NN_09 NCLEX WHAT YOU NEED TO KNOW PART2

143. Select the recommendation given by a nurse to a group of clients at a cancer prevention seminar that is most effective in reducing the risk for colon cancer in persons who have a family history of the illness. A) Avoiding obesity and losing weight reduces the incidence of colon cancer. B) Limit or stop smoking because it places a person at a high risk for colon cancer. C) There is a direct link between using saccharin-containing products and colon cancer, so avoid using the sweetener. D) Limit alcohol intake to one glass of wine per day.

A) Avoiding obesity and losing weight reduces the incidence of colon cancer.

101. During a prenatal visit, the nurse is teaching a pregnant client about sources of complete protein. Identify the food with the highest amount of this nutrient. A) Two boiled eggs B) 1 cup whole-grain cereal C) 1 cup red beans D) One fried chicken leg

A) Two boiled eggs

108. Identify the statement made by a psychiatric clinical nurse specialist to a client with anorexia nervosa that best demonstrates the use of cognitive therapy. A) "You seem to feel much better about yourself when you eat something." B) "Being thin doesn't seem to solve your problems, since you're thin now and still unhappy." C) "It must be difficult to talk about private matters with someone you just met." D) "What are your feelings about not eating the food that you prepare?"

B) "Being thin doesn't seem to solve your problems, since you're thin now and still unhappy."

129. During a well-child visit to the clinic, the nurse notes that a 4-month-old girl is alert, responsive, and has a positive Moro reflex. Identify the statement by the nurse to the mother about the child's growth and development that is most appropriate. A) "Your child is developing normally, so bring her back in 1 month for a checkup." B) "There appears to be a neurological delay in your child's development. We will need to refer her to a pediatrician." C) "Your child needs more stimulation at home. Play lively music when she is in her crib." D) "Your child has a severe developmental delay due to lack of proper care. I'm going to have to report you to social services."

B) "There appears to be a neurological delay in your child's development. We will need to refer her to a pediatrician."

169. A 73-year-old man receives hydralazine (Apresoline) 20 mg PO at 0800. When the nurse checks his blood pressure at 0900, she obtains a reading of 72/44 mm Hg. The client has been taking this same dose of medication for 3 years. The nurse finds all of the following data in the client's chart. Identify the finding that is most significant for producing the client's current blood pressure. A) Pedal pulses 1 + and weak B) 24-hour fluid intake 1,000 mL ×3 days C) Serum potassium 3.3 mEq/L D) Apical pulse 150 bpm, slightly irregular

B) 24-hour fluid intake 1,000 mL ×3 days

157. Identify the action by the nurse that is most appropriate when caring for a client hospitalized with chronic schizophrenia who has been taking clozapine (Clozaril) for the past 2 weeks. A) Limit the client's fluid intake to 500 mL per day. B) Check the client's white blood cell count and differential every week. C) Obtain a serum cholesterol every month. D) Make sure the client spends at least 30 minutes outside each day in the sun.

B) Check the client's white blood cell count and differential every week.

102. Which nursing action is most important in the care of a client who is receiving 300 mL of Isocal by nasogastric feeding tube every 4 hours? A) Keep the head of bed elevated 35 to 45 degrees at all times. B) Check the tube for placement prior to each feeding. C) Obtain daily weights and accurate I & O to monitor status. D) Monitor the client for dumping syndrome.

B) Check the tube for placement prior to each feeding.

105. A client receiving TPN through a central line reports chest discomfort and mild dyspnea. The nurse notes a churning sound over the Point of Maximal Impulse and tachycardia. Which action should the nurse take first? A) Replace the tubing and the TPN solution immediately. B) Clamp the central catheter and place the client on the left side with the head lower than the body. C) Start oxygen by mask to reduce the hypoxia and notify the primary health-care provider immediately. D) Assess the client for cough and cyanosis while evaluating the central catheter site for signs of infection.

B) Clamp the central catheter and place the client on the left side with the head lower than the body.

84. Identify the nursing action that is most appropriate for a client who is diagnosed with injury to cranial nerves IX and X after a blow to the head. A) Use enemas to maintain normal bowel function. B) Maintain the client in an NPO status. C) Cover both of the client's eyes with soft eye patches to prevent corneal abrasions. D) Keep the head of bed flat for 24 hours after admission.

B) Maintain the client in an NPO status.

146. Identify the nursing action that best prevents autonomic dysreflexia in a client with a spinal cord injury. A) Giving the client his prn dose of oxazepam (Serax) before the muscle spasms begin B) Maintaining the patency of the Foley catheter C) Keeping the client in the sitting position as much as possible D) Monitoring the client's electrolyte levels

B) Maintaining the patency of the Foley catheter

115. The hospital administration has just notified all the unit managers that the care delivery model is to be changed from team nursing to modular nursing because of budget restraints. Identify the action by the unit managers that is essential to the successful implementation of the modular nursing care model. A) Hire nurses who are self-directed and concerned with consistency of care. B) Obtain the cooperation and input from respiratory therapy, radiology, dietary, and laboratory departments and other support services. C) Develop total quality management studies to determine risk areas. D) Initiate a training program for ancillary health workers, such as nurse aides and orderlies.

B) Obtain the cooperation and input from respiratory therapy, radiology, dietary, and laboratory departments and other support services.

118. The nurses on the 7 a.m. to 3 p.m. shift have been complaining to the head nurse that the nurses on the 9 p.m. to 7 a.m. shift have not been doing the ordered client daily weights, and the physicians are very upset when they make their early morning rounds. Identify the initial action the head nurse should take to resolve this conflict. A) Post a stern memo that reminds the night shift nurses to do the daily weights. B) Review the daily weight flow sheet. C) Change the time for daily weights to the late morning. D) Hold a meeting with the physicians to discuss their attitudes.

B) Review the daily weight flow sheet.

123. An 8-year-old girl is brought by her mother to the outpatient clinic with complaints of abdominal cramping and greenish diarrhea. A diagnosis of shigellosis is made after a stool culture. Identify the discharge instruction by the nurse that best explains the requirement for enteric precautions at home. A) Enteric precautions only have to be maintained until the diarrhea stops. B) The child must remain on enteric precautions until she has three stool cultures negative for shigella. C) After the child has been taking the antibiotics for 48 hours, you can stop the enteric precautions. D) The child must remain on enteric precautions for 30 days or until her viral titer is normal.

B) The child must remain on enteric precautions until she has three stool cultures negative for shigella.

160. Identify the intervention by the nurse that has the highest priority when assisting with ADLs for a client diagnosed with multiple myeloma. A) Keep the client on oxygen by nasal cannula at all times. B) Use great care in transferring the client from bed to chair to prevent bone injury. C) Allow the client to rest for 10 minutes before and after each activity. D) Encourage the client to be as independent as possible.

B) Use great care in transferring the client from bed to chair to prevent bone injury.

107. Which statement by a nurse working with a client who is suffering from paranoid delusions and who is not very talkative would block therapeutic communication? A) "You seem to be more suspicious of the other clients today." B) "I feel you have made progress by speaking about your fears". C) "I know just how you feel. I often see the head nurse waiting for me to make a mistake." D) "You mentioned that you see them looking through the window. Please tell me more about that."

C) "I know just how you feel. I often see the head nurse waiting for me to make a mistake."

113. An otherwise healthy 40-year-old woman who is brought into the emergency room (ER) with an overdose is declared brain dead and evaluated for organ donation. On her driver's license, the "Organ Donor" box is checked and there is a legal witness signature present. Identify the action to be taken next by the ER nurse. A) Prepare the body for transfer to the operating room for organ removal. B) Order appropriate tests for tissue typing. C) Attempt to notify the client's family and ask their permission for donation. D) Pack the body in ice to lower metabolism and prevent deterioration of the organs.

C) Attempt to notify the client's family and ask their permission for donation.

139. A 24-year-old woman comes to the family planning clinic with dysuria, purulent vaginal drainage, and perineal pruritus and has a positive culture for a sexually transmitted disease (STD). Identify the STD that the nurse is required to report to the public health department. A) Genital herpes B) Vaginal warts C) Gonorrhea D) Chlamydia

C) Gonorrhea

137. A couple who has been unable to conceive seeks counseling from the nurse in a family planning clinic. In discussing solutions to the couples' difficulties, identify what information the nurse should emphasize. A) Care for health problems not related to pregnancy B) Data supporting the incidences of pregnancy in their age and ethnic groups C) How the couple can better improve their communication skills D) New positions and techniques to use during intercourse

C) How the couple can better improve their communication skills

98. Which postbronchoscopy assessment observed by the nurse in a 54-year-old woman would require immediate intervention? A) Coughing up a moderate amount of dark, blood-tinged mucus B) Negative gag reflex 15 minutes postprocedure C) Presence of a stridor in the upper airway D) Difficulty to arouse with initial disorientation

C) Presence of a stridor in the upper airway

165. A 14-year-old girl is admitted to the ER with a suspected overdose of an unknown drug. Arterial blood gasses are drawn with the following results: pH 7.31, PO2 88, PCO2 59, HCO3 22. Identify the initial action to be taken by the nurse. A) Insert a large gage NG tube for gastric lavage. B) Insert a Foley catheter and obtain a urine for drug screen. C) Use a manual ventilator (Ambu bag) to assist with ventilation. D) Attach the client to a cardiac monitor and watch for dysrhythmia.

C) Use a manual ventilator (Ambu bag) to assist with ventilation.

131. A 15-year-old girl is brought by her mother to the pediatric clinic because she has not yet started her menstrual cycles and shows minimal physical development typical of puberty. When the diagnosis of delayed puberty is made, the girl begins to cry, stating, "Everybody at school makes fun of me because I'm so flat." Select the response by the nurse that best addresses the girl's concerns. A) "Don't worry. This a very common problem and you will soon catch up with your classmates." B) "You are a very beautiful girl just the way you are. You'll probably get zits when you start your development." C) "If you keep busy in band and sports, you won't worry so much about how you look." D) "Let's see if we can figure out what type of clothes you can wear that won't accent your lack of physical development so much."

D) "Let's see if we can figure out what type of clothes you can wear that won't accent your lack of physical development so much."

145. While evaluating a postcolon cancer surgery client who has a new colostomy, the nurse notes that the client is in the denial stage of the grieving process. Select the response by the nurse that best facilitates the client's progression through the grieving process. A) Interpret the denial for the client and point out it is part of the grieving process. B) Confront the client's denial as an unrealistic response. C) Support the client in his denial. D) Accept the denial as one of the stages in the grieving process.

D) Accept the denial as one of the stages in the grieving process.

93. Which finding on the admission assessment would make the nurse question the order for a cerebral angiogram for the client? A) Intermittent memory loss and dizziness for 2 months. B) History of hypertension controlled with angiotensin-converting enzyme inhibitor. C) Presence of a permanent pacemaker implanted 6 months ago. D) Client breaks out in hives when eating shrimp or clams.

D) Client breaks out in hives when eating shrimp or clams.

97. While reviewing the laboratory results for a client, the RN notes that pulmonary function test values are as follows: residual volume 1,800 mL, vital capacity 2,300 mL, and tidal volume 275 mL. Identify the nursing action included in the care plan developed by the LPN that the RN would change. A) Increase fluid intake to 3,500 mL per day. B) Position the client in the high-Fowler's position. C) Contact the dietitian to arrange for a six-feeding, small-portion diet. D) Increase the oxygen flow rate to 10 L/min by rebreather mask for shortness of breath.

D) Increase the oxygen flow rate to 10 L/min by rebreather mask for shortness of breath.

127. After eye surgery, a client is alert, oriented, and has eye patches over both of his eyes. Select the action by the nurse that would have the highest priority in preventing injury to this client. A) Keep the client restrained to prevent him from falling out of bed. B) Walk the client around the room so he knows where the obstacles are located. C) Make sure the bed is in the low position with the side rails down so that the client can exit the bed more easily. D) Show the client how to use the call bell signal and place it within easy reach.

D) Show the client how to use the call bell signal and place it within easy reach.

171. Prior to discharge, a client diagnosed with a gastric ulcer is given prescriptions for cimetidine (Tagamet) and aluminum-magnesium complex (Riopan). Identify the instructions that the nurse should emphasize to the client about these two medications. A) To achieve maximum effectiveness, take them at the same time. B) Take the Riopan with meals and the Tagamet on an empty stomach. C) Make sure to take the medications with a full 8-ounce glass of orange juice. D) The Tagamet can be taken with meals; then wait 1 to 2 hours to take the Riopan.

D) The Tagamet can be taken with meals; then wait 1 to 2 hours to take the Riopan.

138. At the family planning clinic, a 19-year-old woman who has recently become HIV positive is given counseling by the clinic nurse. Identify the instructions by the nurse that are most effective in preventing the transmission of HIV during sexual intercourse. A) You can have unprotected sex if both you and your partner(s) are HIV positive. B) The use of contraceptive measures, such as birth control pills and hormone injections, will limit the spread of the virus. C) The only way to prevent the transmission of HIV is to have an intrauterine device placed. D) Using a latex condom with a potent spermicide during intercourse is one of the best ways to prevent the spread of HIV.

D) Using a latex condom with a potent spermicide during intercourse is one of the best ways to prevent the spread of HIV.

119. Select the statement by a unit manager to the vice president of nursing during a budget meeting that would be most effective in decreasing the staffing ratio on her unit from one nurse for every nine clients to one nurse for every seven clients. "This proposed change will: A) have a positive effect on the usage of institutional resources." B) better meet current national standards of practice." C) help with the recruitment of new nurses to the facility." D) improve the quality of care for the clients on the unit."

D) improve the quality of care for the clients on the unit."

110. A client with severe anxiety is being treated with lorazepam (Ativan) and outpatient therapy. Which statement indicates that the client requires additional discharge instructions for this medication? A) "If I become drowsy or have blurred vision, I need to stop the medication immediately." B) "This medication can be habit forming, so I should take it only as directed." C) "I need to add foods such as fresh fruits and grain to my diet." D) "If I get a cold I should check with my primary health-care provider before taking cold medicines."

A) "If I become drowsy or have blurred vision, I need to stop the medication immediately."

94. After a client is connected to a heart monitor in the ER, the nurse notes an elevated ST segment on the electrocardiogram strip. What nursing action would have the highest priority for this client? A) Assess the vital signs and the degree and location of any chest pain. B) Administer a stat dose of sublingual nitroglycerine spray to dilate the coronary arteries. C) Notify the physician of the client's dire condition. D) Place the client in the prone position to reduce the workload of the heart.

A) Assess the vital signs and the degree and location of any chest pain.

112. Based on accepted standards of care for documentation, identify the element that the nurse should avoid placing in the client's medical record. A) Blank spaces between the lines for late entries B) Date and time on all entries C) Observation about the client's behaviors D) Direct quotes from the family

A) Blank spaces between the lines for late entries

176. A client with a urinary tract infection is given a prescription for sulfamethoxazole (Gantanol), 1 gram by mouth three times a day. Choose the common side effects that can be expected after 3 days. A) Diarrhea and gastrointestinal bloating B) Anxiety and inability to concentrate C) Drowsiness and dizziness D) Headache and hyperactivity

A) Diarrhea and gastrointestinal bloating

150. A 34-year-old mother of three young children who works as an administrative assistant at a university comes to the crisis center due to the inability to sleep, increasing disorganization at her job, and feelings of guilt about her ability to care for her children and house. She tells the nurse that her husband used to help with the children and house a lot, but because of a recent job promotion and additional work hours required, he can no longer do this. The client feels that they cannot afford a full-time housekeeper and has become overwhelmed and depressed over the condition of her house. Select the therapeutic technique to be used by the nurse that best helps this client deal with her altered role performance. A) Environmental modification B) Anticipatory guidance C) Confrontation D) Cognitive restoration

A) Environmental modification

132. A 42-year-old man comes to the outpatient clinic with complaints of joint swelling in his knees and pain in his feet. Select the type of arthritis that is most common in men in the 30 to 50 age range. A) Gouty arthritis B) Rheumatoid arthritis C) Osteoarthritis D) Septic arthritis

A) Gouty arthritis

179. A client with myeloid metaplasia is experiencing joint pain, guaiac-positive stools, and a platelet count of 31,000 per mm3. If a prn dose of meperidine (Demerol) is ordered by all of the following routes, choose the route the nurse should avoid using to give the medication. A) Intramuscular B) Intravenous C) Oral D) Subcutaneous

A) Intramuscular

125. Select the instructions by the nurse that would best prevent postoperative complications in a client who has just undergone a stapedectomy for a bone conduction hearing loss. A) Leave the mouth open when sneezing. B) Use a soft, cotton-tipped applicator to clean the blood and drainage from the affected ear to prevent infection. C) Bend over very slowly during the first 48 hours postoperative. D) Keep the head of bed flat for the first 24 hours.

A) Leave the mouth open when sneezing.

91. Choose the action by the nurse that takes highest priority in the treatment of a child with sickle cell anemia. A) Maintain hydration at two times the normal intake. B) Assist the child in range of motion exercises to increase joint mobility. C) Medicate frequently with analgesics to reduce pain. D) Initiate and maintain reverse isolation.

A) Maintain hydration at two times the normal intake.

135. During a "Health Promotion" class at a senior citizen center, one of the elderly attendees asks the nurse teaching the class, "I know older persons fall frequently. What types of fractures are most common in people in our age group?" Select the type of fracture the elderly most often experience. A) Pelvis B) Lumbar spine C) Hand and wrist D) Tibia

A) Pelvis

128. After a bicycle accident that caused a fractured tibia, a client has a fiberglass cast applied and is discharged to home with crutches. Select the instructions by the nurse about climbing stairs with crutches that would best prevent an additional injury. A) Place the unaffected leg on the first step, then move the crutches and injured leg up to the step together. B) Move the injured leg to the first step, then place the crutches and uninjured leg on the step together. C) Place the injured leg and the crutch on the opposite side on the first step, then move the injured leg and the other crutch up to the step. D) Place both crutches on the first step together, then swing through both legs to the next step.

A) Place the unaffected leg on the first step, then move the crutches and injured leg up to the step together.

117. After her first week on a busy medical surgical unit, the new charge nurse notes that the individual nurses are highly competent but seem to be unable to function productively as a team. Select the action by the charge nurse that would best facilitate team building among the staff. A) Provide an opportunity for the nurses to express feelings and emotions. B) Hire more staff to reduce stress and fatigue from understaffing. C) Allow the staff more input into important policy decision-making. D) Give the staff more time to adjust to the change in charge nurses.

A) Provide an opportunity for the nurses to express feelings and emotions.

126. Identify the position in which an adult client in the recovery room should be placed when he or she complains of a sore throat and is lethargic after a tonsillectomy. A) Side-lying B) High Fowler's C) Trendelenburg's D) Batrachian

A) Side-lying

99. In reviewing the chart of a 15-year-old client who suffered a head trauma in a sports accident, the nurse notes a serum potassium of 2.8 mEq/L and a serum sodium of 122 mEq/L. What addition to the nursing care plan would be most appropriate for the nurse to make based on this information? A) Strict intake and output (I & O) each shift B) Passive range of motion exercises each shift C) Six-feeding, small-portion diet D) Assessment of flank region every 12 hours for kidney tenderness

A) Strict intake and output (I & O) each shift

114. A psychiatric nurse employed in a busy outpatient psychiatric clinic notes that the foreign-born psychiatrist who covers the clinic in the afternoons regularly bills clients for 60-minute sessions that only last 30 to 40 minutes. Under the Federal False Claims Act, select what the nurse must report concerning the physician. A) Upcoding B) Overbilling C) False representation of services D) Medicare fraud

A) Upcoding

156. Identify the intervention by the nurse that would be most therapeutic for a client diagnosed with schizophrenia who has delusions about extraterrestrial spacecraft invading the earth. A) Use distraction to reduce the client's focus on the delusions. B) Ask the client to talk about the delusion and his feelings when he is having it. C) Agree with the delusion to prevent angering the client. D) Point out the absurdity of the delusion and refocus in reality.

A) Use distraction to reduce the client's focus on the delusions.

103. Select the nursing action that would best help reduce the cramping experience by a client who was receiving intermittent feedings though a gastric tube (percutaneous endoscopic gastrostomy tube). A) Warm the feeding to near body temperature prior to administration. B) Elevate the client's head to 35 to 45 degrees during feedings. C) Encourage the client to suck on a hard candy 5 to 10 minutes prior to the feeding. D) Assess the tube for placement prior to each feeding.

A) Warm the feeding to near body temperature prior to administration.

133. During her routine annual physical examination, a 48-year-old woman tells the nurse that she worries about her health all the time, spends 8 to 10 hours at the health center every week, and has spent a larger than usual amount of money on cosmetics over the past 6 months. Select the most appropriate response by the nurse to this client. A) "Your concerns and actions are normal because you are trying to maintain your health and youth." B) "How are you doing at your work? Did you get that promotion you wanted?" C) "Is your husband still helping with the household chores? Support systems are very important." D) "You seem very healthy. You should avoid excessive exercise because it can cause more damage in the long run."

B) "How are you doing at your work? Did you get that promotion you wanted?"

92. Identify the statement made by a client that would indicate to the nurse that additional teaching was required for a client who was scheduled for a lumbar puncture. A) "This procedure will be done in my room." B) "I can get up and go to the bathroom within 1 hour after the procedure." C) "My body will replace the fluid taken by the physician within 12 hours." D) "I have to sign a special procedures permit before the procedure can be done."

B) "I can get up and go to the bathroom within 1 hour after the procedure."

166. Select the statement by the nurse that is most accurate when instructing a client with a newly formed permanent colostomy on how to use the irrigation set to prevent constipation. A) "Make sure the irrigation bag is above the level of your head for best results." B) "Insert the lubricated catheter 2 to 4 inches into the stoma." C) "Dilate the stoma prior to beginning the procedure by using one finger." D) "Use cold water to best stimulate colon peristalsis."

B) "Insert the lubricated catheter 2 to 4 inches into the stoma."

151. A 48-year-old woman had become increasingly depressed since her youngest son left for college 4 months ago. She has been a stay-at-home mother who has focused most of her time and energy on her children and now has little to do. Identify the response by the nurse that best helps the client deal with the spiritual aspects of her concerns. A) "You need to find other outlets for your energy, such as helping at the church soup kitchen." B) "What is it that sustains you when all else fails? You need to rely on yourself for your happiness." C) "You need to focus your anger away from yourself onto a harmless third party." D) "Once you begin to take antidepressants, you will feel better in about a week."

B) "What is it that sustains you when all else fails? You need to rely on yourself for your happiness."

149. A 32-year-old man who is HIV positive and in the later stages of AIDS is hospitalized for treatment of PCP. While the nurse is administering the IV medication, the client begins to cry and states, "None of my friends and relatives visit or call me anymore because of this disease." Select the response by the nurse that best promotes a positive self-concept for this client. A) "I'll talk with your physician and arrange a consultation with a psychologist so you can deal with these negative feelings." B) "You seem very down today. Let's talk about what's going on." C) "I'm sure they want to visit and call, but may be afraid they'll say the wrong thing. I can call them for you." D) "It sure seems that if they don't call or visit, they are not really friends to begin with. Just forget about them."

B) "You seem very down today. Let's talk about what's going on."

95. After reviewing the laboratory results for the clients to which the nurse is assigned, select the client the nurse should assess first. A) 53-year-old man with a CPKMB of 3 percnet B) 33-year-old man with a cTnT2 of 0.8 ng/mL C) 48-year-old woman with a LDH1 of 25 percent D) 64-year-old woman with a triglyceride level of 175 mg/dL

B) 33-year-old man with a cTnT2 of 0.8 ng/mL

116. An HIV-positive client with Pneumocystis carinii pneumonia (PCP) is confused and keeps removing the IV piggy back (IVPB) needle during the administration of his trimethoprim-sulfamethoxazole (Bactrim). Select the instructions by the charge registered nurse to the licensed practical nurse administering medications that would best rectify this situation. A) Give the client his prn sedative a half hour before the IVPB medication. B) Assign one of the certified nursing assistants to stay with the client during the medication administration. C) During the 30 minutes the medication infuses, place the client in bilateral wrist restraints. D) Call the physician and request the medication by mouth.

B) Assign one of the certified nursing assistants to stay with the client during the medication administration.

90. Select the teaching point the community health nurse should emphasize as a clue to possible attempted suicide when conducting a parenting class about suicidal ideation in school-aged children. A) Poor grades in school B) Children giving away favorite CDs or toys C) Insisting that smoking cigarettes is "cool" D) Becoming more aggressive with classmates

B) Children giving away favorite CDs or toys

136. While climbing over a barbed wire fence, a 22-year-old man received a deep laceration on his arm and hand. After washing and dressing the laceration with an antibiotic ointment, the emergency department nurse notes that the client has had all his immunizations, with his last tetanus at age 18 for another injury. Select the action that should be taken by the nurse at this time. A) Instruct the client on care of the laceration at home. B) Give a tetanus toxoid injection. C) Order a serum tetanus titer test. D) Advise the client to get another tetanus immunization in 2 years.

B) Give a tetanus toxoid injection.

86. Choose the action the nurse should take to elicit the oculocephalic response in a motor vehicle accident victim who is unconscious. A) Use a wisp of cotton to stimulate the cornea. B) Hold the eyelids open while turning the client's head. C) Squirt ice water into the client's ear canal. D) Hold both eyelids open and shine a bright light into the eyes.

B) Hold the eyelids open while turning the client's head.

168. Identify the action the nurse should take when he notes that a client who is receiving captopril (Capoten) for congestive heart failure has developed hyperkalemia. A) Give the next dose with a full 240 mL glass of water. B) Hold the next dose and notify the physician. C) Increase the client's intake of fresh fruits and vegetables. D) Reduce the dose by half and give both a.m. and p.m.

B) Hold the next dose and notify the physician.

172. Select the response by the nurse to a 22-year-old woman that best answers her question on why she must take two antibiotics, ceftriaxone (Rocephin) and doxycycline (Vivox), for a gonorrhea infection. A) These two antibiotics taken together lessen the side effects of each other. B) Many people who have gonorrhea also have a Chlamydia infection, and these two medications will eliminate both. C) The medications potentiate each other and are stronger together than separately. D) The course of treatment can be shortened to 5 days when two antibiotics are used.

B) Many people who have gonorrhea also have a Chlamydia infection, and these two medications will eliminate both.

144. The nurse in an outpatient clinic notes that a client with a persistent nagging cough has come in for treatment after hearing about the seven signs of cancer on the TV show Dr. Oz. Identify the statement by the nurse that best reinforces this client's understanding of the warning signs of cancer. A) All the signs have to be present to detect cancer. B) Other signs to look for include indigestion, difficulty swallowing, and changes in the size or shape of a mole. C) If you develop persistent nausea, skin rash, or acute pain, you are at high risk for having a cancer. D) The warning signs you hear about are just to scare people who do not schedule regular appointments into visiting the physician.

B) Other signs to look for include indigestion, difficulty swallowing, and changes in the size or shape of a mole.

155. A client with an antisocial personality disorder is caught shoplifting and as part of his probation agreement is required to spend 1 month at a psychiatric facility for treatment. Select the intervention by the nurse that has the highest probability of success in treating this disorder. A) Using daily one-on-one sessions with the nurse B) Placing the client in group peer therapy with strong external controls C) Initiating treatment with antianxiety medications D) Quickly placing the client in isolation when he acts out

B) Placing the client in group peer therapy with strong external controls

82. A 78-year-old client who experiences angina after even minimal activity is treated with medications. Identify the medication mode of action that the nurse would give to best decrease myocardial oxygen consumption and reduce chest pain. A) Increase preload. B) Reduce afterload. C) Reduce preload. D) Increase contractility.

B) Reduce afterload.

153. A 22-year-old man who is diagnosed with obsessive-compulsive disorder (OCD) that includes a compulsion to check all faucets to make sure they do not drip is hospitalized when he is no longer able to function at home or work due to his behavior. In the psychiatric unit, his actions consume a major part of his waking hours, and often he misses meals and other scheduled activities. Identify the intervention by the nurse that is most likely to precipitate a panic attack in this client. A) Asking the client about his repressed feelings after he completes his ritual B) Requiring the client to participate in scheduled meal times even if his rituals are not complete C) Pointing out to the client that his actions are meaningless D) Using thought stopping and aversion therapy to block the ritualistic actions

B) Requiring the client to participate in scheduled meal times even if his rituals are not complete

111. Identify the assessment found by a nurse on a client who is admitted with a possible accidental overdose of imipramine (Tofranil) that would require the most immediate intervention. A) Depressed deep tendon reflexes and Glasgow Coma Scale rating of 9 B) Sinus tachycardia of 128 with a QRS complex of 0.14 second C) Ecchymotic areas on arms and a hematocrit of 33 percent D) Distended abdomen and decreased bowel sounds

B) Sinus tachycardia of 128 with a QRS complex of 0.14 second

175. Select the best time for the nurse to administer a prn dose of morphine sulfate, 5 mg IV, to a client who is experiencing leg pain after an open reduction for a fractured femur. A) When the pain is in the moderate to severe range B) When the pain first starts, before it becomes severe C) No more than every 6 hours to prevent morphine addiction D) Regularly every 4 hours

B) When the pain first starts, before it becomes severe

109. A client is being treated for depression with phenelzine (Nardil). Which statement by the client indicates that the goal for the client to understand the potential side effects of the antidepressant has been achieved? A) "I should wear sturdy and supportive shoes when I'm outside" B) "My legs should be elevated when I'm sitting." C) "I must avoid eating at Chinese restaurants." D) "Colognes and perfumed soaps can cause allergic reactions."

C) "I must avoid eating at Chinese restaurants."

152. A 5-foot, 5-inch tall, 15-year-old girl who weighs 88 lb is admitted to the hospital with a diagnosis of anorexia nervosa. After the second day in the hospital, the child gains 1 lb. Select the nurse's response to the weight gain that most enhances the child's recovery. A) "Now that little amount of weight didn't kill you!" B) "If you follow your diet plan and the goals we established, you will be back to normal in no time." C) "It must be scary for you to think that you gained that much weight." D) "Your family and I are very happy and pleased about your weight gain."

C) "It must be scary for you to think that you gained that much weight."

142. Select the instruction by the nurse that is most helpful in relieving the pain from an episiotomy in a 1-day postpartum client. A) Increase fluid intake to 2,000 mL per day. B) Keep the head of bed elevated 45 degrees. C) Apply an ice pack to her perineum. D) Use a sitz bath twice a day.

C) Apply an ice pack to her perineum.

173. Select the discharge instructions by the nurse to a client diagnosed with pruritus that most increase the effectiveness of a prescribed emollient. A) Apply the medication at night before you go to bed. B) To keep it in contact with the skin longer, wrap the area with a gauze dressing after applying the cream. C) Apply the cream immediately after a bath or shower. D) To protect your skin from the drying effects of hot water, apply the cream just before you take a bath or shower.

C) Apply the cream immediately after a bath or shower.

178. A client with a history of prolapsed mitral valve complains to the ER nurse that he is having palpitations (pounding heart) even at rest. Identify the discharge instructions by the nurse that are most effective in reducing future episodes of this symptoms. A) Make sure you eat foods high in potassium, like oranges and bananas. B) You will need to increase your fluid intake to 2 to 3 liters per day. C) Avoid beverages that contain caffeine, like coffee and colas. D) Limit your activity as much as possible.

C) Avoid beverages that contain caffeine, like coffee and colas.

96. During the 0700 beginning of the shift assessment, the nurse finds a male client who was diagnosed with type 1 diabetes mellitus to be difficult to arouse. Per unit protocol, arterial blood gases and a blood glucose are performed. The results show pH 7.01, PO2 92, PCO2 36, HCO3 9, blood glucose 873. What action should the nurse take first? A) Administer the client's 0800 dose of NPH insulin immediately. B) Notify the physician and the house supervisor of the client's condition. C) Begin an IV with 0.5 percent normal saline and prepare sodium bicarbonate for administration. D) Attempt to arouse the client and determine what he ate the previous evening to raise his blood glucose.

C) Begin an IV with 0.5 percent normal saline and prepare sodium bicarbonate for administration.

81. Identify the action the nurse should take first when the low tidal volume alarm on a positive pressure, volume-cycled ventilator begins and continues to sound. A) Check for water buildup in the ventilator tubing. B) Disconnect the oxygen supply to the ventilator. C) Check for separation of the ventilator tube from the endotracheal tube. D) Encourage the client to cough to remove excessive secretions.

C) Check for separation of the ventilator tube from the endotracheal tube.

85. Select the instruction given by the nurse to a group of senior citizens attending a class on aging at a senior center that best addresses the normal age-related changes in the skin. A) Avoid using emollients because of the increased elasticity of your skin. B) Because of the increase in the activity of the sweat glands, you will have to take more baths and use deodorant more often. C) Even minor cuts will require special attention because of slower healing. D) As you age, your fingernails and toenails grow more quickly and require more frequent cutting to prevent ingrown nails.

C) Even minor cuts will require special attention because of slower healing.

121. The oxygen saturation on a client with acute infective bronchitis drops to 84 percent, and he develops severe dyspnea. There is a standing order for a handheld nebulizer (HHN) treatment prn for shortness of breath, and respiratory therapy is designated to give all respiratory treatments in the facility. When the nurse calls the respiratory therapist, he states that he has several more treatments to give but he should be there in 10 or 15 minutes. Select the action by the nurse that would be most appropriate at this time. A) Increase the flow rate of the client's oxygen until the respiratory therapist can arrive. B) Call the respiratory therapist back and insist that he come immediately. C) Give the HHN treatment himself or herself. D) Give the client a prescribed leave it in prn sedative to reduce anxiety.

C) Give the HHN treatment himself or herself.

104. The nurse notes that the primary health-care provider has prescribed that the TPN that a client had been receiving for the past 10 days be discontinued and changed to 0.9 percent normal saline. Which action would be most appropriate for the nurse to take? A) Stop the TPN and change the solution to 0.9 percent normal saline as soon as it was available. B) Allow the remaining TPN to infuse until the bag was empty and then change the solution to 0.9 percent normal saline. C) Gradually reduce the rate of the TPN over the next 4 to 6 hours, then change the solution to 0.9 percent normal saline. D) Question the primary health-care provider about the change because the solution is inappropriate.

C) Gradually reduce the rate of the TPN over the next 4 to 6 hours, then change the solution to 0.9 percent normal saline.

40. Select the instructions given by the nurse that are most accurate for a woman who is HIV positive and 3 months pregnant who comes to the prenatal clinic for care. A) You will need a C-section to prevent the transmission of the virus to your baby. B) There is a good chance that your baby will not be infected with the virus if you take your medications. C) In a large percentage of the cases, the virus is transmitted through the placenta. D) Your baby will be very ill from the HIV infection when it is born.

C) In a large percentage of the cases, the virus is transmitted through the placenta.

163. Identify the dietary teaching by the nurse that best promotes the comfort of a client in the late stages of cirrhosis who has ascites. A) You must increase your daily fluid intake to 3 liters per day to avoid dehydration. B) Your protein intake should be between 100 and 120 grams per day. C) Keep your sodium intake to 1 to 2 grams per day. D) Extra fats in your diet are necessary to maintain your energy levels.

C) Keep your sodium intake to 1 to 2 grams per day.

148. A 22-year-old man is recovering from injuries obtained in an automobile accident in which he was the driver and his 20-year-old girlfriend was killed. His parents have requested that information about the girl's death be withheld from the client, including restricting visitors and phone calls. While bringing the client a leave-it prn pain medication, the nurse notices that the local television lead news story is about the accident. Select the best action by the nurse in response to this situation. A) Talk loudly to the client so that he will not be able to hear the news. B) Turn the TV off stating that the pain medication will work better with less environmental stimuli. C) Leave the TV on and then answer any questions the client has. D) "Accidentally" change the channel while raising the head of the bed.

C) Leave the TV on and then answer any questions the client has.

134. A 72-year-old woman is injured in a fall down a flight of steps at home and is placed on bedrest in the hospital. Select the intervention(s) by the nurse for this client that best prevent the complications of immobility. A) Limiting the fluid intake to 200 mL per shift to prevent dependent edema. B) Giving the client a full bed bath and feeding her all meals to reduce potential injury to fragile bones. C) Massaging bony prominences and turning the client every 2 hours. D) Ambulating the client to the bathroom instead of using the bedpan.

C) Massaging bony prominences and turning the client every 2 hours.

130. The parents of a 10-year-old boy ask the nurse about his acting-out behavior. Select the behavior(s) that best identifies when a child this age requires professional help. A) Peer relationships are affected. B) Family relationships are affected. C) Multiple aspects of the child's life are affected. D) The child's grades in school show a decline.

C) Multiple aspects of the child's life are affected.

177. Identify the teaching point that has the highest priority when the nurse is instructing a client about the home use of respiratory medications for treatment of his emphysema. A) If you stop taking expectorants suddenly, there will be a rebound effect. B) Avoid driving your car for 2 hours after using the nasal decongestant. C) Never use glass, stainless steel, or plastic when taking mucolytics. D) Be sure to use water either orally or inhaled with mucous secretions to decrease the amount of the secretions.

C) Never use glass, stainless steel, or plastic when taking mucolytics.

88. A 37-year-old woman has an internal radioactive implant placed for the treatment of uterine cancer. Select the action the nurse should take first when she finds the implant in the bed linens during routine care. A) Quickly leave the room and call for help. B) Use plastic forceps to replace the implant after donning a lead apron. C) Place the implant in a lead-lined container with a pair of long-handled forceps. D) Tell the client how to re-insert the implant.

C) Place the implant in a lead-lined container with a pair of long-handled forceps.

83. Select the nursing action that takes highest priority in providing care for a client diagnosed with an organic brain syndrome. A) Place the client in a group of clients to maintain his social skills. B) Order foods for the client that are attractive and tasty to maintain nutritional status. C) Provide a safe environment to prevent injury. D) Encourage as much self-care as possible to maintain independence.

C) Provide a safe environment to prevent injury.

158. Identify the intervention by the nurse that best maintains a safe hospital environment for a client diagnosed with Korsakoff's syndrome who is hospitalized because of several falls due to an unsteady gate. A) Reinforcing activity restrictions by repeating instructions frequently B) Placing the client in a quiet, nonstimulating room away from the busy nurses' station C) Providing assistance as needed, including walker or cane, when the client ambulates D) Limiting the client's visitors to immediate family only

C) Providing assistance as needed, including walker or cane, when the client ambulates

162. Identify the best response by the nurse to a physician's prescription for temazepam (Restoril) 15 mg PO, prn for a hospitalized client. A) Question the order because the dose is too large. B) Give it as ordered when the client is restless. C) Schedule the medication for half strength. D) Question the order because the dose is too small.

C) Schedule the medication for half strength

120. A particularly vocal staff nurse on a busy obstetrical unit has been complaining to the other nurses about the unit manager's preferential treatment of the night shift nurses. Select the action the unit manager should take to resolve this problem that best demonstrates the use of the assertive approach to conflict resolution. A) Note that the vocal staff nurse is not intelligent enough to understand the situation and disregard her comments as worthless. B) Arrange for the transfer of the staff nurse to the night shift. C) Set up a time and place for a one-on-one meeting with the staff nurse. D) Wait until there is an opportunity to use the incident to confront the staff nurse in front of her colleagues.

C) Set up a time and place for a one-on-one meeting with the staff nurse.

106. A one-day postoperative client has both morphine sulfate and meperidine (Demerol) prescribed for pain. Upon which assessment would the nurse decide to give the meperidine rather than the morphine sulfate? A) Pain has increased from a 2/10 to a 6/10 B) BP 90/58, pulse 62 bpm C) Temperature 99.2°F, respirations 10/min D) Awake, alert, and oriented ×3

C) Temperature 99.2°F, respirations 10/min

124. Select the instructions given by the nurse to a preoperative client going for a hiatal hernia repair about the use of an incentive spirometer that best describes its use postoperatively. A) If you use it as prescribed, you won't need a nasogastric (NG) tube. B) You will not need as much postoperative pain medication if used every 2 hours. C) Using it every 2 hours will help increase your respiratory effectiveness. D) You will be able to begin eating much sooner if you use it every 4 hours.

C) Using it every 2 hours will help increase your respiratory effectiveness.

164. Identify the diet change recommendation by the nurse that best helps reduce the cramping experienced by a client who is diagnosed with chronic renal failure and has severe abdominal and leg cramping during hemodialysis treatments. A) You need to increase your fluid intake between treatments to 4 liters per day. B) Restrict your potassium intake to 80 mEq per meal. C) Your fluid intake should not exceed 1 liter per 24 hours. D) Low biological quality protein foods will help reduce muscle spasms.

C) Your fluid intake should not exceed 1 liter per 24 hours.

141. During the assessment of a 35-week gestation client admitted to the obstetrics unit in active labor, the nurse notes the following: estimated fetal weight less than 2,500 grams; membranes ruptured 12 hours ago; blood type AB negative; positive rubella titer; positive vaginal culture for Group B streptococcus; current vital signs: T 99.2°F, P 104, R 26, BP 128/88. Identify the most appropriate action by the nurse at this time. A) Administer a measles, mumps, and rubella vaccine. B) Call the on-call pediatrician to warn him about a premature infant delivery. C) Order a type and crossmatch for two units of blood. D) Administer an ordered IV antibiotic.

D) Administer an ordered IV antibiotic.

87. Identify the action the nurse takes to best prevent contractures in a client with second- and third-degree burns of the legs. A) Hyperextend the client's legs by elevating them on two pillows. B) Apply ace bandages to the entire leg. C) Have the client perform active range of motion exercises every hour. D) Apply knee splints.

D) Apply knee splints.

180. Identify the discharge instructions by the nurse that best help prevent potential complications related to the pacemaker for a 65-year-old man who received an implanted ventricular demand pacemaker for treatment of a complete atrioventricular block secondary to an anterior myocardial infarction. A) Avoid all activities that require raising your arms over your head. B) When a microwave oven is in use, stay out of the room. C) You will not be able to fly because the airport metal detectors will disrupt the pacemaker function. D) Avoid using a cellular phone.

D) Avoid using a cellular phone.

159. Choose the instructions to an elderly woman with osteoarthritis that best help her maintain normal activities of daily living (ADLs) and complete her usual household chores. A) Try to complete all your chores before lunch because the pain and soreness is less serious in the morning. B) If you rest in the morning and afternoon, you will be able to complete your chores in the evening with less discomfort. C) Make sure you do warm-up and stretching exercises before you do your chores to maximize your agility. D) Do your chores at a pace that is comfortable for you, resting frequently after periods of activity.

D) Do your chores at a pace that is comfortable for you, resting frequently after periods of activity.

89. Identify the action by the nurse that would best promote a positive therapeutic community milieu when several clients in the psychiatric inpatient unit ask the unit manager if she could extend the visiting hours until 9 p.m. A) Explain that she cannot make that decision, and it must be referred to the administrator. B) Ask the clients to offer their suggestion during individual therapy sessions. C) Suggest that the clients elect two members of their group as representatives to speak for the whole group. D) Encourage the clients to bring their concerns to the next community meeting.

D) Encourage the clients to bring their concerns to the next community meeting

170. Select the medication that the ER nurse should give to an unconscious client experiencing a severe hypoglycemic reaction. A) Hydrocortisone B) D50W C) Sodium bicarbonate D) Glucagon

D) Glucagon

167. Identify the instructions about the care of the urinary system the nurse should give to a 44-year-old hospitalized woman who has an indwelling urinary catheter and IV who insists on going to the smoking room for a cigarette every few hours. A) Place the drainage bag on the floor when you are sitting to prevent pulling on the catheter. B) Clamp the catheter before you leave and unclamp it when you return. C) Loop the drainage tubing around the IV pole to keep it in place. D) Hang the drainage bag on the pole at a level to keep it below your bladder at all times.

D) Hang the drainage bag on the pole at a level to keep it below your bladder at all times.

161. Select the recommendation by the nurse that is most helpful in restoring a normal sleep pattern to a 58-year-old man who has chronic insomnia. A) A regular waking time in the morning will help re-establish your circadian sleep cycle. B) Using an occasional sleeping pill will be of some benefit. C) A light snack before bed will help encourage sleep. D) I am going to refer you to a sleep specialist for further evaluation.

D) I am going to refer you to a sleep specialist for further evaluation.

174. Identify the statement by the public health nurse that most accurately describes treatment with immune globulin for the wife and two children of a client who was diagnosed with hepatitis A. A) One injection provides immunity for life. B) If the family has not been in close contact with the client, they do not need the medication. C) The medication conveys active immunity. D) If administered more than 2 weeks after exposure, it may not be effective.

D) If administered more than 2 weeks after exposure, it may not be effective.

100. Identify the additional assessment the nurse should make when the serum uric acid level of a 64-year-old man is 12.8 mg/dL. A) Glasgow coma scale each shift B) Heart sounds every 4 hours for murmurs and clicks C) Flank region every 12 hours for kidney tenderness D) Joints for tenderness and swelling

D) Joints for tenderness and swelling

147. Using crisis intervention theory in the care of a 26-year-old woman who was raped 1 week ago, select the intervention by the nurse that best achieves successful treatment. A) Preventing rape trauma syndrome B) Helping the woman grow to a higher level of functioning C) Referring the woman to a rape victims' group therapy session D) Restoring the woman to her prerape level of functioning

D) Restoring the woman to her prerape level of functioning

122. A client infected with hepatitis C becomes confused, pulls out his IV catheter, and bleeds profusely on the bed rail and floor. Select the instructions by the nurse to the housekeeper that would best prevent the spread of the infection. A) Clean the area with 70 percent alcohol. B) Mop the floor with a strong ammonia solution. C) Let the blood dry first before cleaning to limit the spread of the infection. D) Wipe all contaminated surfaces with a 5 percent chlorine bleach solution.

D) Wipe all contaminated surfaces with a 5 percent chlorine bleach solution.

154. Identify the initial intervention by the nurse that is most effective in treating a 23-year-old woman who is diagnosed with a dependent personality disorder. A) Encouraging the client to make more decisions, starting with simple ones like what to select from a menu B) Teaching the client about the nature of the disorder and what the usual treatments are for it C) Placing the client in a group therapy session with other clients who have dependent personality disorder D) Working with the client to identify and express feelings of anger

D) Working with the client to identify and express feelings of anger