Promotion and Maintenance Teaching and Learning Child Health Consider which type of immunity a young infant would have. Immunizations can be eliminated because a newborn will not have had any. 0

442 MCSA A client is brought to the Emergency Department after taking a dose of penicillin. Which of the following diagnoses is the highest priority in this client who is demonstrating anaphylaxis? 1. Ineffective airway clearance 2. Decreased cardiac output 3. Risk for injury 4. Anxiety

1 Because laryngeal spasms and bronchial constriction can occur with anaphylaxis, assessing the client's airway is top priority. The nurse should maintain and establish a patent airway first. Remember the ABCs (airway, breathing, and circulation), cardiac output would come next followed by risk for injury and finally anxiety. Analysis Safe Effective Care Environment: Safety and Infection Control Nursing Process: Planning Adult Health: Immunological Recall the ABCs (airway, breathing, and circulation). Airway is always a priority. 0

227 MCSA The nurse must assess the temperature and blood pressure of a client on contact precautions every shift. Which is the appropriate nursing action to minimize the spread of microorganisms? 1. Keep the equipment in the client's room. 2. Store the equipment in the soiled utility room between uses. 3. Cleanse the equipment after each use. 4. No special action is required with the equipment.

1 Equipment for client care is dedicated to the client on contact precautions and kept in the client's room. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Fundamentals The key word <i>appropriate</i> suggests there is only one correct answer. Look for the nursing action that would limit the spread of pathogenic microorganisms. 0

426 MCSA A 2-year-old child has eczema that causes extreme itching. Treatment has not been able to control the rash. It has been determined that the primary allergen is wheat. An appropriate nursing diagnosis would be: 1. Risk for infection. 2. Imbalanced nutrition, more than body requirements. 3. Ineffective infant feeding behavior. 4. Noncompliance.

1 Because of the itching, the child will be scratching. Intense scratching can break the skin, and the child might develop a bacterial infection secondary to the skin trauma. Imbalanced nutrition, more than body requirements, does not clearly state the problem with the food 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. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Child Health 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. 0

121 MCSA A client is taking an over-the-counter preparation containing bismuth subsalicylate (Pepto-Bismol) for diarrhea. Which of the following side effects would a nurse monitor for that is unique to the bismuth portion of this drug? 1. Darkening of the tongue 2. Dyspepsia 3. Abdominal pain 4. Diarrhea

1 Bismuth-containing preparations, such as Pepto-Bismol, can cause all the listed side effects, but transient darkening of the tongue and stool is a specific side effect to bismuth. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Assessment Pharmacology The critical word in the stem of the question is <i>unique</i>. 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. 0

399 MCSA The nurse is caring for a pediatric client with acquired immunodeficiency syndrome (AIDS). Which activity by the nurse should be reported to the employee health department as an exposure for the nurse? 1. While flushing out the used bedpan, fluid splashes in the nurse's eyes. 2. The nurse does not wear a mask while in the client's room. 3. During the bath, the nurse removes gloves when giving a backrub on intact skin. 4. The nurse is stabbed with a sterile syringe to be used to draw up the client's medications

1 Body fluid-contaminated liquids may contain the human immunodeficiency virus (HIV) and can be absorbed through the eye mucosa. The other activities do not expose the nurse to blood and/or body fluids of the client and therefore pose no risk of contracting HIV. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Evaluation Child Health 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. 0

412 MCSA A 13-year-old child is scheduled for a bone marrow aspiration. The nurse has explained the procedure to the patient and his mother. Which statement by the mother indicates a need for additional teaching? 1. "How long will it take my child to wake up from the anesthesia?" 2. "I can't believe they will take the sample out of his hip." 3. "He will need to be watched for bleeding and infection after the procedure." 4. "The doctors are going to use this test to find out why he can't fight infections."

1 Bone marrow aspirations are usually performed under local anesthesia unless the child is too small to cooperate to hold still. The other statements are correct and do not require further follow-up or teaching. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Evaluation Child Health Eliminate all responses that indicate correct understanding of a bone marrow aspiration, then consider each of the options left. 0

295 MCSA A 2-year-old child in the hospital for a fractured femur breaks out with chickenpox. Which nursing intervention will best prevent secondary skin infections? 1. Caladryl lotion to lesions 2. Acetylsalicylic acid 3. Immune globulin for the first 3 days 4. Nubaine every 4 hours as needed for pain

1 Caladryl will reduce itching and discomfort and therefore diminish scratching and skin breakdown. Acetylsalicylic acid should not be given to young children with a viral disease because of the relationship to Reye syndrome. Immunoglobin will not decrease skin eruptions. Nubaine is a narcotic analgesic. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Child Health 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. 0

407 MCSA A 2-year-old child hospitalized for a fractured femur breaks out with chickenpox. The physician has written the following orders: Which intervention will best prevent secondary skin infections? 1. Apply Caladryl lotion to lesions prn 2. Acetaminophen (Tylenol) 320 mg orally every six hours prn 3. Immunize all siblings 4. Institute airborne and contact isolation

1 Caladryl will reduce itching and discomfort and therefore diminish scratching and skin breakdown. Acetylsalicylic acid should not be given to young children with a viral disease because of the relationship to Reye's syndrome. Immunizing the sibling and isolation will have no effect on skin eruptions. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Child Health 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. 0

195 MCSA The nurse would expect to find a diminished pCO₂ level in the assigned client who has which of the following physical assessment findings? 1. Hyperventilation 2. Hypoventilation 3. Prolonged expiration 4. Stridor

1 Carbon dioxide is eliminated from the body as exhaled gas. The faster the rate of breathing, the greater the quantity of carbon dioxide eliminated. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Respiratory Note the stem of the question contains the words <i>diminished</i> <i>pCO₂</i>, which indicates that the client is blowing off excessive CO₂. Use knowledge of respiratory disorders to select the option that is consistent with excessive respiration, which is option 1. 1

246 MCSA Which of the following statements made by a client receiving ophthalmic corticosteroids indicates a need for further teaching? 1. "I remove my contact lenses before instilling the medication, then put them back in after 30 minutes." 2. "I am not wearing my contact lenses for the duration of the corticosteroid treatment." 3. "I will take my medication for the length of time prescribed by my physician." 4. "I will return to my physician to have my eyes examined after my treatment is completed."

1 Clients receiving ophthalmic corticosteroids have an increased risk of infection. Contact lenses should not be used during ophthalmic corticosteroid therapy. Options 2, 3, and 4 indicate an appropriate understanding of ophthalmic corticosteroid therapy. Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Evaluation Pharmacology 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. 0

173 MCSA Which of the following statements made by a client regarding human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) would the nurse seek to further clarify? 1. "I can get the disease from eating contaminated food products." 2. "Blood tests will tell me if I have a nutritional anemia." 3. "Maintaining adequate fluid and fiber intake will help me." 4. "If I feel sick to my stomach, I should not drink liquids."

1 Contaminated foods are not a source of HIV/AIDS infection. While contaminated foods may cause GI symptoms and food poisoning due to various etiologic agents, they do not cause the transmission of this disease. 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. Application Physiological Integrity: Basic Care and Comfort Nursing Process: Assessment Foundational Sciences: Nutrition The critical word in the stem of the question is <i>clarify</i>. 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. 0

233 MCSA A client with venous stasis ulcers is being treated with an Unna boot. The nurse should include which of the following additional interventions in the plan of care? 1. Elevating legs and assessment of peripheral pulses 2. Keeping legs dependent for pain relief and improved circulation 3. Wet to dry dressings to ulcer twice daily 4. Elevating legs and standing as much as possible

1 Elevation of the extremities promotes venous return. Pulses are assessed to ensure adequate circulation. Option 3 is unnecessary because the Unna boot is treating the ulcer and is changed every 1 to 2 weeks. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Cardiovascular 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. 0

188 MCSA The nurse must assess the temperature and blood pressure of a client on contact precautions for wound infection every shift. Which is the appropriate nursing action to minimize the spread of microorganisms? 1. Keep the equipment in the client's room. 2. Store the equipment in the soiled utility room between uses. 3. Cleanse the equipment after each use. 4. No special action is required with the equipment.

1 Equipment for client care is dedicated to the client on contact precautions and kept in the client's room. Any other action does not uphold principles of infection control. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Adult Health: Integumentary The key word appropriate suggests there is only one correct answer. Look for the nursing action that would limit the spread of pathogenic microorganisms. 0

410 MCSA A young infant is diagnosed with severe combined immunodeficiency disorder (SCID). The nurse has taught the mother about the disease. The statement by the mother that indicates a lack of understanding is: 1. "My child will grow out of this." 2. "Bone marrow transplantation may be possible." 3. "The prognosis for this disease is not good." 4. "My child contracted the disease because of me."

1 Even with aggressive treatment, prognosis is poor. Current developments in bone marrow transplantation are hopeful. Because of possible genetic involvement, parents may feel some guilt. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Evaluation Child Health Determine which statement is incorrect information about SCID. 0

182 MCSA The client is admitted with all of the following orders to treat diabetic ketoacidosis (DKA) with severe metabolic acidosis. Which order would the nurse determine to be the first priority in managing this client? 1. Start IV fluid infusion for rehydration. 2. Insert an indwelling urinary catheter. 3. Administer NPH insulin. 4. Initiate continuous pulse oximetry

1 Fluid and electrolyte replacement is the highest priority. Hyperglycemia is treated with regular insulin rather than NPH insulin (option 3). Concurrent administration of IV regular insulin would also be done as a priority. The items in the other options can be done after definitive treatment for dehydration is done. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Planning Adult Health: Endocrine and Metabolic 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. 0

142 MCSA During a scheduled exam the client's glycosylated hemoglobin was found to be 9%. The client has had diabetes mellitus for 3 years. The nurse should do which of the following? 1. Explore the client's general dietary pattern for the past 4 months. 2. Assess for signs of infection and client's intake for the past 24 hours. 3. Review the client's understanding of diabetic foot care. 4. Immediately give sliding scale insulin medication.

1 Glycosylated hemoglobin is elevated due to long-term hyperglycemia. Values greater than 8 percent indicate consistently poor control of blood glucose and the need to assess the client's dietary pattern for the past several months in relation to the treatment plan. The other options do not apply. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Endocrine and Metabolic 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. 0

396 MCSA Medication instruction for the client with rheumatoid arthritis (RA) should include which the following teaching points? 1. Injection of gold salts requires monitoring for anaphylactic reactions every half-hour. 2. Treatment with sulfasalazine requires fluid restriction to avoid nausea and vomiting. 3. NSAIDs, acetaminophen, and aspirin may be used interchangeably to decrease inflammation associated with RA. 4. Penicillamine may be safely used during pregnancy

1 Gold salts may cause anaphylaxis. Sulfasalazine may cause nausea and vomiting, but fluids should be encouraged (option 2). Acetaminophen does not provide the same anti-inflammatory effects as ASA and NSAIDs (option 3). Penicillamine cannot be used during pregnancy (option 4). Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Analysis Adult Health: Immunological 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. 0

169 MCSA The nurse is reviewing the results of a male client's recent lipid profile. The nurse notes that the client is experiencing beneficial effects of a heart healthy diet and exercise after noting elevations in which laboratory value? 1. High-density lipoprotein (HDL) 2. Low-density lipoprotein (LDL) 3. Total cholesterol 4. Triglycerides

1 HDL is felt to be a beneficial lipoprotein because of its protective function against coronary artery disease. An elevation in this level is healthy and indicates compliance with diet and exercise recommendations. LDL and HDL are fractions of the total cholesterol level. Triglycerides and LDL have proven to be major contributors to and predictors of coronary artery disease, making elevations in all three remaining options threats to cardiovascular health in the future. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Assessment Adult Health: Cardiovascular 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 <i>H</i> and associate this with the word <i>healthy</i> to make the positive association between these. 0

310 MCSA A child who enters the nursing clinic has a diagnosis of rule out severe combined immunodeficiency disease (SCID). The child is being seen in the clinic because of a possible infection. In evaluating the lab reports, the nurse would expect to find: 1. Low immunoglobulin titers. 2. Elevated white blood cell counts. 3. Elevated eosinophil counts. 4. Positive RAST tests.

1 Immunoglobulin titers are low in children with SCID, with or without an infection. The low titer levels are what prevent the child from fighting an infection. The other options do not address this concept. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Child Health The critical concept is the severe combined immunodeficiency. Select the option that contains the laboratory value that would be expected in this client. 0

273 MCSA A nurse is eating in a restaurant when a woman who is 8 months pregnant at the next table begins to choke. Which of the following hand placements should the nurse use to perform the Heimlich maneuver? 1. Midsternum 2. Lower sternum 3. Midway between umbilicus and xiphoid process 4. Midway between umbilicus and symphysis pubis

1 In a pregnant client, the Heimlich maneuver is performed in a manner that avoids causing injury to the fetus. For this reason, the hand placement is at the midsternum rather than at the abdomen (options 3 and 4). The lower sternum (option 1) should be avoided to prevent accidental fracture of the xiphoid process, which could lead to internal injury. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Cardiovascular 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. 0

210 MCSA The nurse interprets that which of the following statements made by a coworker is a typical staff response when working with a client diagnosed with a paranoid personality disorder? 1. "He constantly criticizes his care. I'm so frustrated." 2. "He is so pleasant but so shy." 3. "He has a wonderful sense of humor but he doesn't let it show often." 4. "I am pleased he was so helpful with his roommate. He can be so irritable at times."

1 Individuals diagnosed with paranoid personality disorder frequently are critical or argumentative to maintain a safe distance between themselves and others related to their inability to trust others. Nursing staff may need to remind themselves that criticism of nursing 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. Analysis Psychosocial Integrity Nursing Process: Analysis Mental Health 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 <i>paranoid</i> and evaluate each option for consistency to make an appropriate selection. 0

417 MCSA The mother of a 1-year-old child says that breast-feeding her infant is sufficient to provide immunity. She does not want to sign the permit for immunizations. What is the nurse's best approach in working with this client? 1. Discuss active and passive immunity. 2. Tell her immunizations are legally mandatory. 3. Ask about the mother's diet. 4. Give the immunization without her permission.

1 Infants receive passive immunity, which lasts 3 to 4 months, through the placenta or breastmilk. Active immunity lasts long term and is acquired by exposure to disease or immunizations. Analysis Health Promotion and Maintenance Nursing Process: Implementation Child Health 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. 0

333 MCSA Which of the following viruses is most likely to be acquired through casual contact with an infected individual? 1. Influenza virus 2. Herpes virus 3. Cytomegalovirus (CMV) 4. Deficiency virus (HIV)

1 Influenza virus is transmitted through respiratory droplets. Herpes virus is transmitted by direct contact and HIV through blood and body fluids. Cytomegalovirus is an opportunistic infection. Analysis Safe Effective Care Environment: Safety and Infection Control Nursing Process: Assessment Adult Health: Immunological The key element in the question is the term 'casual contact.' This leads to the correct response of influenza. 0

360 MCSA Which of the following is used to treat Klebsiella pneumoniae? 1. Aminoglycosides 2. Penicillins 3. Metronidazole (Flagyl) 4. Sulfonamides

1 Klebsiella is a Gram-negative rod. Aminoglycosides are used effectively against Gram-negative bacteria by binding to ribosome and preventing protein synthesis. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology Eliminate option 3 as Flagyl is an anti-fungal. Recall that penicillins and sulfonamides are not used to treat Klebsiella. 0

161 MCSA The client is receiving a loading dose of lidocaine (Xylocaine) 100 mg IV for treatment of ventricular tachycardia. The nurse prepares to take which action next? 1. Start a continuous IV infusion at 1 to 4 mg/minute. 2. Repeat the dose every 10 minutes for 1 hour or PRN. 3. Begin oral procainamide (Pronestyl) therapy. 4. Prepare for pacemaker insertion to override the dysrhythmia.

1 Lidocaine is given via IV push in doses of 1 to 1.5 mg/kg. The initial loading dose (bolus) is intended to achieve adequate blood levels to suppress ventricular dysrhythmias and is followed by an infusion of 1 to 4 mg/min via infusion pump. The initial bolus lasts 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. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Planning Pharmacology 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. 0

347 MCSA Which of the following is incorrect concerning Lyme disease? 1. The disease is caused by rickettsial pathogens. 2. Humoral and cell-mediated responses by the body will not generally be sufficient to eliminate the disease. 3. The disease is transmitted through ticks. 4. If untreated it may lead to complications of arthritis and destruction of joints.

1 Lyme disease is a spirochetal infection. Examples of rickettsial infections are Typhus and Rocky Mountain Spotted Fever. Knowledge Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological Note the word 'incorrect' in the question stem is asking for identification of the only option that is not related to Lyme disease. 0

159 MCSA A client diagnosed with hypochondria states an allergy to the dyes used in diagnostic tests and "all" radioisotopes. The nurse explains that the client could undergo which diagnostic procedure without risk of possible allergic response? 1. Magnetic resonance imaging (MRI) 2. Myelogram 3. Ventilation/perfusion (VQ) scan 4. Computed tomography (CT) scan with contrast

1 MRI is the only diagnostic examination listed that does not possibly require the ingestion or administration of contrast or radioactive material. Options 2 and 4 involve the use of contrast dyes or agents, while option 3 uses a radioisotope. Application Physiological Integrity: Reduction of Risk Potential Communication and Documentation Adult Health: Immunological 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. 0

376 MCSA Mycoplasmal infections are usually resistant to antibiotics such as penicillin because: 1. Mycoplasma have no cell wall membrane. 2. Most mycoplasma have become methicillin-resistant. 3. Mycoplasma does not replicate using DNA. 4. Penicillin cannot penetrate the mycoplasma capsule.

1 Mycoplasma have no cell wall membrane and therefore are not sensitive to penicillin, which works by interfering with cell wall synthesis. Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Analysis Pharmacology This item requires knowledge of mycoplasma and penicillins. Eliminate options 2, 3, and 4 as being incorrect. 0

431 MCSA A 2-month-old infant has been admitted with a diagnosis of sepsis. The nurse would monitor the child for evidence of: 1. Hypothermia. 2. Rash. 3. Sunken fontanels. 4. Glucosuria.

1 Neonates with sepsis may display either hypothermia or hyperthermia, but hypothermia is more common. The other symptoms are not associated with sepsis. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Child Health Recall that neonates are as likely to demonstrate hypothermia as hyperthermia. 0

113 MCSA An 86-year-old client will be undergoing a surgical procedure. Which of the following changes would the nurse make in the informed consent process for this elderly client? 1. Providing adequate time for the client to process the information 2. Encouraging the family members to make the decision for the client 3. Encouraging the client to sign immediately before the client forgets the purpose of the surgery 4. Providing the client with reading material about the surgery and the postoperative instructions

1 Older clients need time to digest the information and ask questions. Option 2 is incorrect because most older clients are able to make decisions for themselves. Option 3 can be considered coercion, while option 4 can be appropriate but is not the best option since clients need more than reading material for an informed consent. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Implementation Fundamentals 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. 0

155 MCSA A client of 26 weeks gestation experiences a partial placenta abruptio. She asks, "Will this harm my baby?" The nurse responds that this may: 1. Decrease the amount of nutrients the fetus receives. 2. Cause a buildup of urine in the fetus, causing kidney damage. 3. Cause the fetus to develop hydrops. 4. Cause a fetal anomaly

1 One of the major functions of the placenta is provision of nutrients to the fetus across the placenta membrane. An interference with the placenta circulation, such as abruptio placentae, 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. Application Physiological Integrity: Physiological Adaptation Teaching and Learning Maternal-Newborn 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 <i>partial</i> to aid in selecting the correct option. 0

145 MCSA The nurse would utilize which of the following interventions when caring for a client with chronic pain disorder to help that client cope with the disorder? 1. A program of physical exercise 2. Music therapy for expression 3. Patient-controlled analgesia pump 4. Complete bedrest

1 Physical exercise, within the client's ability level, reduces muscle tension and pain. Additionally, exercise creates a feeling of greater self-efficacy. Verbal expression of conflicts 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. Application Psychosocial Integrity Nursing Process: Implementation Mental Health Note that critical words in the question are <i>chronic pain</i> and <i>cope</i>. 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. 0

415 MCSA A child is in the clinic for a prick test. Because of the risk of anaphylaxis, the nurse has which of the following medications available for emergency treatment? 1. Epinephrine (Adrenalin) 2. Prednisone (Deltasone) 3. Naloxone (Narcan) 4. Cromolyn sodium (Intal)

1 Prick tests determine allergens. Should the child have an allergy, epinephrine might be needed to counteract anaphylaxis. Corticosteroids such as prednisone are helpful in minimizing allergic response, but would not be effective in the management of anaphylaxis. In addition, pretreatment with prednisone would make test results invalid. Naloxone reverses the effects of opioid analgesics, and cromolyn sodium is useful in managing asthma. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Planning Child Health 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.

475 MCSA A client develops severe angioedema involving her face, hands, and feet with burning and stinging of the lesions after consuming her 9:00 A.M. medications. A significant risk factor for allergies that the nurse should question the client about is: 1. A family history of allergies. 2. The use of OTC medications. 3. Recurrent infections or illnesses. 4. Home medications she is taking.

1 Reactions such as these may be genetic and knowing whether other members of a family have similar reactions is useful in determining a cause. The use of OTC medications and home medications may be helpful, but if this reaction has not occurred before, it is less likely to be from those sources. Option 3 would not offer any assistance at this time. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Assessment Adult Health: Immunological This question requires knowledge about family history of allergies. 0

343 MCSA A young adult male relates to the nurse that he has recently experienced signs and symptoms of infection. His neutrophil count is lower than normal. The nurse concludes that most likely he: 1. Has a bacterial infection. 2. Has a viral infection. 3. Has an immune deficiency disorder. 4. Is recovering from the illness.

2 Neutrophil counts are often decreased in viral infections and elevated in bacterial infections. Neutropenia can occur because of chemotherapy and immunosuppression. With recovery, his neutrophil count should be returning to normal. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This item requires application of factual knowledge that viral infection often lowers neutrophil count. 0

116 MCSA An adult client with diabetes insipidus who has been taking desmopressin (DDAVP) intranasally comes to the clinic for a regularly scheduled appointment. The nurse assesses the client's mental status and notes some disorientation and behavioral changes. Significant pedal edema is also present. What should be the nurse's next action? 1. Check vital signs and notify the physician. 2. Have the client return in the morning for reevaluation. 3. Instruct the client to limit salt intake for a few days. 4. Suggest that the client change the route of administration to subcutaneous injections.

1 Signs of overdosage of desmopressin, an antidiuretic hormone, include blood pressure and pulse elevation, mental status changes, and water and sodium retention. Because the medication therapy needs to be interrupted, the nurse should notify the physician. Option 2 would place the client at risk because of lack of timely treatment. Options 3 and 4 would not address the current complication. Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology 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. 0

397 MCSA The nurse writing a care plan determines that which of the following is a priority nursing diagnosis early in the care of a client with scleroderma? 1. Impaired skin integrity 2. Disturbed body image 3. Activity intolerance 4. Hopelessness

1 Skin manifestations are a common finding in clients with scleroderma and therefore require preventative and supportive nursing care as the priority. As the disease progresses, 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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Planning Adult Health: Immunological 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. 0

384 MCSA The nurse assesses the client with rheumatoid arthritis for which of the following characteristic joint changes? 1. Swan-neck deformity and ulnar deviation 2. Heberden's and Bouchard's nodes 3. Tophi 4. Charcot's joints

1 Swan-neck deformity occurs at the proximal interphalangeal (PIP) joint and ulnar deviation occurs as a result of joint destruction with disease progression. Heberden's and Bouchard's 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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological 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. 0

296 MCSA A child is being treated at home for chickenpox. The home-health nurse is visiting and notes an elevated temperature. To prevent a common complication of an elevated temperature, the nurse recommends which of the following? 1. Tepid sponge baths 2. Aspirin as needed for fever control 3. Keep child well covered to prevent chilling 4. Antibiotics as ordered

1 Tepid baths allow heat to be removed from the body. Aspirins are avoided because of the risk of Reye syndrome. The child should wear only light clothing to allow heat to escape. Antibiotics are not usually ordered for this viral infection. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Child Health 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. 0

174 MCSA The registered nurse is assigned to the postpartum unit. Which task could the RN safely delegate to an unlicensed assistive person (UAP)? 1. Ambulate a client who had a vaginal delivery yesterday. 2. Complete the admission assessment on a newly delivered client. 3. Call the physician to report a low hemoglobin level. 4. Verify a unit of blood prior to transfusion.

1 The RN is responsible for delegating tasks appropriately and is responsible for the actions of unlicensed employees. Ambulating a postoperative client is the only task 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. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management 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. 0

280 MCSA The nurse responds to a code of an adult client on the hospital unit. In the room are two students performing cardiopulmonary resuscitation (CPR). The nurse 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? 1. Positioned at the side of the client, leaning directly over the victim, with arms straight, using a smooth, straight downward thrust 2. Positioned with arms slightly bent, using a quick bouncing movement 3. Using the heel of one hand to depress the sternum 4. Positioned leaning slightly backwards, with arms straight, using a smooth, straight downward thrust

1 The bent arms will displace the downward force and make the chest compressions less effective. Bouncing movements decrease effectiveness of resuscitation, and most likely will cause injuries. Using the heel of one hand is appropriate for CPR in the child. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Fundamentals 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. 0

268 MCSA A nurse has begun to resuscitate a 10-month-old infant. After delivering breaths, the nurse next checks the pulse at which of the following locations? 1. Brachial 2. Radial 3. Carotid 4. Temporal

1 The brachial artery is the correct location for determining whether an infant under one year of age has a pulse. The radial artery would not generate enough pulsation in an infant to be 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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Child Health 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. 0

338 MCSA An infection characterized by bacterial resistance that develops may be linked to the fact that the bacterial capsule: 1. Contributes to the invasiveness of pathogenic bacteria. 2. Plays a major role in adherence of bacteria. 3. Does not protect the organism from phagocytosis. 4. Is always composed of glutamic acid.

1 The capsule contributes to the invasiveness of pathogenic bacteria. Encapsulated bacteria are protected from phagocytosis unless coated with anticapsular antibody. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This item requires application of knowledge of bacterial resistance. Option 4 can be eliminated because of use of the absolute 'always'. 0

287 MCSA A school nurse is performing cardiopulmonary resuscitation (CPR) on a 9-year-old child. Rescue breathing has been initiated. The child has no pulse. The nurse would begin chest compressions using which of the following methods? 1. Both hands interlocked, compressing the sternum 1 1/2-2 inches 2. The heel of one hand to the depth of 1-1 1/2 inches 3. The middle and ring fingers at a depth of 1/2-1 inch 4. The heel of one hand 1 1/2-2 inches

1 The child is old enough to apply the adult guidelines, which are 1 1/2-2 inches for effective chest compressions. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Fundamentals 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.

408 MCSA A mother known to be infected with the human immunodeficiency virus (HIV) gives birth to a healthy-appearing male infant. Which plan is best to follow up on the infant's HIV status? 1. CD4+ counts every three months until 2-years-old 2. p24 antigen test one time 3. White blood cell counts every four weeks 4. ELISA at 2 months of age.

1 The child will need to be tested at approximate three-month intervals until the child is 18 months to 2 years. CD4+ counts are used to assess a young child's immune status and risk for disease progressions. The p24 antigen test needs to be repeated if positive. The ELISA is used with children over 18 months. Application Health Promotion and Maintenance Nursing Process: Assessment Child Health Be aware that tests for HIV are repeated over time. 0

131 MCSA Which of the following should be the highest priority of the education plan for a client being treated with medication therapy for a generalized seizure disorder? 1. Take medication even if there is no seizure activity. 2. Physical dependency may result from extended use of medications. 3. Urine may turn pink to brown but is not harmful. 4. Therapeutic effects of medications may not be seen for 2 to 3 weeks.

1 The client must understand the medication information as a priority item. Option 2 is a false statement. Effective medication dosing should control seizure activity (option 4). Teaching that urine may turn pink to brown may be included if appropriate, but is not the highest priority. Application Physiological Integrity: Physiological Adaptation Nursing Process: Planning Adult Health: Neurological The critical words in the stem of the question are <i>highest priority</i>. 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. 0

140 MCSA The nurse would select which of the following as a priority nursing diagnosis for a client who has many physical complaints that are not supported by diagnostic test evidence? 1. Ineffective individual coping 2. Impaired adjustment 3. Impaired verbal communication 4. Pain

1 The client who has many physical complaints with no organic basis is not conscious of conflicts and stressors, and is, therefore, unable to use other means to cope with anxiety. There is no evidence of impaired adjustment or verbal communication. Nothing in the stem of the question specifically states that the client is in pain. Analysis Psychosocial Integrity Nursing Process: Planning Mental Health A key phrase is <i>many physical complaints</i> and a critical word is <i>priority</i>. 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. 0

199 MCSA A client asks the nurse to repeat what the physician explained about the anesthesia planned for an upcoming procedure. The nurse understands the procedure will be performed under moderate sedation. Which statement should the nurse make to the client concerning moderate sedation? 1. "You will be able to breathe and respond appropriately to physical stimuli and words that are spoken." 2. "Your pain threshold will be decreased so you can tolerate the pain." 3. "You will have a patent airway and will be able to remember and comprehend what is happening." 4. "You will not be awake but you will still feel slight pain during the surgical intervention."

1 The definition of moderate sedation is that there is a minimal depression of the level of consciousness in which the client is able to maintain a patent airway and respond appropriately to verbal and physical stimuli. The pain threshold is increased so that the client can tolerate pain (option 2). Amnesia is induced partially with conscious sedation (option 3). Option 4 is false because the client is awake. Application Physiological Integrity: Reduction of Risk Potential Communication and Documentation Fundamentals 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. 0

316 MCSA The nurse in the hospital would suspect severe combined immunodeficiency disorder (SCID) when which child is admitted to the unit? 1. A 2-month-old with thrush and low white blood cell counts 2. A 2-year-old with history of recent repeated infections 3. A newborn with positive TORCH titer 4. A newborn admitted with positive ELISA test

1 The first infection often seen in these children is oral candidiasis (thrush). That along with the low white blood cell count would a be a warning symptom. A 2-year-old is unlikely to have survived this long undiagnosed. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Child Health Two of the options refer to a newborn. Eliminate those options because maternal antibodies acquired intrauterinely will protect these infants. 0

400 MCSA The pediatric nurse would suspect severe combined immunodeficiency disorder (SCID) when which of the following children is admitted to the hospital nursing unit? 1. A 2-month-old with thrush and low white blood cell counts 2. A 2-year-old with history of recent repeated infections 3. A newborn with positive TORCH titer 4. A newborn admitted with positive ELISA test

1 The first infection often seen in these children is oral candidiasis (thrush). That symptom, along with the low WBC count, would be a warning symptom of SCID. A 2-year-old is unlikely to have survived this long undiagnosed. ELISA tests evaluate HIV infection, and a TORCH titer is unrelated. A newborn is too young for symptoms to have manifested. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Child Health 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. 0

418 MCSA The nurse is caring for several children in a hospital unit where there has been a recent outbreak of 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: 1. Toddler with severe combined immunodeficiency disease. 2. Preschooler in traction for a fractured femur. 3. School-age child with eczema. 4. Teenager with frequent stools secondary to malabsorption syndrome.

1 The immunocompromised child would be the one at greatest risk for acquiring an infectious organism. The other children would be at less risk for acquiring the gastrointestinal infection. Analysis Safe Effective Care Environment: Safety and Infection Control Nursing Process: Analysis Child Health The ability to fight infection is related to the immune system. Select the child with a disease of the immune system. 0

293 MCSA A mother overhears two nurses discussing the incubation period for a measles outbreak. The mother 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? 1. It describes a period when the child might be contagious. 2. It determines the severity of the infection. 3. It varies depending on the age of the child. 4. It is a time when medications can prevent the development of symptoms.

1 The incubation period is the time between exposure and outbreak of the disease. It is often a period when the child can be contagious without others being aware of the possible exposure. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Communicable Disease 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. 0

422 MCSA A mother overhears two nurses discussing a measles outbreak. The nurses are talking about the incubation 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? 1. Describes a period when the child might be contagious 2. Determines the severity of the infection 3. Varies depending on the age of the child 4. Is a period of time when medications can prevent the development of symptoms

1 The incubation period is the time between exposure and outbreak of the disease. It is often a period when the child can be contagious without others being aware of the possible exposure. Application Safe Effective Care Environment: Safety and Infection Control Teaching and Learning Child Health To answer this question correctly, it is necessary to understand the concept of the incubation period. 0

221 MCSA Following the administration of a measles-mumps-rubella (MMR) vaccine, the nurse should make a priority assessment for which of the following client manifestations? 1. Wheezing 2. Pain 3. Anxiety 4. Vomiting

1 The nurse should assess for signs and symptoms of hypersensitivity reaction following the administration of all vaccines. Wheezing is a sign of hypersensitivity reaction and warrants 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. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Assessment Pharmacology 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. 0

138 MCSA A client is admitted to the pre-surgical area before undergoing surgery to repair a detached retina. The admitting nurse would take which of the following actions first? 1. Position the client properly. 2. Darken the bedside area of the client. 3. Administer the prescribed preoperative analgesic. 4. Cover the affected eye.

1 The priority nursing intervention is one that maintains contact of the retina with the choroid by positioning the client so the detached area falls against the choroid. It is unnecessary to darken the client's immediate environment. A preoperative medication may be ordered, but 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. Analysis Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Adult Health: Eye and Ear The critical words in the question are <i>actions</i> and <i>first</i>. 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. 0

433 MCSA A 4-year-old child has been exposed to chickenpox. After the nurse has provided information about chickenpox, the nurse asks the mother to repeat the information. The mother's statement that indicates a need for additional information is: 1. "During the prodromal period, my child will have pox all over his body." 2. "Chickenpox is a viral infection that can be spread to other children." 3. "I should monitor my child for Reye Syndrome, which is a complication of chickenpox." 4. "My child should not visit my pregnant sister at this time."

1 The prodromal period refers to the period of time between the initial symptoms and the presence of the full-blown disease. The rash would not be apparent during this time. All the other statements are correct. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Evaluation Child Health Understanding the meaning of the term "prodomal" will guide the learner to the right response. 0

463 MCSA Education in the community about HIV should consist of which of the following? 1. It is not as big of a threat as it once was. 2. Unprotected sex should never be engaged in unless both partners are known to be HIV-negative. 3. HIV can be transmitted by the oral (saliva) route. 4. HIV2 virus is the most common form in the United States.

2 Consenting sexual partners should be tested to determine that each is HIV-negative if 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. Application Health Promotion and Maintenance Nursing Process: Implementation Adult Health: Immunological This question requires knowledge about HIV. 0

302 MCSA The clinic nurse is working with a toddler who has been diagnosed with roseola (exanthema subitum) after being seen for fever and a skin rash. The nurse makes which response to the mother who asks how to reduce the risk of infecting other children at home? 1. "There is no way to reduce risk because the route of transmission is unknown." 2. "Do not allow the child to cough or sneeze in the presence of others whenever possible." 3. "Use disposable dishes and eating utensils, and dispose of them in a separate trash bag." 4. "Select one bathroom to be used exclusively by the toddler until the rash clears."

1 The route of transmission of roseola is unknown. It is not known to be transmitted by the respiratory tract (option 2), contact with contaminated articles (option 3), or body secretions such as urine or stool (option 4). Analysis Physiological Integrity: Physiological Adaptation Teaching and Learning Child Health 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. 0

332 MCSA Which of the following is true concerning human immunodeficiency virus (HIV)? 1. HIV infection involves CD4 receptor protein on the surface of helper T-cells. 2. The presence of circulating antibodies that neutralize HIV is evidence that the individual has immunity to HIV. 3. HIV replication occurs extracellularly. 4. DNA replication is similar to that of other viruses.

1 The virus makes a DNA copy of its own RNA using the reverse transcriptase enzyme and the DNA copy is inserted into the genetic material of the infected cell. Knowledge Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological Identify the response that addresses the pathophysiology of HIV. 0

479 MCSA The client who received a bone marrow transplant for treatment of leukemia develops a skin rash 10 days after the transplant. The nurse recognizes that this reaction indicates that: 1. The skin is a target organ for destruction by T-cells. 2. The client's circulating antibodies are rejecting the donor bone marrow. 3. A delayed hypersensitivity reaction is occurring with necrosis of donor tissue. 4. The client's epithelial T-cells are destroying new white cells produced by the donor marrow

1 This is an example of graft-versus-host disease (GvHD), which is a complication of bone marrow transplants. When immunocompetent graft cells recognize host tissue as foreign, a cell-mediated immune response is initiated. The skin, liver, and gastrointestinal tract are often targets. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about leukemia 0

364 MCSA One of the primary concerns with treatment for tuberculosis is: 1. Compliance with drug therapy. 2. The lack of antibacterial agents that are effective against tuberculosis. 3. Bone marrow suppression caused by drug therapy. 4. Hospitalization and isolation for long periods of time.

1 Treatment for tuberculosis often requires months of antimicrobial therapy and compliance must be encouraged. Analysis Health Promotion and Maintenance Nursing Process: Implementation Pharmacology 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. 0

484 MCSA While obtaining a review of systems the client informs you that he is "highly allergic" to many food items and medications. You conclude that which hypersensitivity reaction would be responsible for this type of clinical presentation? 1. Type 1, IgE mediated hypersensitivity 2. Type 2, cytotoxic hypersensitivity 3. Type 3, immune complex-mediated hypersensitivity 4. Type 4, delayed hypersensitivity

1 Type 1 hypersensitivity involves humorally mediated antigen-antibody reactions. Food allergies and medications can provide a localized as well as systemic response. Clients who have a history of multiple allergies usually have high IgE levels that are a characteristic measure of this type of reaction. The other hypersensitivity reactions do not apply to this characteristic presentation. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about hypersensitivity reactions. 0

369 MCSA <i>Helicobacter pylori</i> is able to survive in the acidic environment of the stomach because of the enzyme: 1. Urease. 2. Protease. 3. Lipase. 4. Alkaline phosphatase.

1 Urease breaks down urea in the stomach, producing ammonia that increases the pH to allow survival of <i>Helicobacter pylori</i>. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Gastrointestinal Select the option that would influence pH in the stomach. 0

460 MCSA A client with AIDS who is at high risk and having multiple opportunistic diseases would probably have a low CD4 count and which of the following? 1. High viral load (greater than 100,000) 2. Low viral load (less than 10,000) 3. Moderate viral load (10,000 to 100,000) 4. Zero viral load

1 When the viral load (number of circulating HIV particles per milliliter) is high and the CD4 count is low, the client is most at risk. This would explain why the opportunistic infections are 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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological Recognize the inverse relationships in each option. 0

285 MCMA The nurse in the pediatric unit walks into a 5-year-old child's room and notes the child is on the floor, unconscious and cyanotic. The lunch tray is near the bed, with half of the food consumed. What interventions would the nurse perform? Select all that apply. 1. Open mouth, using tongue/jaw lift, to visualize any foreign object. 2. Perform a blind finger sweep. 3. Open the airway, and attempt rescue breathing. 4. Palpate for a brachial pulse, and begin compressions if not present. 5. Call for an external defibrillator.

1, 3 Since the child was eating, you must determine if foreign body airway occlusion (FBAO) has occurred. This can be accomplished by the tongue/jaw lift and visualization of the mouth. Opening the airway and attempting rescue breathing would aid in identifying if FBAO is present. Blind finger sweeps are not done. The nurse would not check a brachial pulse on a 5-year-old, and an external defibrillator is not the core issue when there is FBAO. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Fundamentals 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. 0

192 MCMA A client with osteoporosis who has experienced fractures in the past is now admitted for dizziness and shortness of breath and has been determined to be at risk for falls. Which nursing intervention to assist this client can the nurse delegate to the unlicensed assistive person (UAP)? Select all that apply. 1. Clear the room of unnecessary objects. 2. Inquire if the dizziness has led to any recent falls. 3. Remain with the client during ambulation. 4. Ask physical therapy to evaluate the client for a walker. 5. Advise the client about the benefits of calcium in the diet.

1, 3 The nurse can delegate procedures to the UAP and retains responsibility for the outcomes of those tasks that are delegated. Clearing the room of unnecessary objects and remaining with the client during ambulation are among those that can be delegated. The nurse needs to retain responsibility for assessment (option 2), teaching (option 5), and collaborating with the interdisciplinary team (option 4). Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Adult Health: Musculoskeletal Use the principles of delegation to answer the question. Eliminate those options that represent assessment, teaching, or interdisciplinary communication or collaboration. 0

198 MCMA An adult client arrives to the Emergency Department with complaints of chest pain and shortness of breath. The nurse concludes that which of the following points, if present in the client's history, would indicate that this pain may be related to cardiac disease? Select all that apply. 1. History of diabetes and smoking 2. Recent travel out of the country 3. The pain increases with activity 4. The pain is reproducible when taking a deep breath 5. The client is experiencing sweating and nausea when the pain is severe

1, 3, 5 Knowledge of the cardiovascular disease risk factors and associated symptoms can assist in determining the origin of chest pain and direct the nurse to prioritize and implement appropriate care. Diabetes, smoking, and hypertension are known modifiable and non-modifiable risk factors to cardiac disease. Chest pain that occurs during activity may indicate cardiac ischemia due to the increased oxygen demand. Associated symptoms of nausea and 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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Cardiovascular 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 <i>recent</i>, 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. 0

420 MCMA An infant is being discharged from the infant and children's unit with a positive TORCH titer. Parents should be informed that: (Select all that apply.) 1. The child may shed the virus for a year. 2. TORCH is a genetic disorder. 3. Pregnant women should avoid contact with the baby. 4. Since the infant is asymptomatic at birth, there will be no residual effect. 5. The earlier in pregnancy that TORCH occurred, the greater the risk to the embryo.

1, 3, 5 TORCH is the acronym for a set of microbes that includes toxoplasmosis; other (including syphilis and hepatitis); rubella; cytomegalovirus; and herpes simplex. If an infant has one of the 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. Analysis Safe Effective Care Environment: Safety and Infection Control Teaching and Learning Child Health Recall what the acronym TORCH stands for in order to answer the question correctly. 0

177 MCMA A client who is legally blind has been admitted to the nursing unit. Which of the following activities should the nurse delegate to the unlicensed assistive person (UAP)? Select all that apply. 1. Assist the client with meals. 2. Complete the admission interview form. 3. Assess the impact of the lost vision on the client's daily life. 4. Assist the client to ambulate in the hall. 5. Ask the client what community services are being utilized.

1, 4 The UAP can perform procedures and nursing care activities. Client care that requires assessment (options 2, 3, and 5) are not within the scope of the functions of the UAP. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Adult Health: Eye and Ear Recall that UAPs are trained and educated to perform simple care procedures. Use this framework to eliminate each of the incorrect options systematically. 0

281 MCMA While performing CPR using a bag-valve mask on an adult client, the nurse observes that the chest is not rising and falling with ventilations. What interventions could be used to improve ventilations? Select all that apply. 1. Reposition airway, and try again to ventilate. 2. Increase the rate of ventilations. 3. Increase the oxygen flow into the bag. 4. Forcefully collapse the bag to ventilate. 5. Ensure the mask covers the nose and mouth with a good seal.

1, 5 Proper positioning of the airway is essential for rescue breathing, and might not be established with the first attempt. BLS guidelines recommend a second attempt to open the airway. A good seal over the mouth and nose is necessary to ensure ventilations are being delivered to the client. These two interventions must be established before any other steps are taken to ventilate the client. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Fundamentals 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. 0

309 MCMA A child is being treated at home for chickenpox. The home-health nurse is visiting and notes an elevated temperature. To prevent a common complication of an elevated temperature, the nurse recommends which of the following? Select all that apply. 1. Antipyretics such as acetaminophen and ibuprofen 2. Aspirin as needed for fever control 3. Keep child well covered to prevent chilling 4. Antibiotics as ordered Remove unnecessary clothing

1, 5 Tepid baths allow heat to be removed from the body. Aspirins are avoided because of the risk of Reye Syndrome. The child should have only light clothing to allow heat to escape. Antibiotics are not usually ordered for this viral infection. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Child Health Knowledge of the nursing management of a child with fever will help to choose the correct answer. 0

163 MCSA A client recovering from Guillain-Barré syndrome is admitted to the rehabilitation unit for general rehabilitative care. The nurse anticipates that which of the following methods will most likely be used to provide nutritional support for the client during this time? 1. Using a gastrostomy tube for feedings due to high incidence of malabsorption 2. Maintaining oral intake with adequate calories to maintain positive nitrogen balance 3. Limiting fresh fruit in the diet 4. Using thickened liquids to prevent aspiration

2 A client who is recovering from Guillain-Barré syndrome will need a diet that promotes positive nitrogen balance in order to counteract the effects of long periods of immobility on the body. Option 1 is incorrect—there is no evidence to support that the client is experiencing malabsorption at this time. Option 3 is incorrect because there is no clinical reason to limit fresh fruit. Even though the client may experience difficulty in chewing and swallowing, this is 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). Application Physiological Integrity: Basic Care and Comfort Nursing Process: Planning Foundational Sciences: Nutrition The key words in the stem of the question are <i>general rehabilitative care</i>. 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. 0

167 MCSA The nurse has delegated to an unlicensed assistive person (UAP) the care of a client who had a right hemisphere thrombotic stroke with hemiplegia. The nurse would give further direction to the UAP after noting that the UAP did which of the following? 1. Provided passive range of motion exercises to the affected arm and leg 2. Placed a chair for a visitor to the left of the bed 3. Placed the overbed table to the right side of the bed 4. Sat the client up slowly

2 A client with right hemisphere stroke has left-sided paralysis or paresis and may have unilateral neglect. The UAP should keep all items on the right side so that the client is aware they exist in the environment. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Evaluation Adult Health: Neurological 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. 0

129 MCSA A female client has been successfully resuscitated after cardiac arrest. Her arterial blood gas reveals a pH of 7.6. The nurse attributes this result to which of the following? 1. Anaerobic metabolism, which caused lactic acid production 2. Excess sodium bicarbonate, which was administered during the resuscitation 3. Repeat blood gases, which are performed during a code, frequently show acidosis 4. Normal blood gas results

2 A pH of 7.6 indicates an alkalotic state. The administration of bicarbonate would be the best answer. Anaerobic metabolism and the production of lactic acid lead to an acidotic state, explaining why blood gases drawn during a code usually show acidosis. This pH is not within normal limits. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Evaluation Adult Health: Respiratory 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. 0

331 MCSA Which of the following refers to the ability of bacteria to produce pathologic changes or disease in the host? 1. Virulence 2. Pathogenicity 3. Toxogenicity 4. Latency

2 A pathogen is any organism capable of causing disease. Pathogenicity refers to the ability of the organism to cause pathologic changes. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological Note the use of the word "pathologic" in the question. This will lead to selection of the correct response. 0

108 MCSA During which of the following procedures should the labor and delivery nurse wear protective goggles in addition to gloves? 1. Changing a soaked disposable bed pad 2. Assisting during an amniotomy 3. Starting an intravenous line 4. Washing dirty instruments

2 According to standard precautions, the caregiver should wear goggles when contamination from splashing is possible, as when the membranes are artificially ruptured (amniotomy). The other options place the nurse at risk for contamination from skin contact, necessitating the use of gloves. Analysis Safe Effective Care Environment: Safety and Infection Control Nursing Process: Planning Maternal-Newborn 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.

215 MCSA Which of the following instructions would be appropriate for the nurse to include in the discharge teaching of an adolescent following a spinal fusion? 1. No contact sports will be allowed again. 2. The adolescent should not bend at the waist. 3. Walking is limited to only one half mile per day. 4. The adolescent should not climb stairs.

2 Activity restrictions should be followed for 6 to 8 months following a spinal fusion. Lying, standing, sitting, walking, normal stair climbing, and gentle swimming are generally allowed 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. Application Physiological Integrity: Physiological Adaptation Teaching and Learning Child Health 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. 0

485 MCSA A client who receives a positive antinuclear antibody (ANA) test result with a titer level > 1:40 does not understand what the test result means and asks the nurse for an explanation. Which of the following responses to the client would be most appropriate in this situation? 1. "The test result is normal." 2. "The test indicates that you may have an autoimmune disorder, and this result should be discussed in more detail with your physician." 3. "You should have the test repeated to verify its specificity for autoimmune disorders." 4. "Your test result is specific for the detection of systemic lupus, and this should be discussed further with your physician."

2 Antinuclear antibodies indicate the presence of an autoimmune disorder. They are not considered specific for systemic lupus, because many other autoimmune disorders have significant numbers of these antibodies. This reported titer is suggestive of the presence of ANA antibodies, and therefore it is an abnormal response. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about ANA testing. 0

476 MCSA After being bitten by an unknown insect, a client allergic to wasp stings is brought to a clinic by a coworker. Upon arrival, the client is anxious and having difficulty breathing. The first action by the nurse is to: 1. Administer oxygen. 2. Maintain the client's airway. 3. Remove the stinger from the site. 4. Place the client in a recumbent position with legs elevated.

2 Airway is always first (ABCs) when determining priority in an emergency situation such as this. All of the other options are accurate and should be implemented, but with the symptom of difficulty breathing, laryngeal edema is a priority concern. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Adult Health: Immunological Remember the ABCs (airway, breathing, and circulation). Airway is a key priority. 0

180 MCSA Which of the following behaviors would the nurse conclude is expected in a client who suffers from localized amnesia? 1. Wandering about in his neighborhood using a new name. 2. Forgetting about what happened during an assault. 3. Awareness of only a few of many alters. 4. Feelings of separation from his body.

2 All of the options are dissociative responses. However, only localized amnesia is the inability to recall events in a circumscribed time period. Analysis Psychosocial Integrity Nursing Process: Assessment Mental Health Focus on the critical words <i>expected</i> and <i>localized amnesia</i>. These words indicate that the correct option is one that is consistent with what is assessed in this state. Focus on the word <i>localized</i> in the question and the time-bound nature of option 2 to choose correctly. 0

154 MCSA The nurse is leading a support group for adult children of aging parents who have come to live in their home because of deteriorating health. Which of the following principles does the nurse encourage the group members to follow to promote quality of life for all concerned? 1. Do as much as possible for aging parents to prevent problems from occurring. 2. Allow independence in those things that are safe or with minimal risk of harm. 3. Let the parents do whatever they want as a means to maintain their self-esteem. 4. Take over responsibility for making important decisions to avoid major financial losses.

2 Allowing independence as long as possible gives dignity and self-worth to clients. Option 1 is not helpful because it does not foster independence within the scope of remaining abilities. Option 3 could result in harm to the parents. Option 4 could be degrading and does not foster maintaining independence within limits of current ability. Application Health Promotion and Maintenance Teaching and Learning Fundamentals 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. 0

144 MCSA The nurse notes on the antepartal history that the client has an android pelvis. The nurse plans to assess this client carefully because of the increased risk of which of the following? 1. Occiput posterior position 2. Prolonged labor 3. Precipitous delivery 4. Developing postpartum complications

2 An android pelvic structure is narrow in both the anterior-posterior diameter and the lateral diameter, and can cause a prolonged labor with a large fetus or a malpositioned fetus. Application Health Promotion and Maintenance Nursing Process: Analysis Maternal-Newborn First determine the significance of the critical word <i>android</i> 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 <i>andr-</i> refers to males and from there determine that it indicates a narrower pelvis. 0

329 MCSA A client presents in the emergency department with fever of 102 degrees F, malaise, and a productive cough. Which of the following should be done first? 1. Administer the prescribed antibiotic 2. Obtain a sputum culture 3. Administer acetaminophen to lower fever 4. Teach client the importance of handwashing

2 Antibiotics may affect the outcome of the culture. Fever will continue to be present until the bacteria are eliminated, making obtaining a culture a priority. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Fundamentals This item requires priority setting. All of the options may be pertinent, but identification of the first step is important. 0

110 MCSA When evaluating the effectiveness of nursing care plans used for an anxious client, it is important to validate that the client understands that: 1. Defense mechanisms should not be used. 2. Some anxiety can be helpful. 3. He should strive to never experience anxiety. 4. He should try to avoid the fight or flight response.

2 Anxiety can be a healthy protective response to an actual threat. Defense mechanisms are unconscious psychological responses designed to diminish or delay anxiety. Anxiety, at times, cannot be avoided and is a healthy adaptive reaction when it alerts the person to impending threats. Analysis Psychosocial Integrity Nursing Process: Evaluation Mental Health 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. 0

111 MCSA In assessing a hospitalized client 1 hour after receiving hydralazine (Apresoline) 20 mg PO, the nurse notes that the BP is 68/42. The client has been taking this medication for several years at home without difficulty. Which of the following factors most likely contributed to this episode of hypotension? 1. Dose is excessive for this medication. 2. Total intake for the previous 24 hours is 1,000 mL. 3. Serum potassium is 5.8 mEq/L. 4. Heart rate is 145 beats per minute.

2 Apresoline is a vasodilator and if the client becomes dehydrated, hypotension will result. In other words, during dehydration both preload and afterload are reduced, causing the <i>tank</i> to get larger with less volume. The normal dose of hydralazine is 5 to 25 mg PO. Serum potassium is high but unrelated to apresoline. The increased heart rate is a reflexive response to the low cardiac output to compensate with decreased preload and afterload. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Assessment Pharmacology 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. 0

284 MCSA The nurse is performing basic life support on an infant who is under 1 year of age. The nurse thought the brachial pulse was present, but is unsure. What action would the nurse take next? 1. Count the pulse you feel for one minute to verify. 2. Begin chest compressions. 3. Palpate the apical impulse. 4. Palpate the carotid pulse.

2 BLS guidelines indicate that when not confident that signs of circulation are present, if you feel no pulse, or if you feel a pulse rate less than 60/minute with poor signs of perfusion, you begin chest compressions. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Fundamentals 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. 0

223 MCSA When assessing the genitourinary system of a 75-year-old male client, the nurse questions the client about symptoms of which of the following conditions that is common in older men? 1. Testicular cancer 2. Benign prostatic hyperplasia 3. Testicular torsion 4. Gonorrhea

2 Benign prostatic hyperplasia (BPH) is the most common disorder of the aging male client. Testicular cancer is the most common cancer in men between the ages of 15 and 35. Testicular torsion occurs at any age and gonorrhea is highest in occurrence during the sexually active years. Women 15 to 19 years old and men 20 to 24 years old have the highest rate. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Renal and Genitourinary The critical words in the stem of the question are <i>older men</i>. Recall that the prostate gland undergoes changes in later life to help select the correct option. 0

372 MCSA A woman with recurring gonorrhea or chlamydia should be concerned about which of the following? 1. Urethritis 2. Pelvic inflammatory disease 3. Pyelonephritis 4. Arthritis

2 Both gonorrhea and chlamydia may be asymptomatic, with the bacteria invading reproductive organs prior to detection. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Reproductive Consider that both of these are STDs and affect the organs of reproduction. 0

387 MCSA The nurse looks for results of which laboratory measurement that provides a reliable indicator of lymphocyte status in a client with HIV infection? 1. B lymphocytes 2. T-helper cells (CD₄) 3. Natural killer cells (NK) 4. T-cytotoxic cells

2 CD₄ cells are indicative of a client's HIV status. As the disease progresses, the T-helper cells decrease in number and lose their ability to function effectively, 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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological 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. 1

235 MCSA The nurse is teaching a client and family about health maintenance with chronic obstructive pulmonary disease (COPD). The nurse explains to the family that nutrition is important in managing this condition using which rationale? 1. COPD clients have an adequate immune response. 2. COPD clients are at increased risk of suffering from malnutrition. 3. COPD clients are likely to experience weight gain due to fluid retention. 4. Decreased energy requirements lead to weight gain.

2 COPD places a client at risk to develop malnutrition due to reduction in muscle mass and fat reserves. Option 1 is incorrect because COPD clients are more likely to suffer from respiratory infections due to altered immune response (decreased cell-mediated immunity, altered immunoglobulin production, and impaired cellular resistance). Options 3 and 4 are incorrect 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). Application Physiological Integrity: Basic Care and Comfort Teaching and Learning Foundational Sciences: Nutrition 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. 0

186 MCSA 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? 1. Oranges 2. Grapefruit 3. Bananas 4. Grapes

2 Calcium channel blockers should be administered with a high-fat meal; grapefruit should be avoided before and after dosing due to its ability to alter drug effects. The foods listed in the other options will not have a dose-altering effect. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology 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. 0

428 MCSA A child with severe combined immunodeficiency disorder (SCID) is being discharged from the hospital to home. Client teaching is important to reach client goals. The nursing care goal for the client before and after discharge would be that the child: 1. Remains well oxygenated. 2. Remains free of infection. 3. Maintains hydration. 4. Avoids contact with other people.

2 Care of the immunocompromised child focuses on preventing infection. The nursing implementations related to reaching this goal might include limiting contact with a large number of people, but that would not be the goal of the nursing care plan. Analysis Health Promotion and Maintenance Nursing Process: Planning Child Health Recognize that a child with an immunodeficiency will not be able to fight infections, so prevention is important. 0

130 MCSA The nurse would anticipate finding which of the following client characteristics when working with a client who has a pain disorder? 1. A preference to handle pain without medication 2. A lack of understanding of the relationship between pain and stress 3. Adequate role performance 4. Structural damage at the site of pain

2 Characteristics of a client with pain disorder include believing there is a physical cause for distress when there is no organic basis, the need to use analgesics or drugs to reduce pain, and impaired role performance. Analysis Psychosocial Integrity Nursing Process: Assessment Mental Health The critical words in the stem of the question are <i>anticipate</i> and <i>pain disorder</i>. 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. 0

352 MCSA The drugs of choice for treating chlamydia include: 1. Antifungal agents. 2. Macrolides such as erythromycin (E-Mycin). 3. Interferon (Roferon-A). 4. Vancomycin (Vancocin).

2 Chlamydia is a bacteria and responds to bacteriostatic agents that interfere with protein synthesis. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology 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. 0

381 MCSA A client diagnosed with scleroderma is complaining of painful fingers that change colors (pale to red) when washing dishes. Which suggestion by the nurse might help the client with this symptom? 1. Increase the water temperature. 2. Use gloves during dishwashing. 3. Start physical therapy to increase blood flow to the hands. 4. Take over-the-counter H₂ receptor antagonist medications.

2 Clients who have scleroderma usually have Raynaud's phenomenon. Raynaud's can be triggered by temperature changes, and prolonged water contact may cause activation. Use of gloves when washing dishes may prevent temperature changes yet still allow the client to participate in ADLs. Hotter water may increase the risk of scalding and so is not suggested. Physical therapy and H₂ receptor blockers are indicated for treatment of esophageal problems associated with scleroderma. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Immunological 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. 1

455 MCSA A common clinical manifestation of a transfusion reaction (type II hypersensitivity reaction) is: 1. Diarrhea. 2. Fever. 3. Hypertension. 4. Bradycardia.

2 Common manifestations are fever, chills, low back pain, hypotension, tachycardia, nausea, and vomiting. Urticaria and red-colored urine are often seen. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Assessment Adult Health: Immunological This question requires knowledge about hypersensitivity reactions. 0

478 MCSA Over-the-counter (OTC) pseudoephedrine tablets and nasal sprays are used by a client to control symptoms of seasonal rhinitis. In teaching the client about the use of OTC allergy medications, the nurse advises the client that: 1. Seasonal allergies should be treated only with prescription drugs. 2. Overmedication with decongestant nasal sprays may increase her nasal congestion and swelling. 3. Pseudoephedrine may cause drowsiness, and she should not drive or use machinery while taking it. 4. She should take the pseudoephedrine continuously to prevent allergy symptoms from developing.

2 Decongestant nasal sprays have a rebound effect, which causes congestion and swelling of the mucous membranes with long-term use. Although temporary relief may be obtained, continued chronic use of the sprays may be needed due to this engorgement of the vessels and increased congestion. This client may need to consult an allergist or physician. This question 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. Analysis Health Promotion and Maintenance Nursing Process: Implementation Adult Health: Immunological Use knowledge of allergy medications to answer this question. 0

334 MCSA A female prostitute enters the clinic for treatment of a sexually transmitted disease. Given that this disease is the most prevalent in the United States, the nurse can anticipate that the woman has which of the following? 1. Herpes 2. Chlamydia 3. Gonorrhea 4. Syphilis

2 Epidemiological studies indicate chlamydia as the most prevalent sexually transmitted disease in the United States. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological This question requires application of factual knowledge about the disease chlamydia. 0

311 MCSA The nurse is working in a clinic that provides free immunizations to clients with financial hardship. In the morning before seeing any of the day's clients, the nurse checks that which of the following supplies is available should a client experience an anaphylactic allergic reaction to a vaccine? 1. Albuterol (Proventil) 2. Epinephrine 3. Immunoglobulin 4. Toxoid

2 Epinephrine 1:1000 is the drug of choice for an acute anaphylaxis reaction. A child may have allergies yet unknown at the time of immunizations. Albuterol is a bronchodilator that opens the airway but epinephrine is the drug of choice during anaphylaxis. Toxoids and immunoglobulins are other classes of drugs that affect the immune system but they do not treat anaphylaxis. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Planning Child Health Knowledge of the emergency management of anaphylaxis will aid in choosing the correct answer. Learn to automatically pair anaphylaxis with epinephrine. 0

141 MCSA A client presents to the Emergency Department with inspiratory and expiratory wheezes and intercostal retractions. A diagnosis of acute bronchospasm secondary to acute bronchitis is made. Epinephrine (Bronkaid) is ordered to be given subcutaneously. The nurse would anticipate seeing the intended effect of the medication in: 1. 1 minute. 2. 5 minutes. 3. 10 minutes. 4. 15 minutes.

2 Epinephrine is a beta-adrenergic agent that has beta 1 adrenergic action, causing increased heart rate and increased force of myocardial contraction. The results of subcutaneous epinephrine should be seen in 5 minutes. The effects may last up to 4 hours. The other options are incorrect. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Planning Pharmacology 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. 0

356 MCSA The Epstein-Barr virus is most often associated with: 1. Hepatitis B. 2. Mononucleosis. 3. Streptococcal infections. 4. Tuberculosis.

2 Epstein-Barr virus is the causative agent for mononucleosis. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological The question is asking about a virus. Options 3 and 4 are bacterial and can be eliminated. 0

240 MCSA A client diagnosed with 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." The nurse concludes that the client is displaying: 1. Hallucinations. 2. Ideas of reference. 3. Delusions. 4. Loose association.

2 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. 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 1). Delusions are false beliefs 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). Application Psychosocial Integrity Nursing Process: Assessment Mental Health 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. 0

367 MCSA The mother of a 12-year-old who has been diagnosed with mycoplasma pneumonia wants to know what illness she has. The best explanation would be that: 1. It is more severe than pneumonia caused by other bacteria. 2. It is described as walking pneumonia. 3. It is characterized by copious sputum production. 4. It is more difficult to treat.

2 Mycoplasma pneumonia is an atypical form of pneumonia, occurs often in children, and is transmitted by droplets. Signs and symptoms are similar to bacterial pneumonia and the virulence is no worse. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological Recall that 'walking pneumonia' is the common term for mycoplasma pneumonia. 0

291 MCSA The nurse is monitoring clients in the dining room of a rehabilitation unit. An adult stroke client begins to cough after eating a piece of meat. What intervention would the nurse use to help this client? 1. Perform the Heimlich maneuver with the client in a sitting position. 2. Encourage the client to continue to cough to clear the airway. 3. Wait until the client becomes unconscious to perform the Heimlich maneuver. 4. Attempt a finger sweep to help remove the piece of meat.

2 Individuals with partial obstruction can still breathe and cough. They are to be encouraged to continue this. FBAO interventions are to be used only with severe or complete airway obstruction. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Fundamentals 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. 0

337 MCSA Nurses should understand the chain of infection because it refers to: 1. The linkages between various forms of microorganisms. 2. The sequence required for transmission of disease. 3. The clustering of bacteria in a specific pattern. 4. Increasing virulence patterns among species of microorganisms.

2 Infection occurs in a predictable sequence requiring virulence, movement from a reservoir, and entry into a susceptible host. Knowledge Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological Note that the question stem is asking about the 'chain of infection' which most closely relates to option 2, referring to transmission of disease. 0

220 MCSA The nurse is planning care for a client recently admitted with paranoid ideation. The nurse determines that it would be counterproductive to do which of the following when working with this client? 1. Ensure that a consistent program schedule be followed. 2. Confront and challenge inaccuracies in the client's ideation. 3. Orient the client to the unit and introduce him to the other staff. 4. Establish clearly defined expectations of the client.

2 It would be counterproductive to confront and challenge a client's paranoid ideation until trust has been developed. A consistent program schedule will cut down on the number of surprises for the client and help develop trust in the staff (option 1). Orienting the client to the 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). Analysis Psychosocial Integrity Nursing Process: Analysis Mental Health The core issue of the question is knowledge of therapeutic communication techniques with a client who is paranoid. Note the word <i>counterproductive</i> in the stem and the word <i>challenge</i> in the correct option. It will help you to choose correctly if you can make an association between these words. 0

464 MCSA Which of the following is responsible for direct antigen attack and destruction? 1. Helper T cells 2. Killer T cells 3. Suppressor B cells 4. Memory B cells

2 Killer T cells bind with cell surface antigen or virus-infected or foreign cells. Killer T cells destroy the antigen by combining with it and then either destroying its cell membrane or releasing cytotoxic substances into the cell. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about direct antigen attacks. 0

404 MCSA A mother brings her child to the clinic complaining of malaise and low-grade temperature. In reviewing the 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: 1. Mumps. 2. Measles (Rubeola). 3. Chickenpox. 4. Rubella.

2 Koplik's spots are associated with measles (rubeola) and appear on the buccal mucosa two days before and after the onset of the rash. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Child Health Knowledge of the presenting signs and symptoms and clinical manifestations of measles will aid in choosing the correct answer. 0

349 MCSA One structural difference in the cell wall of fungi that makes them susceptible to antifungal agents is that: 1. Spore formation weakens the cell wall. 2. The cell wall is composed of ergosterol rather than cholesterol. 3. All fungi are composed of single cells. 4. Most fungi do not have a cell wall.

2 Most antifungal agents act by inhibiting biosynthesis of ergosterol. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological Select the only response that speaks to the composition of the cell wall. 0

496 MCSA A client who is HIV-positive and is taking antiretroviral medications asks why he was told that a change in medication might be expected during the course of treatment. The best explanation to give the client is: 1. "Antiretroviral medication regimens must be changed to prevent expected toxicity to major organs." 2. "Antiretroviral resistance is a major challenge to long-term management of HIV infection, and drug therapy may change based on research results." 3. "Monotherapy is recommended for the treatment of HIV and must be adjusted." 4. "Your treatment regimen will remain in place and is unlikely to change."

2 One of the most critical problems with regard to antiretroviral therapy is the emergence of antiretroviral resistance as the HIV virus continues to mutate. Combination therapies have been proven to be more effective in treating disease progression. Antiretroviral therapies, in proper dosage, do not cause specific organ toxicity although they can cause myelosuppression. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Immunological This question requires knowledge about HIV and antiretroviral medications. 0

324 MCSA The nurse is providing care to a toddler who has ingested an unknown amount of his grandfather's medication which is described as "a white pill." The physician has ordered the gastric lavage and administration of activated charcoal. What action should the nurse take? 1. Question the order because gastric lavage and activated charcoal are not to be used together. 2. Perform the gastric lavage and then administer the activated charcoal. 3. Administer the activated charcoal, then perform gastric lavage. 4. Perform gastric lavage, leaving the saline solution in the stomach, and then administer the activated charcoal.

2 Option 1 is incorrect as gastric lavage would be performed before the administration of activated charcoal. The activated charcoal will aid in the absoption and removal of any medication left after gastric lavage is completed. The term lavage indicates wash the stomach, removing the saline after administration. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Implementation Child Health Consider the purpose of the lavage and activated charcoal to deternine the correct order of administration. 0

494 MCSA Which of the following nursing diagnoses has the highest priority for a client who has rheumatoid arthritis? 1. Fatigue 2. Pain 3. Ineffective role performance 4. Disturbed body image

2 Pain and pain control are the most important elements of care for a client who has rheumatoid arthritis. Interventions aimed at pain management will allow the client to function at a more optimal level. While the other diagnoses are important, pain management remains the critical factor. Analysis Physiological Integrity: Basic Care and Comfort Nursing Process: Analysis Adult Health: Immunological Recall that pain management is a high priority. 0

303 MCSA A college student was hospitalized following onset of a severe case of pertussis. In preparing for discharge, the nurse would correct which client statement that indicates a misconception about postdischarge care? 1. "Irritants that I breathe, such as smoke or dust, could make me have coughing spells again." 2. "I will try to avoid being around people for a full week after going home so I don't spread this to others." 3. "I will be very careful to wash my hands often." 4. "It will still be important to try to drink a lot of fluids when I go home."

2 Pertussis is most infectious early in the course of the disease, so it is not necessary for the client to self-isolate following discharge from the hospital. Coughing bouts may still be triggered by irritants, so these should be avoided. Frequent handwashing and increased fluid intake are generally helpful measures that should also be continued in the home setting. Analysis Physiological Integrity: Physiological Adaptation Teaching and Learning Adult Health: Communicable Disease 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. 0

487 MCSA Hydroxychloroquine (Plaquenil) is prescribed for a client for the treatment of rheumatoid arthritis. The nurse would include which one of the following measures as part of client teaching with regard to this medication? 1. Take this medication on an empty stomach to minimize gastric irritation. 2. Have an initial baseline eye exam performed and adhere to follow-up exam schedule to monitor for potential ocular changes. 3. Monitor weight and vital signs as the medication can cause fluid retention and pulse elevations. 4. Be aware that medication can cause drowsiness and do not take it if planning to drive

2 Plaquenil is an antimalarial agent used in the treatment of rheumatoid arthritis. This medication can cause retinal toxicity, and therefore the client should be closely monitored for this possibility with specified visual exams. Gastric irritation, fluid retention, pulse elevations, and drowsiness are not routinely seen with this type of medication. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Immunological This question requires knowledge about medication side effects. 0

345 MCSA Which of the following is correct concerning prion disease? 1. Prions are opportunistic organisms frequently seen in clients with HIV. 2. Prions have been linked to chronic degenerative disorders of the central nervous system such as Creutzfeldt-Jakob disease. 3. Lesions are usually distributed throughout the body. 4. Prions are similar to viruses in their nucleic acid structure.

2 Prions are associated with degenerative encephalopathies. While similar to viruses, they lack nucleic acid and lesions are usually limited to a single organ. Knowledge Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This item is a knowledge question, requiring that the student recall a fact. 0

391 MCSA Which of the following assessments by the nurse warrants further investigation to determine if the client has rheumatoid arthritis (RA)? 1. Negative family history 2. Complaints of prolonged morning stiffness lasting for 1 hour 3. Occasional use of NSAIDs for aches and pains 4. Complaints of pain with movement

2 Prolonged morning stiffness is associated with RA. Occasional use of NSAIDs is not by itself a direct link to the development of RA. Complaints of pain with movement are more likely to be associated with degenerative joint disease (osteoarthritis). Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological 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. 0

491 MCSA Regardless of the type of isolation precautions that a client has been assigned, which of the following actions by the nurse should be given the highest priority in terms of infection control? 1. Using strict aseptic technique 2. Washing of hands before and after giving client care 3. Checking sterile supplies for expiration date 4. Changing intravenous tubing according to hospital policy

2 Regardless of isolation precautions, the basic action by the nurse to prevent infection is hand washing. All of the other options should also be followed but hand washing establishes the first line of defense and is therefore of highest importance. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Analysis Adult Health: Immunological Recall that hand washing is generally a high priority. 0

447 MCSA A client with A-negative blood can receive which type of blood transfusion in order to avoid any allergic reaction? 1. A+ 2. A- 3. O+ 4. AB+

2 Remember the Rh must also match besides the type of blood (A in this case). Rh matching is not just for mothers and infants to prevent erythroblastosis fetalis. Analysis Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Adult Health: Immunological Use the process of elimination to determine the correct answer. 0

383 MCSA A client is to start taking prednisone for the treatment of rheumatoid arthritis (RA). Which client statement indicates that medication teaching was successful? 1. "I will take the medication on an empty stomach to maximize absorption." 2. "I will take the specific dose ordered at the same time every day." 3. "I will not have to limit my sodium intake." 4. "I will not have to adjust my insulin regimen."

2 Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important to take this medication at the same time each day and to become aware of tapered-dose effect. Steroids are usually taken with foods to minimize GI upset. Steroids cause fluid retention, and therefore sodium intake may be restricted. Steroids also increase blood glucose, so insulin therapy dosages may have to be adjusted. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Evaluation Adult Health: Immunological 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. 0

457 MCSA A positive tuberculosis (TB) skin test would be manifested in which of the following? 1. Red area 3-cm wide within 24 hours 2. Red, raised area at least 5 mm, 72 hours later 3. Redness and urticaria, 72 hours later 4. Raised area, 24 hours later

2 TB skin tests are read 72 hours after administration and a true positive reading should show 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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological This question requires knowledge about TB skin test. 0

436 MCSA A sexually active teenager with flu-like symptoms is given an ELISA test that returns negative. The physician informs her that another ELISA test will be conducted in several weeks. The client wants to know why. The best explanation is that: 1. The first test may be inaccurate. 2. The antibodies do not always show up initially. 3. The test is sensitive and can give false positives. 4. It is standard practice.

2 The ELISA test may be negative upon initial testing and positive at the time of seroconversion, which takes 6 to 12 weeks after infection. This time period when the antibodies are negative is called the seroconversion window and virally infected individuals may have negative antibody tests. Analysis Safe Effective Care Environment: Safety and Infection Control Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about the ELISA tests. 0

375 MCSA A client has recently experienced fever, chills, headache, and myalgia from influenza. The symptoms have diminished; however, fatigue is still present. This is an example of what stage of the infectious process? 1. Resolution 2. Convalescent 3. Acute 4. Prodromal

2 The convalescent stage occurs when the infection is contained and symptoms are diminished. The acute stage is when all symptoms are present; prodromal is the presence of initial symptoms; resolution is elimination of an organism. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological Use the definition of the term 'convalescent' (getting better) to identify it as the correct response. 0

421 MCSA An infant with acquired immunodeficiency syndrome (AIDS) will be attending daycare. The daycare workers are concerned about spreading the human immunodeficiency virus (HIV). The public health nurse is explaining to the workers the precautions they should take. The nurse would include in this discussion which of the following precautions that need to be taken? 1. Storing all of this infant's supplies separately from those of the other children 2. Wearing gloves when changing the child's diapers 3. Always wearing gloves and isolation gowns when handling the infant 4. Minimizing contact with the infant when it is febrile

2 The HIV virus is spread by contact with blood and body fluids. Clean gloves should be worn when changing the diapers as bare hands would expose the workers to body fluids. It is not necessary to store the infant's items separately from those of others, since the virus is not transmitted on objects. It is also not necessary, and in fact is excessive, to wear isolation gowns, and it is unnecessary to minimize contact when the infant has a fever. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Child Health 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. 0

294 MCSA A 9-year-old child is at the 98th percentile for weight and at the 40th percentile for height. The school nurse determines that this child is: 1. Underweight or small in stature. 2. Overweight or large in stature. 3. Experiencing a prepubescent growth spurt. 4. Normal for size.

2 The NCHS growth charts use the 5th and 95th percentiles as criteria for determining those children who fall outside the normal limits for growth. Children whose height and weight are 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. Analysis Health Promotion and Maintenance Nursing Process: Analysis Child Health 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. 0

450 MCSA The pathophysiology behind the destructive power of AIDS is that HIV kills the: 1. B cells that produce antibodies. 2. T-helper cells. 3. White blood cells. 4. Platelets.

2 The T-helper cells are the primary target for the parasite to infect in order to replicate. The virus destroys the T-cells and along with this destruction, memory cells can also be destroyed, hence opportunistic infections are more prevalent. Knowledge Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about blood borne transmissions. 0

359 MCSA Which of the following is true of botulism? 1. It is caused by a staphylococcus bacteria. 2. Neurotoxins produced by the bacteria cause paralysis. 3. It is a resident bacterium in the intestinal flora. 4. It produces a toxin that leads to necrosis of epithelial cells.

2 The bacteria produces a neurotoxin that blocks release of acetylcholine at the neuromuscular junction. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological The key term in the correct response is 'neurotoxin.' The neurotoxin produces the characteristic symptom of stiff jaw. 0

158 MCSA While making rounds, the nurse observes a client receiving oxygen by this mode. The nurse concludes the client is using this mode of oxygen therapy because of which primary benefit? COMP_TEST_AAHBDMR0.jpg 1. The ability to prevent rebreathing of exhaled carbon dioxide. 2. Oxygen concentration can be regulated. 3. Constant humidity can be administered to liquefy pulmonary secretions. 4. The ability to deliver up to 100% oxygen concentration for clients with COPD.

2 The client in the photograph is receiving oxygen through a Venturi mask. Oxygen administered by a Venturi mask can be regulated to deliver between 24% and 50%, which is a benefit for clients who require higher oxygen supplement without mechanical ventilation. The 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. Application Physiological Integrity: Basic Care and Comfort Nursing Process: Analysis Adult Health: Respiratory 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. 0

259 MCSA The nurse is preparing to administer a purified protein derivative (PPD) tuberculin skin test to a client. Before administration, the nurse should take which of the following actions? 1. Cleanse the area thoroughly with soap and water. 2. Ensure that the client has not had a positive test result in the past. 3. Determine whether the client can return to the office in 24 hours for the test to be read. 4. Instruct the client not to wash the area for 48 hours.

2 The client who has had a positive PPD test in the past should be evaluated with a chest x-ray, which is the screening test of choice in this case. The arm should be cleansed with alcohol and allowed to air dry prior to the administration of the test. The test is usually read in 48 to 72 hours and the client may wash the area as usual. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Assessment Adult Health: Integumentary 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. 0

115 MCSA The nurse is caring for the client who is recovering from partial thickness burns. Which of the following breakfast options indicates client understanding of the recommended diet? 1. Two slices of toast with butter, orange juice, skim milk 2. Two poached eggs, hash brown potatoes, whole milk 3. Three pancakes with syrup, two slices of bacon, apple juice 4. One cup of oatmeal with skim milk, 1/2 grapefruit, coffee

2 The eggs provide 24 grams of protein and the whole milk adds calories. The other options are lower in protein and calories. A client recovering from burns requires a high-protein, high-calorie diet. Option 1 does not reflect an adequate protein source. Option 3 reflects an 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. Analysis Physiological Integrity: Basic Care and Comfort Nursing Process: Evaluation Foundational Sciences: Nutrition 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. 0

361 MCSA Which of the following is true of Helicobacter pylori bacteria? 1. It protects the stomach from harmful acids. 2. It causes erosion of gastric mucosa. 3. It is an acid-fast bacillus. 4. It is transmitted through contaminated water.

2 The enzyme urease produced by the bacteria raises the pH of the stomach, allowing the bacteria to survive. Urea in the stomach is converted to ammonia, which is cytotoxic to gastric mucosa. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Gastrointestinal Note the term 'erosion of gastric mucosa' in option 2. Recall that H. Pylori is often associated with ulcers of the GI tract. 0

330 MCSA The drug of choice to treat a "walking" or mycoplasmal pneumonia is: 1. Mebendazole (Vermox). 2. Erythromycin (E-mycin). 3. Chloroquine (Aralen hydrochloride). 4. Chloramphenicol (Chloromycetin).

2 The erythromycin products are the best for treating mycoplasmal pneumonia or walking pneumonia. Vermox is used for helminthic infections; Aralen hydrochloride is used for protozoal infections; and Chloromycetin is used for spirochetal infections. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology Select the option that identifies a drug commonly used for pneumonias. 0

402 MCSA A 12-year-old boy is hospitalized and diagnosed with the recent development of human immunodeficiency virus (HIV) infection secondary to factor transfusions for hemophilia. The family is very concerned about 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? 1. Explain to the family that the infection cannot be spread by casual contact. 2. Demonstrate positive acceptance of the child with each contact. 3. Explain that prophylactic drugs will prevent the virus from spreading. 4. Show the family how to wash their hands properly.

2 The family has stated multiple concerns, and demonstrating acceptance of the child is the best way to foster acceptance of the child and development of further coping skills. Prevention of transmission, handwashing, and drug therapy are all important, but none of these individually targets the global concerns of the family. Analysis Psychosocial Integrity Nursing Process: Implementation Child Health 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. 0

319 MCSA A 12-year-old boy is hospitalized and diagnosed with the recent development of human immunodeficiency virus (HIV) infection secondary to factor transfusions for hemophilia. The family of the child is very 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: 1. Explain to the family that the infection cannot be spread by casual contact. 2. Demonstrate positive acceptance of the child with each contact. 3. Explain that prophylactic drugs will prevent the virus from spreading. 4. Show the family how to wash their hands properly.

2 The family will need to know how to protect themselves from the virus. Handwashing is the first line of protection. However, family coping skills will best be enhanced by the nurse demonstrating acceptance of the child. This along with child and family education will help the family deal with this disease. Analysis Psychosocial Integrity Communication and Documentation Child Health Knowledge of the emotional support and care of the child with HIV will help to choose the correct answer. 0

279 MCSA The nurse is called to assist with the resuscitation of a 16-year-old who dove into the shallow end of a swimming pool. He is unconscious, and currently is lying on his back out of the water near the pool. What method would the nurse use to open the airway? 1. Head-tilt chin-lift 2. Jaw thrust 3. Tongue/jaw lift 4. Insert an airway from the emergency kit

2 The jaw thrust maneuver is used when there is suspicion of a neck injury. Diving into shallow water is a known cause of spinal cord injuries. Despite the unconsciousness of the client and the inability to assess for spinal injury, a neck injury is to be suspected in this client. In all other scenarios, the head-tilt chin-lift is appropriate to open the airway. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Fundamentals 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. 0

266 MCSA A client is brought to the emergency department awake and alert following a fall from a ladder from a height of 15 feet. While the nurse is conducting an initial assessment, the client becomes unresponsive and stops breathing. Which method should the nurse use to open the airway? 1. Head-tilt chin-lift 2. Jaw thrust 3. Tongue-jaw lift 4. None; client needs emergency intubation

2 The jaw thrust maneuver is used whenever head or cervical spine injury is suspected to avoid causing further physiological damage. The head-tilt-chin-lift method (option 1) is the standard method for opening the airway when there is no suspected cervical spine injury. The tongue-jaw lift (option 3) aids in visualizing foreign bodies in the airway. The client does not need emergency intubation (option 4). Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Cardiovascular 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. 0

445 MCSA The mother of a child with swollen lymph nodes is extremely panic-stricken that the swelling means cancer. The nurse could calm the mother by stating that: 1. "The finding is very alarming and could be serious, but you must remember it may be insignificant also." 2. "The lymph nodes are the organs that filter foreign products and may only be swollen because of an infection." 3. "The lymph nodes will swell quite often and we may not ever know it." 4. "The lymph nodes are the major organ indicating a problem with the immune system."

2 The mother is already alarmed enough, and the nurse needs to be careful with wording of the response. Option 2 is correct and is not alarming so that the mother may be able to focus on a different perspective besides cancer. Application Psychosocial Integrity Nursing Process: Implementation Adult Health: Immunological Use the process of elimination to discover the correct answer. 0

162 MCSA The nurse on a cardiac medical unit has an unlicensed assistive person (UAP) assigned to the nursing team. The nurse would delegate which of the following client care activities to the UAP? 1. Assist the client to choose low-fat and low-sodium food selections from the dietary menu. 2. Measure client's pulse, blood pressure, and oxygen saturation after ambulation. 3. Explain the need to alternate activity periods with rest. 4. Help the client use nitroglycerin left at the bedside if chest pain occurs.

2 The nurse should delegate the activity that is procedural in nature, which is within the scope of training of the UAP. The nurse does not delegate teaching (options 1 and 3) or interventions for chest pain (option 4). Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management Keep in mind the principles of delegation. Recall that the nurse does not delegate assessment, teaching, or medication administration to a UAP. 0

212 MCSA The nurse working on an adult medical-surgical unit would assign which of the following clients to the licensed practical/vocational nurse (LPN/LVN) under the supervision of the RN? 1. A 45-year-old client admitted yesterday after a nephrectomy 2. A 78-year-old client with diabetes mellitus and osteoarthritis 3. A 32-year-old client with a fractured pelvis from an auto accident 3 days ago 4. A 62-year old client who underwent pelvic exenteration receiving medication via patient-controlled analgesia

2 The nurse should delegate the care of the 78-year-old client with diabetes and osteoarthritis. This client has a stable medical status. The nurse would want to assess the client recently admitted following nephrectomy and the 32-year-old who fractured the pelvis. Since pelvic 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. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management 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. 0

265 MCSA A 58-year-old client reports to the nurse during a health history that the physician recently diagnosed a type of dementia. The nurse checks in the medical record for documentation related to which of the following most likely disorders? 1. Senile dementia 2. Presenile dementia 3. Pseudodementia 4. Vascular dementia

2 The onset of dementia symptoms for this client was at or before 58 years of age. When Alzheimer's disease occurs in people under the age of 65, it is called presenile dementia. Application Psychosocial Integrity Nursing Process: Assessment Mental Health 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. 0

175 MCSA The client has undergone hypophysectomy using a transphenoidal approach. You change the mustache dressing, noting clear exudate with a pale yellow colored ring at the edge of the drainage on the dressing. You should do which of the following next? 1. Document this as serous drainage and continue to monitor the client. 2. Assess for headache and check the glucose level in the drainage. 3. Apply an ice pack to the nasal bridge and a large, fluffy dressing. 4. Lower the head of the bed to decrease the gravity pressure on the wound.

2 The presence of a halo effect indicates cerebrospinal fluid (CSF). Glucose present in the nasal drainage also suggests that the drainage is CSF. A persistent headache indicates a CSF leak. The physician needs to be informed of these assessment findings and the client must be maintained on bedrest to stop the leak. A spinal tap may be done to decrease CSF pressure. 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. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Endocrine and Metabolic 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. 0

201 MCSA The nurse is administering nitrogen mustard (Mustargen) and notes swelling at the intravenous (IV) site. The nurse should take which of the following actions initially? 1. Continue with infusion after trying to aspirate for a blood return. 2. Stop administration and attempt to aspirate. 3. Flush the line with saline. 4. Obtain a new site for drug administration.

2 The question indicates that extravasation may be occurring. Prompt nursing action in general will minimize tissue damage; therefore nursing actions should be initially directed towards 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 may still be vesicant drug remaining in the tubing. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology 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. 0

278 MCSA A nurse who normally works on an adult medical unit has floated to the pediatric unit for the day. One of the 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: 1. Perform a finger sweep to check for choking. 2. Open the client's airway, and perform rescue breathing at approximately 20 breaths/minute. 3. Once you establish unresponsiveness, begin chest compressions. 4. Call for help after giving one rescue breath.

2 The rate of rescue breathing for a child is 20 breaths/minute, compared with 12 breaths/minute for an adult. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Fundamentals 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. 0

282 MCSA While recording interventions during a code for an 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? 1. 1 every 10 seconds 2. 1 every 5 seconds 3. 1 every 3 seconds 4. No change in frequency is warranted

2 The rate of rescue breathing for an adult client is 12/minute, or 1 every 5 seconds. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Fundamentals 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.

454 MCSA The parents of a child who is in surgery having a splenectomy ask the nurse how their child can live without a spleen. The nurse's best response is: 1. "Somehow the body in its miraculous form takes over." 2. "The liver and bone marrow assume its function." 3. "The spleen slowly begins to atrophy anyway and serves little purpose after adulthood." 4. "It is a vital organ, but most people do fine when it is removed."

2 The spleen is vital in storing blood and in the breakdown of red blood cells, but it is not essential for life. The liver and bone marrow assume its function when it is removed, and most clients do well even though it is removed. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about splenectomy. 0

452 MCSA A client with recent HIV seroconversion and early infectious disease asks the nurse what to expect in terms of disease progression. The nurse tells the client that although the disease can vary greatly among individuals, the usual pattern of progression includes: 1. About a 10-year period of vague and nonspecific symptoms before the onset of AIDS. 2. Eight to 12 years of chronic flu-like symptoms before the development of serious opportunistic infections or tumors. 3. A 10-year period of normal to slightly decreased T cell counts followed by about 2 years of symptoms before AIDS occurs. 4. An 8- to 10-year period of asymptomatic infection in which the virus is in remission before it becomes active and causes opportunistic diseases.

2 The stages of HIV are varied, but most clients begin with flu-like symptoms that occur days to weeks after contracting the virus. Following this is a long asymptomatic period; however the virus is still present. It is unclear why or when a client moves from being asymptomatic to AIDS. Application Psychosocial Integrity Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about HIV. 0

465 MCSA A nurse accidentally gets stuck with a needle from a known hepatitis B client. The protocol would be for her to receive a hepatitis B immune globulin to offer: 1. Artificial active immunity. 2. Natural acquired immunity. 3. Artificial passive immunity. 4. Natural passive immunity.

3 After exposure to a known antigen such as hepatitis, temporary immunity is recommended in the form of immune globulins. If the nurse had received the hepatitis B vaccine (Heptavax), he 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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological Use the rule of opposites to answer this question. 0

258 MCSA A school-age child has recently been diagnosed as having a seizure disorder. The parents express a concern about what will happen if the child has a seizure at school. The parents are afraid other children will make fun of their child. Which of the following responses by the nurse would be most helpful? 1. The child should always wear a Medic Alert bracelet. 2. The parents should talk with the teacher about how to handle the situation. 3. The child should learn about the pathophysiology of seizures so his self-esteem will not be affected. 4. The parents should make an appointment with a psychiatrist to talk about their concerns.

2 The teacher is most aware of the varied reactions of the classmates and together the parents and teacher can plan strategies to promote acceptance of this child. A Medic Alert bracelet is appropriate but will not improve self-esteem. A psychiatrist might be consulted if the child shows symptoms of altered self-esteem, but this is not required now. Application Physiological Integrity: Physiological Adaptation Communication and Documentation Child Health 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. 0

243 MCSA A 9-year-old child is being treated with methimazole for Graves' disease. She has not responded to the drug therapy as quickly as the physician expected so a thyroidectomy is being considered. The child's mother asks the nurse, "Why would the physician seem hesitant to encourage the surgery?" Which response by the nurse is best? 1. "The surgery will leave a scar on the child's neck and will cause problems with her self-esteem." 2. "Removal of the thyroid gland may result in permanent hypothyroidism, which will require lifelong hormone replacement therapy." 3. "The convalescent time for this surgery is 6 months." 4. "Removal of the thyroid gland causes a change in thermoregulation."

2 The thyroidectomy is the third alternative treatment used when medication and iodine-based radiation therapy are unsuccessful. There is a great concern of causing hypothyroidism in the client. The other statements are not reflective of the underlying concern with performing a thyroidectomy in a child. Application Physiological Integrity: Physiological Adaptation Communication and Documentation Child Health 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. 0

299 MCSA A child is exposed to a playmate who contracted chickenpox. Two days later, the child is admitted to the hospital for another problem, and the parents inform the nurse of the exposure on admission. How long after the exposure should the child be watched for signs of upper respiratory illness? 1. 5 to 10 days 2. 10 to 21 days 3. 21 to 25 days 4. One month

2 The upper respiratory symptoms may be early prodromal symptoms of chickenpox. The incubation period of chickenpox is 10 to 21 days. The other responses are either too short (option 1) or too long (options 3 and 4). Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Child Health 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. 0

168 MCSA The nurse determines that a client who has an infection with which of the following antibiotic-resistant microorganisms requires transmission-based droplet precautions? 1. Methicillin-resistant <i>Staphylococcus aureus</i> 2. Penicillin-resistant <i>Streptococcus pneumoniae</i> 3. Vancomycin-resistant <i>enterococci</i> 4. Vancomycin-intermediate-resistant <i>Staphylococcus</i>

2 Transmission-based precautions are required for all these organisms. Only penicillin-resistant <i>Streptococcus pneumoniae</i> is transmitted via respiratory droplets. The organisms specified in options 1, 3, and 4 are transmitted by direct contact. Analysis Safe Effective Care Environment: Safety and Infection Control Nursing Process: Assessment Adult Health: Respiratory Knowledge of droplet precautions is necessary to answer the question. Penicillin-resistant <i>Streptococcus pneumoniae</i> 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. 0

437 MCSA A client experiences an anaphylactic reaction after taking an antibiotic for the first time. The results of this Type I hypersensitivity response are caused by: 1. A histamine precursor causing anaphylaxis. 2. Antigen-IgE-mast cell interaction. 3. Cell-mediated response. 4. Massive numbers of destroyed red blood cells.

2 Type I hypersensitivity reactions are caused by widespread antigen-antibody reactions such as anaphylaxis. These responses are usually immediate and lead to an antigen-antibody complex 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. Knowledge Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about hypersensitivity responses. 0

499 MCSA A client with tuberculosis is being admitted to the medical-surgical unit. Which type of precautions should the nurse institute to protect the client and staff from possible exposure? 1. Standard precautions 2. Contact precautions 3. Airborne precautions 4. Droplet precautions

3 Airborne precautions should be instituted for all clients being admitted with a diagnosis of tuberculosis. Specific CDC guidelines may also be instituted to prevent TB transmission in healthcare facilities. Standard precautions should be maintained for all clients in the hospital setting. Contact and droplet precautions do not apply to this disease process. Application Physiological Integrity: Basic Care and Comfort Nursing Process: Implementation Adult Health: Immunological This question requires knowledge about isolation procedures. 0

216 MCSA The physician has prescribed Vitamin D for a client. The client asks the nurse what the medication is for. Which of the following is the best response by the nurse? 1. "Vitamin D decreases intestinal absorption of calcium and phosphorus and decreases their mobilization from bone." 2. "Vitamin D helps regulate calcium and phosphorus balance." 3. "Vitamin D helps the kidneys rid the body of excess calcium and phosphorus." 4. "Vitamin D decreases blood levels of calcium and phosphorus."

2 Vitamin D regulates calcium and phosphorus levels by increasing blood levels, increasing intestinal absorption and mobilization from bone, and reducing renal excretion of both elements. The statements in the other options are the opposites of the actions of Vitamin D. Application Physiological Integrity: Pharmacological and Parenteral Therapies Teaching and Learning Pharmacology 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. 0

120 MCSA Certain that her stomach pain is a symptom of cancer, a female client with somatization disorder exhibits pressured, rapid speech; elevated pulse and 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? 1. Pain 2. Anxiety 3. Hopelessness 4. Disturbed body image

2 When a client with a somatization disorder does not receive symptom relief, anxiety increases (as evidenced by her current symptoms). Although the client may experience pain, hopelessness, and disturbed body image, the major issue is anxiety. Analysis Psychosocial Integrity Nursing Process: Planning Mental Health 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 <i>somatization disorder</i>. Review this topic area if this question was difficult.

389 MCSA A male client who has acquired immunodeficiency syndrome (AIDS) asks why oral progesterone (Megace) is being prescribed for treatment. What is the nurse's best response? 1. "Megace is used to treat the nausea associated with this infection." 2. "Megace is used as an appetite stimulant to boost nutritional support." 3. "Megace provides symptomatic relief of constipation." 4. "Megace is used as an antineoplastic agent for palliative treatment."

2 While Megace is used as a palliative treatment for clients with advanced cancers, this is not the rationale for its use with AIDS. In AIDS clients, it provides appetite enhancement. Side effects of Megace can include nausea and constipation. Application Physiological Integrity: Pharmacological and Parenteral Therapies Communication and Documentation Adult Health: Immunological 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. 0

254 MCSA Parents of a 10-year-old boy with mild cerebral palsy ask the nurse about having their son join a Boy Scout troop that meets after school. The boy attends a regular grade school class. The nurse considers which of the following when formulating a response? 1. The rigors of most scout events would be physically beyond this child's capability. 2. Scouting can provide children of all abilities with opportunities for recreation and socialization. 3. It would be embarrassing for the child to be different from the other boys and lower his self-esteem. 4. It is more important that the child conserve his energy for doing schoolwork.

2 While work or industry is the primary developmental task of children this age, emphasis should not be placed exclusively on school. Recreational activities are an integral part of growing up, and all efforts should be made to provide access to such programs. Scouting programs provide recognition of individual successes and strengths and can do much to enhance a child's self-esteem. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Child Health Consider the word <i>mild</i> in the stem of the question and choose the response that is the broadest and most encompassing. 0

245 MCSA A client with a diagnosis of paranoid schizophrenia who threatened his parents with a knife was placed on a 48-hour hold by the courts and the psychiatrist. The nurse explains to the family that once the 48-hour hold is expired, the psychiatrist and court must determine if the client is: 1. A danger to himself. 2. A danger to himself and others. 3. Agreeable to take his medications. 4. Willing to remain in outpatient treatment.

2 With this client, being a danger only to himself (option 1) isn't enough, he may not be a danger to himself but he still may want to harm his parents (others). Although the goal is for the client to continue to take his medication (option 3) and remain in treatment (option 4), safety is a priority. Depending on state law, the length of hold may be either 48 or 72 hours. Analysis Safe Effective Care Environment: Safety and Infection Control Nursing Process: Analysis Mental Health The core issue of the question is safety of all possible clients in the question. Note the association between the word <i>knife</i> in the stem and the word <i>danger</i> to narrow the possibilities to options 1 and 2. Choose option 2 over 1 because it is the most comprehensive option. 0

219 MCSA A family member is sitting at bedside and observes the nurse admitting the client from the postanesthesia care unit (PACU) following a surgical procedure. The family member asks why the area around the surgical wound is orange. Which of the following statements about surgical skin preparation is the best response to the family member? 1. "It reduces the risk of all postoperative complications." 2. "It reduces the risk of postoperative wound infection." 3. "It lessens the chance for decreased tissue perfusion." 4. "It decreases the possibility for dermatitis."

2 Wound infection is decreased by skin preparation when debris and transient microbes from the skin are removed. The other possibilities are all incorrect since skin preparation will not prevent complications such as positioning injury or pressure ulcers. Dermatitis does not result if surgical skin preparation is omitted. Application Physiological Integrity: Reduction of Risk Potential Communication and Documentation Fundamentals 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. 0

378 MCSA Which one of the following suggestions by the nurse would be most helpful to a human immunodeficiency virus (HIV) positive client who has altered taste perception? 1. Drink plenty of salty broths and other fluids to stimulate taste buds. 2. Try zinc supplementation to improve taste perception. 3. Increase intake of meat to at least one serving per day. 4. Avoid using plastic eating utensils.

2 Zinc deficiency is associated with taste changes; therefore, supplementation may benefit a client experiencing altered taste perception. Drinking salty broth and fluids will not help with taste changes but may help restore electrolyte balance in clients experiencing diarrhea. Dairy 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." Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Immunological 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. 0

290 SEQ The nurse working in a food manufacturing plant is summoned to help with a worker who has collapsed. Upon arrival, the nurse finds an adult male lying on the floor near wires from a bottle-packing machine. The 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. 1. Approach the client and determine unconsciousness. 2. Direct an employee to turn off the electrical power to the surrounding machines. 3. Activate the emergency medical system (EMS), and summon the automatic external defibrillator (AED). 4. Begin the ABCs of cardiopulmonary resuscitation (CPR).

2, 1, 3, 4 Most electric shock injuries in adults occur at work, as is possible in this scenario. Removing the electrical source that this client is on or near and providing scene safety prior to approaching the victim are the first steps in this sequence. Then follow the BLS guidelines for EMS activation, CPR, and AED use. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Fundamentals 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. 0

102 SEQ The nurse on the oncology unit has received intershift reports on 4 clients. In what order should the nurse assess these clients? Place in order of priority by clicking and dragging the options below to move them up or down. 1. Client receiving radiation therapy who has a white blood cell (WBC) count of 4,500/mm³ 2. Client receiving chemotherapy who has a platelet count of 50,000/mm³ 3. Client who is crying because she has newly learned that her cancer has metastasized 4. Client who has questions about upcoming chemotherapy

2, 1, 4, 3 The nurse should assess first the client who has the low platelet count (normal 150,000-450,000/mm³), and then the client who has the borderline low WBC count, because these represent greater and then lesser threat to physiological status. From there, the nurse should answer the questions for the client going for chemotherapy, and finally see the client who is upset so that the nurse can plan to spend time with this client. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Planning Adult Health: Oncology 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. 1

117 MCMA The nurse is assigned to the care of a client receiving radiation therapy for cancer. Which of the following activities needed in the care of a client receiving external beam radiation therapy could be safely delegated to an unlicensed assistive person (UAP) working on the nursing unit? Select all that apply. 1. Observe the skin site following a treatment session. 2. Document intake from the meal trays. 3. Assess variations in level of fatigue during the shift. 4. Explore how the client is coping with treatment. 5. Assist the client to ambulate in the hall.

2, 5 Simple activities and nursing procedures can be delegated to the UAP. For this client, this would include ambulation and documentation of intake and output. The RN retains responsibility for assessment, teaching, and counseling the client. For this reason, the nurse should not delegate assessment of the skin at the treatment site, patterns of fatigue, or how the client is coping with the diagnosis and treatment. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Adult Health: Oncology Recall that the RN does not delegate assessment, teaching, and counseling and evaluate each of the options in relation to these guidelines. 0

132 MCMA The pediatric nurse needs to rearrange room assignments of clients to accommodate three additional clients who will be admitted during the day. Which two of the following clients would be best for the nurse to place together in the same room? Select all that apply. 1. An 8-year-old who has encephalitis 2. A 10-year old who has a white blood cell count of 2,800/mm³ 3. A 12-year-old who had an appendectomy 4. An 11-year-old with scarlet fever 5. A 9-year-old receiving chemotherapy for cancer

2, 5 The child with the low white blood cell count (normal 5,000-10,000/mm³) and the child receiving chemotherapy are at risk for infection and could be cohorted together because they should both be on neutropenic precautions. The child who underwent appendectomy should be separated from the children with viral encephalitis and scarlet fever. The children with infections should not be cohorted because one is viral (encephalitis) and one is bacterial (scarlet fever) in origin. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management 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. 1

4 The illustration shows the typical appearance of skin that has eczema. Use of a mild soap such as Dove^® or Tone^® prevents the skin from 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. Application Physiological Integrity: Physiological Adaptation Teaching and Learning Child Health 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 <i>hot</i> and <i>daily</i> in option 1, <i>liberally</i> and <i>entire</i> in option 2, and <i>all</i> in option 3. Although option 4 contains the word <i>only</i>, note that it is tempered when combined into the phrase <i>only as needed</i>. 1

205 MCSA To decrease skin irritation in children with the condition illustrated, the nurse instructs the parents do which of the following? COMP_TEST_BAL_F_2305.jpg 1. Take hot baths (not showers) daily 2. Liberally apply a lotion of choice over entire body 3. Use fabric softener for all clothes 4. Use mild soap only as needed

214 MCSA A mother calls a clinic nurse to state that a letter had come home with her child from school stating she should examine her child for the nits from <i>pediculosis capitis</i>. She asks where she should look for these nits. The nurse would tell the mother to examine: 1. The forehead and scalp. 2. In the webs of the fingers. 3. The hair shafts at the nape of the neck. 4. In the folds of elbows.

3 <i>Pediculosis capitis</i> is head lice. The nits (eggs) are usually found at the nape of the neck or behind the ears. Head lice do not move away from the scalp to lay eggs; therefore, other choices are not appropriate. Application Physiological Integrity: Physiological Adaptation Communication and Documentation Child Health Note that the word <i>capitis</i> 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. 0

106 MCSA A client experiences severe nausea for up to 2 weeks following her chemotherapy treatment. Which statement indicates a need for further instruction on management of nausea? 1. "I need to call my doctor if I lose more than 10 percent of my body weight." 2. "I should try to eat bland, chilled foods, and drink liquids separate from my meals." 3. "I need to lie down for an hour after each meal." 4. "I should call the doctor if my nausea doesn't go away, to see if a different anti-emetic could provide better relief."

3 A client at risk for nausea should not lie down for at least 30 minutes after meals to avoid aspiration. The physician should be notified of excessive weight loss (option 1). Foods and beverages are better tolerated when they are neither hot nor cold (option 2). Option 4 is a good client action if other measures fail (option 4). Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Evaluation Pharmacology 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. 0

493 MCSA A client who has been diagnosed with an autoimmune disorder questions the nurse as to what impact this may have on activities of daily living in the years to come. The best explanation that you, as the nurse, can give is: 1. "The changes will be subtle at first so it won't be noticeable to others." 2. "It is hard to predict what the disease process has in store for any one individual." 3. "I can hear the concern in your voice. Perhaps we can talk for awhile and discuss some of your concerns." 4. "I would suggest the use of any available remedy that might give you some comfort."

3 A client diagnosed with an autoimmune disease is faced with a lifetime of chronic illness and yet may not appear acutely ill because of the episodic nature of remissions and exacerbations. The nurse promotes a therapeutic relationship by allowing the client to ventilate feelings. It is inappropriate to minimize any changes that a client may experience that are unnoticeable to 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. Application Psychosocial Integrity Nursing Process: Implementation Adult Health: Immunological This question requires knowledge about therapeutic communication. 0

443 MCSA In addition to a viral load of 25,000, which of the following would indicate that the medications being taken by a client with AIDS are working? 1. Rare occurrence of symptoms 2. Negative ELISA test 3. CD4 cell count of 490 4. WBC of 1,700 mm

3 A client with AIDS will have exacerbations and remissions with opportunistic infections, therefore symptoms may vary. With a diagnosis of AIDS, an ELISA test would remain positive 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. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Evaluation Adult Health: Immunological Use the process of elimination to answer this question. 0

103 MCSA Which nutritional measure would help a client with gastroesophageal reflux disease (GERD) to minimize the risk of symptoms? 1. Eating 3 large meals a day with no snacks 2. Using a lot of garlic to season food rather than salt 3. Limiting intake of coffee drinks to 2 or fewer cups a day 4. Using peppermint candies to take away the bitter taste in the mouth

3 A client with GERD should limit (or possibly eliminate) the intake of coffee because this can relax LES pressure and lead to symptoms. The other options would not be warranted because all would contribute to the development of symptoms: large meals, spicy foods (extra garlic), and peppermint (which would relax LES pressure). Application Physiological Integrity: Basic Care and Comfort Nursing Process: Planning Foundational Sciences: Nutrition 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. As an alternative, eliminate options that would aggravate symptoms, which in this case are options 1, 2, and 4. 0

393 MCSA A client will undergo scratch tests for allergies. In teaching the client about the planned tests, the nurse should include which of the following information? 1. This test allows us to rule out one or two specific antigens. 2. The scratch test is the most sensitive allergy test. 3. Results can be obtained in 30 minutes. 4. The scratch test involves drawing a small amount of blood from the client.

3 A scratch test tests many allergens at once. It is of low sensitivity, but many allergens can be tested at once, and the results can be obtained in 30 minutes. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Immunological 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. 0

252 MCSA The nurse should implement contact precautions with the client with which of the following health problems? 1. Scarlet fever. 2. Pertussis. 3. A wound infection. 4. Rubella.

3 A wound infection can be spread by direct contact with the wound. Scarlet fever, pertussis, and rubella involve the spread of infection by respiratory particle droplets larger than 5 microns. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Fundamentals 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. 0

471 MCSA An individual who is HIV-positive and who develops memory loss, difficulty concentrating, euphoria, and lethargy is developing which of the following? 1. Alzheimer's disease 2. Senile dementia 3. AIDS dementia complex 4. Wasting syndrome

3 AIDS dementia complex involves cognitive, behavioral, and motor deficits and is a common central nervous system complication of untreated HIV. Along with the above symptoms, apathy, confusion, hallucinations, personality changes, unsteady gait, leg tremors, impaired handwriting, and mental slowing will occur. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about AIDS dementia. 0

344 MCSA A young girl presents with fever and abdominal distention. Her mother states that she has also "coughed up blood" in recent days. Which of the following is compatible with these symptoms? 1. Mycoplasma pneumonia 2. Rickettsial infection 3. Infection with nematodes 4. Infection with spirochetes

3 Abdominal distention is caused from infestation of worms. Blood in sputum often results from migration of worms through alveoli. Mycoplasma pneumonia has similar side effects as bacterial pneumonia (cough, fatigue, rales, and temperature). Spirochetes cause fever, neck stiffness, and lymphadenopathy; rickettsial infections cause headaches, nausea, vomiting, and muscle aches. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological Select the response which best corresponds with the symptoms. 0

342 MCSA Which of the following drugs would be most effective in treating genital herpes? 1. Penicillin (Bicillin) 2. Rifampin (Rifadin) 3. Acyclovir (Zovirax) 4. Ribavirin (Virazole)

3 Acyclovir is the antiviral drug of choice for treating herpesvirus. Penicillin products are used for a wide variety of bacterial infections. Rifadin is used for TB and Virazole is an antiviral agent. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology 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. 0

209 MCSA An adolescent is undergoing a spinal fusion for scoliosis. Which of the following would not need to be included in the preoperative teaching completed by the nurse? 1. Deep-breathing and coughing exercises, use of incentive spirometry 2. Use of postoperative pain medications 3. The procedure for the spinal fusion and bone grafting 4. Placement of a urinary catheter to drain urine after surgery

3 All of the information above is needed by the adolescent undergoing a spinal fusion but the physician, not the nurse, should explain the actual procedure. The nurse should focus on the care of this child following surgery, the exercises for breathing, turning, moving extremities, 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. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Planning Child Health 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. 0

207 MCSA Which of the following is an assessment finding with developmental dysplasia of the hip in a 5-year-old child? 1. Asymmetry of gluteal and thigh fat folds 2. Positive Ortolani-Barlow maneuver 3. Telescoping of the femoral head into the pelvis 4. Limited abduction of the affected hip

3 All symptoms listed are clinical manifestations of developmental dysplasia of the hip, although the only one that would be found in a 5-year-old would be the telescoping of the 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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Child Health Specific knowledge about this disorder is needed to answer the question. Take time to review this disorder if you had difficulty with this question. 0

204 MCSA The nurse is caring for a 15-year-old primipara who delivered yesterday. The nurse identifies the following nursing diagnosis for this client: risk for altered parenting related to knowledge deficit in newborn care. Which is the most appropriate intervention when planning this client's discharge teaching? 1. Have the client watch a video on newborn care. 2. Give her information about a support group for adolescent mothers. 3. Demonstrate how to care for the newborn and have the client return the demonstration. 4. Give the client printed instructions on newborn care.

3 Although all of the options may be appropriate, demonstrating newborn care will allow the client to ask questions and gain confidence as she cares for her baby. Having her return the demonstration will allow the nurse to evaluate the teaching. Application Health Promotion and Maintenance Teaching and Learning Maternal-Newborn Recall principles of teaching and learning, and recall that active participation leads to most effective learning outcomes. 0

194 MCSA The client experienced an 18-hour labor with a second stage that lasted 2 hours. When the nurse brings the infant into the room 1 hour after delivery, the client tells the nurse to leave the infant in the crib and shows no interest in holding the newborn. The nurse should record which of the following nursing diagnoses in the chart? 1. Ineffective individual coping related to assuming parental role 2. Powerlessness related to loss of individual choices 3. Fatigue related to prolonged labor 4. Anxiety related to feelings of incompetence in parenting role

3 Although this client is not demonstrating positive signs of bonding at this time, it is important to look at her history before concluding that she is not bonding well with her infant. This client just experienced a long labor and the influence of fatigue on the attachment process should be considered. It is important to continue to assess infant bonding with this client throughout her hospitalization to reach a nursing judgment based on evidence. Analysis Health Promotion and Maintenance Nursing Process: Analysis Maternal-Newborn 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. 0

466 MCSA The immune complexes in type III allergic reactions cause a localized reaction of tissue necrosis. This is called: 1. Gangrene. 2. Inflammation. 3. Arthus. 4. Infarction.

3 An Arthus reaction is a type III hypersensitivity reaction that causes acute, localized edema and tissue inflammation (usually of the skin). It usually occurs at the site of an injection of an antigen in a client previously sensitized. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about Arthus reactions. 0

472 MCSA The nurse encourages a new mother to breastfeed her infant, even for a short time, because colostrums in breast milk will provide the infant with: 1. Indefinite active immunity to childhood illnesses. 2. Passive immunity to all childhood illnesses for several months. 3. Passive immunity to diseases to which the mother has immunity. 4. Active immunity for several years to diseases to which the mother has immunity.

3 Antibodies that the mother has will be passed on to the infant. This form of immunity is natural versus artificial. Remember the difference between passive (temporary immunity) and active (long-term). Words such as indefinite (option 1) and all (option 2) should be red flags that these are incorrect. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about passive versus active immunities. 0

474 MCSA Initial evidence that should indicate to the nurse that a client may experience a systemic anaphylactic reaction to an injected allergen is the development of: 1. Dyspnea. 2. Dilation of the pupils. 3. Itching and edema at the injection site. 4. A wheal and flare reaction at the injection site.

3 Any local reaction (type I hypersensitivity) to an injected allergen should place the nurse or health care provider on guard for a possible anaphylactic reaction. The client should be closely 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. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological Use intuition to determine the initial response. 0

136 MCSA The nurse is giving general information about antihypertensive medications to a young female client with a history of hypertension. The nurse includes that which of the following types of antihypertensives should not be used if the client becomes pregnant? 1. Vasodilators 2. Diuretics 3. Angiotensin converting enzyme (ACE) inhibitors 4. Calcium channel blockers

3 Because ACE inhibitors can cause fetal harm or death, they should be discontinued as soon as pregnancy is detected. Their effect on breastfeeding infants is unknown. The effect of other medications is unknown during pregnancy. Application Physiological Integrity: Pharmacological and Parenteral Therapies Teaching and Learning Pharmacology 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. 0

184 MCSA The nurse is taking the health history of a 77-year-old man. Which of the following symptoms reported by the client would the nurse consider to be an abnormal finding? 1. Delay of urination, hesitation, and decreased flow of urine stream 2. Increased tolerance to spicy foods 3. Increased isolating behaviors after his wife's death 4. Slight dizziness when getting up too quickly after lying down for a while

3 Bladder and sphincter weakness are normal with the aging process. Decreased tolerance to spicy foods also is reflected by decreased acidity and motility of the digestive processes that 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 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. Analysis Health Promotion and Maintenance Nursing Process: Assessment Fundamentals 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. 0

326 MCSA The nurse is providing information about reducing exposure to antigens in a client who is allergic to dust. 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? 1. Hardwood floors with attractive throw rugs decorate the family room 2. The adult family members have switched to the nicotine patch as they attempt to stop smoking 3. The room is decorated with hanging live plants and arrangements of silk flowers 4. The family reports they take turns vacuuming the entire house each day

3 Both live and silk flowers will have increased dust levels associated with them. The other activities are appropriate. Analysis Health Promotion and Maintenance Nursing Process: Evaluation Child Health Eliminate those options which would reduce dust in the environment leaving only the incorrect response. 0

469 MCSA The reason the AIDS virus is so devastating to the immune system is that it attacks: 1. Neutrophils. 2. B lymphocytes. 3. CD4 lymphocytes. 4. CD8 lymphocytes.

3 CD4 or T helper cells are those that play a key role in controlling the immune response by 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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about the AIDS virus. 0

206 MCSA A client who is taking warfarin (Coumadin) therapy comes to the office for a follow-up visit and states that he has taken propoxyphene with aspirin (Darvon Compound 65) for aches and pains related to an old back injury. How should the ambulatory care nurse respond to this information? 1. Ask the client how long his back been hurting him and assess the need for a referral for pain management. 2. Tell the client that it is important to prevent the pain cycle from starting and to continue to take Darvon as ordered by the physician. 3. Advise the client that Darvon contains aspirin, which may interfere with Coumadin therapy, and consult with the physician for an alternate pain medication. 4. Instruct the client that continued daily use of Darvon would help to relieve back pain, but would require an increase in the dose of the Coumadin.

3 Clients who are taking Coumadin should be alerted to the potential for drug interactions when they are on long-term anticoagulation therapy. Aspirin can potentiate the effect of Coumadin and interfere with the ability to maintain a therapeutic level. The use of Darvon, although previously prescribed, is not in the best interest of the client at this time due to Coumadin therapy. Telling the client to keep taking Darvon would lead to drug interactions (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. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology 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. 0

448 MCSA In assessing a client with a suspected latex allergy, the nurse should ask which of the following? 1. "Are your hands usually moist or dry?" 2. "What drug allergies do you have?" 3. "Are you allergic to bananas or kiwi fruit?" 4. "What types of surgeries have you had?"

3 Clients with a history of allergies to fruit such as bananas or kiwi tend to have latex allergies. 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. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Assessment Adult Health: Immunological Use the process of elimination to determine the correct answer. 0

189 MCSA A client presents to the clinic with a chief complaint of a swollen and painful great toe. He states that his brother has it, and he has the same symptoms. The physician suspects gout. What specific laboratory test would the nurse expect to be ordered for this client? 1. Calcium 2. Hematocrit 3. Uric acid 4. Sodium

3 Clients with gout will usually have elevated serum uric acid levels. Laboratory findings as well as physical assessment will confirm the diagnosis. The joint of the great toe is usually involved in initial attacks of acute gouty arthritis as seen in the accompanying figure. There are many other factors that will affect the results of hematocrit, serum calcium, and sodium levels. Erythrocyte sedimentation rate (ESR or sed rate) and white blood cell (WBC) counts will also be elevated in cases of gout. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Planning Adult Health: Endocrine and Metabolic The core issue of the question is knowledge of diagnostic testing for gout. Recall that the word gout contains the letter <i>u</i> to associate this with measurement of uric acid, which begins with <i>u</i>. 0

157 MCSA Case management has become an important nursing care model in the 21st century. Which of the following clients would most likely be selected for case management? 1. A 21-year-old male with a gunshot wound in the ER 2. A 32-year-old male with a fractured pelvis 3. A 75-year-old female awaiting a hip replacement 4. A 41-year-old male coming in for outpatient tonsillectomy

3 Clients with less complex and more common diagnoses are selected for case management. The clients in the remaining options have problems that are more likely to have variation in their conditions (options 1 and 2) or have a less common diagnosis (option 4). Analysis Safe Effective Care Environment: Management of Care Nursing Process: Analysis Leadership/Management Focus on the critical words <i>case management</i>. Use the common definition of this method to eliminate each option systematically. 0

300 MCSA The home-health nurse sees a child with mumps. The mother says that the child is not eating well and asks for suggestions. The nurse most appropriately suggests which of the following? 1. Provide warm, chopped foods. 2. Provide cool table foods with spices. 3. Provide cool fluids with minimum of acids. 4. Provide a regular diet tray at frequent intervals.

3 Cool fluids will help decrease the swelling of the glands around the mouth and neck. Acidic foods are too irritating and difficult to swallow. Warm, chopped foods may be difficult to swallow (option 1), and spices are also likely to be irritating (option 2). The child should be given small, frequent meals with soft foods rather than a regular diet (option 4). Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Child Health 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. 0

261 MCSA A child is admitted to the nursing unit with acute renal failure (ARF). When reviewing the nursing 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? 1. Chickenpox 2. Influenza 3. Dehydration 4. Hypervolemia

3 Dehydration results in hypovolemia, which can precipitate acute renal failure in infants and children. The other responses are incorrect because they don't directly impact renal perfusion. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Child Health 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. 0

231 MCSA The nurse is making a plan of care for a client who is prescribed fluphenazine (Prolixin) 1 mg daily at bedtime. The nurse will include which of the following to monitor for side effects of the medication? 1. Remind him frequently to rise slowly when getting out of bed or from a chair. 2. Assess for dizziness or lightheadedness frequently during the day. 3. Make sugarless hard candy, gum, and water available during the day. 4. Monitor for confusion frequently.

3 Dry mouth occurs from the anticholinergic effects seen with fluphenazine. Options 1 and 2 are incorrect because orthostatic hypotension is not a major side effect of fluphenazine. Confusion (option 4) is not a side effect of this agent. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Planning Pharmacology 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. 0

335 MCSA Endotoxins differ from exotoxins in that exotoxins have which of the following characteristics? 1. Are composed of lipopolysaccharides 2. Are found only in Gram-negative bacteria 3. Are easily destroyed by heat 4. Are typically not very toxic

3 Endotoxins are often not destroyed even by autoclaving. Options 1, 2, and 4 are descriptions of endotoxins. Knowledge Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This is a question that requires application of facts about endotoxins and exotoxins. 0

149 MCSA The nurse examines the white blood cell (WBC) differential for a client who experienced a severe allergic reaction. The nurse anticipates that which of the following values will be elevated? 1. Neutrophils 2. Monocytes 3. Eosinophils 4. Lymphocytes

3 Eosinophils are responsible for responding to allergic reactions. Neutrophils and monocytes are primary responders to infection and tissue injury and inflammation. Lymphocytes assist in immune responses. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Assessment Adult Health: Immunological 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. 0

416 MCSA A mother brings a 3-year-old child to the clinic for a well-child checkup. The child has not been to the clinic since 6 months of age. The nurse determines that which of the following is the priority care for this child? 1. Assess growth and development. 2. Begin dental care. 3. Update vaccinations. 4. Complete hearing screening.

3 Every time a child enters the healthcare system, the immunization status should be checked. Some children have uncertain history of immunization due to parental noncompliance or special circumstances, such as being refugees. Analysis Health Promotion and Maintenance Nursing Process: Planning Child Health 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. 0

385 MCSA In establishing a plan of care to manage pain for a client with rheumatoid arthritis, what intervention would the nurse use to increase the client's mobility? 1. Have the client work through pain by continuing exercise in order to establish endurance. 2. Have the client use pain medication only when pain is present. 3. Teach the client that both heat and cold applications may help to relieve pain. 4. Teach the client to flex muscle groups when pain is felt in an extremity.

3 Heat and cold applications can provide analgesia and relieve muscle spasms. The individual client will have to determine whether heat, cold, or alternation of both is most effective. Pain 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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Planning Adult Health: Immunological 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. 0

341 MCSA A young male college student came to the clinic after contracting genital herpes. Which of the following interventions would be most appropriate? 1. Encourage him to maintain bedrest for several days 2. Monitor temperature every 4 hours 3. Instruct him to avoid sexual contact during acute phases of illness 4. Encourage him to use antifungal agents regularly

3 Herpes is a virus and is spread through direct contact. An antifungal would not be useful; bedrest and temperature measurement are usually not necessary. Application Health Promotion and Maintenance Nursing Process: Implementation Adult Health: Immunological Because the priority with this condition is prevention of transmission select the option that would accomplish this. 0

176 MCSA The client is experiencing severe itching with a skin disorder. Which of the following drugs, if ordered, would the nurse administer as an appropriate oral preparation to decrease the itching? 1. Cimetidine (Tagamet) 2. Lorazepam (Ativan) 3. Hydroxyzine (Atarax) 4. Bupivacaine (Sensorcaine)

3 Hydroxyzine hydrochloride is an antihistamine that is a competitive inhibitor of the H₁ receptor. It is used to treat various reactions that are mediated by histamine. It will decrease the pruritus produced by the release of histamine. Cimetidine is an H₂ 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. Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Planning Pharmacology 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. 1

242 MCSA The mother of a 2-month-old receiving immunizations for the first time will also be a beginning nursing student when the next semester starts. When the 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? 1. Mode of transmission 2. Portal of entry 3. Susceptible host 4. Portal of exit

3 Immunizations interrupt the chain of infection by generating immunity in a susceptible host by introducing a weakened or killed antigen into the body. Immunizations do not affect the portal of entry, portal of exit, or the mode of transmission of a pathogenic organism. Application Safe Effective Care Environment: Safety and Infection Control Teaching and Learning Fundamentals 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. 0

269 MCSA The nurse on a surgical nursing unit has just called a code blue using the telephone in the room of an unresponsive client who had abdominal surgery. Which of the following actions would be appropriate during initiation of CPR? 1. Open the airway using the jaw thrust method. 2. Deliver one deep breath before checking for a pulse. 3. Depress the sternum 1.5 to 2 inches during cardiac compressions. 4. Reevaluate status every 2 to 3 minutes until the code team arrives.

3 In an adult, the sternum should be depressed during CPR to a depth of 1.5 to 2 inches. The head-tilt-chin-lift method of opening the airway is used for the client who has no head or neck injury (option 1). The nurse should deliver two breaths to initiate ventilation (option 2). The nurse should reevaluate the client's status after approximately 1 minute (option 4). Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Cardiovascular 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. 0

470 MCSA The "seroconversion window" of HIV infection refers to that time which: 1. The individual has been infected and the acute mononucleosis symptoms appear. 2. The individual has been infected and initial symptoms appear. 3. The individual has been infected and antibody levels are detectable. 4. The individual has been infected and opportunistic diseases occur.

3 In category A of the CDC classification, individuals who have been infected may not 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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about the seroconversion in HIV. 0

236 MCSA The nurse provides discharge instructions to the client taking an antihypertensive medication. The nurse should include in the teaching plan that a hypertensive crisis will exist if the diastolic blood pressure (BP) is greater than which of the following? 1. 100 mmHg 2. 120 mmHg 3. 130 mmHg 4. 140 mmHg

3 In hypertensive urgencies, clients present with a systolic BP greater than 240 mmHg and diastolic BP greater than 120 mmHg. In hypertensive emergencies, the client's diastolic BP is greater than 130 mmHg. Application Physiological Integrity: Pharmacological and Parenteral Therapies Teaching and Learning Pharmacology 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. 0

239 MCSA Following placement of a central venous line, which information should the nurse report immediately to the physician? 1. Pain at the insertion site 2. Fever 3. Increased heart rate and respiratory rate 4. Diminished breath sounds in lung bases

3 Increased heart rate and/or respiratory rate within minutes to several hours following central venous line insertion are symptoms of a pneumothorax caused by puncture of the pleura. The 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. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Implementation Adult Health: Respiratory 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 <i>bases</i> with lung sounds, which indicates atelectasis, not pneumothorax. 0

260 MCSA The nurse determines that an appropriate outcome criterion for the <i>initial</i> nursing care of a client with acute delirium would be which of the following? 1. The client will verbalize dependence on drugs. 2. The client will demonstrate adaptive coping strategies for dealing with stress. 3. The client will be oriented to person, place, and time during lucid periods. 4. The client will explore reasons for addictive behaviors.

3 Initially, the delirious client is dazed, drowsy, and perceptions will be disturbed, making it difficult for the client to sustain attention to any mental task. Delirium is characterized by 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. Application Psychosocial Integrity Nursing Process: Planning Mental Health The core issue of the question is understanding of the condition of delirium. The critical word in the stem of the question is <i>initial</i>. With this in mind, choose the option that shows the beginnings of return of neurological status to normal. 0

304 MCSA A child who may have scarlet fever is being evaluated in the urgent care clinic. The nurse concludes that the client's presentation is not consistent with scarlet fever after noting which of the following during assessment? 1. Rash in the axillae and groin 2. Pharyngeal redness and swelling 3. Koplik's spots in the oral mucosa 4. Red strawberry tongue

3 Koplik's spots are seen with roseola, not scarlet fever. Reddened edematous pharynx, red strawberry tongue, and rash in the axillae and groin are findings consistent with scarlet fever. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Communicable Disease 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. 0

313 MCSA A 2-year-old child is seen in the pediatric clinic with 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: 1. The distribution of the rash. 2. The appearance of the rash. 3. Koplik's spots. 4. The low grade fever.

3 Koplik's spots are unique lesions found in the mouth of the individual with rubeola. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Child Health The rash characteristics are not enough to distinguish rubeola from other diseases. Select the one unique feature that is seen in no other disease. 0

139 MCSA A client has been admitted to the nursing unit with a three-day history of severe nausea and vomiting with diarrhea. The client is experiencing fatigue, anorexia, and muscle weakness. Based on this history, which laboratory findings should the nurse expect to find? 1. Calcium 11.6 mg/dL 2. Sodium 144 mEq/L 3. Potassium 2.9 mEq/L 4. Calcium 7.4 mEq/L

3 Loss of potassium caused by vomiting and diarrhea, in addition to lack of replacement intake, will lead to a risk for hypokalemia (normal range is 3.5-5.1 mEq/L). Calcium levels (normal 9-11 mg/dL) are not affected by vomiting and diarrhea and the sodium level (normal 135-145 mEq/L) will be elevated with the loss of potassium. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Analysis Adult Health: Gastrointestinal Critical words in the question are <i>vomiting and diarrhea</i>. 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. 0

317 MCSA A 5-year-old child is brought into the clinic after experiencing an insect sting. The child appears to be going into anaphylactic shock. The nursing action with the highest priority is: 1. Assessment of urinary output 2. Application of cold, wet compresses 3. Maintaining an open airway 4. Encouraging fluid intake

3 Maintaining an open airway is always the highest priority. With anaphylactic shock, the airway may constrict, mucous membranes swell, and air trapping occurs. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Child Health 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. 0

401 MCSA A 5-year-old child is brought into the clinic after being stung by an insect. The child appears to be going into anaphylactic shock. Which of the following nursing actions is of highest priority? 1. Assess urinary output to determine renal perfusion 2. Apply cold, wet compresses to the site 3. Position the child's head to maintain an open airway 4. Establish intravenous access for medication delivery

3 Maintaining an open airway is always the highest priority. With anaphylactic shock, the airway may constrict, mucous membranes swell, and air trapping occurs. The second priority would be airway access, followed by renal assessment, and finally site care. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Planning Child Health Use the ABCs—airway, breathing, and circulation to answer questions related to anaphylaxis. Airway is always the first priority in life-threatening situations. 0

183 MCSA The nurse would include which of the following statements when discussing nutritional status with a client who is infected with human immunodeficiency virus (HIV) and is progressing toward acquired immunodeficiency syndrome (AIDS)? 1. Clients who are asymptomatic have adequate nutritional stores of nutrients. 2. The HIV wasting syndrome is seen in the latter stages of the disease process. 3. Malnutrition is seen as a consequence of the immune disease. 4. Vitamin and mineral deficiencies occur in the latter stages of the disease process.

3 Malnutrition is seen as a consequence of the HIV/AIDS virus because the disease process has a progressive effect on client's nutritional status. Option 1 is incorrect—even clients who are asymptomatic may already have nutrient deficiencies and could be experiencing subclinical signs of malnutrition. Option 2 is incorrect because 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—clients can experience vitamin and mineral deficiencies early on during the disease process. Application Physiological Integrity: Basic Care and Comfort Teaching and Learning Foundational Sciences: Nutrition 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. 0

238 MCSA The nurse would choose to use medical aseptic technique when collecting which of the following specimens? 1. C & S from an abdominal wound 2. Sputum specimen via a tracheostomy 3. Stool specimen for ova and parasites 4. Urine specimen via straight cath

3 Medical asepsis requires clean, not sterile, technique. Only option 3 requires medical aseptic technique. Collecting a wound culture (option 1), suctioning a tracheostomy (option 2), and catheterizing the client (option 4) all require the nurse to use sterile asepsis. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Planning Fundamentals 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. 0

482 MCSA Which of the following atypical findings would the nurse look for in the older adult client who presents with an infection? 1. Fever 2. Erythema and edema 3. Behavioral changes and confusion 4. Leukocytosis

3 Mental status changes ranging from restlessness to confusion is one of the most frequent "atypical" signs of infection in older adults. Fever, erythema, edema, and leukocytosis may be 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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological Recall that changes in behavior are early signs of change in status. 0

386 MCSA Which of the following information will the nurse use when explaining therapeutic measures to a client taking methotrexate (Rheumatrex) for rheumatoid arthritis? 1. Relief of symptoms will be assessed for within 1 week of starting medication. 2. Fluids should be restricted to prevent possible edema formation. 3. Drug doses will be adjusted for optimum effect at lowest dose once relief has been established. 4. Six months of therapy will be adequate to stop the disease process from progressing.

3 Methotrexate treatment takes several weeks to effect relief. Once relief is obtained, the dose is adjusted to achieve maximum response at the lowest dose. If the drug is discontinued, then symptoms of the disease do return. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Immunological 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. 0

179 MCSA A client with bone cancer receiving chemotherapy has developed bone marrow suppression. Which laboratory report is of highest priority for the nurse to monitor at this time? 1. Calcium 2. Phosphorus 3. White blood cell (WBC) count 4. Serum prostate-specific antigen (PSA)

3 Most chemotherapeutic agents cause some degree of bone marrow suppression. This results in a decrease in leukocyte and erythrocyte counts, both components of a hematology testing. Calcium, phosphorus, and serum PSA levels are not specifically affected by bone marrow 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. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Assessment Adult Health: Oncology The critical word in the question is <i>priority</i>. 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. 0

424 MCSA A 14-year-old child is receiving intravenous antibiotics for an infection. The physician has ordered gentamycin (Garamycin). Because of the side effects of this drug, the nurse would monitor: 1. Temperature. 2. Blood pressure. 3. Intake and output. 4. Breath sounds.

3 One of the most common side effects of gentamycin is nephrotoxicity. The nurse can monitor kidney function by monitoring intake and output. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Evaluation Child Health Gentamycin is a member of the aminoglycoside group of antibiotics, all of which are nephrotoxic and ototoxic. 0

441 MCSA Which of the following individuals is at highest risk of contact with HIV? An individual who: 1. Counsels HIV victims and their families. 2. Works with athletes who perspire a lot. 3. Collects blood donations via a mobile blood unit. 4. Performs physicals involving an ELISA test for insurance companies.

3 Only fluids containing blood or blood cells have been identified as a mode of transmission for 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. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Assessment Adult Health: Immunological This question requires knowledge about blood borne pathogens. 0

196 MCSA A client is scheduled for an ophthalmic examination. Before administering the prescribed epinephrine solution, the nurse would assess for which of the following conditions? 1. Hypotension 2. Wide-angle glaucoma 3. Angle-closure glaucoma 4. Brow ache

3 Ophthalmic epinephrine is used to produce mydriasis for ocular examination. Dilation of pupil further constricts ocular fluid outflow, possibly causing an acute attack of glaucoma in a client with narrow-angle glaucoma. Systemic absorption also causes hypertension and tachycardia. Brow ache is a typical side effect of adrenergic agonists such as epinephrine (option 4). Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Assessment Pharmacology 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. 0

181 MCSA The client will be discharged to home tomorrow on an antidepressant medication that will be taken once daily in the morning. He asks, "Do I have to take medicine every day? How will I be able to sleep when I go home? Do you think I'll be able to work, too, even though I have been in the hospital this long?" The nurse's best response is: 1. "The best approach is to take it one step at a time, so that everything will work out." 2. "I understand you're worried, but you and your wife will decide tomorrow when you get home." 3. "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?" 4. "I'll do my best to set up a plan for discharge that you can take home with you and refer to later."

3 Option 3 is correct because it acknowledges the client's feelings and addresses his concerns while still allowing him to make decisions for his present and future. Options 1 and 2 disregard and negate the client's feelings. Option 4 acknowledges his concern but takes away his decision-making options by having someone else (the nurse) make a plan for his daily activities, rather than have him participate and make decisions for himself with help. Application Psychosocial Integrity Communication and Documentation Mental Health 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. 0

225 MCSA Which of the following statements indicates that a client understands appropriate information about premenstrual syndrome (PMS)? 1. "I have PMS all month long." 2. "My husbands says if we had sex more often it would help my PMS." 3. "PMS starts about 10 days before my period." 4. "I should drink more coffee when I have PMS."

3 PMS occurs only during the luteal phase of the menstrual cycle (7 to 10 days before menstrual flow begins). Increasing sexual activity doesn't prevent PMS, and caffeine can worsen the symptoms. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Evaluation Adult Health: Renal and Genitourinary The critical word in the question is <i>understands</i>. 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. 0

336 MCSA A client exhibiting symptoms of a rickettsia infection probably acquired it through: 1. Respiratory droplets. 2. Mosquitos. 3. Bites or feces of ticks, lice, or fleas. 4. Direct skin contact.

3 Rickettsia are parasites of ticks, fleas, and lice. Influenza is an example of transmission by respiratory droplets, encephalitis is transmitted by mosquitos; lice and scabies are transmitted by direct contact. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This is a question that requires application of knowledge about the transmission of rickettsia. 0

500 MCSA You have been asked to perform a home assessment on a client who has longstanding rheumatoid arthritis. Which one of the following findings should receive the highest priority for follow-up teaching? 1. The client lives in an apartment building that has an elevator. 2. The client has an installed handrail support in the bathroom. 3. The client has area rugs scattered throughout the apartment. 4. The client keeps her medications in a plastic case on the kitchen counter.

3 Scattered area rugs are a potential safety hazard for an individual who has longstanding RA because of possible joint deformities and contractures that could increase risk of falls. All of the other assessment findings are considered to be supportive of this client with RA because they enhance mobility, safety, and medication compliance. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Evaluation Adult Health: Immunological Use the process of elimination to answer this question. 0

147 MCSA The nurse is seeking employment in a hospital that uses a shared governance model. The nurse should accept a job offer in the hospital that has which of the following attributes? 1. Staff nurses delegate activities to certified nursing assistants (CNAs). 2. A unit manager seeks advice from her supervisor. 3. Staff nurses and CNAs make their own schedules. 4. Procedure manuals are written by a committee of nurse managers.

3 Shared governance is based on the philosophy that nursing practice is best determined by nurses. Option 1 represents standard nursing practice. Option 2 is unrelated to governance. Option 4 represents leadership input into decision-making for the organization. Application Safe Effective Care Environment: Management of Care Nursing Process: Analysis Leadership/Management The critical words in the question are <i>shared governance</i>. Choose the option that gives the best evidence of some kind of sharing. 0

379 MCSA Which of the following suggestions would the nurse give to a client with human immunodeficiency virus (HIV) infection to best alleviate nausea? 1. Drink liquids with meals. 2. Eat high-fat foods. 3. Eat small, frequent meals. 4. Lie down after eating.

3 Small, frequent meals help lessen nausea because they require less work of digestion and do not overwhelm the client with food odors from a lengthy meal. High-fat foods are more 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. Application Physiological Integrity: Physiological Adaptation Teaching and Learning Adult Health: Immunological 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. 0

301 MCSA The mother of a 3-year-old child with measles calls the nurse at the clinic and asks what she can do to help decrease the redness and itching. The nurse responds that which of the following actions is likely to be helpful? 1. Overdress the child and cause him to perspire. 2. Keep the child out of drafts. 3. Bathe the child in an oatmeal (Aveeno) bath. 4. Provide adequate oral fluids.

3 Soothing the skin with an oatmeal-based substance will decrease the itching and redness. Overdressing the child will increase perspiration and thereby increase the itching. Although drinking adequate fluids is helpful, it does not directly affect the itching. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Child Health 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. 0

191 MCSA The nurse should question an order for which beta agonist used to treat respiratory disease in a client with a history of atrial fibrillation accompanied by intermittent heart rates of 100/minute or greater? 1. Terbutaline (Brethine) 2. Pirbuterol (Maxair) 3. Isoproterenol (Isuprel) 4. Metaproterenol (Alupent)

3 Terbutaline, pirbuterol, and metaproterenol are all beta 2 stimulants. Isoproterenol stimulates beta 1 and beta 2 receptors and therefore is contraindicated and should not be used with clients with tachydysrhythmias. Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology 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. 0

104 MCSA A client who is 20 weeks gestation is concerned about how to tell her 3-year-old son about her pregnancy. Which of the following would be the best statement when counseling this client? 1. "If he is not pleased with the news of a new baby, you should tell him that you are disappointed in him." 2. "Tell him that he is going to have a lot of responsibilities in helping care for the baby." 3. "Try to provide extra attention to him and include him in plans for the baby." 4. "Tell him that he will have to stay with his grandparents when the baby is born because you will be busy with the baby."

3 The child should be included in planning for the new baby. Children may feel threatened by a new sibling and so may need extra time and attention. Parents should avoid putting too much responsibility on the child. Application Health Promotion and Maintenance Communication and Documentation Maternal-Newborn 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. 0

403 FIB A client must undergo skin testing for allergies. The nurse determines during client history that the client 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.

3 The client needs to discontinue use of antihistamines for 72 hours (3 days) prior to allergy testing to avoid false negative readings. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Implementation Adult Health: Immunological 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. 0

172 MCSA The nurse working on a neuroscience unit has just received an intershift report. Which of the following assigned clients should the nurse assess first? 1. A client with Parkinson's disease who is crying because she cannot get up easily 2. A client with multiple sclerosis who is having noticeable leg spasms 3. A client who had a hemorrhagic stroke and is complaining of headache 4. A client scheduled for a craniotomy in 4 hours

3 The client who had a hemorrhagic stroke and has a headache could be about to have another bleed. Headache is a classic sign with intracranial bleed, and a second bleed carries a higher 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. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Adult Health: Neurological 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. 0

490 MCSA Which one of the following statements indicates the client's understanding of measures used in the treatment of systemic lupus erythematosus? 1. "I will be able to continue with my tanning bed appointments." 2. "I can go visit this weekend with my grandmother who has been ill with a cold." 3. "I can go for a walk on the beach after 3:00 P.M." 4. "I have to apply SPF 10 sunscreen when I go to the beach."

3 The client's understanding is demonstrated by acknowledging the fact that sun exposure should be limited to times other than 10:00 A.M. to 3:00 P.M. (when the sun is at its highest 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. Application Health Promotion and Maintenance Nursing Process: Evaluation Adult Health: Immunological Use the process of elimination to answer this question. 0

395 MCSA A client presents with dyspnea, pruritis, and localized swelling of the forearm after being stung by a bee. What is the priority intervention? 1. Remove the stinger from the client's arm 2. Keep the client warm with soft blankets 3. Check the tongue for swelling and listen for stridor 4. Place client in the Trendelenburg position

3 The priority intervention is to maintain a patent airway in a potential anaphylactic reaction. Therefore, the nurse should assess for swelling of the tongue and stridor, which could indicate impending respiratory obstruction. The other interventions are supportive measures that can be used during an allergic response. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Immunological 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. 0

213 MCSA The nurse anticipates which of the following regarding sodium restriction for a client diagnosed with ascites secondary to cirrhosis? 1. Sodium restriction is critical in managing the occurrence of ascites; therefore, the client should not receive any sodium. 2. There is no need to restrict sodium as paracentesis can be used to remove excess fluid. 3. If the client experiences resistance to diuretic therapy, there may need to be more stringent sodium restrictions. 4. Diets with sodium restriction are unpalatable; therefore, the client will likely be noncompliant with therapy.

3 The development of ascites (third spacing) is a common complication of cirrhosis. With the development of ascites, sodium restriction is instituted. Depending on the extent and response 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. Application Physiological Integrity: Basic Care and Comfort Nursing Process: Analysis Foundational Sciences: Nutrition 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. 0

459 MCSA A client receiving a unit of packed red blood cells (RBCs) begins to complain of chills, temperature is 101.4 degrees F, pulse is 185, and blood pressure is 80/50. The nurse should do which of the following first? 1. Call the physician 2. Send the blood bag to the laboratory 3. Stop the transfusion and flush the line 4. Continue to record the VS and monitor the client every 5 minutes

3 The key word in this stem is 'first.' All of the options are correct, and the nurse should perform all of them, but in the proper sequence. The transfusion should be stopped because of the signs of a transfusion reaction. The physician then needs to be called at the same time the vital signs and client are monitored every 5 minutes. Sending the bag to the laboratory is the last step. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Adult Health: Immunological This question requires knowledge about the first aid needed. 0

107 MCSA While assessing the chest tube drainage system of a client, the nurse observes a slight rise and fall in the water level in the water seal. The nurse should take which of the following actions? 1. Notify the physician immediately. 2. Have the client cough. 3. Continue to monitor the system. 4. Reposition the chest tube.

3 The movement of the fluid, also referred to as tidaling, in the water indicates normal lung expansion. The physician should not be called unless the movement ceases. Coughing will increase the movement and repositioning the chest tube will have no effect on the oscillation. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Respiratory To answer this question it is necessary to have a basic understanding of chest tube function. Beyond that, note the critical word <i>slight</i> 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. 0

222 MCSA The nurse working on an adult medical-surgical unit would assign which of the following clients to the licensed practical/vocational nurse (LPN/LVN) under the supervision of the RN? 1. A 46-year-old client with COPD who will be seen by the pulmonary rehabilitation specialist in 2 hours 2. A 26-year-old client who is in sickle cell crisis 3. A 59-year-old client with Paget's disease who also has hypertension 4. A 75-year-old client who fractured a hip and is awaiting surgical repair scheduled for mid-morning

3 The nurse should delegate the care of the 59-year-old client with hypertension and Paget's disease. This client has a stable medical status. The nurse would want to assess the client awaiting surgery and complete preoperative care and the preoperative checklist. The nurse 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. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management 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. 0

251 MCSA The nurse working the evening shift on an adult surgical unit would assign which of the following clients to the licensed practical/vocational nurse (LPN/LVN) under the supervision of the RN? 1. A 24-year old client who underwent extraction of four wisdom teeth earlier in the day 2. A 54-year-old client who had a laparoscopic cholecystectomy the previous day and will be discharged 3. A 62-year-old client who underwent open reduction, internal fixation of a fractured femur 3 days ago 4. A 48-year-old client returning from PACU following partial gastrectomy

3 The nurse should delegate the care of the 62-year-old who had surgery 3 days ago to repair the fractured femur. This client has a stable medical status. The nurse would want to assess the client returning to the unit following gastric surgery and the client who had wisdom teeth extraction. The nurse would want to complete discharge teaching with the client who had the cholecystectomy. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management 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. 0

202 MCSA The nurse working on adult medical-surgical unit would assign which of the following clients to the licensed practical/vocational nurse (LPN/LVN) under the supervision of the RN? 1. A 62-year-old client admitted 8 hours ago with exacerbation of COPD 2. A 25-year-old client with a concussion from an auto accident the prior evening 3. An 81-year-old client with chronic heart failure and emphysema admitted 3 days ago 4. A 54-year old client newly diagnosed with diabetes mellitus who will be discharged today

3 The nurse should delegate the care of the 81-year-old client with heart failure and emphysema. This client was admitted 3 days ago and has a stable medical status. The nurse would want to assess the client recently admitted with exacerbation of COPD and the 25-year-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. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management 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. 0

128 MCSA A nurse is explaining to a woman considering pregnancy how rubella is transmitted. The nurse determines that the teaching session had the desired outcome if the client states that rubella is transmitted by: 1. The airborne route. 2. Contaminated food. 3. The droplet route. 4. Direct contact.

3 The nurse would determine that the client understood the information if the client stated rubella is transmitted by the droplet route. Clients with rubella are placed in droplet precautions, as the causative agent is transmitted by particle droplets larger than 5 microns. The other responses are factually incorrect. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Adult Health: Immunological 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. 0

105 MCSA A nurse is caring for a client with pneumonia. ABG results are pH 7.49, PaCO₂ 32 mmHg, HCO₃^- 28 mEq/L, PaO₂ 89 mmHg. This nurse analyzes these results as: 1. Metabolic acidosis, uncompensated 2. Metabolic alkalosis, uncompensated 3. Mixed respiratory and metabolic alkalosis, compensated 4. Respiratory acidosis, uncompensated

3 The pH is elevated, HCO₃^- is elevated, and PaCO₂ is low. This indicates that there is a mixed respiratory and metabolic alkalosis. Clients with pneumonia are prone to develop respiratory alkalosis. Option 1 is incorrect because the HCO₃^- level alone would be decreased. Options 2 and 4 are incorrect because the ABG values do not reflect these conditions. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Respiratory Note the critical word <i>pneumonia</i> 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. Choose option 3 over 4 because the high pH is associated with alkalosis.

208 MCSA The nurse would intervene after noting another nursing staff member take which of the following actions in the care of a child who has had surgery for clubfoot? 1. Applying ice bags to the foot and keeping the ankle and foot elevated on a pillow 2. Checking for drainage or bleeding and observing for swelling around cast edges 3. Administering pain medication immediately when it is due and covering the cast with blankets 4. Performing neurovascular status checks every 2 hours and providing diversional activities

3 The postoperative care of the child undergoing repair of clubfoot would not include administering pain medication immediately when due and covering the cast with blankets. Medication for pain should be administered as needed, and the cast should not be covered 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. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management 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. 0

248 MCSA A 12-year-old boy has signs of precocious puberty. He is 5 feet 7 inches tall, has a deep voice, and has started to shave his facial hair. His friends are envious of his 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? 1. Neither of the child's parents is 6 feet tall. 2. The child doesn't eat enough nutritious food. 3. The early presence of sex hormones stimulates closure of the epiphyseal growth plates, resulting in short stature in the future. 4. Few children attain heights above 6 feet and become professional basketball stars.

3 The premature secretion of testosterone promotes the closure of the epiphyseal growth plates. Many of these children appear very tall around sixth grade, but their friends eventually catch up and surpass them in linear growth. Application Physiological Integrity: Physiological Adaptation Teaching and Learning Child Health 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. 0

292 MCSA The nurse has conducted client teaching with the mother of a 4-year-old child who has been exposed to chickenpox. In evaluating the effectiveness of the instruction, the nurse determines that the mother needs additional information after the mother makes which statement? 1. "I should monitor my child for Reye syndrome, which is a complication of chickenpox." 2. "My child should not visit my pregnant sister at this time." 3. "During the prodomal period, my child will have pox all over his body." 4. "Chickenpox is a viral infection that can be spread to other children."

3 The prodromal period is the time between the initial symptoms and the presence of the full-blown disease. The rash would not be apparent during this time. All the other statements are correct. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Evaluation Child Health 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. 0

267 MCSA The nurse has begun CPR on a 5-year-old child. The nurse times the rate of ventilation to achieve how many breaths per minute? 1. 8 2. 10 3. 20 4. 30

3 The proper ventilation rate for a child or infant is 12 to 20 breaths per minute, which is the same as delivering one breath every 3 to 5 seconds. Ventilation rates of 8 (option 1) or 10 (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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Cardiovascular 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. 0

368 MCSA A middle-aged woman presents with signs and symptoms of urinary tract infection. The most likely causative agent is: 1. <i>Staphylococcus aureus</i>. 2. <i>Treponema pallidum</i>. 3. <i>Escherichia coli</i>. 4. <i>Prions</i>.

3 The proximity of the anus to the urethra in female clients increases the risk for infection from bacteria normally found in the colon, such as <i>E. coli</i>. Prion disease is similar to viruses. <i>Staphylococcus</i> is responsible for many infections such as sepsis, cellulites, and toxic shock syndrome; <i>Treponema</i> causes spirochetal infections. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological 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. 0

211 MCSA A client has been admitted to the hospital with chest pain. The pain has not been relieved after one dose of nitroglycerine (NTG) sublingually. Upon monitoring the vital signs (VS), the nurse notices that the blood pressure has dropped to 126/84 from 130/90. Which of the following actions should the nurse take next? 1. Notify the physician. 2. Obtain an electroencephalogram (EEG). 3. Give another dose of nitroglycerine. 4. Add a dose of nitroglycerine paste.

3 The standard protocol is to administer up to three doses of NTG 5 minutes apart as long as the vital signs remain stable. After three doses, the physician should be called if pain is unrelieved. An electrocardiogram (ECG) may be ordered, but not an EEG (to measure brain waves). Using NTG paste, a longer acting form of the medication, is not appropriate at this time. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology 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. 0

321 MCSA The school nurse is teaching teenagers about how the human immunodeficiency virus (HIV) is spread. The students state they know about blood transfusions, IV drug use, and sexual contact, but question how babies can be born with HIV. The nurse explains that babies can receive the HIV virus: 1. On the genes from the father. 2. On the chromosome from either parent. 3. During delivery from maternal contact. 4. In the nursery from shared equipment.

3 Transmission is by blood or body fluid contact. It is not an inherited disorder. Equipment is not shared in the nursery, but the virus can be spread only if the contact involves blood or body fluid. Application Safe Effective Care Environment: Safety and Infection Control Teaching and Learning Child Health Since HIV is a blood borne pathogen, look for the option that would have blood exposure. 0

357 MCSA Which of the following is correct concerning varicella zoster? 1. It is caused by the influenza virus. 2. It is usually asymptomatic. 3. Painful lesions appear to follow the path of a dermatome. 4. Interferon stimulates viral replication

3 Varicella zoster results from reactivation of a latent virus in sensory cells of the dorsal root ganglion. Activation tends to follow the nerve path. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological The key characteristic of varicella zoster is pain along a dermatome. 0

314 MCSA A young infant is admitted to the pediatric unit with a diagnosis of sepsis. The nurse is completing a nursing assessment. The priority assessment for this infant would be which of the following? 1. Skin integrity 2. Temperature 3. Jaundice 4. Respiratory function

4 Altered temperature, jaundice, and respiratory distress are all symptoms of sepsis in infants. Respiratory function is the highest priority. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Planning Child Health Recognize that all responses are correct for this child. Consider which diagnosis would have the highest priority. 0

363 MCSA Which of the following is true of purified protein derivative (PPD) and tuberculosis? 1. It is used to detect current infection. 2. It is used to prevent tuberculosis. 3. It is used to detect previous exposure of mycobacterial infection. 4. It is used to neutralize toxins produced by the tuberculosis bacillus.

3 While the PPD skin test can detect previous exposure to the tuberculosis bacillus, it does not necessarily establish the presence of active infection. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This requires application of knowledge that PPD is used to screen for TB exposure. Eliminate the options that do not address detection of exposure. 0

425 MCSA A 3-year-old child is admitted to the hospital to rule out an infection. Which diagnostic test does the nurse anticipate being ordered that is likely to differentiate an infection from an allergic response? 1. Hemoglobin and hematocrit 2. Red blood cell count 3. White blood cell differential 4. Platelet agglutinization

3 White blood cells are one component of the general nonspecific immune response. They are among the first responders stimulated by a pathogenic organism. A white cell differential can often determine if the illness is of bacterial, viral, or allergic origin. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Child Health Recall that a WBC count can determine infections. The WBC with differential can also determine if an allergic reaction has occurred. 0

346 MCSA A client has a WBC of 15,000, of which 60 percent are segmented neutrophils and 3 percent are bands. An antibiotic is prescribed. Three days later the WBC remains at 15,000; 62 percent segs and 10 percent bands. This most likely indicates: 1. The infection is resolving. 2. The client is immunocompromised. 3. The infection is severe or prolonged and not responding to antimicrobial agents. 4. There is a shift to the right in the differential.

3 With bacterial infection there is an increased need for neutrophils. When the percentage of immature neutrophils (bands) increases at a greater rate than mature neutrophils (segs), it is an indication that the infection is severe or prolonged. This is often referred to as a shift to the left. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Hematological Note that the WBC remains the same, making options 1 and 3 incorrect while bands and segs are increased, making option 4 incorrect. 0

241 MCSA A 70-year-old client with chronic obstructive pulmonary disease (COPD) is taking theophylline (Theo-Dur). A blood level is drawn and the result is 25 mg/dL. What explanation by the nurse helps the client understand this lab result? 1. "Your dose of theophylline needs to be increased." 2. "Your blood level is low because the dose was based on total body weight instead of lean body weight." 3. "The lab value could be high because of your age. We may have to decrease the dosage of your medication." 4. "I am sure that lab value is incorrect. Theophylline levels are never that high."

3 With increased age, there is an increased sensitivity to xanthines. Also, there could be other disease processes that may lead to this elevated value. The dose of theophylline should be decreased to get the blood level to the 10 to 20 mg/dL range. Theophylline doses should be based on lean body weight to prevent entering the medication into the adipose tissue. Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Analysis Pharmacology 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. 0

439 MCSA A mother of twins calls the office and speaks to the nurse concerning a rash that has developed on both children since taking an antibiotic prescribed 5 days ago. The nurse knows that this is most likely a: 1. Type I hypersensitivity reaction. 2. Type II hypersensitivity reaction. 3. Type III hypersensitivity reaction. 4. Type IV hypersensitivity reaction.

3 You should have recognized this as serum sickness, a reaction a week after ingestion of a drug. Serum sickness is a type III hypersensitivity reaction where formation of IgG or IgM antibody-antigen complexes occur in the blood. Comprehension Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about hypersensitivity reactions. 0

275 SEQ A nurse enters an adult client's room and says, "Good morning!" while doing initial shift rounds after receiving report. The client does not respond. Put the nurse's actions in order of priority. Click and drag the options below to move them up or down. 1. Call for someone to announce a code blue. 2. Open the airway. 3. Shake the client's shoulder and ask, "Are you okay?" 4. Take the manual resuscitation bag from the head of the bed and give two breaths.

3, 1, 2, 4 The first action of the nurse is to establish unresponsiveness. This can be done by shaking the shoulder and asking if the client is okay. The subsequent actions of the nurse would be to call for help (option 1), open the airway (option 2), and ventilate the client (option 4). Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Cardiovascular 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. 0

468 MCSA The most common transplanted organ affected by graft-versus-host disease (GvHD) is which of the following? 1. Kidney 2. Liver 3. Heart 4. Bone Marrow

4 Graft-versus-host disease is most common with bone marrow transplants. When immunocompetent graft cells recognize host tissue as foreign, a cell-mediated immune response occurs. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about GvHD. 0

277 SEQ A nurse who is walking through a parking lot at the mall notices an adult male who calls out for help before collapsing on the ground. What should the nurse do to perform basic life support correctly? Place the following steps in the correct sequence by clicking and dragging the options below to move them up or down. 1. Perform rescue breathing. 2. Activate the emergency medical system (EMS). 3. Determine unresponsiveness. 4. Position the client, open his airway, and assess for breathing. 5. Check for pulse.

3, 2, 4, 1, 5 Current BLS guidelines include establishing responsiveness as the first step to avoid performing CPR unnecessarily. With the use of AEDs and the benefit of early defibrillation, requesting to get the AED or defibrillator equipment is initiated early in the BLS sequence. Opening the airway, rescue breaths, and assessing circulation follow the recommended sequence. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Fundamentals 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. 0

411 MCMA A child is being treated for human immunodeficiency virus (HIV) infection. In planning health care for this child, the nurse would share information related to which of the following? Select all that apply. 1. Keeping immunizations current 2. Preventing the spread of the organism 3. Encouraging the family to provide home-schooling 4. Encouraging the child to participate in activities with other children 5. Handwashing technique for the entire family

3, 4, 5 The child's immunizations should be kept up-to-date. Live vaccines should be avoided for the child and family. The family will need information on how to protect themselves and how to administer the prophylactic drugs as well as their side effects. The child can safely attend school with proper education of the school personnel. Application Safe Effective Care Environment: Safety and Infection Control Teaching and Learning Child Health Consider all activities which will protect the child and others. 0

133 MCSA A 32-year-old female client who is HIV-positive is receiving treatment at an outpatient clinic. The nurse reviewing the dietary assessment record notes that the client has been skipping meals and progressively losing weight. What dietary interventions would be best for the nurse to suggest to promote weight gain? 1. Have the client keep a food diary and submit it at the next visit so that more information can be obtained regarding food preferences and usual dietary pattern. 2. Tell the client that her weight may fluctuate in response to her menstrual cycle so there is no need to worry for now. 3. Tell the client that additional salt in the diet will help to increase weight. 4. Tell the client that the use of nutrient-dense food and fortified protein shakes will help promote weight gain.

4 A client who is HIV-positive (regardless of sex) is likely to lose weight due to repeated cycle of wasting and malnutrition. The client, who may be unable to merely increase caloric intake, should be instructed in dietary techniques that maximize quality of intake. Option 1 is incorrect—even though a food diary would provide pertinent information, the response allows 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 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. Analysis Physiological Integrity: Basic Care and Comfort Nursing Process: Implementation Foundational Sciences: Nutrition 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. 0

153 MCSA A 28-year-old female client has recently been diagnosed with systemic lupus erythematosus (SLE). Which of the following would be most helpful for the overall management of care? 1. Have the client institute advance directives immediately. 2. Discuss with the client lifestyle modifications that will be needed as the disease progresses. 3. Ascertain information about the client's working environment and suggest limiting work schedule to minimize potential stress. 4. Establish the multidisciplinary healthcare team to help client identify goals.

4 A client who receives a diagnosis of SLE will be profoundly affected by the chronic nature of this autoimmune disease process. The establishment of a healthcare team using a multidisciplinary approach will help the client to identify and realize individual goals. Even 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. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Planning Adult Health: Immunological 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. 0

435 MCSA A person who is HIV-positive starts to exhibit signs of AIDS. The indication that the client has seroconverted would be partially diagnosed by which of the following? 1. Low viral load 2. High CD4 count 3. High white blood count (WBC) 4. High viral load

4 A client with AIDS will usually have a low CD4 count and a high viral load. What is desired is to have a high CD4 count and a low viral load (which should normally be zero). The white blood count will usually show neutropenia. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological This question requires knowledge about viral loads and CD4 levels. 0

264 MCSA Evidence that the outcome of "restore tissue integrity" has been met in a client with a venous stasis ulcer includes: 1. Absence of bleeding. 2. No reports of pain. 3. Increased activity tolerance. 4. No signs of inflammation or infection.

4 A goal of venous ulcer care is for the client to experience no signs of inflammation or infection. This is the goal directly related to tissue integrity. The other options are good outcomes but do not relate directly to the question as stated. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Evaluation Adult Health: Cardiovascular Focus on the term <i>skin integrity</i> 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. 0

164 MCSA Based on the highest risks during this period of life, what would be the focus of the nurse who is setting up a health promotion booth for healthy adults in their thirties? 1. Screenings for breast, cervical, uterine, and prostate cancers 2. Chest x-rays for lung cancer 3. Bone density test for osteoporosis 4. Safety education for accident prevention

4 A healthy 30-year-old has the greatest risks of safety related to lifestyle behaviors: multiple sexual partners, "on the edge" lifestyle (thrill seekers), haphazard dietary intake, speeding, not sleeping enough. Application Health Promotion and Maintenance Nursing Process: Planning Fundamentals 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. 0

151 MCSA The nurse assesses the results of a vancomycin (Vancocin) blood level drawn just prior to the next scheduled intravenous (IV) dose. The nurse would collaborate with the prescriber after drawing which of the following correct conclusions about the result? 1. There is a high serum level, indicating the peak level is too high. 2. This test measures the highest therapeutic concentration and it is low. 3. Toxicity is evident, suggesting the drug's half-life is too short with the frequency prescribed. 4. The drug level is low, indicating the drug dosage and/or frequency should be increased.

4 A serum specimen for peak level is drawn 15 to 30 minutes after IV administration to test for toxicity. Trough drug levels are drawn just prior to administration of the next IV dose to measure whether satisfactory therapeutic levels are being maintained. If the peak is too high, toxicity can occur and the dose needs to be reduced and/or the frequency of administration extended. If the trough is too low, then the dosage and/or frequency of administration need to be increased. Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Analysis Pharmacology 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 <i>just prior to</i> 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. 0

382 MCSA The white blood cell (WBC) count of a client with systemic lupus erythematosus (SLE) shows a shift to the left. Which nursing diagnosis reflects the highest priority for this client? 1. Ineffective health maintenance 2. Impaired skin integrity 3. Ineffective individual coping 4. Ineffective protection

4 All identified nursing diagnoses are of concern for a client with SLE. However, the results of the laboratory test demonstrate an increased risk for infection that is due to the disease process and/or possible treatment measures such as steroids and immunosuppressive agents. A shift to the left in a WBC differential indicates an increased number of immature cells, suggesting infection. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Planning Adult Health: Immunological 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. 0

429 MCSA A child is being worked up for allergies. The mother asks how the diagnosis will be made. The nurse explains that diagnosis of allergies is based on: 1. Medical history of urticaria alone. 2. IgG levels. 3. Decreased eosinophils count. 4. RAST test.

4 Allergies are confirmed by a RAST test. RAST is a radioallergosorbent test that detects IgE antibodies that are part of the allergic response. Urticaria is itching and is symptomatic of allergies and other diseases, and an increase in eosinophils is diagnostic of allergies. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Child Health 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. 0

398 MCSA An infant is admitted to the pediatric unit with a diagnosis of sepsis. The nurse is completing a nursing assessment. The priority assessment for this infant would be 1. Skin integrity. 2. Temperature. 3. Jaundice. 4. Respiratory function.

4 Altered temperature, jaundice, and respiratory distress are all symptoms of sepsis in infants. Respiratory function is the highest priority because without an adequate airway and breathing, the client cannot maintain life. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Child Health 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. 0

477 MCSA The nurse discusses the prevention and management of allergic reactions with a beekeeper who has developed a hypersensitivity to bee stings. The nurse identifies a need for additional teaching when the client states: 1. "I need to think about a change in my occupation." 2. "I should wear a Medic-alert bracelet indicating my allergy to bee stings." 3. "I will learn to administer epinephrine so that I will be prepared if I am stung again." 4. "I will need to take maintenance doses of corticosteroids to prevent reactions to further stings."

4 Although a change in occupation may be wise, the beekeeper can practice cautious steps and preventative measures to protect self. A Medic-alert bracelet is highly suggestive and epinephrine (Epi-Pen) should be with him always. Use of corticosteroids as a maintenance dose is not recommended because of the vast majority of side effects. Analysis Health Promotion and Maintenance Nursing Process: Evaluation Adult Health: Immunological Use the process of elimination to determine the correct answer. 0

370 MCSA A client with an infection caused by amebiasis will most likely have gastrointestinal symptoms. Another site that could be affected is the: 1. Lung. 2. Brain. 3. Kidney. 4. Liver.

4 Amebic infection can be carried via the blood to other organs, with the liver as the most common site, causing liver abscess. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological Recall that the liver is structurally close to the GI tract. 0

405 MCSA A child is being seen in ambulatory clinic for vague symptoms. A CBC with differential is drawn. The nurse notes that the basophil count on the CBC is elevated. The nurse concludes that the problem is probably: 1. Allergic in nature. 2. Viral-based. 3. Bacterial in nature. 4. A chronic condition.

4 An elevated basophil count is associated with a chronic infection, inflammatory reactions, or stress. It is not associated specifically with allergy, viral infection, or bacterial infection. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Analysis Child Health Knowledge of the laboratory values and possible findings will help to choose the correct answer. 0

306 MCSA The spouse of a postal worker who contracted cutaneous anthrax asks the nurse whether this communicable disease can be treated. Which of the following responses by the nurse is most appropriate? 1. "No, there is only supportive care available for the itching associated with skin lesions." 2. "No, although we will be ready to provide aggressive respiratory support measures if needed." 3. "Yes, the infection can be treated with antiviral agents and immune globulin." 4. "Yes, the infection can be treated with antibiotics such as ciprofloxacin or erythromycin."

4 Anthrax is caused by a bacterium and is therefore amenable to treatment with antibiotics. Antivirals and immune globulin play no role in treating this disease, and the statements in options 1 and 2 are incorrect because they indicate no treatment is available. Analysis Physiological Integrity: Physiological Adaptation Communication and Documentation Adult Health: Communicable Disease 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. 0

488 MCSA The nurse has conducted discharge teaching for a client diagnosed with myasthenia gravis. The nurse evaluates that the client understood the instructions given with regard to the administration of anticholinesterase medication if the client takes the medication: 1. On a full stomach. 2. Only at night. 3. With 8 ounces of milk. 4. 30 minutes prior to meals.

4 Anticholinesterase medications are aimed at symptom management. These medications should be taken prior to eating to help the client chew and swallow and to minimize gastric upset. Taking this medication at night may not provide symptom relief and since absorption is variable, the client may not be assured of receiving the correct dose. The medication does not have to be taken with milk in order to minimize gastric upset. Taking the medication on a full 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. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Evaluation Adult Health: Immunological Recall that an empty stomach is often optimal to enhance medication absorption. 0

234 MCSA A priority nursing action needed following a full body scan would include which of the following actions by the nurse? 1. Pain assessment due to discomfort of the actual procedure 2. Vital signs to assess for possible bleeding 3. Prophylactic antiemetic due to radiation exposure causing nausea 4. Therapeutic communication to reduce possible anxiety caused by outcomes

4 Anxiety reduction is needed when the client is waiting for the outcome of tests to assist them in processing their feelings and exploring their options based upon the results of the test. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Implementation Adult Health: Oncology 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. 0

483 MCSA A client has an unexplained weight loss of more than 10 percent of ideal body weight (IBW) and voices nonspecific complaints of fatigue and nausea over the last 6-month period. The nurse should place the highest priority on further assessing the client when the client makes which of the following statements? 1. "I have had a low-grade fever for the past week." 2. "I had a blood transfusion several years ago after having surgery." 3. "I have been taking vitamin supplements on a daily basis for the last 2 weeks." 4. "I have been tested for HIV in the past, but the results were negative."

4 Any client who presents with unexplained weight loss and persistent nonspecific complaints of fatigue and nausea should be evaluated with regard to HIV status. Testing measures are not always conclusive and it is not apparent from the client's statement exactly what specific tests were administered. Low-grade fever does not correlate directly with the presence of HIV. Vitamin supplements could be considered to be supportive and protective. A history of blood transfusion may prove to warrant further assessment but it is not the highest priority at the present time. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about the importance of HIV screening. 0

224 MCSA The nurse is teaching a class on newborn care to a group of expectant parents. In explaining why the parents need to protect the infant from heat loss, the nurse should discuss that the characteristic of the infant's skin that is responsible for heat loss is: 1. Lanugo. 2. Nonfunctioning sebaceous glands. 3. Nonfunctioning apocrine glands. 4. Thinner skin.

4 At birth, the infant's skin is thin with little subcutaneous fat. In addition, the infant has a greater proportion of body surface area relative to the amount of water present in the skin. Lanugo is shed within a few weeks of birth and has no relationship to heat loss. Sebaceous glands and apocrine glands are immature in the infant but are not related to heat loss or temperature regulation. Application Health Promotion and Maintenance Teaching and Learning Maternal-Newborn Specific information on the functions of the skin is needed to answer the question. Look at the critical word <i>newborn</i> and think about the characteristics of newborn skin to help make a selection. 0

371 MCSA Which of the following properties would allow distinction between Hepatitis A and Hepatitis B infection? 1. Jaundice 2. Fever 3. Alanine aminotransferase (ALT) level 4. Incubation period

4 Both forms of hepatitis may result in jaundice, fever, and elevated liver enzymes, but the incubation period for Hepatitis B is greater than that for Hepatitis A. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological Use the process of elimination to eliminate options 1, 2, and 3 as they occur with both Hepatitis A and B. 0

492 MCSA An HIV-positive client now presents with a CD₄ count of &lt; 200/ul and invasive cervical cancer. How would the nurse evaluate these findings in terms of current CDC definitions? 1. The client has seroconverted. 2. The client is HIV-positive. 3. The client is in the latent period of the disease process. 4. The client has acquired immunodeficiency syndrome.

4 CDC case definition of AIDS for adults states that the two factors described in the question are diagnostic of progression to AIDS. Seroconversion and positive HIV status has already occurred. The latent period is considered to be one in which the individual is asymptomatic. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about HIV clients. 1

312 MCSA The child has been diagnosed with mumps. The home-health nurse has given the mother instructions on caring for the child during the acute period. Which statement by the mother indicates a need for additional education? 1. "I can give my child acetaminophen for fever." 2. "My child will be more comfortable if I give him fluids and soft foods." 3. "I should watch my child for headache and vomiting." 4. "I will give my child antibiotics every four hours around the clock."

4 Children with mumps are uncomfortable but rarely very ill. Give non-aspirin analgesics and antipyretics to control fever and pain. Swallowing and chewing may be painful so give fluids and soft foods. Be alert to signs of complications such as headache, stiff neck, vomiting, and photophobia which may indicate meningeal irritation. Antibiotics are not prescribed. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Evaluation Child Health 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. 0

366 MCSA The most serious disadvantage of clinical use of chloramphenicol (Chloromycetin) is the: 1. Nausea and vomiting it causes. 2. Slow and incomplete absorption from the gastrointestinal tract. 3. Ineffectiveness when given by mouth. 4. Possibility of bone marrow suppression.

4 Chloramphenicol is reserved for serious infection because it may cause bone marrow suppression. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology Look for bone marrow suppression when side effects or disadvantages of chloramphenicol are requested. 0

486 MCSA Which one of the following measures would be beneficial in helping a client with a past history of anaphylaxis to develop a plan for handling possible allergic reactions? 1. Have acetaminophen (Tylenol) readily available. 2. Have acetylsalicylic acid (ASA) readily available. 3. Have diphenhydramine (Benadryl) readily available. 4. Have an EpiPen (Epinephrine) readily available.

4 Clients with a past medical history of anaphylaxis should have epinephrine readily available for emergencies because it is the drug of choice for treatment. Tylenol and ASA will not mediate the chemical response to prevent anaphylaxis. Benadryl, although an antihistamine, may not be effective enough to prevent a full-blown anaphylactic response. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Planning Adult Health: Immunological This question requires knowledge about anaphylaxis. 0

146 MCSA A client receiving hydroxyamphetamine (Paredrine) for open-angle glaucoma demonstrates an understanding of the medication's serious side effects when informing the health care provider of which of the following symptoms? 1. Stinging on instillation 2. Occasional headache 3. Occasional brow ache 4. Confusion

4 Confusion and increased heart rate are signs of toxicity or adverse side effects of hydroxyamphetamine. Stinging, headache, and brow ache are usual side effects of hydroxyamphetamine. Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Evaluation Pharmacology 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. 0

394 MCSA The nurse would expect which of the following findings in a client with an immunologic disorder associated with an HLA antigen? 1. Acute course 2. Frequent effects on reproductive capacity 3. Genetic determination 4. Chronic and possibly subacute course

4 Diseases with HLA associations have poorly understood etiologies, are usually chronic or subacute in nature, and have limited effect on reproductive capacity. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological 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. 0

193 MCSA A client is receiving radiation to the head and neck area for treatment of cancer. What interventions would you use to help the client's complaint of a dry mouth? 1. Have client eat prior to radiation therapy. 2. Encourage the client to eat larger portions of food. 3. Advise the client to use mouthwash. 4. Suggest the use of sugar-free candies.

4 Dry mouth can be a common complaint of clients undergoing radiation therapy. Using sugar-free candies or gum will help to stimulate the flow of saliva and ease the discomfort that the client is experiencing without contributing to dental caries or lack of appetite from sugar 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. Application Physiological Integrity: Basic Care and Comfort Nursing Process: Implementation Foundational Sciences: Nutrition 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. 0

339 MCSA Which of the following client laboratory test results would likely be elevated with nematode infestation? 1. Neutrophils 2. Liver enzymes 3. Red blood cells 4. Eosinophils

4 Eosinophilia is present with allergies and infestation with parasites. Neutrophils are elevated with acute infections and bacterial organisms. Options 2 and 3 are irrelevant. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological White blood cells would be elevated, eliminating options 2 and 3. 0

340 MCSA A nurse researcher is interested in the epidemiology of HIV. This means that the researcher is concerned about which of the following? 1. The causation of the disease. 2. How the disease is transmitted. 3. The most effective treatment regimens. 4. The distribution of the disease in a given population.

4 Epidemiology is the study of how various states of health are distributed in the population. Knowledge Health Promotion and Maintenance Nursing Process: Assessment Adult Health: Immunological Select the option with the word 'population.' 0

432 MCSA A 12-year-old child with positive human immunodeficiency virus (HIV) antibodies is going home from the hospital. Which of the following would be the most important home-going instructions? 1. Growth and developmental milestones 2. Immunization schedules 3. Lab studies and results 4. Prevention of the spread of HIV

4 Families need to know that casual contact cannot spread HIV. However, basic infection control practices must be maintained to prevent exposure through body fluids. Growth and development milestones and immunization schedules are routine elements of teaching, and 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. Analysis Safe Effective Care Environment: Safety and Infection Control Teaching and Learning Child Health The spread of infection would be a concern for this child whether at home or at the hospital. 0

305 MCSA The nurse is assessing a child in the outpatient clinic who has fever, lethargy, nausea, and vomiting. The nurse notes that the child's cheeks have the appearance of being wind-burned or slapped. The nurse suspects which of the following childhood communicable diseases? 1. Chickenpox 2. Measles 3. Diphtheria 4. Fifth disease

4 Fifth disease is characterized by flulike symptoms such as fever, malaise, nausea, and vomiting, and by the characteristic "slapped cheeks" appearance. This finding is not characteristic of chickenpox, measles, or diphtheria. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Communicable Disease 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. 0

160 MCSA A client had assumed a new identity and gained employment when he was found 400 miles away from his home. The mental health nurse interprets that this client's behavior is characteristic of: 1. Amnesia. 2. Akathisia. 3. Confabulation. 4. Fugue state.

4 Fugue states are characterized by wandering or moving away from one's familiar place with an amnesia for the complete past, including self. The person often assumes a new identity for the duration of the fugue. Amnesia is simply a loss of memory owing to brain damage or to severe emotional trauma. Akathisia is an abnormal condition characterized by restlessness and agitation. Confabulation is replacement of gaps in memory with imaginary information. Analysis Psychosocial Integrity Nursing Process: Analysis Mental Health 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. 0

351 MCSA The drug of choice for systemic fungal infections is: 1. Nystatin (Mycostatin). 2. Penicillin (Penn-VK). 3. Isoniazid (INH). 4. Amphotericin B (Fungizone).

4 Fungizone and Mycostatin are both antifungal agents. Mycostatin is most commonly used for topical application, while Fungizone is used systemically. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology Select the antifungal agent that can be given intravenously. 0

166 MCSA The nurse is caring for a client who has just been diagnosed with Graves' disease. Client education regarding medication therapy needs to include which of the following? 1. Atropine 2. Thyroxine 3. Insulin 4. Propylthiouracil (PTU)

4 Graves' disease is caused by elevated levels of thyroid hormone. Clients experience tachycardia, nervousness, insomnia, increased heat production, and weight loss. Medication 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 does not need insulin, because the pancreas is not affected by Graves' disease (option 3). Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Teaching and Learning Pharmacology 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. 0

322 MCSA A child is to receive "allergy shots." The mother tells the office nurse that she is a nurse and asks why she can't give her child his shots at home because she was trained to give insulin injections to the family pet. The office nurse should respond: 1. "That sounds like a good idea, then your child will not be exposed to other children in the office waiting room." 2. "Let me check your injection technique this time, and next time you can give it at home." 3. "No, your insurance company will not pay for allergy shots in the home." 4. "Allergy shots should be given in a controlled environment so you will need to bring your child in for his shots."

4 Hyposensitization injections carry the risk of allergic reaction including anaphylaxis. They should only be given in a controlled environment with emergency drugs and equipment on hand. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Child Health The core concept in this question is maintaining a safe environment for the child. 0

358 MCSA Which of the following viral infections has been associated with Guillian-Barré syndrome? 1. Human immunodeficiency virus (HIV) 2. Epstein-Barr 3. Cytomegalovirus (CMV) 4. Influenza

4 Influenza has been associated with Guillian-Barré syndrome, which causes progressive paralysis. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological Eliminate options 1, 2, and 3 which have no known association with Guillian-Barré. 0

190 MCSA A female client has been diagnosed with a dependent personality disorder. Which statement is likely to be her response to the nurse's suggestion that she complete her morning care? 1. "I'll have no problem in deciding what to wear." 2. "I think you should wear more makeup." 3. "I think this outfit looks good on me." 4. "What do you think I should wear?"

4 It is difficult for individuals diagnosed with dependent personality disorder to make decisions on their own (options 1 and 3); rather, they try to get others to make decisions for them. This characteristic is reflected in DSM-IV diagnostic criteria. They would be disinclined to make critical remarks (option 2) related to their need for support from others. Analysis Psychosocial Integrity Nursing Process: Implementation Mental Health The critical word in the stem of the question is <i>dependent</i>. 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. 0

380 MCSA To enhance meeting the psychosocial needs of a client on transmission-based precautions, the nurse should place highest priority on which of the following? 1. Letting the client sleep to build up stamina 2. Maintaining strict precautions when entering and leaving the room so that the client feels he or she is getting the best care 3. Providing client care within a limited time frame to maintain isolation and keep client safe 4. Providing the client with diversional activities to enhance sensory input

4 It is important to assess the psychosocial needs of a client on transmission-based precautions and to intervene to provide sensory stimulation for the client. Isolation procedures can cause clients to become depressed and withdrawn and to sleep excessively. Although it is important 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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Planning Adult Health: Immunological 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. 0

498 MCSA A client who is diagnosed with myasthenia gravis (MG) had not been compliant with his medication regimen and has missed several doses of pyridostigmine (Mestinon). For which complication would the nurse monitor? 1. Gastrointestinal symptoms 2. Vertigo 3. Bradycardia 4. Respiratory distress

4 The client should be monitored for myasthenic crisis, which is often a result of missed or under medication. The other options (gastrointestinal symptoms, vertigo, and bradycardia) are associated with cholinergic crisis. Cholinergic crisis is usually the result of overmedication. Both complications are viewed as acute in nature and may require airway assistance. The nurse must be acutely aware of the potential for clients with MG to have these types of complications. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological Consider the respiratory depression in MG as a priority. 0

297 MCSA A child has been diagnosed with mumps, and the mother has been given instructions on caring for the child during the acute period. Which statement by the mother indicates a need for additional education? 1. "I can give my child acetaminophen for fever." 2. "My child will be more comfortable if I give him fluids and soft foods." 3. "I should watch my child for headache and vomiting." 4. "I will give my child antibiotics every four hours around the clock."

4 Mumps is a viral infection and thus antibiotics will not be effective. The other statements are true. Acetaminophen, fluids, and soft foods are helpful, and the mother should watch for vomiting and headache. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Evaluation Child Health 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. 0

353 MCSA Which of the following is generally associated with spirochetal infections? 1. Skin rash 2. Unproductive cough and fever 3. Toxic shock 4. Neuropathies

4 Neuropathies are usually associated with spirochetal infections along with lymphadenopathy, 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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological This item requires application of learned factual information. 0

203 MCSA A client has been referred for dietary teaching regarding the management of hepatitis. The nurse would base development of nutritional goals on which of the following pieces of information? 1. The type of hepatitis that the client has, as this will affect the treatment 2. The need for tube feedings to allow the liver to rest and regenerate 3. That dietary fats should be limited 4. That the diet should be high in calories and high in protein

4 Nutritional goals for a client with hepatitis are aimed at providing a diet that is high in calories (3,000-4,000 kcal) and high in quality protein (1.5-2.0 g/kg). The diet should also be adequate in carbohydrates to spare protein and fat, provide concentrated calories, and improve the 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. Application Physiological Integrity: Basic Care and Comfort Nursing Process: Planning Foundational Sciences: Nutrition The critical word in the stem of the question is <i>hepatitis</i>. From this point, analyze that the client recovering from hepatitis needs a high-calorie, high-protein diet for healing to make the correct selection. 0

283 MCSA The nurse has been performing CPR on an adult client. The nurse notes that after a series of cycles of compressions and ventilations have been completed, 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? 1. Keep the client flat on his back, and elevate the head of the bed 30 degrees. 2. Place the client on oxygen by face mask. 3. Continue rescue breathing until the client no longer tolerates the procedure. 4. Place the client on his side, moving his head and torso simultaneously without twisting.

4 Once breathing and circulation return, the recommended position if no injury is the "recovery" position. It has been found to be optimal to keep the airway open, and also will reduce the risk of aspiration if the client has an emesis. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Fundamentals 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. 0

427 MCSA A child's mother tells the nurse that her child has been on steroids for several months. Which of the following vaccines is contraindicated? 1. Tetanus toxoid 2. Recombinant hepatitis B vaccine 3. Poliovirus vaccine inactivated 4. Poliovirus vaccine live oral trivalent

4 Oral polio virus vaccine contains a live virus, which could cause an infection in a child who is immune-depressed as a result of taking steroids. Analysis Health Promotion and Maintenance Nursing Process: Implementation Child Health The word "live" in the option should be a clue to the right response. 0

135 MCSA A client with acute respiratory distress syndrome (ARDS) shows no improvement despite increases in the concentration of oxygen administered. What intervention should the nurse attempt which may improve ventilation-perfusion matching? 1. Transfusion of packed red blood cells 2. Infusion of albumin 3. Positioning supine with head elevated 30 to 45 degrees 4. Prone positioning

4 Placing the client with ARDS in a prone position allows for expansion of the posterior chest wall, which may be effective in enhancing oxygenation. Transfusing red blood cells or albumin does not increase oxygenation in ARDS. Option 3 should have been done as an initial measure. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Respiratory The core issue of the question is an intervention that may increase oxygenation in a client with ARDS. Note the critical words <i>nursing intervention</i> 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. 0

134 MCSA The nurse would assess a 76-year-old client for which common problems that most increases the risk for major complications of heart and lung disease? 1. Taking over-the-counter meds with prescription meds 2. Sharing medications with family and friends 3. Following directions exactly and taking medications on a regular basis 4. Polypharmacy resulting from visits to multiple doctors

4 Polypharmacy is using multiple doctors and multiple pharmacies to get the health care needed often from a variety of specialists. The overall problem is that different doctors may 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. Analysis Health Promotion and Maintenance Nursing Process: Assessment Pharmacology 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. 0

228 MCSA The nurse would implement which of the following as the most important measure on the surgical unit on the first postoperative day following surgical repair of an abdominal aneurysm? 1. Administer anticoagulant therapy. 2. Position the legs in Trendelenburg position. 3. Apply elastic stockings to both legs. 4. Palpate peripheral pulses every 2 to 4 hours.

4 Pulses are assessed frequently to ensure adequate circulation is present and an occlusion or leakage of the graft has not occurred. Pulses should be marked preoperatively so the nurse has a comparison point postoperatively. Pulses may be absent for a short-term postoperatively 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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Cardiovascular Note the critical words <i>first postoperative day</i>. 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. 0

495 MCSA A client who has been diagnosed with scleroderma is complaining of pain in his fingertips and pallor followed by blanching of the extremities and redness. The nurse communicates in intershift report that the client reports symptoms of which of the following disorders? 1. Joint swelling and effusion 2. Symmetric polyarthritis 3. Swan-neck deformity 4. Raynaud's phenomenon

4 Raynaud's phenomenon is a common presentation in clients who have scleroderma. It is characterized as a vasospastic disease of the periphery that causes color changes ranging from pallor to reactive hyperemia. Joint swelling, effusion, and symmetric polyarthritis can be seen in other autoimmune processes such as systemic lupus erythematosus and rheumatoid arthritis. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about scleroderma. 0

362 MCSA Which of the following is associated with streptococcal infection? 1. Tuberculosis 2. Pelvic inflammatory disease 3. Toxic shock syndrome 4. Arthritis

4 Scarlet fever, rheumatic fever, and glomerulonephritis can all result from streptococcal bacteria. Tuberculosis is caused by M. tuberculosis; PID by Neisseria gonorrhoeae; and toxic shock by staphylococcus. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological Use process of elimination to eliminate those options not associated with streptococcal infection. 0

263 MCSA An 18-year-old client is seen in the Emergency Department with sudden onset of severe scrotal pain, nausea, and an absent cremasteric reflex. The nurse should suspect which of the following conditions? 1. Hydrocele 2. Prostatitis 3. Varicocele 4. Testicular torsion

4 Severe scrotal pain, nausea, and absent cremasteric reflex are characteristic of testicular torsion. Severe pain and an absent cremasteric reflex are not typical symptoms of the disorders listed in the other options. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Renal and Genitourinary Note the critical word <i>sudden</i> 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 <i>torsion</i> indicates twisting, which is compatible with the symptoms described by the client. 0

462 MCSA The wife of a client diagnosed as HIV-positive states she will never be able to have sexual intercourse again. The nurse should respond with: 1. "It probably would be best not to engage in sexual activity." 2. "It shouldn't be a problem as long as oral or anal sex is avoided." 3. "Perhaps counseling for you and your husband would help." 4. "Sexual activity can be resumed, but you must always have protected sex."

4 Sexual activity if one partner is positive for HIV can be resumed as long as protection is always used. Option 1 is inappropriate and option 2 is incorrect. Option 3 may need to occur but seems to be an answer that avoids the client's concern at this time. Application Health Promotion and Maintenance Nursing Process: Implementation Adult Health: Immunological This question requires knowledge about HIV states. 0

143 MCSA A client is admitted to the hospital with a primary diagnosis of hip fracture and a secondary diagnosis of Sjögren's syndrome. Which one of the following orders would be of most concern with regard to the nutritional status of the client? 1. NPO after midnight for surgery with a 7:30 a.m. case 2. IV of lactated Ringer's at 125 mL/hr 3. Maintain diet as tolerated 4. Restrict oral fluids to 1,000 mL/day

4 Sjögren's syndrome is an autoimmune disease that destroys exocrine glands in the body, and leads to a generalized "dryness" of body systems. The restriction of fluids is a concern because the use of fluids helps to keep the oral cavity moist. There is no information to suggest that the client has a need for fluid restriction due to other disease processes so this order should be clarified. All of the other options are reasonable for this client. Analysis Physiological Integrity: Basic Care and Comfort Nursing Process: Planning Foundational Sciences: Nutrition 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. 0

247 MCSA A nurse is teaching a new group of hospital teen volunteers about the chain of infection. Which of the following items would the nurse include as an example of how an infection would spread through droplets? 1. Nonsterile surgical instruments 2. Soiled linens 3. Contaminated dressings 4. Sneezing and coughing

4 Sneezing and coughing are examples of modes of transmission, whereby droplet nuclei can be transmitted directly to a susceptible host. Application Safe Effective Care Environment: Safety and Infection Control Teaching and Learning Fundamentals 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. 0

440 MCSA In working with clients with HIV, the nurse knows that the illness is more difficult to manage once AIDS has been diagnosed. Which of the following best characterizes HIV disease? 1. Individuals who test positive are carriers and considered contagious. 2. Clinical manifestations have a characteristic and predictable sequence. 3. The HIV virus invades cells primarily via the bloodstream. 4. Symptoms result from opportunistic pathology.

4 Symptoms of HIV infection are vague and nonspecific. Characteristic manifestations of HIV disease resulting from opportunistic infections and neoplasm make treatment difficult. Invasion may be from sexual contact as well as blood contact. HIV is not always predictable because the virus can lie dormant for many years. There are really no carrier states in HIV. Comprehension Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological This question requires knowledge about HIV/AIDS. 0

320 MCSA A newborn has health problems immediately after birth. The mother tells the nurse that the doctor suspected a TORCH infection, but she does not know what causes this. The nurse would respond that a TORCH is: 1. A viral disease like meningitis. 2. A bacterial infection that causes mental retardation. 3. A blood borne pathogen that is contracted during delivery. 4. An acronym for a group of infections that can harm the fetus.

4 TORCH is an acronym for toxoplasmosis; other, which includes hepatitis and syphilis; rubella; cytomegalovirus; and herpes simplex. These infections are caused by bacteria, viruses, and other organisms. Application Physiological Integrity: Physiological Adaptation Teaching and Learning Child Health Since all the letters in TORCH are capitalized that should be a hint that this is an acronym. 0

187 MCSA The client is admitted with thyroid storm. Assessment reveals: BP 188/102, HR 132 regular, RR 28 full depth and symmetrical, no urine output since admission to the Emergency Department 3 hours ago, alert, and anxious. Which of the following would be the high priority nursing diagnosis for this client? 1. Deficient fluid volume related to decreased absorption as evidenced by no urine output since admission 2. Anxiety related to fear as evidenced by client's appearance 3. Ineffective breathing pattern related to increased metabolism as evidenced by RR 28 4. Decreased cardiac output related to increased ventricular workload as evidenced by adverse vital signs

4 Tachycardia, hypertension, and tachypnea increase stroke volume and tissue demand for oxygen, leading to increased cardiac workload and possible heart failure. If fluid volume deficit is present, there is an additional risk for decreased cardiac output. There is insufficient data to determine fluid volume status. The tachypnea is a symptom of the increased metabolic rate. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Endocrine and Metabolic 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. 0

365 MCSA The tetracyclines are identical in their overall mechanism of action and are often used similarly to: 1. Sulfonamides. 2. Penicillins. 3. Isoniazid (INH). 4. Chloramphenicol (Chloromycetin).

4 Tetracyclines and chloramphenicol are identical in mechanism of action and organisms against which they are effective. Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology Select the option most like tetracyclines in action. 0

272 MCSA A nurse witnesses an adult male collapse at the airport and an automated external defibrillator (AED) is brought to the scene. The nurse should do which of the following in utilizing the device? 1. Press the electrodes down firmly, because the client has a hairy chest. 2. Instruct another person at the scene to keep the airway open during delivery of the electric shock. 3. Initiate CPR after 5 minutes if the AED has not restored a perfusing cardiac rhythm. 4. Quickly wipe up the spilled coffee under the victim's chest before using the AED.

4 The client should not be lying in water or other liquid, which could lead to burns or to defibrillating another individual who comes in contact with the liquid during AED shock delivery. The electrodes should not be placed on hairy areas, or the site should be shaved (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). Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Cardiovascular 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. 0

197 MCSA The nurse is working on an orthopedic unit. After receiving intershift report, which client should the nurse assign to the unlicensed assistive person (UAP)? 1. A client with a newly applied cast who has increasing pain despite medication 2. A client with osteoporosis admitted 2 hours ago who fell and fractured the vertebra at L1 3. A client with a below-knee amputation who is anxious because "the leg feels like it's still there" 4. A client who had surgical repair of a fractured left hip 6 days ago and will be discharged to a rehabilitation facility near the end of the day

4 The client that is the most stable and with the fewest needs that the nurse must attend to is the client who is 6 days postoperative and awaiting placement in a rehabilitation facility. The 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. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Adult Health: Musculoskeletal Recall the principles of delegation and that clients who need assessment or teaching need to remain under the direct responsibility of the nurse. 0

124 MCSA A primigravida client of 16 weeks gestation states that she has not yet felt fetal movement. The nurse's best response is: 1. "Your fetus will move any day now. Call me in a week if you don't feel it." 2. "Your fetus will begin moving at about 20 weeks gestation." 3. "You should have been feeling the movement already." 4. "Your fetus has been moving for the past 9 weeks without you feeling it. You will feel it within a month."

4 The embryo's muscles spontaneously contract beginning at 7 weeks. The mother perceives sensations of movement of the fetus from 16 to 20 weeks gestation. A primigravida usually perceives movement closer to 20 weeks. Application Health Promotion and Maintenance Communication and Documentation Maternal-Newborn 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). 0

148 MCSA The nurse observes an unlicensed assistive person (UAP) in the room of a client with severe acute respiratory syndrome (SARS). Which of the following actions by the UAP indicates intervention and further teaching by the nurse is needed? 1. The UAP wears a protective gown, gloves, N95 respirator, and eye protection when entering the room. 2. The UAP does not remove the stethoscope, blood pressure cuff, and thermometer being kept in the room. 3. The UAP removes all personal protective equipment and washes the hands right before leaving the client's room. 4. The UAP visits with the client for 25 minutes.

4 The employee should limit the amount of time in the client's room to minimize exposure. In option 1, the employee is wearing the correct combination of personal protective equipment. In option 3, the employee has followed the correct procedure for exiting the client's room. Equipment required for the care of the isolation client should remain in the client's room to limit exposure to other clients on the nursing unit. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Evaluation Adult Health: Respiratory 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. 0

109 MCSA A client with cancer has a calcium level of 11.8 mg/dL. Which of the following symptoms would indicate a need for the nurse to call the physician for treatment orders? 1. Increased gastric motility 2. Peaked T waves on 12-lead ECG 3. Muscle spasms 4. Muscle weakness

4 The normal calcium level is 9.0-11.0 mg/dL, making this client hypercalcemic. Muscle weakness is a key feature of hypercalcemia due to alterations in excitable membranes. This occurs as a complication in some clients with cancer. Peaked T waves, muscle spasm, and increased gastric motility are signs of hyperkalemia. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Planning Adult Health: Oncology 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. 0

446 MCSA A client reports to the clinic complaining of itching and weeping along the back of her legs. Upon 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: 1. Type I hypersensitivity. 2. Type II hypersensitivity. 3. Type III hypersensitivity. 4. Type IV hypersensitivity.

4 This type of contact dermatitis is commonly a delayed reaction and a type IV hypersensitivity. This reaction is cell-mediated rather than antibody-mediated and delayed 24 to 48 hours. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological This question requires knowledge about hypersensitivity reactions. 0

217 MCSA The nurse working on an adult medical-surgical unit would assign which of the following clients to the licensed practical/vocational nurse (LPN/LVN) under the supervision of the RN? 1. A 45-year-old client who underwent bilateral adrenalectomy the previous day 2. A 66-year-old client being discharged to home following arthroscopy 3. A 24-year old with hemophilia who fractured a leg after falling from a horse yesterday 4. A 53-year-old client with hypertension and chronic renal insufficiency

4 The nurse should delegate the care of the 53-year-old client with hypertension and chronic renal insufficiency. This client has a stable medical status. The nurse would want to assess the client recently admitted following adrenalectomy and the 24-year-old who has hemophilia and 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. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management 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. 0

232 MCSA The nurse working on an adult medical unit would assign which of the following clients to the licensed practical/vocational nurse (LPN/LVN) under the supervision of the RN? 1. A 46-year-old client who will undergo cardiac catheterization later in the morning 2. A 54-year-old client who has osteoarthritis and low back pain 3. A 62-year-old client admitted the previous evening with chest pain 4. A 79-year-old client who has chronic bronchitis and early Alzheimer's disease

4 The nurse should delegate the care of the 79-year-old who has chronic bronchitis and early Alzheimer's disease. This client has a stable medical status. The nurse would want to assess the client undergoing cardiac catheterization and complete the preparation activities for the 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. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management 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. 0

256 MCSA A new staff nurse wants to clarify her responsibilities regarding delegation. To which of the following documents would the nurse mentor refer this nurse? 1. Policy manual 2. Job description 3. ANA standards of care 4. State nurse practice act

4 The state nurse practice act defines the scope of nursing practice in each state. Although there are general principles that apply to all, each state retains the right to formulate its own 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. Application Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management Use knowledge of the source of various regulations to answer the question. If needed, review concepts related to legal governance of nursing practice. 0

253 MCSA The nurse is caring for a 68-year-old male diagnosed with benign prostatic hyperplasia (BPH). Which of the following statements by the client indicates the need for further teaching? 1. "The enlarged prostate gland causes me to get up three times every night to urinate." 2. "The enlarged prostate gland may produce blood in my urine." 3. "I can get urinary tract infections because of the enlarged prostate gland." 4. "I should cut down on the fluids I drink so I won't have to urinate so often."

4 The statements in the first three options correctly describe signs of BPH. Option 4 indicates the need for further teaching because the client should increase his fluid intake (unless contraindicated) to prevent urinary tract infections and lessen dysuria. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Evaluation Adult Health: Renal and Genitourinary The critical words in the stem of the question are <i>need for further teaching</i>. 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. 0

480 MCSA A client who tested positive for HIV 3 years ago is admitted to the hospital with <i>Pneumocystis carinii</i> pneumonia and a CD4 count of 200 mm₃. Based on diagnostic criteria established by the Centers for Disease Control and Prevention, the client is diagnosed as having: 1. Category A: Persistent generalized lymphadenopathy (PGL). 2. Category B. 3. Latent chronic disease. 4. Category C: AIDS.

4 This client has a Category C2, which is an AIDS-indicator condition (pneumonia) and a CD4 count between 200 and 499. Category A: PGL is persistent generalized lymphadenopathy and would not be accompanied by the pneumonia. Category B has several conditions that may occur but <i>Pneumocystis carinii</i> pneumonia is not one of these. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Immunological This question requires knowledge about HIV. 1

114 MCSA The labor and delivery nurse would make it a priority to assess which of the following two newborn body systems immediately after birth? 1. Gastrointestinal and hepatic 2. Urinary and hematologic 3. Neurologic and temperature control 4. Respiratory and cardiovascular

4 To begin life, the infant must make the adaptations to establish respirations and circulation. These two changes are crucial to life. All other body systems become established over a longer period of time (options 1, 2, 3). Analysis Health Promotion and Maintenance Nursing Process: Assessment Maternal-Newborn Use the ABCs—airway, breathing, and circulation—as the strategy for answering this question. 0

127 MCSA The nurse is talking with the unlicensed assistive person (UAP) about time management skills and techniques. Which of the following statements would the nurse make if intending to act as a coach? 1. "You must get the vital signs taken on time or you will be disciplined." 2. "You never report morning blood glucose levels on time." 3. "Your timely response to clients' call lights is exemplary." 4. "It may be helpful if you bring in linens to the client rooms when you restock the gloves."

4 To coach is to give direction and suggestions for improvement. Option 4 illustrates this concept. Option 1 is threatening rather than coaching. Option 2 is a criticism without a suggestion for improvement. Option 3 is helpful as a statement of positive reinforcement but does not specifically give direction for future actions. Analysis Safe Effective Care Environment: Management of Care Communication and Documentation Leadership/Management The critical word in the stem of the question is <i>coach</i>. Use the ordinary definition of the word and choose the option that gives suggestions or advice to improve performance. 0

226 MCSA Which of the following symptoms would the nurse assess for in a client with the most common generalized seizure disorder? 1. Periods of inattention and daydreaming 2. Sudden loss of muscle tone and falling 3. Repetitive small muscle group activity 4. Tonic and clonic activity of the extremities

4 Tonic-clonic seizures are the most common generalized seizures. Periods of inattention and daydreaming characterize an absence seizure. Sudden loss of muscle tone and falling characterize an atomic seizure. Repetitive small muscle group activity characterizes a partial seizure. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Neurological 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. 0

388 MCSA The nurse who is providing care to a group of clients concludes that the client with which of the following problems exhibits a type III immune-complex-mediated hypersensitivity reaction? 1. Transfusion reaction 2. Goodpasture's syndrome 3. Transplant rejection 4. Systemic lupus erythematosus

4 Transfusion and Goodpasture's are examples of type II cytotoxic hypersensitivity reactions and are involved with the activation of complement. Lupus is an example of a type III hypersensitivity reaction, which involves IgG and IgM with the activation of complement. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Immunological 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. 0

118 MCSA A 76-year-old woman visits the ambulatory clinic with reports of having difficulty reading and doing needlework because of visual distortions with blurring of images directly in the line of vision. The peripheral vision assessment by the nurse yields normal findings. The nurse suspects that this client is experiencing which of the following visual problems? 1. Glaucoma 2. Detached retina 3. Cataracts 4. Macular degeneration

4 Visual difficulty caused by distortions and impairment of central vision is common with macular degeneration. Peripheral vision in most cases is normal. The symptoms are not characteristic of glaucoma (loss of peripheral vision), cataracts (gradual deterioration of vision with opacity of lens), or detached retina (sudden change in vision with a sense of a curtain falling over the field of vision). Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Eye and Ear 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. 0

250 MCSA The nurse determines that the <i>highest</i> priority action when caring for a client who has alcohol-withdrawal delirium would be: 1. Reality orientation. 2. Restraint application. 3. Referral to Alcoholics Anonymous. 4. Replacement of fluids and electrolytes.

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. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Planning Mental Health 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. 0

178 MCSA A client who has a history of Graves' disease accompanied by exophthalmos is arriving from surgery. Based on the observations as you note the photo, what should you educate the unlicensed assistive person (UAP) to do? COMP_TEST_AAHBDMS0.jpg 1. Keep the client's room warm to promote comfort. 2. Obtain fingerstick blood glucose every 2 hours twice. 3. Keep the head of the bed flat for 4 hours. 4. Provide eye protection measures for the client.

4 With exophthalmos, the eyelids may not cover and protect the cornea of the eye. Thus, eye protection from the sheets or preventing the hands from accidentally touching the eyes is needed while the client is in bed. With Graves' disease, clients usually experience heat intolerance, thus less covering and a cool room are preferred (option 1). Hyperglycemia is not usually associated with Graves' disease. The head of the bed should be elevated 30 degrees to minimize eye pressure (option 3). Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management 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. 0

257 SEQ The nurse is preparing to enter the room of a client with pneumonia caused by penicillin-resistant <i>Streptococcus pneumoniae</i> (PRSP). The client has a 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. 1. Eye protection 2. Gloves 3. Mask 4. Gown

4, 3, 1, 2 The gown is applied first, as it takes the most time to don. The mask is donned next, followed by eye protection. These items can be more securely applied with ungloved hands. Gloves are donned last, so the gloves can be pulled up to cover the cuffs of the gown. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Fundamentals Rationalize the ordering based on nursing knowledge of standard precautions and surgical asepsis. 0

409 MCMA A toddler is being discharged from the hospital diagnosed with allergies. The child is on corticosteroids and prophylactic antibiotics. The nurse will discuss environmental control of the home and include which of the following suggestions: (Select all that apply.) 1. Cleaning the baby's room with sterile water. 2. Covering the wood floor with carpeting for easier cleaning. 3. Not allowing the dog outside because it will pick up pollens in its coat. 4. Insisting that no one smoke in the house. 5. Storing the out of season clothes in another room.

4, 5 Carpet, bedding, fabrics, pets, dust, and cigarette smoking can cause allergic reactions. Option 1 can be eliminated as the use of sterile water is unnecessary. Analysis Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Child Health Remember that anything that would hold dust should be removed from the child's room. 0

414 MCMA The nurse has explained allergy-proofing the home to the mother of a child with dust allergies. Which statement by the mother indicates a clear understanding of appropriate allergy-proofing? (Select all that apply.) 1. "I'm going to replace the cotton curtains on the window with blinds." 2. "The only toys allowed in his bedroom are his stuffed toys." 3. "I should store his out-of-season clothes in his bedroom." 4. "The mattress and box springs both need to be enclosed in a thick plastic cover." 5. "I will try to clean and vacuum the bedroom frequently to limit dust collection."

4, 5 Cloth items hold in dust. Only essential items should be stored in the child's bedroom, and those should be in drawers or closets. Stuffed animals retain dust and should be removed from the bedroom. Cotton curtains would be preferred over blinds because cotton curtains can be washed frequently. Both the mattress and the bed should be enclosed in special plastic covers to eliminate a source of dust. Analysis Health Promotion and Maintenance Nursing Process: Evaluation Child Health Consider what objects would hold dust and eliminate them from the environment. 0

73 MCSA Which of the following would be an appropriate intervention for the nurse to include in a plan of care for a client with clinical diagnosis of bulimia? 1. Assess for laxative and diuretic possession. 2. Supervise mealtimes to ensure eating. 3. Observe for ritualistic eating patterns. 4. Reward nonpurging behavior with a favorite snack.

Answer: 1 Abuse of laxatives and diuretics is a frequent <i>purging</i> behavior for bulimic clients. Options 2 and 3 pertain to anorexia nervosa clients. In regard to option 4, food should never be used as a reward. Application Physiological Integrity: Basic Care and Comfort Nursing Process: Planning Foundational Sciences: Nutrition The critical word in the question is <i>bulimia</i>. 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.

75 MCSA A parent asks the nurse what to do with rough edges of her child's cast, which are beginning to cause excoriation on the child's skin. Which of the following responses by the nurse describes the appropriate action to take? 1. "Perform good skin care to the skin around the cast edges, with a protective barrier like Vaseline." 2. "Call the physician to have the rough edges of the cast cut away." 3. "Tape a soft towel to the edge of the cast to provide some protection from the rough edges." 4. "Petal the cast edges with strips of adhesive tape, placing the tape from just inside the cast over the edge to outside the cast."

Answer: 4 When a cast is dry, edges that are not smooth or covered by a piece of stockinette should be covered to prevent skin irritation. This can be done by petaling the cast edges with strips of adhesive tape, beginning each strip on the inside of the cast, and folding over the edge to the outside of the cast. Application Physiological Integrity: Physiological Adaptation Communication and Documentation Child Health 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. 0

69 MCSA A client presents to the Emergency Department with a complaint of chest pain. Which serum laboratory test does the nurse check off on the laboratory slip as part of a protocol order to rule out an acute myocardial infarction? 1. LDH⁴ 2. Troponin 3. Amylase 4. CK-MM

Troponin is a sensitive test that indicates damage to the myocardial cells. A CK-MM isoenzyme elevation would indicate skeletal muscle damage. The LDH⁴ isoenzyme is utilized to determine hepatic function and amylase is a digestive enzyme. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Assessment Adult Health: Cardiovascular 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. 1

32 MCSA After correctly positioning a client for a wound dressing change, the nurse sets up a sterile field, placing the wound supplies in the field. The nurse 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? 1. Ensure the client's safety, cover the field with a sterile towel, and respond to the other client. 2. Continue quickly with the procedure, and then assist the other client, checking back with the first client as soon as possible. 3. Ensure the client's safety, discard the sterile equipment, and respond to the other client. 4. Explain the situation to the client needing wound dressing change, leave the sterile supplies in place, and attend to the other client.

1 A client fall is a potential medical emergency; however, the nurse's responsibility is ensuring the safety of the client being attended to. Option 2 ignores the safety of the potentially injured client. Option 3 wastes supplies. Option 4 could lead to a contaminated sterile field. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management 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.

99 MCSA The nurse has just read the results of a client's tuberculin (TB) test at a health fair. An induration is apparent. The client asks what this means. The nurse's best response would be: 1. "A positive test means that you have been exposed to the TB organism. It does not mean that you currently have active bacteria. Further testing will be needed." 2. "A positive TB test means that you currently have active TB, and you will need to be isolated immediately." 3. "Many false positives occur. You can expect to be retested in 6 months." 4. "A positive TB test means that you are currently infectious and will need to be started on medication immediately."

1 A positive TB test means that the organism is present in the body in either an active or a dormant state. It should not be ignored nor should further testing be deferred for several months. The client can expect to be scheduled for sputum tests for the presence of the bacillus 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. Application Physiological Integrity: Reduction of Risk Potential Communication and Documentation Adult Health: Respiratory Note the presence of the critical word <i>best</i>. 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. 0

82 MCSA As part of the ongoing assessment of a client who has an electrical burn, a complete blood count (CBC), electrolyte panel, and renal panel were ordered. The nurse would expect to find which of the following results? 1. Potassium level of 5.9 mEq/L 2. Potassium level of 2.8 mEq/L 3. Hematocrit of 28 mg/dL 4. White blood cell count of 4,000/mm³

1 After burn injuries, an elevated potassium level (normal 3.5-5.1 mEq) is expected because of cellular tissue damage with release of intracellular potassium into the bloodstream. The hematocrit will be elevated (not decreased as in option 4) due to hemoconcentration, and the white blood cell count will be elevated as part of the inflammatory response to injury. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Integumentary 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. 1

56 MCSA The nurse would be most careful to assess for stomatitis in a client receiving which of the following chemotherapeutic agents? 1. Fluorouracil (5-FU) 2. Cisplatin (Platinol) 3. Bleomycin (Blenoxane) 4. Vincristine (Oncovin)

1 Although many chemotherapy agents can cause stomatitis, the antimetabolites are commonly known for causing this side effect. Fluorouracil is the only drug listed in this class. Cisplatin is an alkylating agent; bleomycin is an antitumor antibiotic; and vincristine is a plant (vinca) alkaloid. Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Analysis Pharmacology 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.

53 MCSA The nurse is admitting a client with thermal burns to both arms and anterior trunk. The client asks for a drink of water. What is the most appropriate response for the nurse to make? 1. "I'm sorry, you cannot drink anything right now; let me moisten your mouth instead." 2. "I can only give you juice to drink, not water." 3. "I'll get you a drink as soon as I'm finished." 4. "Would you also like me to order you a meal tray?"

1 Clients should remain NPO upon admission to the clinical setting with a major burn. Initial fluid replacement is started via the parenteral route. NPO status is maintained because the client may be in shock with blood flow directed away from the digestive organs to more vital 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. Application Physiological Integrity: Basic Care and Comfort Nursing Process: Implementation Foundational Sciences: Nutrition 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.

30 MCSA Which of the following care measures should the nurse include in the discussion when teaching home care measures to the parents of a child who has bilateral bacterial conjunctivitis? 1. Use of warm, moist, disposable compresses to remove crusting 2. Use of oral antihistamine medication to relieve eye itching 3. Use of ophthalmic corticosteroids to decrease inflammatory response 4. Use of topical anesthetics applied to relieve discomfort

1 Crusting of dried exudate is common with bacterial conjunctivitis and it is important for the child's vision and safety that the crusts are removed. Warm, moist wipes aid in comfort and they need to be disposable to reduce the risk of transmitting the infection to others in the home. Oral antihistamines, ophthalmic corticosteroids, and topical anesthetics are not indicated in the management of bacterial conjunctivitis. Application Physiological Integrity: Physiological Adaptation Teaching and Learning Child Health Note the critical word <i>conjunctivitis</i> in the stem of the question. Recall that this infection is highly contagious. Then determine the correct option by associating the word <i>disposable</i> in the correct option with the concept of infection in the stem of the question.

89 MCSA The client is to undergo an extensive process of allergy testing as an outpatient. The nurse would complete which of the following as a priority intervention during the initial testing? 1. Have emergency equipment available in the event of an anaphylactic reaction. 2. Instruct the client to wear a t-shirt to assure easy access to the skin testing sites. 3. Give discharge instructions prior to testing since the client will be able to go home immediately after the testing. 4. Set up the room before the client enters the examination area.

1 Emergency airway and resuscitation equipment should be readily accessible whenever allergy testing is administered because of the potential for hypersensitivity response and anaphylactic reaction. Because of the potential for a serious reaction, the client will be asked to wait in the 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. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Planning Adult Health: Integumentary Note the critical word <i>priority</i> 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. 0

27 MCSA The nurse would place highest priority on which of the following nursing interventions when planning to prevent atelectasis in the newly admitted postoperative client? 1. Hourly coughing and deep breathing 2. Assisting the client out of bed 3. Administration of bronchodilators 4. Supplemental oxygen

1 Frequent coughing and deep breathing is an easy maneuver that has great benefit to optimize ventilation in the postoperative client. Good pain management facilitates effective coughing and deep breathing. Getting the client out of bed and administering oxygen and 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. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Planning Adult Health: Respiratory 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.

8 MCSA The nurse places highest priority on taking which of the following actions to reduce the spread of microorganisms when caring for a client at risk for infection? 1. Wash hands before and after client care. 2. Use clean gloves when implementing client care. 3. Institute transmission-based precautions. 4. Place the client in a private room.

1 Hand hygiene is a core principle of standard precautions. Using gloves is appropriate when there is a risk of exposure to blood, body fluids, secretions, and excretions. However, handwashing should be done after removal of gloves. Not all clients require transmission-based precautions (option 3) or a private room (option 4). Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Fundamentals Use the process of elimination based on nursing knowledge of standard precautions. Elements of transmission-based precautions are not initiated with all clients.

20 MCSA The nurse concludes that a child is in Piaget's concrete operations stage after observing which of the following traits in the child? 1. Conservation. 2. Egocentrism. 3. Animism. 4. Preconventional thought

1 In Piaget's theory on development the conservation is a hallmark sign in the concrete operational stage. Options 2, 3, and 4 are not characteristic of this stage. Application Psychosocial Integrity Nursing Process: Analysis Mental Health 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

92 MCSA The nurse in the emergency department is caring for a client who has fallen 20 feet from a roof. While performing the primary assessment, the most important nursing intervention will be which of the following? 1. Maintain cervical spine precautions. 2. Assess for facial lacerations. 3. Remove clothing. 4. Perform a mental status exam.

1 It is essential that the client's spinal cord be immobilized to prevent further injury and loss of function. Assessing for lacerations, exposure of the client, and performing a full mental status exam are all part of the secondary assessment. Analysis Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Adult Health: Neurological Focus on the critical words <i>most important</i>. 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.

88 MCSA The nurse is caring for a young child who has mitt restraints. Which of the following priority actions needs to be done regularly to ensure that the child's needs are met? 1. Check adequacy of circulation and skin condition. 2. Check that the tongue blades in pockets are intact and ends are covered or padded. 3. Ensure that the straps are tied to nonmovable parts of the crib. 4. Check that the call bell is pinned to the child's gown.

1 It is important that circulation is checked regularly. Typically the restraints are removed, one at a time, every 2 hours to evaluate skin condition and circulation. Although options 3 and 4 are correct, they are not the best response as they do not have to be checked as regularly as the circulation and skin condition. Option 2 applies to an elbow restraint. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Child Health Focus on the word <i>priority</i> 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. 0

95 MCSA The nurse observes a sinus rhythm pattern on the cardiac monitor of a client admitted with diarrhea and vomiting. On physical assessment, the nurse is unable to palpate a central pulse. The nurse would suspect that the client is demonstrating which of the following? 1. Pulseless electrical activity (PEA) 2. Ventricular fibrillation 3. Asystole 4. Ventricular tachycardia

1 PEA is associated with what appears to be a normal electrical conduction pattern but there is no mechanical pumping of the myocardium. Ventricular fibrillation, ventricular tachycardia, and asystole will not demonstrate an effective electrical conduction pattern on the cardiac monitor. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Cardiovascular Associate the words <i>unable to palpate</i> in the stem of the question with the word <i>pulseless</i> in the correct option. Otherwise, it is necessary to understand the pathophysiology involved in this question. 0

57 MCSA The nurse will be working with an unlicensed assistive person (UAP) for the work shift. Prior to delegating care to the UAP, the nurse places high priority on which of the following? 1. Determining that the UAP is competent to perform the required task 2. Providing written directions to the UAP 3. Making sure all the necessary supplies are available at the client's bedside 4. Informing clients that an unlicensed staff member will be assigned to them

1 Safe and effective delegation is based on knowledge of the laws governing nursing practice and knowledge about job duties and responsibilities. Nurses must understand the competencies and training of unlicensed assistive personnel. Application Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management 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. 0

12 MCSA The Emergency Department has recently experienced a significant increase in client visits. The year-to-date census reveals a 20% increase in admission from the same period last year. In an effort to reduce staff stress and burnout by empowering the staff, the nurse manager uses which of the following approaches to demonstrate shared leadership? 1. Encourages the formation of self-directed work teams. 2. Encourages the group to try out nursing approaches that are evidence-based. 3. Suggests that staff who have demonstrated charting excellence be given opportunities for professional development activities. 4. Provides constructive criticism and facilitates the group to meet their goals.

1 Shared leadership recognizes that there are many leaders within a group so the leader encourages the formation of self-directed work teams. In transformational leadership, the leader encourages risk taking such as trying out nursing approaches that are evidence-based or research-based. A transactional leader uses incentives to promote productivity such as giving rewards for excellent performance. A democratic leader provides constructive criticism and facilitates the group to meet their goals. Application Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management The core issue of the question is knowledge of various leadership styles. Use this knowledge and the process of elimination to make a selection.

100 MCSA An anxious client begins to yell and interrupt other clients. The client's speech is rapid and pressured. What action should the nurse take? 1. Ask the client to speak more slowly and softly. 2. Instruct the other clients to ignore this client's behavior. 3. Point out to the client that the behavior is a sign of anxiety. 4. Remind the client of the need to use good manners when talking with other people.

1 Speaking slowly and softly reduces stress-related emotions. Instructing the clients to ignore the behavior will not assist them in reducing anxiety. A client experiencing severe or panic 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. Application Psychosocial Integrity Nursing Process: Implementation Mental Health 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. 0

80 MCSA The nurse is conducting an educational group on an inpatient unit. One of the clients has not spoken during the group. An effective therapeutic response by the nurse would include: 1. Allowing the client to remain present but nonparticipative. 2. Explaining to the client that everyone in the group needs to participate. 3. Asking the rest of the group members how they feel about this member not sharing. 4. Stopping the group and asking the client to leave.

1 The only respectful therapeutic response here is option 1. The others are contraindicated for any group process. Everyone does not need to participate in every session (option 2). It is inappropriate to focus the group's attention on one individual because of level of participation (option 3). The client should be allowed to remain part of the group until the client is ready to participate (option 4). Application Psychosocial Integrity Communication and Documentation Mental Health 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. 0

49 MCSA A client has a potassium level of 6.8 mEq/L. Which sign or symptom would the nurse expect to find when assessing this client? 1. Peaking of T wave on the telemetry monitor 2. The absence of bowel sounds, such as in an ileus 3. Muscle cramping of the lower extremities 4. Somnolence with early changes

1 The potassium level is abnormally high (normal 3.5-5.1 mEq/L). Since potassium is an intracellular ion, higher levels will alter the electrical pattern of the EKG. "Peaking of a T wave" is an indication that potassium is too high. With <i>hyperkalemia</i> (higher than normal potassium levels), muscle weakness, flaccidity of muscles, diarrhea, abdominal cramping, cerebral irritability/restlessness are present. Therefore, <i>bowel sounds</i> would be <i>hyperactive</i> and not <i>silent</i>, such as with an ileus. Muscles are weak and flaccid, not in a <i>cramping</i> state. Cerebral functions are stimulated and <i>somnolence</i> (sleeping, sluggishness) is not present. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Assessment Adult Health: Cardiovascular 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.

37 MCSA A 4-year-old child has been exposed to chickenpox. After the nurse has provided information about chickenpox, the nurse asks the mother to repeat the information. Which statement by the mother indicates a need for additional information? 1. "During the prodomal period, my child will have pox all over his body." 2. "Chickenpox is a viral infection that can be spread to other children." 3. "I should monitor my child for Reye syndrome, which is a complication of chickenpox." 4. "My child should not visit my pregnant sister at this time."

1 The prodomal period refers to the period of time between the initial symptoms and the presence of the full-blown disease. The rash would not be apparent during this time. All the other statements are correct. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Evaluation Child Health The critical words in the stem of the question are <i>need for additional information</i>. 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.

58 MCSA The nurse believes a client has slight one-sided weakness and further tests the client's muscle strength. The nurse asks the client to hold the arms up with hands supinated, as if holding a tray, and then asks the client to close the eyes. The client's right hand moves downward slightly and turns. The nurse documents and reports that the client has which of the following findings on assessment? 1. Pronator drift 2. Nystagmus 3. Hyperreflexia 4. Ataxia

1 This assessment may be done to detect small changes in muscle strength that might not otherwise be noted. Pronator drift occurs when a client cannot maintain the hands in a supinated position with the arms extended and eyes closed. Nystagmus is the presence of fine, involuntary eye movements. Hyperreflexia is an excessive reflex action. Ataxia is a disturbance in gait. Application Physiological Integrity: Physiological Adaptation Communication and Documentation Adult Health: Neurological Specific knowledge of physical assessment techniques is needed to answer the question. Note the association between the terms <i>supinated</i> in the question and <i>pronator</i> in the correct answer, in response to the client's change in hand position.

1 MCSA A client exposed to <i>Mycobacterium tuberculosis</i> starts on chemoprophylaxis. The nurse provides what instruction to the client? 1. "You will take a single drug such as isoniazid (INH) by mouth every day for 6 to 12 months." 2. "You will be on at least two drugs effective against the tubercle bacillus for three months." 3. "You will be on combination therapy in order to prevent development of drug resistance." 4. "You will need to learn to give yourself subcutaneous injections."

1 To prevent active tuberculosis after exposure, the client is initiated on a single agent regimen, usually isoniazid (INH). For newly diagnosed active disease (option 2), a combination of 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). Application Physiological Integrity: Pharmacological and Parenteral Therapies Teaching and Learning Pharmacology The critical words in the stem of the question are <i>exposed</i> and <i>chemoprophylaxis</i>. 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.

48 MCSA Which of the following actions would the nurse institute that is specific to the care of the assigned client who has tuberculosis? 1. Wearing a particulate respirator mask when taking vital signs. 2. Instructing the client to cover the mouth with the sheet from the stretcher when transported to other hospital departments. 3. Wearing sterile gloves when collecting a sputum specimen. 4. Keeping the client's door open to promote ventilation.

1 Tuberculosis is a respiratory infection, transmitted via airborne droplet nuclei less than 5 microns in size. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Planning Fundamentals Specific knowledge of the mode of transmission of <i>Mycobacterium tuberculosis</i> 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. 0

47 MCMA The nurse has admitted to the surgical unit a client who just underwent open reduction and internal fixation of a severely fractured right radius and ulna. Which nursing care activities would be appropriate for the nurse to delegate to the Licensed Practical/Vocational Nurse (LPN/LVN)? Select all that apply. 1. Measure vital signs every 30 minutes. 2. Report drainage on the cast if it appears. 3. Assess neurovascular status of the fingers of the casted arm hourly. 4. Elevate the casted arm above heart level. 5. Administer the prescribed intramuscular analgesic as ordered.

1, 2, 4, 5 The LPN/LVN is trained to collect data that is then reported to the registered nurse (RN). However, assessment remains the responsibility of the RN. For these reasons, the LPN/LVN can be expected to take vital signs, report drainage, administer medication, and elevate the casted limb. The RN should retain the responsibility for assessing neurovascular status to the casted extremity in the immediate postoperative period. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management 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

5 MCMA Which of the following actions would the nurse take to maintain medical asepsis when caring for a client with diabetes mellitus on the medical nursing unit who requires irrigation of a leg ulcer and insulin injections? Select all that apply. 1. Wash hands before and after client care. 2. Wear personal protective equipment during the dressing change. 3. Recap a needle after administering insulin. 4. Change the dressing for a diabetic ulcer using sterile gloves. 5. Wipe the rubber stopper on the insulin vial before withdrawing dose.

1, 2, 5 Options 1, 2, and 5 are core principles of medical asepsis. Option 3 violates principles of medical asepsis. Option 4 uses principles of surgical asepsis. Option 6 is unrelated to the needs of this client. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Fundamentals 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.

34 MCMA The nurse is teaching a group of adults about health screenings for cancer. The nurse would include in the discussion which of the following points? Select all that apply. 1. Genetic screening is helpful in identification of cancer risks. 2. Annual medical exams uncover most tumors. 3. Men need to perform breast and testicle exams monthly. 4. Annual mammograms are recommended after a total mastectomy. 5. Inspection of the skin for cancer becomes less important as one ages.

1, 3 Genetic screening can identify markers for several types of cancer. One method to remind men to perform self-checks for cancer is to mark a calendar to monthly check for changes. Self exams as well as regular medical tests and exams uncover tumors. After a total mastectomy, women do not need mammograms. Skin cancer risk increases with age. Application Health Promotion and Maintenance Teaching and Learning Adult Health: Oncology Elimination of number 4 and looking suspiciously at the phrase <i>most tumors</i> will help to discriminate between the options. When in doubt, identify alternatives with <i>most</i> or <i>all</i> in the answer as false.

9 MCMA The nurse would report to the physician which of the following abnormal laboratory values for a 58-year-old client newly admitted to the nursing unit with fever and diarrhea? Select all that apply. 1. White blood cell count 12,260/mm³ 2. Sodium 142 mEq/L 3. Potassium 3.9 mEq/L 4. Blood urea nitrogen 38 mg/dL 5. Serum creatinine 0.9 mg/dL

1, 4 The white blood cell count is elevated (normal 5,000-10,000/mm³), as is the BUN (0.8-22 mg/dL). These changes would be expected with infection (noted by fever) and possibly accompanying dehydration from diarrhea. The sodium (135-145 mEq/L), potassium (3.5-5.1 mEq/L), and serum creatinine (0.8-1.6 mg/dL) are all within normal limits. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Analysis Adult Health: Immunological 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.

38 MCSA The school health nurse is interested in promoting safety in the high school population. In planning safety education for this age group and their parents, the nurse would recognize that which of the following is a developmental risk factor for adolescents? 1. Substance abuse as a lifestyle means of dealing with stress 2. Feelings of immortality related to perception of being invulnerable to risks that affect others 3. Sports-related injuries that are usually related to not obeying rules and/or intense competition 4. Polypharmacy, which results in mixing of multiple medications

2 Adolescents tend to feel that they are invulnerable and that if anything bad will happen, it will affect others but not themselves. They also tend to feel immortal, as it is difficult for them to comprehend their own death. Option 1 is a factor related to the adult, option 3 is related to school-age children, and option 4 is related to the elderly. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Analysis Fundamentals 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. 0

31 MCSA After a client has experienced a seizure, what is the most appropriate position in which the nurse should place the client? 1. On back with head raised 15 degrees 2. On the side 3. On abdomen 4. Upright in chair

2 After the seizure, the client will be postictal, which is a deep sleeping state. She/he could aspirate secretions unless side-lying to promote drainage from the upper airway. Positioning 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. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Adult Health: Neurological 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.

40. MCSA The nurse is conducting an initial interview with a 10-year-old boy who has been brought to the mental health clinic by his parents. The nurse can establish rapport and credibility with the child by asking the child about his: 1. Behavioral symptoms. 2. Interests and hobbies. 3. Relationships with friends and family members. 4. Medical problems in the past.

2 Children at 10 years of age are egocentric and concerned with themselves. Asking about interests and hobbies is likely to foster establishment of rapport. Focusing on behavioral symptoms (option 1) could lead to an adversarial relationship. Children often are uncomfortable talking about friends and family (option 3) until they get to know a person better. Most children are unconcerned about past medical problems (option 4); they are focused on the here-and-now. Application Psychosocial Integrity Nursing Process: Assessment Mental Health 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.

84 MCSA After delivery, a Chinese client states she needs to restore the balance between hot and cold forces in her body and refuses to bathe. The most appropriate nursing intervention is to: 1. Show her a videotape on postpartum self-care. 2. Recognize her cultural beliefs and respect her wishes. 3. Discuss postpartum complications related to poor personal hygiene. 4. Request a psychiatric consult for this client.

2 Chinese clients may perceive an imbalance in the hot and cold forces in the body after delivery. They will avoid sources of cold, such as wind, cold beverages, and water (even if warmed) to regain a sense of balance between these extremes. A client's culture plays a very 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. Application Health Promotion and Maintenance Nursing Process: Implementation Maternal-Newborn 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.

60 MCSA The nurse knows that a client in the long-term care unit suffers from dysthymia. The <i>most</i> important nursing intervention to include in the nursing care plan is: 1. Provide at least 2 hours of quiet time every morning for the client. 2. Encourage the client to eat in the main dining room with other clients. 3. Include at least three regular meals per day and no snacks. 4. Include at least 2 liters of clear liquids per day in the diet regime.

2 For clients with dysthymia, a major concern is social isolation. Option 1 is contraindicated, as is option 3. If the client has a poor appetite, assigning 2 liters of liquid intake (option 4) is not therapeutic, nor is planning three regular meals per day (option 3). Analysis Psychosocial Integrity Nursing Process: Planning Mental Health 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.

101 MCSA The nurse suspects that hepatotoxicity is developing in a dark-skinned client who is on an antibiotic. In what area of the body should the nurse assess for jaundice? 1. Palms of the hands or soles of the feet 2. Hard palate of oral cavity 3. Sclera 4. Conjunctivae

2 Jaundice in the dark-skinned client can best be observed by assessing the hard palate. Normally fat may be deposited in the layer beneath the conjunctivae that can reflect as a 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. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Assessment Pharmacology 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. 0

13 MCSA A 56-year-old client reports to the nurse that his sleep patterns are different than when he was younger. The nurse anticipates that this client is likely to be experiencing which normal developmental pattern? 1. 6 to 8 hours of sleep per night with about 20 to 25% of rapid eye movement (REM) sleep and a marked decrease in Stage IV non-REM (NREM) sleep. 2. 6 to 8 hours of sleep per night with about 20% REM sleep and a decrease in Stage IV NREM sleep. 3. Erratic sleep because of work schedule with about 30% of REM sleep and no marked decrease in Stage IV NREM sleep. 4. Light sleep with equal amounts of REM sleep and NREM sleep.

2 Middle-aged adults have a decrease in deep sleep, stage IV NREM. Option 1 is an expected pattern in older adults; option 3 is expected in young adults, and option 4 is expected in neonates. Analysis Physiological Integrity: Basic Care and Comfort Nursing Process: Assessment Fundamentals 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.

91 MCSA A female client has been taking norethindrone (Micronor) oral contraceptive pills. Which of the following items is most likely to be found in her health history? 1. Superficial phlebitis 2. Currently breastfeeding 3. Dysmenorrhea 4. Menarche at age 18

2 Norethindrone (Micronor) contains only progestin and no estrogen. Because estrogen may decrease lactation, progestin-only pills are commonly used in lactating women. The other options do not address the issue of contraception during lactation. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Assessment Pharmacology 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. 0

6 MCSA Laboratory test results indicate a client is in the nadir period that follows administration of a chemotherapy drug. Which drug should the nurse avoid administering to this client at this time? 1. Acetaminophen (Tylenol) 2. Ibuprofen (Motrin) 3. Diphenhydramine (Benadryl) 4. Guanefesin (Robitussin)

2 Red blood cells, white blood cells, and platelet counts may be decreased during the nadir period following administration of chemotherapy that has hematological toxicity. Medications that inhibit platelet aggregation should be avoided during the nadir period following 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. Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology 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.

79 MCSA The client is scheduled for a barium enema and is expressing concern that the barium will not be evacuated and a bowel obstruction will occur. What would be the best response for the nurse to make to the client? 1. "Don't worry. The physicians will make sure that all of the barium is out of your bowel before you return to the unit." 2. "You will be given extra fluids, laxatives, and an enema if you have not expelled the barium within 24 hours." 3. "The barium they are using will not cause an obstruction." 4. "Should I have the test rescheduled for when you are less concerned about it?"

2 The client will, in most cases, return to the unit with barium still present in the bowel. The physician will order laxatives or enemas if the client is potentially not able to expel the barium on his or her own. The nurse should encourage the client to increase fluid intake if possible as well. This is a common concern for many clients undergoing this procedure, and their feelings should not be ignored or belittled. Analysis Physiological Integrity: Reduction of Risk Potential Communication and Documentation Adult Health: Gastrointestinal Note the critical words <i>best response</i> 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.

29 MCSA A client's hemoglobin level is 14 grams/dL. Which interpretation of the laboratory value by the nurse is most accurate? 1. Client has a low value and is malnourished. 2. Client has a normal laboratory value and has no nutritional risk. 3. Client has a low to normal value indicative of a nutritional risk. 4. Client has an elevated value indicative of polycythemia.

2 The laboratory value given is within normal limits (12-16.5 grams/dL). All the other statements are inaccurate. The client is not malnourished (option 1), at nutritional risk (option 3), and does not have polycythemia (high level) as indicated by option 4. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Analysis Adult Health: Hematological 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.

24 MCSA The fetal head is determined to be presenting in a position of complete extension. After learning of this, the nurse anticipates which of the following? 1. Precipitous labor and delivery 2. Prolonged labor and possible cesarean delivery 3. Normal labor and spontaneous vaginal delivery 4. Forceps-assisted vaginal delivery

2 The normal attitude of the fetal head is one of moderate flexion. Changes in fetal attitude, particularly the position of the head, present larger diameters to the maternal pelvis, which contributes to a prolonged and difficult labor and increases the likelihood of cesarean delivery. Analysis Health Promotion and Maintenance Nursing Process: Analysis Maternal-Newborn 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.

2 MCSA The nurse delegates an unlicensed assistive person (UAP) to assist a client with a clean urinary catheterization procedure. The client had formerly been able to do the procedure but because of arthritis, he has been unable to perform the catheterization. Although the UAP has done this procedure before, which of the following must the nurse emphasize to the UAP? 1. Let the client do most of the procedure and report the expected output. 2. Report immediately any unusual observations, such as bleeding. 3. Complete in proper order the steps of the procedure. 4. Perform health teaching while performing the procedure.

2 The nurse ensures that the UAP understands the importance of reporting immediately any difficulties during the procedure such as bleeding. This provides for safe and effective care. Option 1 is incorrect because the client cannot do the procedure because of arthritis. Option 3 is unnecessary if the UAP is qualified to do the procedure. Option 4 is a function of the nurse, not the UAP. Application Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management 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.

35 MCSA During a coffee break, the nurse notices two coworkers arguing about how to handle a difficult client. Their voices are raised and body postures are tense and defensive. Which would be the most appropriate approach for the nurse to use to address this conflict between staff members? 1. Let it pass because the coworkers probably did not intend to be critical. 2. Speak privately to the coworkers, telling them about personal reactions to this public encounter. 3. Confront and reprimand the coworkers publicly. 4. Inform each coworker privately that it would be most helpful not to display this behavior again.

2 The nurse should speak privately to the coworkers about their behavior and the impact on the nurse overhearing them. It does not help the climate of the unit to let it pass (option 1). The nurse is not in a position to confront and reprimand coworkers (option 3). Option 4 is somewhat plausible but option 2 personalizes the discussion between the nurse and the coworkers, and thus is best to diffuse the situation. Application Safe Effective Care Environment: Management of Care Communication and Documentation Leadership/Management 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 MCSA The school nurse is assessing a muscular 17-year-old female who is coming to the high school health service for complaints of edema, voice changes, and hair loss. The nurse's <i>primary</i> analysis based on the subjective and objective data is that the student: 1. Is going through a stage of puberty. 2. May be using steroids. 3. May be abusing barbiturates. 4. Is using marijuana regularly.

2 The student's age, along with symptoms of hair loss and edema indicate that this is not a stage of puberty. The symptoms are not indicated in abuse of barbiturates or marijuana use. By the process of elimination, the correct answer is option 2. In order to answer this correctly you need to have noted the muscular build of the student and know the signs and symptoms of illegal steroid use. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Analysis Pharmacology 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.

18 MCSA A client with metabolic acidosis is admitted. Which of the following laboratory values would the nurse expect to find in this client? 1. pH 7.40; serum potassium 3.8 mEq/L 2. pH 7.36; serum potassium 3.1 mEq/ L 3. pH 7.2; serum potassium 6.2 mEq/ L 4. pH 7.0; serum potassium 5.5 mEq/ L

3 A client in metabolic acidosis may also be hyperkalemic. As the hydrogen ions shift from the ECF to the ICF, potassium enters the ECF, leading to an increased serum potassium. pH values of < 7.35 are associated with acidosis (option 2). Options 3 and 4 have K⁺ 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. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Endocrine and Metabolic Note the critical word <i>acidosis</i> 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 <i>metabolic</i> 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. 1

39. MCSA When giving directions to a 24-year-old female with possible appendicitis who is about to undergo a pelvic sonogram, which statement should the nurse make to the client? 1. "Drink nothing for several hours prior to the exam." 2. "You will be given an enema to cleanse the bowel." 3. "Drink plenty of liquids so you will have a full bladder." 4. Do not take any medications prior to the exam."

3 A full bladder is necessary to bounce the sound waves off to compare other tissues or structures are being assessed. If done during pregnancy, the fetus must be over 26 weeks to not have the restriction for the full bladder, since the amniotic fluid would be used at that point. It would not be helpful to be NPO, because this would deprive the client of fluids. Enemas and refraining from medications are unnecessary. Application Physiological Integrity: Reduction of Risk Potential Teaching and Learning Adult Health: Gastrointestinal 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.

10 MCSA The mental health nurse working with children anticipates that unrealistic expectations or a sense of failure to meet standards would cause a 10-year-old child to develop a sense of which of the following? 1. Shame 2. Guilt 3. Inferiority 4. Role confusion

3 According to Erikson's stages of development, a 10-year-old child is experiencing industry vs. inferiority. Shame (option 1), guilt (option 2), and role confusion (option 4) occur at other developmental levels. Application Psychosocial Integrity Nursing Process: Analysis Mental Health 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.

23 MCSA The nurse is working with a client suffering from chronic diarrhea. In teaching ways to reduce diarrhea, the nurse would encourage the client to avoid which of the following that contribute to the development of diarrhea? 1. Excessive intake of cheese and eggs 2. Habitually ignoring the urge to defecate 3. Anxiety or anger 4. Lack of exercise

3 Anxiety or anger increases peristalsis leading to subsequent diarrhea. Excessive intake of cheese or eggs, ignoring the urge to defecate, and lack of exercise can lead to the development of constipation. Application Physiological Integrity: Basic Care and Comfort Nursing Process: Implementation Fundamentals 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.

44 MCSA After reviewing the client's health history, the nurse concludes that which of the following is the most significant factor related to the development of bronchogenic carcinoma for this client? 1. Asthma 2. Smokeless tobacco 3. Cigarette smoking 4. Air pollution

3 Cigarette smoking is the leading cause of lung cancer. Smokeless tobacco is more often associated with oral cancer. Air pollution may also be a contributing factor to development of lung cancer. History of asthma is not associated with greater risk of lung cancer. Analysis Health Promotion and Maintenance Nursing Process: Assessment Adult Health: Respiratory 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.

42 MCSA As the nursing unit representative member serving on the hospital quality management committee, the nurse has been asked to evaluate the quality of nursing services on the unit. What would be an appropriate quality improvement activity for the nurse to ask team members to participate in? 1. Tracking the number of accidents or incidents on the unit 2. Documenting nursing time and activities spent on direct client care 3. Administering a client and family satisfaction survey 4. Assessing clients and report acuity to shift managers daily

3 Client and family satisfaction surveys are a formal set of activities that can be used to remedy deficiencies identified in the quality of direct patient care, administrative, and support services. Incident reports (option 1) serve as an indicator of risk. Documentation of time and activities related to direct care may be done as part of time and motion studies. Acuity relates to the need for nursing staff on the unit. Application Safe Effective Care Environment: Management of Care Nursing Process: Planning Leadership/Management Note the critical word <i>services</i> 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.

14 MCSA The nurse concludes that teaching has been effective when the laboring client's partner shouts, "She's crowning!" as: 1. The nurse first starts to see a little of the baby's head. 2. The baby's head recedes upward between pushing contractions. 3. The perineum is thin and stretching around the occiput. 4. The mouth and nose are being suctioned.

3 Crowning is the point in time when the perineum is thin and stretching around the fetal head both between and during contractions. Delivery is imminent when crowning occurs. Crowning 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. Analysis Health Promotion and Maintenance Nursing Process: Evaluation Maternal-Newborn The critical word in the stem of the question is <i>crowning</i>. Use knowledge of what occurs during crowning and the process of elimination to make a selection. Visualize the word <i>crown</i> and select the answer that matches the part of the head that a crown would sit on.

45 MCSA The nurse is setting up the breakfast tray for a client with gastroesophageal reflux disease (GERD) and notices one food that the client should not eat. Which food should the nurse remove from the meal tray? 1. Poached egg 2. Dry toast 3. Coffee with cream 4. Skim milk

3 Foods that reduce lower esophageal sphincter (LES) pressure will increase reflux symptoms. These include coffee, fatty foods, alcohol, and chocolate. All the other items can be given to the client. Analysis Physiological Integrity: Basic Care and Comfort Nursing Process: Analysis Foundational Sciences: Nutrition 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.

16 MCSA After three defibrillation attempts, the client continues to be in a pulseless ventricular tachycardia. A lidocaine bolus of 100 mg IV is administered. The nurse would expect to see which of the following as a therapeutic response to lidocaine? 1. Conversion from a ventricular tachycardia to a ventricular fibrillation 2. Slowing of heart rate to 80 beats per minute 3. A reduction in ventricular irritability 4. An increase in the level of consciousness

3 Lidocaine is the primary medication used to treat ventricular dysrhythmias. Lidocaine suppresses automaticity in the HIS-Purkinje system by elevating electrical stimulation threshold of the ventricle during diastole, thus decreasing ventricular irritability. Ventricular fibrillation (option 1) is a worsening dysrhythmia. Slowing the heart rate (option 2) without 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. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Evaluation Pharmacology 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.

25 MCSA The nurse notices that an elderly nursing home resident has not been eating or drinking as much as usual. Which assessment finding would best indicate the presence of fluid volume deficit? 1. Clear lung fields with unlabored respirations 2. Tenting and dry, flaky skin 3. Increased drowsiness, mild confusion, and concentrated urine 4. Hand veins that fill within 3 to 5 seconds of being lowered below the heart

3 Mental status changes and concentrated urine are common signs of dehydration in the elderly. Tenting and dry, flaky skin are consistent changes seen with normal aging. Hand veins that fill within 3 to 5 seconds and clear lungs sounds with unlabored breathing are normal findings. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Cardiovascular Note the critical words in the question are <i>not eating or drinking</i> and <i>deficit</i>. 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 <i>clear</i> and <i>dry</i> respectively. Choose option 3 over 4 recalling that neurological symptoms are often present with altered fluid balance because sodium imbalance may occur simultaneously. 0

43 MCSA When a female client preparing for surgery suddenly bursts into tears, the preoperative holding unit nurse should take which of the following actions? 1. Pull the curtain closed and leave the area to provide privacy. 2. Be silent as a sign of compassion. 3. Ask the client to share what she is feeling. 4. Continue with the physical preparation of the client.

3 Option 3 is best because it represents a communication with the client and is open-ended. Options 1 and 2 are not the most appropriate initial approaches since the client is not 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. Application Physiological Integrity: Reduction of Risk Potential Communication and Documentation Fundamentals 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.

81 MCSA A client is experiencing seizure activity. The nurse should prepare to administer which of the following medications according to protocol? 1. Selegilene (Eldepryl) 2. Diclofenac sodium (Voltaren) 3. Phenytoin (Dilantin) 4. Sumatriptan (Imitrex)

3 Phenytoin is a first-line anticonvulsant medication that is used to control seizure activity. Selegilene (option 1) is used to treat Parkinson's disease. Diclofenac (option 2) is an NSAID, while sumatriptan (option 4) is used to treat headaches. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology 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.

98 MCSA A client has experienced a near-drowning event in salt water. The nurse anticipates that one of the complications this client may experience is: 1. Heart block. 2. Renal failure. 3. Pulmonary edema. 4. Respiratory alkalosis.

3 Pulmonary edema occurs as a result of fluid shifts caused by the ingestion of the hypertonic salt water. The result is fluid collecting in the interstitial spaces causing pulmonary edema. Hypoxia, hypovolemia, and acidosis occur as a result of near-drowning incidents. Application Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Respiratory Note the critical words <i>salt water</i> 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.

41 MCSA The nurse is providing medication instructions to a client. The nurse informs the client that persistent gynecomastia can result from taking which of the following newly prescribed diuretics? 1. Hydrochlorothiazide (HCTZ) 2. Furosemide (Lasix) 3. Spironolactone (Aldactone) 4. Indapamide (Lozol)

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 may persist after discontinuing spironolactone. Application Physiological Integrity: Pharmacological and Parenteral Therapies Teaching and Learning Pharmacology 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.

90 MCSA A client who has been experiencing panic attacks asks why the physician has ordered several laboratory tests. The nurse's answer should incorporate which of the following pieces of information? 1. Laboratory tests can differentiate between true anxiety and the anxiety associated with depression. 2. Laboratory tests can determine the specific cause of the panic attacks. 3. Physiologic symptoms associated with panic disorders often mimic medical disorders. 4. Symptoms of panic disorders are usually related to hypochondriasis.

3 Symptoms associated with a number of medical conditions are very similar to the symptoms associated with panic attacks. When a medical condition is present, it should be identified and treated. The other options are inaccurate responses to the client's question. Application Psychosocial Integrity Communication and Documentation Mental Health 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. 0

93 MCSA Which breakfast option indicates to the nurse that the client with coronary artery disease requires further diet instruction? 1. Orange juice, shredded wheat, skim milk, toast with jelly 2. Grapefruit juice, oatmeal, 1% milk, bagel with jelly 3. Canned peaches, egg omelet, whole milk, fruited yogurt 4. Applesauce, bagel with margarine, egg-white omelet, skim milk

3 The American Heart Association recommends a diet with reduced saturated fats and cholesterol for clients with coronary artery disease. Canned peaches are high in concentrated 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. Analysis Physiological Integrity: Basic Care and Comfort Nursing Process: Evaluation Foundational Sciences: Nutrition The wording of the question tells you that the correct answer to the question is the one that contains incorrect items. Correlate the words <i>coronary artery disease</i> 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.

50 MCSA The nurse is preparing to take a client to the electroconvulsive therapy (ECT) treatment suite. The nurse must ensure that which of the following pretreatment processes has been completed? 1. The client's husband has signed the consent form. 2. The client is wearing snug-fitting clothing. 3. The client is NPO. 4. The client has been given ample liquids before the procedure.

3 The client should be NPO before the procedure in order to be given anesthesia for the procedure (options 3 and 4). The client, not the husband, should sign the consent form (option 1). The client should be wearing loose-fitting clothing (option 2). Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Implementation Mental Health 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.

61 MCSA A client who is receiving intravenous heparin by protocol orders has an activated partial thromboplastin time (APTT) level of 140 seconds (control time is 36 seconds). What is the priority action that the nurse should institute? 1. Increase the heparin dose as the APTT level is not therapeutic. Obtain a repeat APTT in 6 hours. 2. Stop the heparin therapy for 6 hours, then restart the therapy at the same unit dose and obtain a repeat APTT in 6 hours. 3. Stop the heparin therapy for 1 hour. Decrease the rate of infusion per protocol and restart the medication in 1 hour. Obtain a repeat APTT in 2 to 3 hours from the restart of the infusion. 4. Obtain an additional APTT in 1 hour and continue to monitor the client.

3 The effectiveness of a heparin protocol is monitored by trending APTT results to achieve a therapeutic level. An APTT of 140 is above the therapeutic level of anticoagulation and therefore the infusion should be stopped per protocol, and resumed at a decreased dose in one 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 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. Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology 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. 0

96 MCSA While teaching a client about the proper administration of dipivefrine (Propine), the nurse would provide which of the following instructions? 1. Gently squeeze eyes closed for 30 seconds immediately after instillation of medication. 2. Close, but do not squeeze, eyes immediately after instillation of medication. 3. Do not blink for 30 seconds after instillation of medication. 4. Close the eyes for 1 full minute after instillation of medication.

3 To promote absorption, the client should not blink for 30 seconds after the administration of dipivefrine. Options 1, 2, and 4 are incorrect for the administration of dipiveprine. Application Physiological Integrity: Pharmacological and Parenteral Therapies Teaching and Learning Pharmacology 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.

85 MCSA While talking with a client the nurse notes that the client rapidly becomes more uncomfortable and anxious. What action should the nurse take? 1. Ask specific, focused questions to elicit detailed information about the source of the client's stress. 2. Encourage the client to try to relax by using guided imagery or other means preferred by the client. 3. Refocus the conversation on a less threatening topic. 4. Stop the interview at this time.

3 When a client's level of anxiety markedly increases the nurse can relieve the anxiety by altering the focus of the discussion. Asking the client more details or abruptly stopping the 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. Application Psychosocial Integrity Nursing Process: Implementation Mental Health 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

7 MCSA The newborn nursery has recently formed a unit policy and procedure committee. The nurse, while attending and participating in the meetings, determines that which nurse exemplifies a situational leader? 1. The nurse who offers suggestions, asks questions, and guides the group toward achieving group goals. 2. The nurse who recognizes the group's need for autonomy and abdicates responsibility. 3. The nurse who relies on the organization's rules, policies, and procedures to direct the group's work. 4. The nurse who recognizes that leadership style depends on the readiness and willingness of the group or the individuals to perform the assigned tasks.

4 A situational leader recognizes that leadership style depends on the readiness and willingness of the group or the individuals to perform the assigned tasks. The democratic or participative leader offers suggestions, asks questions, and guides the group toward achieving the group goals. The laissez-faire leader recognizes the group's need for autonomy and abdicates responsibility. A bureaucratic leader relies on the organization's rules, policies, and procedures to direct the group's work. Application Safe Effective Care Environment: Management of Care Nursing Process: Analysis Leadership/Management The core issue of the question is knowledge of various leadership styles. Use this knowledge and the process of elimination to make a selection

51 MCSA To minimize the pain related to intramuscular injection of 2 mL of penicillin G benzathine (Bicillin LA) in an adult client, the nurse would take which of the following actions? 1. Apply cold compress to site after injection. 2. Divide the dose and inject half into each deltoid. 3. Limit prolonging the time taken to administer the drug by not aspirating. 4. Administer the drug deep IM slowly into a large muscle such as the gluteus.

4 Administering very thick preparations such as penicillin G with benzathine (Bicillin LA) can be painful. To lessen the pain, intramuscular injection into a larger gluteal muscle should be administered over 12 to 15 seconds to separate the muscle fibers more 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 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. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology 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.

28 MCSA A 14-year-old client has been diagnosed with bipolar disorder. The nurse would expect to see which of the following problems? 1. Intense mood swings lasting only 1 to 2 hours 2. Inflated self-esteem 3. Spending sprees 4. Fire-setting and gang behavior

4 Children with bipolar disorders are often misdiagnosed as having conduct disorder or ADHD. Intense mood swings (option 1), inflated self-esteem (option 2), and spending sprees (option 3) occur more often in adults. Analysis Psychosocial Integrity Nursing Process: Assessment Mental Health 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.

54 MCSA A mother brings a 3-year-old child to the clinic for a well-child checkup. The child has not been to the clinic since 6 months of age. The nurse determines that which of the following is the priority of care for this child? 1. Assess growth and development. 2. Begin dental care. 3. Complete hearing screening. 4. Update vaccinations.

4 Every time a child enters the healthcare system, the immunization status should be checked. Some children have uncertain history of immunization because of parental noncompliance or special circumstances such as being refugees. Once immunization status has been determined, the nurse can go on to assess growth and development and hearing, and to teach the parents about dental care as necessary. Application Health Promotion and Maintenance Nursing Process: Planning Child Health The critical word in the stem of the question is <i>priority</i>. 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.

22 MCSA At the start of the shift there were only three newborns in the nursery, so staffing consisted of one RN and one LPN. Within two hours, three more 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? 1. The LPN can complete the admission assessments and discharge teaching for the five Level 1 newborns. 2. An UAP from the postpartum unit can be reassigned to the nursery to do the discharge teaching. 3. The RN can complete the admission assessments while continuing to stabilize the Level II newborn. 4. Another RN needs to be assigned to the nursery to implement the admission assessments and discharge teaching.

4 It is an RN's responsibility to do assessments, analyze the data, plan and implement care and teaching, and evaluate the outcomes. A second RN needs to be assigned to the nursery to safely manage the care of the Level I newborns. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management 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.

26 MCSA Following a liver transplant the client is taking prednisone among other medications to prevent organ rejection. The nurse should instruct the client to make it a priority to report which of the following signs and symptoms to the health care provider? 1. Moon face 2. Diminished pigmentation 3. Dysphagia 4. Bleeding

4 Liver function includes the regulation of blood clotting and corticosteroids can impair wound healing and irritate the GI tract. Thus, the client should be instructed to report signs and symptoms of bleeding. Option 1 is a side effect of corticosteroids but is not the priority from a physiological basis. Options 2 and 3 do not reflect the associated risk of bleeding with corticosteroid medications. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Immunological 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.

11 MCSA A postoperative client who has an order for 5,000 units of heparin SubQ for three doses wants to know why this drug is being ordered. What information would the nurse provide to the client to best answer the question? 1. "Heparin is used as a common medication in many clients who have surgery." 2. "Heparin is essential during the postoperative period to maintain adequate blood clotting levels." 3. "The injections will be given in the abdomen and are not usually associated with discomfort." 4. "Heparin is being used to prevent blood clots from forming as a result of surgery or decreased mobility."

4 Low-dose heparin therapy is indicated in many postoperative clients to prevent the development of thromboembolic episodes. It is not used in every postoperative situation (option 1), but it is usually used for clients who have orthopedic surgery or are anticipated to 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. 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). Application Physiological Integrity: Pharmacological and Parenteral Therapies Communication and Documentation Pharmacology The critical words in the stem of the question are <i>best answer the question</i>. 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.

3 MCSA The client is in the operating room for a surgical procedure. The nurse in the operating room is monitoring the physiological integrity of the client. Which of the following activities is most appropriate? 1. Determine client satisfaction with care received. 2. Assess client's emotional status. 3. Monitor asepsis in the environment. 4. Calculate fluid loss and its effects.

4 Only option 4 relates to the client's physiological integrity. Options 1 and 2 pertain to the psychological aspects of client care, while option 3 relates to the safety in the environment. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Assessment Fundamentals 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.

15 MCSA A client questions the surgical nurse about the personnel in the operating room. Which of the following initial responses by a nurse to the client's concern is most therapeutic? 1. "The nurses are well-qualified for the job they do." 2. "Have you had a bad experience in the OR?" 3. "You're concerned about the personnel, but you have no need to worry." 4. "Can you tell me about why you are interested in the personnel?"

4 Option 4 gives the client an opportunity to explain to the nurse the reason for asking the question. This helps the nurse understand the client's frame of reference and allows the nurse to best address the client's concern. Options 1 and 3 offer false reassurance and can give the 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. Analysis Physiological Integrity: Reduction of Risk Potential Communication and Documentation Fundamentals 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.

19 MCSA A client has a BUN of 68 mg/dL and a creatinine level of 6.0 mg/dL. The IV fluid is 5% dextrose in 0.9% sodium chloride with 40 mEq KCL @ 100 mL/hour. Which action would be most appropriate for the nurse to take? 1. Encourage more protein in the diet. 2. Ambulate the client more to increase circulation. 3. Take vital signs every hour. 4. Question the use of potassium in the IV fluids. \

4 Potassium (KCL) is contraindicated in clients with renal dysfunctions. It can not be filtered out if there is decreased renal filtration. With increased damage in tissues additional potassium is released, causing an even greater level of potassium that can be life-threatening. Encouraging protein, ambulation, and taking vital signs do not safeguard the client from the danger of this potential electrolyte imbalance. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Implementation Adult Health: Renal and Genitourinary <i>Protein</i> 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 <i>ambulation</i>, will not change the BUN or creatinine since they reflect filtration of the renal system and not the rate of circulation of the blood. <i>Taking the vital signs every hour</i> 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.

52 MCSA The nurse is assigned to the care of an obese client who has gastroesophageal reflux disease (GERD). Which of the following activities could the nurse appropriately delegate to the unlicensed assistant person (UAP)? 1. Teach the client about the need for weight loss. 2. Explore any concerns about the prescribed regimen for managing GERD. 3. Explain why it is important to eat several small meals per day. 4. Instruct the client to remain upright for at least 2 hours after eating.

4 Teaching and assessment are within the domain of the registered nurse (RN) and cannot be delegated to a UAP. The UAP is also not trained in therapeutic communication or counseling techniques. These ancillary caregivers can complete tasks under the supervision and direction of the nurse, and report simple data when asked to do so. With this in mind, the only activity that can be delegated is the simple direction to the client to remain upright after eating. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Adult Health: Gastrointestinal 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.

33 MCSA A client recently diagnosed with type 1 diabetes mellitus is learning to use the American Diabetes Association exchange lists. The nurse determines that the teaching has been effective if the client chooses which of the following as an appropriate exchange for white rice? 1. Egg 2. Tomato 3. Orange 4. Bread

4 The American Diabetes Association Exchange Lists divide food into groups with similar content (milk, vegetables, fruit, starch/bread, meat, and fat). All foods within a list are similar in calories, protein, fat, and carbohydrates if eaten in a certain size portion. Foods may be exchanged within the same list. Rice and bread are starches, egg is meat, tomato is vegetable, and orange is fruit. Analysis Physiological Integrity: Basic Care and Comfort Nursing Process: Evaluation Foundational Sciences: Nutrition 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.

17 MCSA The nurse is assigned to a client diagnosed with head and neck cancer who is receiving enteral feedings via gastrostomy tube. When the nurse is called away to care for another client, which task for this client could most appropriately be delegated to the unlicensed assistive person (UAP)? 1. Determining the amount of residual for the tube feeding 2. Giving mouth care and assessing the oral cavity 3. Exploring how the client is currently coping with the diagnosis 4. Administering a bath and changing bed linens

4 The UAP is qualified to complete simple procedures, such as bathing a client and changing bed linens. While the UAP could possibly administer mouth care to this client, the nurse must assess the oral cavity (option 2) and should be the one to assess tube feeding residual (option 1). UAPs are not trained in therapeutic communication skills and techniques (option 3). Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management 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.

55 MCSA A client who has pancreatitis is experiencing pain. After administering an analgesic, the nurse should place the client in which of the following positions to promote comfort? 1. Supine 2. Prone 3. Left lateral decubitus 4. Sitting up and leaning forward

4 The pain in pancreatitis is usually aggravated by lying in a recumbent position, but improved by sitting up and leaning forward or in the fetal position with the knees pulled up to the chest. This position reduces pressure caused by contact of the inflamed pancreas with the posterior abdominal wall. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Gastrointestinal 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.

68 MCSA The nurse would conclude that hypomagnesemia has not resolved if which of the following neuromuscular signs is still present after treatment? 1. Paralysis 2. Tetany 3. Flaccidity 4. Decreased reflexes

Answer: 2 Effects of hypomagnesemia are mainly due to increased neuromuscular responses. Paralysis, flaccidity, and decreased reflexes may be present with hypermagnesemia. Application Physiological Integrity: Physiological Adaptation Nursing Process: Evaluation Adult Health: Neurological 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.

97 MCSA The nursing unit is short-staffed for the shift and a registered nurse (RN) from the pediatric unit has been floated to the nursing unit. Which of the following clients should the nurse assign to the float nurse? 1. A 32-year-old client newly diagnosed with diabetes who needs dietary and medication teaching 2. A 56-year-old client newly admitted with Guillain-Barré syndrome who has severe leg weakness 3. An 86-year-old client with dementia who will be transferred to a skilled nursing facility during the shift 4. A 59-year-old client who will be returning from surgery following transurethral resection of the prostate

Answer: 1 Pediatric clients can be diagnosed with diabetes and the float nurse should be familiar with this health problem and could do client teaching. The nurse is not as likely to have recent experience in working with clients with Guillain-Barré syndrome or who have had prostate 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. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Adult Health: Endocrine and Metabolic 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. 0

64 MCSA The pregnant client is 7 centimeters, 100% effaced, and at a +1 station. The fetus is in a face presentation. The nurse concludes that teaching has been effective when the client's husband states: 1. "Our baby will come out face first." 2. "Our baby will come out facing one hip." 3. "Our baby will come out buttocks first." 4. "Our baby will come out with the back of the head first."

Answer: 1 Presentation refers to the part of the fetus that is coming through the cervix and birth canal first. Thus a face presentation occurs when the face is coming through first. Analysis Health Promotion and Maintenance Teaching and Learning Maternal-Newborn Associate the word <i>face</i> in the question with the word <i>face</i> in the correct response. The word <i>presentation</i> helps you to choose option 1 over option 2, which also contains the word <i>face</i>, but in an inappropriate context to this question. 0

77 MCSA The registered nurse (RN) is assigned to the postpartum unit. Which task could the RN safely delegate to a beginning student nurse? 1. Ambulate a client who delivered by cesarean 2 days ago. 2. Complete the admission assessment on a newly delivered client. 3. Call the physician to report a low hemoglobin level. 4. Verify a unit of blood prior to transfusion.

Answer: 1 The RN is responsible for delegating tasks appropriately and is responsible for the actions of unlicensed personnel. Ambulating a postoperative client is the only task from those listed that 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. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management Note the critical word <i>beginning</i> 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.

62 MCMA The nurse has admitted to the intermediate care unit a client who sustained a spinal cord injury at T1 in a motor vehicle accident. Which of the following nursing care activities can the nurse delegate to the unlicensed assistive person (UAP) when working with this client? Select all that apply. 1. Measure oxygen saturation level every hour. 2. Listen to breath sounds. 3. Provide mouth care. 4. Teach use of incentive spirometer. 5. Assess for Homan's sign while bathing client.

Answer: 1, 3 The UAP can perform tasks or nursing care activities under the direct supervision of the registered nurse (RN). The nurse retains responsibility for assessment (options 2 and 5) and teaching (option 4). Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management 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. 0

66 MCSA A child diagnosed with deficiency of growth hormone who needs replacement drug therapy comes to the clinic for treatment. Which one of the following nursing diagnoses would be most appropriate for this client? 1. Imbalanced nutrition: More than body requirements 2. Disturbed body image 3. Diversional activity deficit 4. Decreased cardiac output

Answer: 2 Children with growth hormone deficiency are smaller than their peers and frequently experience problems with self-esteem and body image. Option 1 would be the opposite problem of what the client is experiencing. The nursing diagnoses in options 3 and 4 are unrelated to the client in this question. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Endocrine and Metabolic 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. 0

87 MCSA A client has just finished a dose of intravesicular chemotherapy as treatment for bladder cancer. When giving instructions to the unlicensed assistive personnel (UAP) who will give routine care to this client, what statement should the nurse make? 1. "Be sure the client flushes the toilet after each use." 2. "Cleanse the toilet with bleach after each use for the next 6 hours." 3. "Ask the client to wipe the toilet seat with tissue after each bathroom use." 4. "Assist the client to the bathroom and wear sterile gloves for pericare."

Answer: 2 For 6 hours following intravesicular chemotherapy, the toilet should be disinfected after each use. This will help ensure that the biohazard of excreted chemotherapy drug is contained. The toilet may also be double-flushed. Options 1 and 3 are insufficient, while option 4 is unnecessary and does not address the biohazardous aspect of chemicals remaining in the toilet. Application Safe Effective Care Environment: Management of Care Nursing Process: Implementation Adult Health: Oncology 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 <i>sterile</i>. Clean gloves are needed only. 0

83 MCSA A client with congestive heart failure (CHF) has been advised to follow a low-sodium diet. Which statement by the client indicates to the nurse that diet teaching has been effective? 1. "If I stop adding table salt, I shouldn't have any problems." 2. "I need to avoid eating processed foods and canned meats and vegetables." 3. "I can still use a small amount of table salt in cooking." 4. "I only have to worry about salty-tasting foods like potato chips."

Answer: 2 In a 2-gram sodium diet, foods high in sodium content should be eliminated. It is not enough to stop adding salt or to go only by taste; clients should also be taught to read food labels for hidden sodium content. Added salt while cooking is allowed in a 4-gram sodium diet, not a 2-gram sodium diet. Analysis Physiological Integrity: Basic Care and Comfort Nursing Process: Evaluation Foundational Sciences: Nutrition The critical words in the question are <i>low-sodium</i>. 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.

70 MCSA The nurse is planning for a multidisciplinary team meeting concerning a client with bipolar disorder. In discussing the client's safety needs, the nurse would be sure to include: 1. Placement of the client in a four-bed room. 2. The client's risk level for self-harm. 3. Unrestricted visitors. 4. The need of the client to participate daily in many concentrated activities.

Answer: 2 The client's level of risk for self-harm is a major concern. The client may need a private room (option 1) and restricted visitors (option 3) if in a manic state. The client should not be overstimulated (option 4). Application Psychosocial Integrity Nursing Process: Planning Mental Health Critical words in the stem of the question are <i>safety</i> and <i>bipolar disorder</i>. 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. 0

78 MCSA A client presents to the Emergency Department with a stab wound to the right upper abdominal quadrant. The client's vital signs are BP 85/60, pulse 125, and respiratory rate of 28 breaths/minute. The nurse should immediately suspect damage to what organ? 1. Stomach 2. Liver 3. Large intestine 4. Kidney

Answer: 2 The primary organ in the right upper quadrant of the abdominal cavity is the liver. Because of the early shock symptoms, which are presented, it would be expected that this organ has possibly been lacerated, causing extensive uncontrolled internal bleeding. The other organ systems would not be located in this area. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Gastrointestinal 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. 0

72 MCSA The nurse admitting a client with a history of trigeminal neuralgia (tic Douloureux) would question the client about which of the following manifestations? 1. Facial droop accompanied by numbness and tingling 2. Stabbing pain that occurs with twitching of part of the face 3. Aching pain and ptosis of the eyelid 4. Burning pain and intermittent facial paralysis

Answer: 2 Trigeminal neuralgia is manifested by spasms of pain that begin suddenly and last anywhere from seconds to minutes. Clients often describe the pain as stabbing or similar to an electric 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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Neurological Note the critical word <i>neuralgia</i> 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.

59 MCSA When a client has arterial blood gases drawn from the radial artery, the nurse should plan to do which of the following? 1. Hold the site for up to 1 minute. 2. Transfer the blood sample to a heparinized test tube. 3. Pack the sample in ice for transporting to the laboratory. 4. Obtain a second specimen after 10 minutes for comparison.

Answer: 3 <i>Packing the sample in ice</i> will minimize the changes in gas levels during the transportation of the specimen to the lab. The arterial site should be held for 5 minutes or longer if the client is 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. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Implementation Adult Health: Respiratory 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 <i>heparinized</i> and the blood is not transferred to a test tube. Finally, eliminate option 4 because it is unnecessary.

76 MCSA A 3-month-old infant is diagnosed with leukemia. Which of the following does the nurse anticipate will be part of the plan of care for this infant? 1. The baby will be placed in isolation. 2. Leukemia is familial and other children should be assessed. 3. All immunizations will be withheld during exacerbations. 4. The baby will be NPO during chemotherapy

Answer: 3 Immunizations should be withheld during leukemia exacerbations because the immune system is compromised and the client cannot manage an appropriate response to the 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. Application Physiological Integrity: Physiological Adaptation Nursing Process: Planning Child Health 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. 0

74 MCSA A client has a strong family tendency toward hypertension. He denies that he will get hypertension because he watches what he eats, gets plenty of exercise, and keeps his weight within normal range. When implementing the plan of care, the nurse would do which of the following? 1. Praise the client and reassure him that these actions will prevent him from becoming hypertensive. 2. Emphasize that no matter what he does, the client will eventually develop hypertension because of his family history. 3. Recognize the client's efforts towards a healthy lifestyle and emphasis that early detection is essential to prevent complications. 4. Recommend that the client request antihypertensive medications prophylactically because of his family history.

Answer: 3 Lifestyle modifications and recognition of risk factors are important parts of prevention of long-term complications. Family history is a very strong risk factor but encouraging the client to maintain his current lifestyle and following up with health screening would be the best plan of action. False reassurance that he will never be hypertensive and prophylactic antihypertensive medications are inappropriate. Analysis Health Promotion and Maintenance Communication and Documentation Adult Health: Cardiovascular 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.

67 MCMA The nursing unit is understaffed and a nurse from the surgical intermediate care unit has been floated to the unit for the day shift. Which of the following two clients should the nurse assign to this RN float nurse? Select all that apply. 1. A client newly admitted with exacerbation of heart failure 2. A client newly diagnosed with type 2 diabetes mellitus 3. A client who underwent emergency appendectomy during the night 4. A client with nephrolithiasis scheduled for lithotripsy later in the morning 5. A client admitted with thyrotoxicosis

Answer: 3, 4 The intermediate care surgical nurse should be most comfortable assuming the care of surgical clients. Heart failure, diabetes, and thyrotoxicosis are medical problems, and the client with diabetes will also require extensive teaching. The client with nephrolithiasis may also require teaching about the procedure, but since the client will undergo moderate sedation, the nurse would be completing typical preoperative care. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management Note the critical word <i>surgical</i> 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

71 MCSA A nurse is teaching a female client newly diagnosed with <i>Helicobacter pylori</i> infection. The nurse anticipates that which of the following medications will not be used after learning the client is pregnant? 1. Metronizadole 2. Amoxicillin 3. Clarithromycin 4. Ciprofloxacin

Answer: 4 Ciprofloxacin is not recommended for <i>Helicobacter pylori</i> infection during pregnancy. The other medications can be used after consulting with the physician. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Planning Pharmacology 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.

86 MCSA The nurse is preparing a client for discharge who will be taking lithium carbonate. Which of the following statements indicates that the client is feeling comfortable with being discharged on an antimanic medication? 1. "I don't want to take the medicine you will give me, but you said I have to." 2. "I know that if I take my lithium every day I won't have to come to the hospital again." 3. "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 check-up like you said." 4. "Even though I don't like taking medicine, I will take lithium daily with 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 few weeks I won't feel shaky anymore."

Answer: 4 Option 4 is correct because the client is honest, has an understanding of how to take the medication and what the side effects are, and knows that the side effect will subside eventually. Options 1 and 2 indicate that the client is feeling forced to take the medication but has no desire or understanding of the benefits of the daily routine and dosages. Option 3 indicates that the client has memorized the actions but does not understand the benefits or side effects of the medications. Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Communication and Documentation Pharmacology 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. 0

63 MCSA The nurse has been instructed to have a surgical consent form signed by a client who will be undergoing a surgical procedure. What is the most essential information to include in the discussion prior to the client signing the permission? 1. The client's diagnosis 2. Treatment proposed and the cost 3. The technical aspects of the procedure 4. Right to withdraw consent

Answer: 4 The client's right to withdraw consent is necessary to be part of the consent and it means that coercion was not utilized in obtaining the signature. It is the physician's responsibility, not the nurse's, to explain the diagnosis (option 1) and the need for the surgical procedure (option 2). Cost (option 2) is not an important aspect for informed consent. The technical aspects of the 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. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Implementation Fundamentals 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. 0