NCLEX Practice Questions

A client is admitted with a Ewing's sarcoma. Which symptoms would be expected due to this tumor's location? ❍ A. Hemiplegia ❍ B. Aphasia ❍ C. Nausea ❍ D. Bone pain

. Answer D is correct. Sarcoma is a type of bone cancer; therefore, bone pain would be expected. Answers A, B, and C are not specific to this type of cancer and are incorrect.

Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as: ❍ A. A cephalohematoma ❍ B. Molding ❍ C. Subdural hematoma ❍ D. Caput succedaneum

Answer A is correct. A swelling over the right parietal area is a cephalohematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line because it is outside the cranium but beneath the periosteum. Answer B, molding, is overlapping of the bones of the cranium and, thus, incorrect. In answer C, a subdural hematoma, or intracranial bleeding, is ominous and can be seen only on a CAT scan or x-ray. A caput succedaneum, in answer D, crosses the suture line and is edema.

Which laboratory test would be the least effective in making the diagnosis of a myocardial infarction? ❍ A. AST ❍ B. Troponin ❍ C. CK-MB ❍ D. Myoglobin

Answer A is correct. Answer A, AST, is not specific for myocardial infarction. Troponin, CK-MB, and myoglobin, in answers B, C, and D, are more specific, although myoglobin is also elevated in burns and trauma to muscles.

The client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept available during the test? ❍ A. Atropine sulfate ❍ B. Furosemide ❍ C. Prostigmin ❍ D. Promethazine

Answer A is correct. Atropine sulfate is the antidote for Tensilon and is given to treat cholenergic crises. Furosemide (answer B) is a diuretic, Prostigmin (answer C) is the treatment for myasthenia gravis, and Promethazine (answer D) is an antiemetic, antianxiety medication. Thus, answers B, C, and D are incorrect.

The nurse is assigned to care for an infant with physiologic jaun- dice. Which action by the nurse would facilitate elimination of the bilirubin? ❍ A. Increasing the infant's fluid intake ❍ B. Maintaining the infant's body temperature at 98.6°F ❍ C. Minimizing tactile stimulation ❍ D. Decreasing caloric intake

Answer A is correct. Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temperature is important but will not assist in eliminating bilirubin; therefore, answer B is incorrect. Answers C and D are incorrect because they do not relate to the question.

The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because: ❍ A. Grimacing and writhing movements decrease with relaxation and rest. ❍ B. Hypoactive deep tendon reflexes become more active with rest. ❍ C. Stretch reflexes are increased with rest. ❍ D. Fine motor movements are improved.

Answer A is correct. Frequent rest periods help to relax tense muscles and preserve energy. Answers B, C, and D are incorrect because they are untrue statements.

A new nursing graduate indicates in charting entries that he is a licensed practical nurse, although he has not yet received the results of the licensing exam. The graduate's action can result in what type of charge: ❍ A. Fraud ❍ B. Tort ❍ C. Malpractice ❍ D. Negligence

Answer A is correct. Identifying oneself as a nurse without a license defrauds the pub- lic and can be prosecuted. A tort is a wrongful act; malpractice is failing to act appro- priately as a nurse or acting in a way that harm comes to the client; and negligence is failing to perform care. Therefore, answers B, C, and D are incorrect.

The physician has prescribed tranylcypromine sulfate (Parnate) 10mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause: ❍ A. Hypertension ❍ B. Hyperthermia ❍ C. Melanoma ❍ D. Urinary retention

Answer A is correct. If the client eats foods high in tyramine, he might experience malignant hypertension. Tyramine is found in cheese, sour cream, Chianti wine, sher- ry, beer, pickled herring, liver, canned figs, raisins, bananas, avocados, chocolate, soy sauce, fava beans, and yeast. These episodes are treated with Regitine, an alpha- adrenergic blocking agent. Answers B, C, and D are not related to the question.

The nurse recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough? ❍ A. Mask ❍ B. Gown ❍ C. Gloves ❍ D. Shoe covers

Answer A is correct. If the nurse is exposed to the client with a cough, the best item to wear is a mask. If the answer had included a mask, gloves, and a gown, all would be appropriate, but in this case, only one item is listed; therefore, answers B and C are incorrect. Shoe covers are not necessary, so answer D is incorrect.

The nurse on the 3-11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action? ❍ A. Call the surgeon and ask him or her to see the client to clarify the information ❍ B. Explain the procedure and complications to the client ❍ C. Check in the physician's progress notes to see if understanding has been documented ❍ D. Check with the client's family to see if they understand the procedure fully

Answer A is correct. It is the responsibility of the physician to explain and clarify the procedure to the client. Answers B, C, and D are incorrect because they are not within the nurse's purview.

The client is admitted with a BP of 210/120. Her doctor orders furosemide (Lasix) 40mg IV stat. How should the nurse adminis- ter the prescribed furosemide to this client? ❍ A. By giving it over 1-2 minutes ❍ B. By hanging it IV piggyback ❍ C. With normal saline only ❍ D. By administering it through a venous access device

Answer A is correct. Lasix should be given approximately 1mL per minute to prevent hypotension. Answers B, C, and D are incorrect because it is not necessary to be given in an IV piggyback, with saline, or through a venous access device (VAD).

When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain? ❍ A. A history of radiation treatment in the neck region ❍ B. A history of recent orthopedic surgery ❍ C. A history of minimal physical activity ❍ D. A history of the client's food intake

Answer A is correct. Previous radiation to the neck might have damaged the parathy- roid glands, which are located on the thyroid gland, and interfered with calcium and phosphorus regulation. Answer B has no significance to this case; answers C and D are more related to calcium only, not to phosphorus regulation.

The nurse is caring for a client scheduled for removal of the pitu- itary gland. The nurse should be particularly alert for: ❍ A. Nasal congestion ❍ B. Abdominal tenderness ❍ C. Muscle tetany ❍ D. Oliguria

Answer A is correct. Removal of the pituitary gland is usually done by a transphe- noidal approach, through the nose. Nasal congestion further interferes with the airway. Answers B, C, and D are not correct because they are not directly associated with the pituitary gland.

The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes: ❍ A. Rotating application sites ❍ B. Limiting applications to the chest ❍ C. Rubbing it into the skin ❍ D. Covering it with a gauze dressing

Answer A is correct. Sites for the application of nitroglycerin should be rotated, to prevent skin irritation. It can be applied to the back and upper arms, not to the lower extremities, making answer B incorrect. Answer C is contraindicated to the question, and answer D is incorrect because the medication should be covered with a prepared dressing made of a thin paper substance, not gauze.

A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure? ❍ A. Bradycardia ❍ B. Tachycardia ❍ C. Premature ventricular beats ❍ D. Heart block

Answer A is correct. Suctioning can cause a vagal response and bradycardia. Answer B is unlikely and, therefore, not most important, although it can occur. Answers C and D can occur as well, but they are less likely.

The nurse is making assignments for the day. Which client should be assigned to the nursing assistant? ❍ A. A client with Alzheimer's disease ❍ B. A client with pneumonia ❍ C. A client with appendicitis ❍ D. A client with thrombophebitis

Answer A is correct. The client with Alzheimer's disease is the most stable of these clients and can be assigned to the nursing assistant, who can perform duties such as feeding and assisting the client with activities of daily living. The clients in answers B, C, and D are less stable and should be attended by a registered nurse.

The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is: ❍ A. To lower the blood glucose level ❍ B. To lower the uric acid level ❍ C. To lower the ammonia level ❍ D. To lower the creatinine level

Answer C is correct. Lactulose is administered to the client with cirrhosis to lower ammonia levels. Answers A, B, and D are incorrect because this does not have an effect on the other lab values.

The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available? ❍ A. The client with Cushing's disease ❍ B. The client with diabetes ❍ C. The client with acromegaly ❍ D. The client with myxedema

Answer A is correct. The client with Cushing's disease has adrenocortical hypersecre- tion. This increase in the level of cortisone causes the client to be immune sup- pressed. In answer B, the client with diabetes poses no risk to other clients. The client in answer C has an increase in growth hormone and poses no risk to himself or others. The client in answer D has hyperthyroidism or myxedema, and poses no risk to others or himself.

A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usu- ally be included in the plan? ❍ A. Closed chest drainage ❍ B. A tracheostomy ❍ C. A mediastenal tube ❍ D. Percussion vibration and drainage

Answer A is correct. The client with a lung resection will have chest tubes and a drainage-collection device. He probably will not have a tracheostomy or medicastenal tube, and he will not have an order for percussion, vibration, or drainage. Therefore, answers B, C, and D are incorrect.

A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect? ❍ A. The client is observed shaving only one side of his face. ❍ B. The client is unable to distinguish between two tactile stimuli presented simultaneously. ❍ C. The client is unable to complete a range of vision with- out turning his head side to side. ❍ D. The client is unable to carry out cognitive and motor activity at the same time.

Answer A is correct. The client with unilateral neglect will neglect one side of the body. Answers B, C, and D are not associated with unilateral neglect.

The nurse has just received a change-of-shift report. Which client should the nurse assess first? ❍ A. A client 2 hours post-lobectomy with 150ccs drainage ❍ B. A client 2 days post-gastrectomy with scant drainage ❍ C. A client with pneumonia with an oral temperature of 102°F ❍ D. A client with a fractured hip in Buck's traction

Answer A is correct. The first client to be seen is the one who recently returned from surgery. The other clients in answers B, C, and D are more stable and can be seen later.

Which of the following roommates would be most suitable for the client with myasthenia gravis? ❍ A. A client with hypothyroidism ❍ B. A client with Crohn's disease ❍ C. A client with pylonephritis ❍ D. A client with bronchitis

Answer A is correct. The most suitable roommate for the client with myasthenia gravis is the client with hypothyroidism because he is quiet. The client with Crohn's disease in answer B will be up to the bathroom frequently; the client with pylonephritis in answer C has a kidney infection and will be up to urinate frequently. The client in answer D with bronchitis will be coughing and will disturb any roommate.

Which action by the novice nurse indicates a need for further teaching? ❍ A. The nurse fails to wear gloves to remove a dressing. ❍ B. The nurse applies an oxygen saturation monitor to the ear lobe. ❍ C. The nurse elevates the head of the bed to check the blood pressure. ❍ D. The nurse places the extremity in a dependent position to acquire a peripheral blood sample.

Answer A is correct. The nurse who fails to wear gloves to remove a contaminated dressing needs further instruction. Answers B, C, and D are incorrect because they indicate an understanding of the correct method of completing these tasks.

The nurse is making assignments for the day. Which client should be assigned to the pregnant nurse? ❍ A. The client receiving linear accelerator radiation therapy for lung cancer ❍ B. The client with a radium implant for cervical cancer ❍ C. The client who has just been administered soluble brachytherapy for thyroid cancer ❍ D. The client who returned from placement of iridium seeds for prostate cancer

Answer A is correct. The pregnant nurse should not be assigned to any client with radioactivity present. Therefore, the client receiving linear accelerator therapy is cor- rect because this client travels to the radium department for therapy, and the radiation stays in the department; the client is not radioactive. The client in answer B does pose a risk to the pregnant client. The client in answer C is radioactive in very small doses. For approximately 72 hours, the client should dispose of urine and feces in special containers and use plastic spoons and forks. The client in answer D is also radioactive in small amounts, especially upon return from the procedure.

A 24-year-old female client is scheduled for surgery in the morn- ing. Which of the following is the primary responsibility of the nurse? ❍ A. Taking the vital signs ❍ B. Obtaining the permit ❍ C. Explaining the procedure ❍ D. Checking the lab work

Answer A is correct. The primary responsibility of the nurse is to take the vital signs before any surgery. The actions in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for this question.

To ensure safety while administering a nitroglycerine patch, the nurse should: ❍ A. Wear gloves ❍ B. Shave the area where the patch will be applied ❍ C. Wash the area thoroughly with soap and rinse with hot water ❍ D. Apply the patch to the buttocks

Answer A is correct. To protect herself, the nurse should wear gloves when applying a nitroglycerine patch or cream. Answer B is incorrect because shaving the shin might abrade the area. Answer C is incorrect because washing with hot water will vasodilate and increase absorption. The patches should be applied to areas above the waist, mak- ing answer D incorrect.

The graduate licensed practical nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority? ❍ A. Maintain the client's systolic blood pressure at 70mmHg or greater ❍ B. Maintain the client's urinary output greater than 300cc per hour ❍ C. Maintain the client's body temperature of greater than 33°F rectal ❍ D. Maintain the client's hematocrit less than 30%

Answer A is correct. When the cadaver client is being prepared to donate an organ, the systolic blood pressure should be maintained at 70mmHg or greater to ensure a blood supply to the donor organ. Answers B, C, and D are incorrect because they are unnecssary actions for organ donation.

The physician has ordered sodium warfarin (Coumadin) for the client with thrombophlebitis. The order should be entered to administer the medication at: ❍ A. 0900 ❍ B. 1200 ❍ C. 1700 ❍ D. 2100

Answer C is correct. Sodium warfarin is administered in the late afternoon, at approxi- mately 1700 hours. This allows for accurate bleeding times to be drawn in the morn- ing. Therefore, answers A, B, and D are incorrect.

The client with diabetes is preparing for discharge. During dis- charge teaching, the nurse assesses the client's ability to care for himself. Which statement made by the client would indicate a need for follow-up after discharge? ❍ A. "I live by myself." ❍ B. "I have trouble seeing." ❍ C. "I have a cat in the house with me." ❍ D. "I usually drive myself to the doctor."

Answer B is correct. A client with diabetes who has trouble seeing would require fol- low-up after discharge. The lack of visual acuity for the client preparing and injecting insulin might require help. Answers A, C, and D will not prevent the client from being able to care for himself and, thus, are incorrect.

The physician prescribes captopril (Capoten) 25mg po tid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten? ❍ A. Tinnitus ❍ B. Persistent cough ❍ C. Muscle weakness ❍ D. Diarrhea

Answer B is correct. A persistent cough might be related to an adverse reaction to Captoten. Answers A and D are incorrect because tinnitus and diarrhea are not associ- ated with the medication. Muscle weakness might occur when beginning the treatment but is not an adverse effect; thus, answer C is incorrect.

The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside? ❍ A. A pair of forceps ❍ B. A torque wrench ❍ C. A pair of wire cutters ❍ D. A screwdriver

Answer B is correct. A torque wrench is kept at the bedside to tighten and loosen the screws of crutchfield tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of forceps, wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus, are incorrect.

The nurse is caring for a client with a malignancy. The classifica- tion of the primary tumor is Tis. The nurse should plan care for a tumor: ❍ A. That cannot be assessed ❍ B. That is in situ ❍ C. With increasing lymph node involvement ❍ D. With distant metastasis

Answer B is correct. Cancer in situ means that the cancer is still localized to the pri- mary site. Cancer is graded in terms of tumor, grade, node involvement, and mestata- sis. Answer A is incorrect because it is an untrue statement. Answer C is incorrect because T indicates tumor, not node involvement. Answer D is incorrect because a tumor that is in situ is not metastasized.

The nurse is obtaining a history of an 80-year-old client. Which statement made by the client might indicate a possible fluid and electrolyte imbalance? ❍ A. "My skin is always so dry." ❍ B. "I often use a laxative for constipation." ❍ C. "I have always liked to drink a lot of ice tea." ❍ D. "I sometimes have a problem with dribbling urine."

Answer B is correct. Frequent use of laxatives can lead to diarrhea and electrolyte loss. Answers A, C, and D are not of particular significance in this case and, therefore, are incorrect.

A client with cancer is admitted to the oncology unit. Stat lab val- ues reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is expe- riencing which of the following? ❍ A. Hypernatremia ❍ B. Hypokalemia ❍ C. Myelosuppression ❍ D. Leukocytosis

Answer B is correct. Hypokalemia is evident from the lab values listed. The other lab- oratory findings are within normal limits, making answers A, C, and D incorrect.

The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should: ❍ A. Document the finding ❍ B. Send a specimen to the lab ❍ C. Strain the urine ❍ D. Obtain a complete blood count

Answer B is correct. If the dialysate returns cloudy, infection might be present and must be evaluated. Documenting the finding, as stated in answer A, as not enough; straining the urine, in answer C, is incorrect; and dialysate, in answer D, is not urine at all. However, the physician might order a white blood cell count.

The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery? ❍ A. Hearing aid ❍ B. Contact lenses ❍ C. Wedding ring ❍ D. Artificial eye

Answer B is correct. It is most important to remove the contact lenses because leav- ing them in can lead to corneal drying, particularly with contact lenses that are not extended-wear lenses. Leaving in the hearing aid or artificial eye will not harm the client. Leaving the wedding ring on is also allowed; usually, the ring is covered with tape. Therefore, answers A, C, and D are incorrect.

Lidocaine is a medication frequently ordered for the client experi- encing: ❍ A. Atrial tachycardia ❍ B. Ventricular tachycardia ❍ C. Heart block ❍ D. Ventricular brachycardia

Answer B is correct. Lidocaine is used to treat ventricular tachycardia. This medica- tion slowly exerts an antiarrhythmic effect by increasing the electric stimulation threshold of the ventricles without depressing the force of ventricular contractions. It is not used for atrial arrhythmias; thus, answer A is incorrect. Answers C and D are incorrect because it slows the heart rate, so it is not used for heart block or brachycar- dia.

The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because: ❍ A. The client is at risk for evisceration. ❍ B. The client will require frequent dressing changes. ❍ C. The straps provide support for drains that are inserted in the incision. ❍ D. No sutures or clips are used to secure the incision.

Answer B is correct. Montgomery straps are used to secure dressings that require frequent dressing changes because the client with a cholecystectomy usually has a large amount of drainage on the dressing. Montgomery straps are also used for clients who are allergic to several types of tape. This client is not at higher risk of evisceration than other clients, so answer A is incorrect. Montgomery straps are not used to secure the drains, so answer C is incorrect. Sutures or clips are used to secure the wound of the client who has had gallbladder surgery, so answer D is incorrect.

The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritis. Which would be the most appropriate nurs- ing intervention? ❍ A. Suggest that the client take warm showers B.I.D. ❍ B. Add baby oil to the client's bath water ❍ C. Apply powder to the client's skin ❍ D. Suggest a hot-water rinse after bathing

Answer B is correct. Oils can be applied to help with the dry skin and to decrease itching, so adding baby oil to bath water is soothing to the skin. Answer A is incorrect because bathing twice a day is too frequent and can cause more dryness. Answer C is incorrect because powder is also drying. Rinsing with hot water, as stated in answer D, dries out the skin as well.

Several clients are admitted to the emergency room following a three-car vehicle accident. Which clients can be assigned to share a room in the emergency department during the disaster? ❍ A. The schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis ❍ B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm ❍ C. A child whose pupils are fixed and dilated and his par- ents, and the client with a frontal head injury ❍ D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain

Answer B is correct. Out of all of these clients, it is best to hold the pregnant client and the client with a broken arm and facial lacerations in the same room. The clients in answer A need to be placed in separate rooms because these clients are disruptive or have infections. In the case of answer C, the child is terminal and should be in a private room with his parents.

A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session? ❍ A. "You will be sitting for the examination procedure." ❍ B. "Portions of the procedure will cause pain or discom- fort." ❍ C. "You will be given some medication to anesthetize the area." ❍ D. "You will not be able to drink fluids for 24 hours before the study."

Answer B is correct. Portions of the exam are painful, especially when the sample is being withdrawn, so this should be included in the session with the client. Answer A is incorrect because the client will be positioned prone, not in a sitting position, for the exam. Anesthesia is not commonly given before this test, making answer C incorrect. Answer D is incorrect because the client can eat and drink following the test.

Which information should be reported to the state Board of Nursing? ❍ A. The facility fails to provide literature in both Spanish and English. ❍ B. The narcotic count has been incorrect on the unit for the past 3 days. ❍ C. The client fails to receive an itemized account of his bills and services received during his hospital stay. ❍ D. The nursing assistant assigned to the client with hepa- titis fails to feed the client and give the bath.

Answer B is correct. The Joint Commission on Accreditation of Hospitals will proba- bly be interested in the problems in answers A and C. The failure of the nursing assis- tant to assist the client with hepatitis should be reported to the charge nurse. If the behavior continues, termination may result. Answer D is incorrect because failure to feed and bathe the client should be reported to the superior, not the Board of Nursing.

The nurse is found to be guilty of charting blood glucose results without actually performing the procedure. After talking to the nurse, the charge nurse should: ❍ A. Call the Board of Nursing ❍ B. File a formal reprimand ❍ C. Terminate the nurse ❍ D. Charge the nurse with a tort

Answer B is correct. The action after discussing the problem with the nurse is to doc- ument the incident and file a formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but this is not the first step. A tort is a wrongful act committed against a client or his belongings. Answers A, C, and D are incorrect.

The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin? ❍ A. Cyanocobalamine ❍ B. Protamine sulfate ❍ C. Streptokinase ❍ D. Sodium warfarin

Answer B is correct. The antidote for heparin is protamine sulfate. Cyanocobalamine is B12, Streptokinase is a thrombolytic, and sodium warfarin is an anticoagulant. Therefore, answers A, C, and D are incorrect.

The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse? ❍ A. Notify the police department as a robbery ❍ B. Report this behavior to the charge nurse ❍ C. Monitor the situation and note whether any items are missing ❍ D. Ignore the situation until items are reported missing

Answer B is correct. The best action at this time is to report the incident to the charge nurse. Further action might be needed, but it should be determined by the charge nurse. Answers A, C, and D are incorrect because notifying the police is overreacting at this time, and monitoring or ignoring the situation is an inadequate response.

The nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should: ❍ A. Change the nursing assistant's assignment ❍ B. Explore the interaction with the nursing assistant ❍ C. Discuss the matter with the client's family ❍ D. Initiate a group session with the nursing assistant

Answer B is correct. The best action for the nurse to take is to explore the interaction with the nursing assistant. This will allow for clarification of the situation. Changing the assignment in answer A might need to be done, but talking to the nursing assis- tant is the first step. Answer C is incorrect because discussing the incident with the family is not necessary at this time; it might cause more problems. Answer C is not a first step, even though initiating a group session might be a plan for the future.

Due to a high census, it has been necessary for a number of clients to be transferred to other units within the hospital. Which client should be transferred to the postpartum unit? ❍ A. A 66-year-old female with a gastroenteritis ❍ B. A 40-year-old female with a hysterectomy ❍ C. A 27-year-old male with severe depression ❍ D. A 28-year-old male with ulcerative colitis

Answer B is correct. The best client to transport to the postpartum unit is the 40-year- old female with a hysterectomy. The nurses on the postpartum unit will be aware of normal amounts of bleeding and will be equipped to care for this client. The clients in answers A and D will be best cared for on a medical-surgical unit. The client with depression in answer C should be transported to the psychiatric unit.

The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to: ❍ A. Take the blood pressure, pulse, and temperature ❍ B. Ask the client to rate his pain on a scale of 0-5 ❍ C. Watch the client's facial expression ❍ D. Ask the client if he is in pain

Answer B is correct. The best way to evaluate pain levels is to ask the client to rate his pain on a scale. In answer A, the blood pressure, pulse, and temperature can alter for other reasons than pain. Answers C and D are not as effective in determining pain levels.

The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated while the client is receiving TPN? ❍ A. Hemoglobin ❍ B. Creatinine ❍ C. Blood glucose ❍ D. White blood cell count

Answer C is correct. When the client is receiving TPN, the blood glucose level should be drawn. TPN is a solution that contains large amounts of glucose. Answers A, B, and D are not directly related to the question and are incorrect.

The nurse is preparing a client for mammography. To prepare the client for a mammogram, the nurse should tell the client: ❍ A. To restrict her fat intake for 1 week before the test ❍ B. To omit creams, powders, or deodorants before the exam ❍ C. That mammography replaces the need for self-breast exams ❍ D. That mammography requires a higher dose of radia- tion than an x-ray

Answer B is correct. The client having a mammogram should be instructed to omit deodorants or powders beforehand because powders and deodorants can be interpret- ed as abnormal. Answer A is incorrect because there is no need for dietary restrictions before a mammogram. Answer C is incorrect because the mammogram does not replace the need for self-breast exams. Answer D is incorrect because a mammogram does not require higher doses of radiation than an x-ray.

A client with cancer is to undergo an intravenous pyelogram. The nurse should: ❍ A. Force fluids 24 hours before the procedure ❍ B. Ask the client to void immediately before the study ❍ C. Hold medication that affects the central nervous sys- tem for 12 hours pre- and post-test ❍ D. Cover the client's reproductive organs with an x-ray shield

Answer B is correct. The client having an intravenous pyelogram will have orders for laxatives or enemas, so asking the client to void before the test is in order. A full blad- der or bowel can obscure the visualization of the kidney ureters and urethra. In answers A, C, and D, there is no need to force fluids before the procedure, to withhold medications, or to cover the reproductive organs.

The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam? ❍ A. "You will need to lay flat during the exam." ❍ B. "You need to empty your bladder before the proce- dure." ❍ C. "You will be asleep during the procedure." ❍ D. "The doctor will inject a medication to treat your ill- ness during the procedure."

Answer B is correct. The client scheduled for a pericentesis should be told to empty the bladder, to prevent the risk of puncturing the bladder when the needle is inserted. A pericentesis is done to remove fluid from the peritoneal cavity. The client will be positioned sitting up or leaning over a table, making answer A incorrect. The client is usually awake during the procedure, and medications are not commonly inserted into the peritoneal cavity during this procedure; thus, answers C and D are incorrect (although this could depend on the circumstances).

The client with a myocardial infarction comes to the nurse's sta- tion stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using? ❍ A. Rationalization ❍ B. Denial ❍ C. Projection ❍ D. Conversion reaction

Answer B is correct. The client who says he has nothing wrong is in denial about his myocardial infarction. Rationalization is making excuses for what happened, projection is projecting feeling or thoughts onto others, and conversion reaction is converting a psychological trauma into a physical illness; thus, answers A, C, and D are incorrect.

The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority? ❍ A. Starting an IV ❍ B. Applying oxygen ❍ C. Obtaining blood gases ❍ D. Medicating the client for pain

Answer B is correct. The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain, making answers A and C incorrect. Answer D, obtaining blood gases, is ordered by the doctor.

A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first? ❍ A. A client with brain attack (stroke) with tube feedings ❍ B. A client with congestive heart failure complaining of nighttime dyspnea ❍ C. A client with a thoracotomy 6 months ago ❍ D. A client with Parkinson's disease

Answer B is correct. The client with congestive heart failure who is complaining of nighttime dyspnea should be seen first because airway is no. 1 in nursing care. In answers A, C, and D, the clients are more stable.

A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate? ❍ A. Blood pressure every 15 minutes ❍ B. Insertion of a Levine tube ❍ C. Cardiac monitoring ❍ D. Dressing changes two times per day

Answer B is correct. The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a Levine tube should be anticipated. Answers A and C are incorrect because blood pressures are not required every 15 minutes, and cardiac monitoring might be needed, but this is individualized to the client. Answer D is incorrect because there are no dressings to change on this client.

A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meq/L. What behavior changes would be most common for this client? ❍ A. Anger ❍ B. Mania ❍ C. Depression ❍ D. Psychosis

Answer B is correct. The client with serum sodium of 170meq/L has hypernatremia and might exhibit manic behavior. Answers A, C, and D are not associated with hyper- natremia and are, therefore, incorrect.

The nurse is assigning staff for the day. Which assignment should be given to the nursing assistant? ❍ A. Taking the vital signs of the 5-month-old with bronchiolitis ❍ B. Taking the vital signs of the 10-year-old with a 2-day post-appendectomy ❍ C. Administering medication to the 2-year-old with peri- orbital cellulites ❍ D. Adjusting the traction of the 1-year-old with a frac- tured tibia

Answer B is correct. The client with the appendectomy is the most stable of these clients and can be assigned to a nursing assistant. The client with bronchiolitis has an alteration in the airway, the client with periorbital cellulitis has an infection, and the client with a fracture might be an abused child. Therefore, answers A, C, and D are incorrect.

During the change of shift, the oncoming nurse notes a discrepan- cy in the number of Percocet (Oxycodone) listed and the number present in the narcotic drawer. The nurse's first action should be to: ❍ A. Notify the hospital pharmacist ❍ B. Notify the nursing supervisor ❍ C. Notify the Board of Nursing ❍ D. Notify the director of nursing

Answer B is correct. The first action the nurse should take is to report the finding to the nurse supervisor and follow the chain of command. If it is found that the pharma- cy is in error, it should be notified, as stated in answer A. Answers C and D, notifying the director of nursing and the Board of Nursing, might be necessary if theft is found, but not as a first step; thus, these are incorrect answers.

Which nurse should be assigned to care for the postpartal client with preeclampsia? ❍ A. The nurse with 2 weeks of experience on postpartum ❍ B. The nurse with 3 years of experience in labor and delivery ❍ C. The nurse with 10 years of experience in surgery ❍ D. The nurse with 1 year of experience in the neonatal intensive care unit

Answer B is correct. The nurse in answer B has the most experience with possible complications involved with preeclampsia. The nurse in answer A is a new nurse to this unit and should not be assigned to this client; the nurses in answers C and D have no experience with the postpartal client and also should not be assigned to this client.

The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion? ❍ A. The security guard ❍ B. The registered nurse ❍ C. The licensed practical nurse ❍ D. The nursing assistant

Answer B is correct. The registered nurse is the only one of these who can legally put the client in seclusion. The only other healthcare worker who is allowed to initiate seclusion is the doctor; therefore, answers A, C, and D are incorrect.

The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care? ❍ A. A 10-year-old with lacerations of the face ❍ B. A 15-year-old with sternal bruises ❍ C. A 34-year-old with a fractured femur ❍ D. A 50-year-old with dislocation of the elbow

Answer B is correct. The teenager with sternal bruising might be experiencing airway and oxygenation problems and, thus, should be seen first. In answer A, the 10-year- old with lacerations might look bad but is not in distress. The client in answer C with a fractured femur should be immobilized but can be seen after the client with sternal bruising. The client in answer D with the dislocated elbow can be seen later as well.

The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority? ❍ A. Continue to monitor the vital signs ❍ B. Contact the physician ❍ C. Ask the client how he feels ❍ D. Ask the LPN to continue the post-op care

Answer B is correct. The vital signs are abnormal and should be reported to the doc- tor immediately. Answer A, continuing to monitor the vital signs, can result in deterio- ration of the client's condition. Answer C, asking the client how he feels, would supply only subjective data. Involving the LPN, in answer D, is not the best solution to help this client because he is unstable.

The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis? ❍ A. A weight loss of 10 pounds in 2 weeks ❍ B. Complaints of numbness and tingling in the extremi- ties ❍ C. A red, beefy tongue ❍ D. A hemoglobin level of 12.0gm/dL

Answer C is correct. A red, beefy tongue is characteristic of the client with pernicious anemia. Answer A, a weight loss of 10 pounds in 2 weeks, is abnormal but is not seen in pernicious anemia. Numbness and tingling, in answer B, can be associated with anemia but are not particular to pernicious anemia. This is more likely associated with peripheral vascular diseases involving vasculature. In answer D, the hemoglobin is low normal.

The nursing is participating in discharge teaching for the post- partal client. The nurse is aware that an effective means of manag- ing discomfort associated with an episiotomy after discharge is: ❍ A. Promethazine ❍ B. Aspirin ❍ C. Sitz baths ❍ D. Ice packs

Answer C is correct. A sitz bath will help with swelling and improve healing. Ice packs, in answer D, can be used immediately after delivery. Answers A and B are not used in this instance.

The nurse witnesses the nursing assistant hitting the client in the long-term care facility. The nursing assistant can be charged with: ❍ A. Negligence ❍ B. Tort ❍ C. Assault ❍ D. Malpractice

Answer C is correct. Assault is defined as striking or touching the client inappropri- ately, so a nurse assistant striking a client could be charged with assault. Answer A, negligence, is failing to perform care for the client. Answer B, a tort, is a wrongful act committed on the client or their belongings. Answer D, malpractice, is failure to per- form an act that the nursing assistant knows should be done, or the act of doing something wrong that results in harm to the client.

A 25-year-old male is brought to the emergency room with a piece of metal in his eye. Which action by the nurse is correct? ❍ A. Use a magnet to remove the object. ❍ B. Rinse the eye thoroughly with saline. ❍ C. Cover both eyes with paper cups. ❍ D. Patch the affected eye only.

Answer C is correct. Covering both eyes prevents consensual movement of the affect- ed eye. The nurse should not attempt to remove the object from the eye because this might cause trauma, as stated in answer A. Rinsing the eye, as stated in answer B, might be ordered by the doctor, but this is not the first step for the nurse. Answer D is not correct because often when one eye moves, the other also does.

15. The nurse is caring for a client with laryngeal cancer. Which find- ing ascertained in the health history would not be common for this diagnosis? ❍ A. Foul breath ❍ B. Dysphagia ❍ C. Diarrhea ❍ D. Chronic hiccups

Answer C is correct. Diarrhea is not common in clients with mouth and throat cancer. All the findings in answers A, B, and D are expected findings.

The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the client? ❍ A. Rest in bed after taking the medication for at least 30 minutes ❍ B. Avoid rapid movements after taking the medication ❍ C. Take the medication with water only ❍ D. Allow at least 1 hour between taking the medicine and taking other medications

Answer C is correct. Fosamax should be taken with water only. The client should also remain upright for at least 30 minutes after taking the medication. Answers A, B, and D are not applicable to taking Fosamax and, thus, are incorrect.

A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate? ❍ A. Reinsert the protruding organ and cover with 4×4s ❍ B. Cover the wound with a sterile 4×4 and ABD dressing ❍ C. Cover the wound with a sterile saline-soaked dressing ❍ D. Apply an abdominal binder and manual pressure to the wound

Answer C is correct. If the client eviscerates, the abdominal content should be cov- ered with a sterile saline-soaked dressing. Reinserting the content should not be the action and will require that the client return to surgery; thus, answer A is incorrect. Answers B and D are incorrect because they are not appropriate to this case.

The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indi- cate a serious side effect of this drug? ❍ A. Uric acid of 5mg/dL ❍ B. Hematocrit of 33% ❍ C. WBC 2,000 per cubic millimeter ❍ D. Platelets 150,000 per cubic millimeter

Answer C is correct. Tegretol can suppress the bone marrow and decrease the white blood cell count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and D are within normal limits, and answer B is a lower limit of normal; therefore answers A, B, and D are incorrect.

The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period? ❍ A. Assessment of the client's level of anxiety ❍ B. Evaluation of the client's exercise tolerance ❍ C. Identification of peripheral pulses ❍ D. Assessment of bowel sounds and activity

Answer C is correct. The assessment that is most crucial to the client is the identifica- tion of peripheral pulses because the aorta is clamped during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities. Answer A is of lesser concern, answer B is not advised at this time, and answer D is of lesser concern than answer A.

The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal pH 7.36, CO2 45, O2 84, HCO3 28. The nurse would assess the client to be in: ❍ A. Uncompensated acidosis ❍ B. Compensated alkalosis ❍ C. Compensated respiratory acidosis ❍ D. Uncompensated metabolic acidosis

Answer C is correct. The client is experiencing compensated metabolic acidosis. The pH is within the normal range but is lower than 7.40, so it is on the acidic side. The CO2 level is elevated, the oxygen level is below normal, and the bicarb level is slightly elevated. In respiratory disorders, the pH will be the inverse of the CO2 and bicarb lev- els. This means that if the pH is low, the CO2 and bicarb levels will be elevated. Answers A, B, and D are incorrect because they do not fall into the range of symp- toms.

The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching? ❍ A. The graduate places the client in a supine position to read the manometer. ❍ B. The graduate turns the stop-cock to the off position from the IV fluid to the client. ❍ C. The graduate instructs the client to perform the Valsalva maneuver during the CVP reading. ❍ D. The graduate notes the level at the top of the meniscus.

Answer C is correct. The client should breathe normally during a central venous pres- sure monitor reading. Answer A indicates understanding because the client should be placed supine if he can tolerate being in that position. Answers B and D indicate understanding because the stop-cock should be turned off to the IV fluid, and the reading should be done at the top of the meniscus.

The nurse is providing discharge teaching for a client taking dis- sulfiram (Antabuse). The nurse should instruct the client to avoid eating: ❍ A. Peanuts, dates, raisins ❍ B. Figs, chocolate, eggplant ❍ C. Pickles, salad with vinaigrette dressing, beef ❍ D. Milk, cottage cheese, ice cream

Answer C is correct. The client taking antabuse should not eat or drink anything con- taining alcohol or vinegar. The other foods in answers A, B, and D are allowed.

A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for: ❍ A. Trendelenburg position ❍ B. Ice to the entire extremity ❍ C. Buck's traction ❍ D. An abduction pillow

Answer C is correct. The client with a fractured femur will be placed in Buck's traction to realign the leg and to decrease spasms and pain. The Trendelenburg position is the wrong position for this client, so answer A is incorrect. Ice might be ordered after repair, but not for the entire extremity, so answer B is incorrect. An abduction pillow is ordered after a total hip replacement, not for a fractured femur; therefore, answer D is incorrect.

The nurse is assisting the RN with discharge instructions for a client with an implantable defibrillator. What discharge instruction is essential? ❍ A. "You cannot eat food prepared in a microwave." ❍ B. "You should avoid moving the shoulder on the side of the pacemaker site for 6 weeks." ❍ C. "You should use your cellphone on your right side." ❍ D. "You will not be able to fly on a commercial airliner with the defibrillator in place."

Answer C is correct. The client with an internal defibrillator should learn to use any battery-operated machinery on the opposite side. He should also take his pulse rate and report dizziness or fainting. Answers A, B, and D are incorrect because the client can eat food prepared in the microwave, move his shoulder on the affected side, and fly in an airplane.

The nurse is performing discharge teaching on a client with diver- ticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client's diet? ❍ A. Roasted chicken ❍ B. Noodles ❍ C. Cooked broccoli ❍ D. Custard

Answer C is correct. The client with diverticulitis should avoid eating foods that are gas forming and that increase abdominal discomfort, such as cooked broccoli. Foods such as those listed in answers A, B, and D are allowed.

The nurse is assisting a client with diverticulosis to select appro- priate foods. Which food should be avoided? ❍ A. Bran ❍ B. Fresh peaches ❍ C. Cucumber salad ❍ D. Yeast rolls

Answer C is correct. The client with diverticulitis should avoid foods with seeds. The foods in answers A, B, and D are allowed; in fact, bran cereal and fruit will help pre- vent constipation.

A home health nurse is planning for her daily visits. Which client should the home health nurse visit first? ❍ A. A client with AIDS being treated with Foscarnet ❍ B. A client with a fractured femur in a long leg cast ❍ C. A client with laryngeal cancer with a laryngetomy ❍ D. A client with diabetic ulcers to the left foot

Answer C is correct. The client with laryngeal cancer has a potential airway alteration and should be seen first. The clients in answers A, B, and D are not in immediate dan- ger and can be seen later in the day.

A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? ❍ A. "Tell me about his pain." ❍ B. "What does his vomit look like?" ❍ C. "Describe his usual diet." ❍ D. "Have you noticed changes in his abdominal size?"

Answer C is correct. The least-helpful questions are those describing his usual diet. A, B, and D are useful in determining the extent of disease process and, thus, are incor- rect.

An infant weighs 7 pounds at birth. The expected weight by 1 year should be: ❍ A. 10 pounds ❍ B. 12 pounds ❍ C. 18 pounds ❍ D. 21 pounds

Answer D is correct. A birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth weight. Answers A, B, and C therefore are incorrect.

The physician has ordered a culture for the client with suspected gonorrhea. The nurse should obtain which type of culture? ❍ A. Blood ❍ B. Nasopharyngeal secretions ❍ C. Stool ❍ D. Genital secretions

Answer D is correct. A culture for gonorrhea is taken from the genital secretions. The culture is placed in a warm environment, where it can grow nisseria gonorrhea. Answers A, B, and C are incorrect because these cultures do not test for gonorrhea.

Which assignment should not be performed by the licensed prac- tical nurse? ❍ A. Inserting a Foley catheter ❍ B. Discontinuing a nasogastric tube ❍ C. Obtaining a sputum specimen ❍ D. Initiating a blood transfusion

Answer D is correct. A licensed practical nurse should not be assigned to initiate a blood transfusion. The LPN can assist with the transfusion and check ID numbers for the RN. The licensed practical nurse can be assigned to insert Foley and French uri- nary catheters, discontinue Levine and Gavage gastric tubes, and obtain all types of specimens, so answers A, B, and C are incorrect.

A client visits the clinic after the death of a parent. Which state- ment made by the client's sister signifies abnormal grieving? ❍ A. "My sister still has episodes of crying, and it's been 3 months since Daddy died." ❍ B. "Sally seems to have forgotten the bad things that Daddy did in his lifetime." ❍ C. "She really had a hard time after Daddy's funeral. She said that she had a sense of longing." ❍ D. "Sally has not been sad at all by Daddy's death. She acts like nothing has happened."

Answer D is correct. Abnormal grieving is exhibited by a lack of feeling sad; if the client's sister appears not to grieve, it might be abnormal grieving. This family member might be suppressing feelings of grief. Answers A, B, and C are all normal expressions of grief and, therefore, incorrect.

The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is: ❍ A. The baby is dehydrated due to polyuria. ❍ B. The baby is hypoglycemic due to lack of glucose. ❍ C. The baby is allergic to the formula the mother is giving him. ❍ D. The baby can lose up to 10% of weight due to meco- nium stool, loss of extracellular fluid, and initiation of breast-feeding.

Answer D is correct. After birth, meconium stool, loss of extracellular fluid, and initia- tion of breastfeeding cause the infant to lose body mass. There is no evidence to indi- cate dehydration, hypoglycemia, or allergy to the infant formula; thus, answers A, B, and C are incorrect..

Which of the following post-operative diets is most appropriate for the client who has had a hemorroidectomy? ❍ A. High-fiber ❍ B. Low-residue ❍ C. Bland ❍ D. Clear-liquid

Answer D is correct. After surgery, the client will be placed on a clear-liquid diet and progressed to a regular diet. Stool softeners will be included in the plan of care, to avoid constipation. Later, a high-fiber diet, in answer A, is encouraged, but this is not the first diet after surgery. Answers B and C are not diets for this type of surgery.

A client with acute leukemia develops a low white blood cell count. In addition to the institution of isolation, the nurse should: ❍ A. Request that foods be served with disposable utensils ❍ B. Ask the client to wear a mask when visitors are present ❍ C. Prep IV sites with mild soap and water and alcohol ❍ D. Provide foods in sealed single-serving packages

Answer D is correct. Because the client is immune-suppressed, foods should be served in sealed containers, to avoid food contaminants. Answer B is incorrect because of possible infection from visitors. Answer A is not necessary, but the utensils should be cleaned thoroughly and rinsed in hot water. Answer C might be a good idea, but alcohol can be drying and can cause the skin to break down.

A client has been receiving cyanocobalamine (B12) injections for the past 6 weeks. Which laboratory finding indicates that the med- ication is having the desired effect? ❍ A. Neutrophil count of 60% ❍ B. Basophil count of 0.5% ❍ C. Monocyte count of 2% ❍ D. Reticulocyte count of 1%

Answer D is correct. Cyanocolamine is a B12 medication that is used for pernicious anemia, and a reticulocyte count of 1% indicates that it is having the desired effect. Answers A, B, and C are white blood cells and have nothing to do with this medica- tion.

37. The physician has ordered that the client's medication be adminis- tered intrathecally. The nurse is aware that medications will be administered by which method? ❍ A. Intravenously ❍ B. Rectally ❍ C. Intramuscularly ❍ D. Into the cerebrospinal fluid

Answer D is correct. Intrathecal medications are administered into the cerebrospinal fluid. This method of administering medications is reserved for the client with metas- tases, the client with chronic pain, or the client with cerebrospinal infections. Answers A, B, and C are incorrect because intravenous, rectal, and intramuscular injections are entirely different procedures.

The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. The doc- tor orders quinidine sulfate. While he is receiving quinidine, the nurse should monitor his ECG for: ❍ A. Peaked P wave ❍ B. Elevated ST segment ❍ C. Inverted T wave ❍ D. Prolonged QT interval

Answer D is correct. Quinidine can cause widened Q-T intervals and heart block. Other signs of myocardial toxicity are notched P waves and widened QRS complexes. The most common side effects are diarrhea, nausea, and vomiting. The client might experience tinnitus, vertigo, headache, visual disturbances, and confusion. Answers A, B, and C are not related to the use of quinidine.

Which client can best be assigned to the newly licensed practical nurse? ❍ A. The client receiving chemotherapy ❍ B. The client post-coronary bypass ❍ C. The client with a TURP ❍ D. The client with diverticulitis

Answer D is correct. The best client to assign to the newly licensed nurse is the most stable client; in this case, it is the client with diverticulitis. The client receiving chemotherapy and the client with a coronary bypass both need nurses experienced in these areas, so answers A and B are incorrect. Answer D is incorrect because the client with a transurethral prostatectomy might bleed, so this client should be assigned to a nurse who knows how much bleeding is within normal limits..

A client has rectal cancer and is scheduled for an abdominal per- ineal resection. What should be the priority nursing care during the post-op period? ❍ A. Teaching how to irrigate the illeostomy ❍ B. Stopping electrolyte loss in the incisional area ❍ C. Encouraging a high-fiber diet ❍ D. Facilitating perineal wound drainage

Answer D is correct. The client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illeostomy, as in answer A; he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect. A high-fiber diet, in answer C, is not ordered at this time.

The first exercise that should be performed by the client who had a mastectomy is: ❍ A. Walking the hand up the wall ❍ B. Sweeping the floor ❍ C. Combing her hair ❍ D. Squeezing a ball

Answer D is correct. The first exercise that should be done by the client with a mas- tectomy is squeezing the ball. Answers A, B, and C are incorrect as the first step; they are implemented later.

A client with glomerulonephritis is placed on a low-sodium diet. Which of the following snacks is suitable for the client with sodi- um restriction? ❍ A. Peanut butter cookies ❍ B. Grilled cheese sandwich ❍ C. Cottage cheese and fruit ❍ D. Fresh peach

Answer D is correct. The fresh peach is the lowest in sodium of these choices. Answers A, B, and C have much higher amounts of sodium.

The licensed practical nurse is working with a registered nurse and a patient care assistant. Which of the following clients should be cared for by the registered nurse? ❍ A. A client 2 days post-appendectomy ❍ B. A client 1 week post-thyroidectomy ❍ C. A client 3 days post-splenectomy ❍ D. A client 2 days post-thoracotomy

Answer D is correct. The most critical client should be assigned to the registered nurse; in this case, that is the client 2 days post-thoracotomy. The clients in answers A and B are ready for discharge, and the client in answer C who had a splenectomy 3 days ago is stable enough to be assigned to an LPN.

Which of the following roommates would be best for the client newly admitted with gastric resection? ❍ A. A client with Crohn's disease ❍ B. A client with pneumonia ❍ C. A client with gastritis ❍ D. A client with phlebitis

Answer D is correct. The most suitable roommate for the client with gastric resection is the client with phlebitis because phlebitis is an inflammation of the blood vessel and is not infectious. Crohn's disease clients, in answer A, have frequent stools that might spread infections to the surgical client. The client in answer B with pneumonia is coughing and will disturb the gastric client. The client with gastritis, in answer C, is vomiting and has diarrhea, which also will disturb the gastric client.

The licensed practical nurse assigned to the post-partal unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam? ❍ A. A gravida IV para 3 that is Rh negative with an Rh- positive baby ❍ B. A gravida I para 1 that is Rh negative with an Rh- positive baby ❍ C. A gravida II para 0 that is Rh negative admitted after a stillbirth delivery ❍ D. A gravida IV para 2 that is Rh negative with an Rh- negative baby

Answer D is correct. The mothers in answers A, B, and C all require RhoGam and, thus, are incorrect. The mother in answer D is the only one who does not require a RhoGam injection.

The home health nurse is planning for the day's visits. Which client should be seen first? ❍ A. The 78-year-old who had a gastrectomy 3 weeks ago with a PEG tube ❍ B. The 5-month-old discharged 1 week ago with pneu- monia who is being treated with amoxicillin liquid sus- pension ❍ C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line ❍ D. The 30-year-old with an exacerbation of multiple scle- rosis being treated with cortisone via a centrally placed venous catheter

Answer D is correct. The priority client is the one with multiple sclerosis who is being treated with cortisone via the central line. This client is at highest risk for complica- tions. MRSA, in answer C, is methicillin-resistant staphylococcus aureas. Vancomycin is the drug of choice and can be administered later, but its use must be scheduled at specific times of the day to maintain a therapeutic level. Answers A and B are incorrect because these clients are more stable.

A client with cancer develops xerostomia. The nurse can help alle- viate the discomfort associated with xerostomia by: ❍ A. Offering hard candy ❍ B. Administering analgesic medications ❍ C. Splinting swollen joints ❍ D. Providing saliva substitute

Answer D is correct. Xerostomia is dry mouth, and offering the client a saliva substi- tute will help the most. Eating hard candy in answer A can further irritate the mucosa and cut the tongue and lips. Administering an analgesic might not be necessary; thus, answer B is incorrect. Splinting swollen joints, in answer C, is not associated with xerostomia.