Part 1

*Question: The maternity nursing instructor asks a nursing student to identify the hormones that are produced by the ovaries. Which hormones identified by the student indicate an understanding of the hormones produced by this endocrine gland? Select all that apply.*

** Rationale: The ovaries are the endocrine glands that produce estrogen and progesterone. Oxytocin is produced by the posterior pituitary gland and stimulates the uterus to produce contractions. LH and FSH are produced by the anterior pituitary gland. TSH is produced by the thyroid gland.

*Question: The medication prescribed is metoclopramide hydrochloride 10 mg intramuscularly times one dose. The medication label reads metoclopramide hydrochloride 5 mg/mL. The nurse prepares how much medication to administer the dose? Fill in the blank.*

** Rationale: Rationale not found

*Question: The medication prescribed is morphine sulfate 6 mg subcutaneously. The medication label states morphine sulfate 10 mg/1 mL. The nurse plans to prepare how much medication to administer the dose? Fill in the blank.*

** Rationale: Rationale not found

*Question: The medication prescribed is prochlorperazine 5 mg intramuscularly, every 4 hours as needed. The medication label states prochlorperazine 10 mg/mL. The nurse prepares how much medication to administer the dose? Fill in the blank.*

** Rationale: Rationale not found

*Question: The medication prescribed is zidovudine, 0.2 g orally, three times daily. The medication label states zidovudine, 100-mg tablets. The nurse prepares to administer how many tablets for one dose? Fill in the blank.*

** Rationale: Rationale not found

*Question: The medication prescription reads phenytoin 0.2 g orally, twice daily. The medication label states 100-mg capsules. The nurse prepares how many capsule(s) to administer one dose? Fill in the blank.*

** Rationale: Rationale not found

*Question: The nurse is assisting the primary health care provider with performing a Rinne tuning fork test on a client. The nurse expects that the steps of the testing will be performed in which priority order? Arrange the actions in the order that they would be performed. All options must be used.*

** Rationale: Rationale not found

*Question: The nurse is caring for a client on the mental health unit who has been declared incompetent through a formal legal proceeding. A guardian has been appointed. The nurse knows that guardians are typically selected from among family members. From the list of family members, what is the order of selection of a guardian for this client? List in descending order of importance from the first to the last choice. All options must be used.*

** Rationale: Rationale not found

*Question: The nurse is checking the remaining volume in a 1000-mL intravenous (IV) bag that is scheduled to infuse over 8 hours on an electronic infusion pump. The nurse has just noted at 11:00 a.m. that the remaining IV fluid is at the 500-mL level. At 12:00 noon, at which numerical level (mL) would the IV fluid be? Fill in the blank.*

** Rationale: Rationale not found

*Question: The nurse is preparing to administer 30 mEq of liquid potassium chloride (KCl) to an adult client. The label on the medication bottle reads 40 mEq/15 mL. The nurse prepares how many milliliters of KCl to administer the correct dose of medication? Fill in the blank. Round your answer to the nearest whole number.*

** Rationale: Rationale not found

*Question: The nurse has applied a hypothermia blanket to a client with a fever. The nurse would inspect the skin frequently to detect which complications of hypothermia blanket use? Select all that apply.*

** Rationale: When a hypothermia blanket is used, the skin is inspected frequently for pressure points that over time could lead to skin breakdown, and peripheral perfusion is observed to ascertain for signs of it being diminished. Options 1, 3, and 4 are not complications of hypothermia blanket use.

*Question: A 15-year-old child is scheduled to receive a series of the hepatitis B vaccine. The child arrives at the clinic for the first dose. The nurse collects data on the child before administering the vaccine and would ask the child about a history of an allergy to which primary product?*

*Answer: Baker's yeast* Rationale: A contraindication to receiving the hepatitis B vaccine is a previous anaphylactic reaction to common baker's yeast. An allergy to eggs, penicillin, and sulfonamides is unrelated to the contraindication to receiving this vaccine.

*Question: A potassium-retaining diuretic is prescribed for a client with heart failure. Which foods would the nurse instruct the client to avoid?*

*Answer: Bananas* Rationale: When the client is taking a potassium-retaining diuretic, the client should avoid foods high in potassium. A banana contains 451 mg of potassium. Cranberry juice (1 cup) contains 61 mg of potassium. A plum contains 48 mg of potassium, and 1 ounce of cheddar cheese contains 28 mg of potassium.

*Question: A client is diagnosed with thrombophlebitis. The nurse would tell the client that which prescription is indicated?*

*Answer: Bed rest with elevation of the affected extremity* Rationale: Elevation of the affected leg facilitates blood flow by the force of gravity and decreases venous pressure, which in turn relieves edema and pain. The foot of the bed is elevated, and bed rest is indicated to prevent emboli and pressure fluctuations in the venous system that occur with walking. The positions in the remaining options are incorrect.

*Question: A client has been given a prescription for gemfibrozil. The nurse plans to instruct the client to limit intake of which food while taking this medication?*

*Answer: Beef* Rationale: Gemfibrozil is a lipid-lowering agent. It is given as part of a therapeutic regimen that also includes dietary counseling, specifically the limitation of saturated and other fats in the diet. Therefore, the intake of red meats is limited. Fish, foods that are spicy, and citrus products do not affect the cholesterol level.

*Question: A postpartum client has lost 700 mL of blood. The vital signs indicate hypovolemia and the uterus remains atonic in spite of treatment. The nurse assisting in caring for the client understands what is necessary in this situation and prepares the client for which treatment?*

*Answer: Emergency surgery* Rationale: Options 1, 2, and 4 identify interventions to reverse uterine atony. When uterine atony cannot be reversed, surgery is required.

*Question: The nurse is assisting in developing a plan of care for a child diagnosed with acute glomerulonephritis. The nurse would include which intervention in the plan of care?*

*Answer: Encourage limited activity and provide safety measures.* Rationale: Activity is limited, and most children, because of fatigue, voluntarily restrict their activities during the active phase of the disease. Catheterization may cause a risk of infection. Fluids should not be forced. Visitors should be limited to allow for adequate rest.

*Question: The nurse is collecting data from parents of a 2-year-old child about mealtime activities. The nurse expects a child this age to have attained which ability?*

*Answer: Holds a cup in one hand* Rationale: By 2 years of age, the child can hold a cup in one hand and use a spoon well. By the age of 3 to 4 years, the child begins to use a fork. By the end of the preschool period, the child should begin to use a knife for cutting. Pouring liquids into a cup is a skill that requires fine motor development.

*Question: A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. Which nursing action is appropriate?*

*Answer: Inform the client that he will need to return in 4 to 6 weeks to be tested because testing before this time is not reliable.* Rationale: There is a blood test available to detect Lyme disease; however, it is not reliable if performed before 4 to 6 weeks following the tick bite. Options 1, 2, and 3 are incorrect.

*Question: A client diagnosed with delirium becomes disoriented and confused at night. Which intervention would the nurse implement initially?*

*Answer: Use an indirect light source and turn off the television.* Rationale: Provision of a consistent daily routine and a low-stimulating environment are important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station may become necessary but is not the initial action.

*Question: The medication prescribed is hydromorphone hydrochloride 3 mg intramuscularly, every 4 hours as needed. The medication label reads hydromorphone hydrochloride 4 mg/1 mL. The nurse would prepare to administer how many mL to the client? Fill in the blank.*

** Rationale: Rationale not found

*Question: A clinic nurse is reviewing the record of a client recently diagnosed with a cataract. Which clinical manifestations associated with this disorder would the nurse expect to be documented in the client's record? Select all that apply.*

** Rationale: A cataract is any opacity of the crystalline lens of the eye. The classic symptom of cataracts is painless progressive loss of vision in one or both eyes. Signs and symptoms of a cataract include hazy, blurred, or double vision (diplopia) and floaters in the visual field. There is increasing nearsightedness, complaints that colors are faded or appear yellowish or brownish, and difficulty with night vision. There may be a need to increase lighting when reading.

*Question: The nurse is assigned to assist the primary health care provider (PHCP) with the removal of a chest tube. Which interventions would the nurse anticipate performing during this process? Select all that apply.*

** Rationale: A chest tube is removed when the lung has fully reexpanded or there is limited drainage. When the chest tube is removed, the client is asked to perform a Valsalva maneuver (i.e., take a deep breath, exhale, and bear down), the tube is quickly withdrawn, and an airtight (occlusive) dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. After the tube is removed, the client should take deep breaths to ensure adequate lung expansion. The tube is not usually clamped before it is removed, and the drainage apparatus must always be lower than the chest tube site.

*Question: A postoperative client has been placed on a clear liquid diet. Which items is the client allowed to consume? Select all that apply.*

** Rationale: A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include water, bouillon, clear broth, carbonated beverages, gelatin, lemonade, Popsicles, and regular or decaffeinated coffee or tea. Pudding, ice cream, and vegetable juices are allowed on a full liquid diet.

*Question: The nurse is assessing a client diagnosed with severe anxiety. Which objective data would the nurse expect to find? Select all that apply.*

** Rationale: A client with severe anxiety cannot focus on anything and is oblivious to surroundings. This client also has difficulty noticing what is going on in the environmentand demonstrates purposeless activity as well as displaying unproductive relief behavior. Learning and problem-solving are not possible at this level, and the person may be dazed and confused. Clients with moderate anxiety have selective inattention where only certain things in the environment are seen or heard unless they are pointed out. Clients exhibiting the panic level of anxiety demonstrate physical behavior that may be erratic, uncoordinated, and impulsive.

*Question: The nurse is collecting data from a client during the first prenatal visit at 12 weeks' gestation. The client is anxious to know what the fetus will look like at this time. The nurse correctly responds to the client by providing which information? Select all that apply.*

** Rationale: At 12 weeks' gestation, the fetus is approximately 6 to 9 cm in length and 19 grams. By the end of the twelfth week, taste buds are present, kidneys are able to secrete urine, and the external genitalia of the fetus have developed to such a degree that the gender of the fetus can be determined visually. The fetus is not able to hear until approximately 24 weeks' gestation. Lecithin begins to appear in the amniotic fluid at approximately 27 to 28 weeks' gestation.

*Question: The nurse caring for a client with a neurological disorder is assisting in planning care to maintain nutritional status. The client has had a swallowing study done that shows the client is at risk for aspiration and is able to feed self. The nurse would review which interventions with the assistive personnel (AP)? Select all that apply.*

** Rationale: A client with suspected dysphagia usually has a swallow study done to verify and detail the dysphagia problem. The client has specific prescribed interventions to deal with the problem, and aspiration precautions are initiated. Thin fluids are easier to aspirate, so prescribed thickeners are added to liquid foods. The client should be observed eating so a caregiver can intervene if choking or coughing occurs. This is also a good opportunity to teach family members about the interventions. The client should be sitting upright at a 90-degree angle. The client should eat small amounts in an unrushed manner. Clients should not take a sip of water after each swallow, but double swallowing (swallowing twice after each bite) may be effective in clearing food from the mouth. The client should be well rested before meals because fatigue is a risk factor for aspiration.

*Question: The nurse notes documentation that a client has conductive hearing loss. The nurse plans care knowing that this kind of hearing loss can be caused by which circumstances? Select all that apply.*

** Rationale: A conductive hearing loss is as a result of a physical obstruction to the transmission of sound waves. Acute otitis media with effusion, a fluid buildup in the middle ear, can block the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in the 8th cranial nerve, or a defect of the sensory fibers that lead to the cerebral cortex.

*Question: The nurse is caring for a postoperative client who has a Jackson-Pratt drain inserted into the surgical wound. Which actions would the nurse take in the care of the drain? Select all that apply.*

** Rationale: A drain is a tube that is placed to drain out fluid and blood near the surgical site that could lead to infection. The tube is connected to a bulb, which is compressed to create a vacuum and pull out the fluid. The nurse should check for patency and that fluid is being pulled out. The bulb should be, and look, compressed in order to create the vacuum. The drainage usually is dark red as a result of blood content, but may be pale yellow with serous fluid. Aseptic technique must be used when emptying the drainage container to avoid contamination of the wound. The bulb of the drain should be emptied when it is half full and at least every 8 to 12 hours. The amount of drainage is documented in the client medical record under intake and output. Curling or folding the drain prevents the flow of the drainage.

*Question: The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse plans care knowing that which facts are true with the use of a fenestrated tracheostomy tube? Select all that apply.*

** Rationale: A fenestrated tracheostomy tube is used when a client is being weaned from breathing through the tracheostomy to breathing normally through the nose and mouth. A fenestrated tube has a small opening in the outer cannula that allows some air to escape through the larynx; this type of tube enables the client to speak. The cuff of the tracheostomy tube must always be deflated before the fenestrated tube is capped. When the cuff is inflated, the tracheostomy tube can be used for mechanical ventilation. When the cuff is deflated and the cap is applied, the client can breathe around the tracheostomy tube. The client continues to need cleaning of the tracheostomy site. The client is unable to breathe through the tracheal opening or at all if the cuff is inflated and the opening capped.

*Question: The nurse is reading the primary health care provider's (PHCP) documentation regarding a pregnant client and notes that the PHCP has documented that the client has an android pelvic shape. The nurse understands that which characteristics are included with this pelvic shape? Select all that apply.*

** Rationale: A gynecoid pelvic shape is rounded with a wide pubic arch and is the most favorable pelvic shape for a vaginal birth. The android pelvic shape is heart-shaped and narrow and is an unfavorable shape for a vaginal birth. An anthropoid pelvic shape is long, narrow, and oval. It is not as favorable for a vaginal birth as the gynecoid pelvic shape, which has straight sidewalls and a wide suprapubic arch; however, it is a more favorable pelvic shape than the platypelloid or android. The platypelloid pelvic shape is flattened with a wide, short oval shape and is an unfavorable shape for a vaginal birth.

*Question: The nurse is reading the primary health care provider's (PHCP) documentation regarding a pregnant client and notes that the PHCP has documented that the client has a platypelloid pelvic shape. The nurse recognizes which characteristics to be present in the platypelloid pelvis? Select all that apply.*

** Rationale: A gynecoid pelvic shape is rounded with a wide pubic arch and is the most favorable pelvic shape for a vaginal birth. The platypelloid pelvic shape has a shallow depth, wide suprapubic arch, may be compatible with vaginal delivery, and has a flattened anteroposterior diameter. The gynecoid pelvis is the only pelvic type to have a deep, curved sacral area.

*Question: The psychiatric nurse knows that a therapeutic nurse-client relationship includes which specific goals and functions? Select all that apply.*

** Rationale: A therapeutic nurse-client relationship may be loosely defined, but specific goals and functions must include facilitating communication of distressing thoughts and feelings, assisting clients with problem solving to help facilitate activities of daily living, helping clients examine self-defeating behaviors and test alternatives, and promoting self-care and independence. Acting as an intermediary between the client and family and accompanying the client to all group therapy sessions are not necessary or reasonable goals and functions in the nurse-client relationship.

*Question: A client is being prepared for a thoracentesis. The nurse reinforces instructions with the client given by the registered nurse. Which points would be included in the instructions? Select all that apply.*

** Rationale: A thoracentesis is a procedure in which fluid is removed from the pleural space. The procedure involves insertion of a needle percutaneously and then removal of the fluid by connecting the needle to a vacuum bottle. Before the thoracentesis, the nurse needs to check for allergies because a local anesthetic is administered. A time-out is performed in which the client identification, coagulation studies, and area of the pleural effusion are verified. A chest x-ray is performed after the procedure. A potential complication is a pneumothorax. The client sits on the bedside and leans over a bedside table, which exposes the area between the ribs. A lung biopsy is often done during a bronchoscopy.

*Question: The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply.*

** Rationale: A wound infection occurs when healing is delayed and pathogens such as bacteria grow in the wound. Signs and symptoms of a wound infection include warmth, redness, swelling, and tenderness of skin around the incision. The client may have fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a wound that was contaminated before surgical exploration; it appears 3 to 6 days after surgery. Slight redness along an incision is a sign of inflammation and should be monitored to determine whether it progresses. A temperature of 98.8° F (37.1° C) is not an abnormal finding in a postoperative client. Itching around a wound may be from irritation or dryness and is not associated with infection. The fact that a client feels cold is not indicative of an infection, although chills and fever are signs of infection. The room temperature may be too cold for client comfort.

*Question: The nurse is assessing a client diagnosed with posttraumatic stress disorder (PTSD). The nurse knows that according to current references, PTSD signs/symptoms can be grouped into which three main categories? Select all that apply.*

** Rationale: Acute stress can lead to posttraumatic stress disorder (PTSD) if symptoms extend beyond 1 month. The three main categories are avoidance, hyperarousal, and reexperiencing. Avoidance occurs when the client changes routines to escape similar situations to the trauma. Hyperarousal occurs when the client has difficulty concentrating or falling asleep, being easily startled, feeling tense, and exhibits angry outbursts. These can combine to make it difficult for victims to complete normal daily tasks. Reexperiencing is repeated reliving of the event that interferes with daily activity. This category includes flashbacks, frightening thoughts, recurrent memories or dreams, and physical reactions to situations that remind you of the event. Anxiety, flashbacks, and difficulty concentrating are behaviors included within the three main categories.

*Question: The nurse is assisting with caring for a client after a craniotomy. Which are the positions that can be used for the client? Select all that apply.*

** Rationale: After a craniotomy, the client is at risk for developing complications of increased intracranial pressure and cerebral edema. The head of the bed is elevated 30 degrees (semi-Fowler's position), and the client's head is maintained in a midline, neutral position to facilitate venous drainage. The foot of the bed should be flat because flexion at the hips will impair venous drainage. Blocking venous drainage increases the risk for increased intracranial pressure and cerebral edema. Remember there are no valves in the veins that drain the head.

*Question: The nurse is reinforcing home-care instructions to a client and family regarding care after left cataract surgery with lens implant. Which statements made by the client indicate an understanding of the instructions? Select all that apply.*

** Rationale: After cataract surgery, the client should not assume positions that will increase the intraocular pressure. This could lead to injury to the surgical site and damage the lens implant. The client should not sleep on the side of the body that was operated on. The client may resume activities such as sitting upright at a table or sitting in a recliner with the feet elevated. The client should not lift anything heavier than 10 lbs. The client should not perform activities that would increase the pressure within the eye, such as bending over to tie shoes or performing pushups.

*Question: The home care nurse is caring for a client who had a below-the-knee amputation of the right leg. What are some teaching points the nurse gives to the client and family? Select all that apply.*

** Rationale: After the sutures or staples are removed, the client begins residual limb care. The home care nurse tells the client and family that they can use a shrinker stocking or sock to cover the wrapped stump because it is easier to apply. The limb also needs to be inspected every day for signs of inflammation or skin breakdown. After the limb is healed, it is cleaned each day with the rest of the body during bathing with soap and water. The limb should be rewrapped 3 times a day and not once a day with an elastic bandage. The elastic bandage should be applied in a figure-eight manner and never wrapped in a top-down manner.

*Question: The student nurse is studying the cellular composition of the brain composed of approximately 100 billion neurons or nerve cells. Although neurons come in a great variety of shapes and sizes, all carry out the same three types of physiological actions. Which are these types of actions? Select all that apply.*

** Rationale: Although neurons come in a great variety of shapes and sizes, all carry out the same three types of physiological actions: respond to stimuli, conduct electrical impulses, and release chemicals called neurotransmitters. Most functions of the brain result from the actions of individual neurons and the interconnections between them. Part of conducting an electrical impulse includes allowing the inward flow of sodium and changing the membrane permeability. Inhibiting actions leading to a negative outcome are not included in the types of actions of neurons.

*Question: The client is informed that she is now in the second stage of labor, the descent phase. Which observations would the nurse make to support this stage of labor? Select all that apply.*

** Rationale: As the fetus's head moves through the vaginal canal (second stage, descent phase), the maternal behaviors noted include increased urge to push, grunting sounds or expiratory vocalization, frequent position changes, and altered respiratory patterns. Early in labor (stage 1), the client may be talkative and will readily follow directions.

*Question: The nurse is collecting data from a pregnant client with a history of cardiac disease and is checking the client for venous congestion. The nurse inspects which body areas, knowing that venous congestion is commonly noted in which areas? Select all that apply.*

** Rationale: Assessment of the cardiovascular system includes observation for venous congestion that can develop into varicosities. Venous congestion is most commonly noted in the legs, vulva, or rectum. Although edema may be noted in the fingers and around the eyes, edema in these areas would not be directly associated with venous congestion. It would be difficult to assess for edema in the abdominal area of a client who is pregnant.

*Question: The nurse is teaching an adolescent female about menstruation. Which statements if made by the adolescent female demonstrate a need for further teaching? Select all that apply.*

** Rationale: First menstruation is termed menarche. The average duration of menstruation is 5 days. Day 1 of menstruation is the first day of the menstrual cycle. Menstruation typically begins 14 days after ovulation. The menstrual cycle prepares the uterine lining for pregnancy implantation. During a menstrual period, a woman loses about 40 mL of blood.

*Question: An oriented client is scheduled to have aversion therapy to change behavior. Before initiating any aversive protocol, the treatment team needs to address which questions? Select all that apply.*

** Rationale: Aversion therapy, also known as aversion conditioning or negative reinforcement, is a technique used to change behavior. In this therapy, a stimulus attractive to the client is paired with an unpleasant event in hopes of associating the stimulus with negative properties. Before beginning this therapy, the following questions must be answered by the treatment team: (1) does the client understand the therapy? (2) Does it violate the client's rights? (3) Is it in the best interest of the client? The following questions are not related to beginning this therapy: (1) Is it covered by the client's insurance? (2) How long will it take for positive results? (3) Has the client's family given permission for this therapy? If aversion therapy is chosen as the most appropriate treatment, ongoing supervision, support, and evaluation of those administering it must occur.

*Question: Which interventions would the nurse include when preparing a plan of care for a child with hepatitis? Select all that apply.*

** Rationale: Because hepatitis can be viral, standard precautions should be instituted in the hospital. The child should be discouraged from sharing toys, so playtime in the playroom with other children is not part of the plan of care. The child will be allowed to return to school 1 week after the onset of jaundice, so indefinite home schooling would not need to be arranged. Jaundice is an expected finding with hepatitis and would not warrant notification of the primary health care provider. Provision of a low-fat, well-balanced diet is recommended. Parents are cautioned about administering any medication to the child because normal doses of many medications may become dangerous because of the liver's inability to detoxify and excrete them. Hand washing is the single most effective measure in control of hepatitis in any setting, and effective hand washing can prevent the compromised child from picking up an opportunistic type of infection.

*Question: The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which data specifically associated with this therapy before the initiation of therapy? Select all that apply.*

** Rationale: Before applying heat or cold therapy, the nurse should collect data related to circulatory status, particularly for the prescribed site. Baseline circulatory status is determined so that the nurse can continuously monitor the client before, during, and after therapy. Circulatory status can be monitored by checking pedal pulses, capillary refill, color of the extremity, and temperature of the skin. If the client already has numbness, it will be difficult to detect injury from the cold application. Condition of the toenails is not directly related to circulatory status. If circulatory status is impaired or numbness is present, the nurse should notify the primary health care provider before heat or cold application.

*Question: A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a nasogastric (NG) tube from the client. Which interventions would be included in the procedure? Select all that apply.*

** Rationale: Before removing the tube, the client should be told about the procedure and review the instructions. The tape or securing device needs to be removed from the client's nose. When the NG tube is removed, the client is instructed to take and hold a deep breath. This will close the epiglottis, and the airway will be temporarily obstructed during the tube removal. This allows for the easy withdrawal of the tube through the esophagus into the nose. The tube is removed with one very smooth, continuous pull. There is no balloon that needs to be deflated on an NG tube.

*Question: The nurse is assisting in a group therapy session. Besides cost savings, which advantages does group therapy have over individual therapy? Select all that apply.*

** Rationale: Besides cost savings, advantages that a group format has over individual therapy include increased feedback, an opportunity to practice new skills in a relatively safe environment, mutual learning, and instilling a sense of belonging. Acutely manic clients should not attend these groups. Also, there is an opportunity to practice group roles and not individual ones.

*Question: A client on the mental health unit is exhibiting distancing and does not speak to his/her family or visitors. Which are some other adverse relationship patterns? Select all that apply.*

** Rationale: Besides distancing, other adverse relationship patterns include cutoffs, conflict, and over involvement. Symbiotic, mutualistic and interpersonal relationship styles are positive not adverse types of relationships. A symbiotic relationship is a positive relationship of mutual benefit or dependence. A mutualistic relationship is when two organisms of different species "work together," each benefiting from the relationship. An interpersonal relationship is a strong, deep, or close association or acquaintance between two or more people that may range in duration from brief to enduring.

*Question: Milieu therapy is prescribed for a client on the psychiatric unit. The nurse knows that besides overcrowding on the unit, milieu characteristics conducive to violence include which factors? Select all that apply.*

** Rationale: Besides overcrowding on the psychiatric unit, milieu characteristics conducive to violence include poor limit setting, staff inexperience, provocative or controlling staff, and arbitrary revocation of privileges. Milieu therapy provides a safe environment that is free of violence and adapted to the individual client's needs and provides greater comfort and freedom of expression than has been experienced in the past by the client. All members contribute to the planning and functioning of the setting. Predominantly male staff members and doors to client's rooms opening from inside to out are not milieu therapy characteristics conducive to violence.

*Question: The nurse is monitoring a client with a blunt head injury sustained from a motor vehicle crash. Which would indicate a basal skull fracture as a result of the injury? Select all that apply.*

** Rationale: Bloody or clear watery drainage from the auditory canal, "Battle's sign" and "raccoon eyes" indicate a cerebrospinal fluid leak following trauma and suggest a basal skull fracture. This warrants immediate attention. Option 5 is indicative of an infectious process. Options 1 and 2 are not specifically associated with a basal skull fracture.

*Question: The nurse reinforces dietary instructions to a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines the client has understood if the client plans to include which foods in the diet? Select all that apply.*

** Rationale: Foods that are high in potassium include bananas, cantaloupe, kiwifruit, oranges, and dried fruits such as raisins. Fruits low in potassium include apples, cherries, grapefruit, canned peaches, pineapple, and cranberries.

*Question: The nurse is reviewing the health care records of assigned clients. Which clients are at highest risk for excess fluid volume? Select all that apply.*

** Rationale: Certain disease processes or medical treatments can put a client at risk for fluid volume excess. The causes of excess fluid volume include decreased kidney function, heart failure, cirrhosis, the use of hypotonic fluids to replace isotonic fluid losses, and the excessive ingestion of table salt. The clients with renal failure and CHF are at risk because the organs are impaired in regulating blood volume. The client with an ileostomy, the client on diuretics, and the client on GI suctioning are at risk for deficient fluid volume due to removal of fluids due to those specific medical treatments.

*Question: The nurse determines that which herbal therapies can be prescribed for use as an antispasmodic? Select all that apply.*

** Rationale: Chamomile has a mild sedative effect and acts as an antispasmodic and anti-inflammatory. Peppermint oil acts as an antispasmodic and is used for irritable bowel syndrome. Topical aloe promotes wound healing. Aloe taken orally acts as a laxative. Kava has an anxiolytic, sedative, and analgesic effect. Ginger is effective in relieving nausea.

*Question: The nurse reinforces instructions regarding diet for a client at risk for hypokalemia. The nurse determines there is a need for further teaching when the client selects which foods as sources high in potassium? Select all that apply.*

** Rationale: Clients taking thiazide or loop diuretics need to have adequate potassium intake and benefit from dietary teaching about the potassium values of foods. Bread and butter, carrots and peas, and peppers and onions are relatively low sources of potassium. Meats and certain fruits and vegetables are high in potassium and include beef and potato salad and avocados and mushrooms.

*Question: A child has been diagnosed with bacterial conjunctivitis. Which clinical manifestations of bacterial conjunctivitis would the nurse expect to note? Select all that apply.*

** Rationale: Clinical manifestations of bacterial conjunctivitis include: swollen lids, inflamed conjunctiva crusting on eyelids, especially in the morning, and purulent drainage. Pain does not occur with bacterial conjunctivitis. Itching and serous (watery) drainage occurs with allergic conjunctivitis.

*Question: The nurse is reinforcing instructions to a client about complete/high quality protein foods. Which food choices would indicate the client understood the teaching? Select all that apply.*

** Rationale: Complete/high-quality proteins are proteins that contain all essential amino acids and are found in a variety of meats, eggs, and dairy products. Beans are incomplete/lower-quality proteins as are some cereals. Oranges and broccoli contain vitamins and minerals and minimal protein.

*Question: The nurse is monitoring a confused older client admitted to the hospital with a hip fracture. Which issues could place the client at increased risk for disturbed thought processes? Select all that apply.*

** Rationale: Confusion in the older client with hip fracture could result from the eyeglasses being left at home, an unfamiliar hospital setting, stress from the fracture, side effects of medications, concurrent systemic diseases, or cerebral ischemia. Relatives at the bedside would help the client's functional level, and hearing aids enhance the client's interaction with the environment and can reduce disorientation.

*Question: The nurse is caring for a client with a health care associated infection caused by methicillin-resistant Staphylococcus aureus. Contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions would the nurse use to perform this procedure? Select all that apply.*

** Rationale: Contact precautions are in place, which include wearing gloves and a gown while providing care to the client. The mask and goggles are indicated because of the potential of splash contact during the wound irrigation procedure. Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, body fluids, secretions, and excretions. Shoe protectors are not necessary and are used in operating rooms in the surgical departments. If the client is under airborne or droplet precautions, a mask is worn by the client when going outside of the room. Goggles are not worn by clients.

*Question: The nurse would institute which interventions for a client diagnosed with Clostridium difficile? Select all that apply.*

** Rationale: Contact precautions are necessary for colonization or infection with a multidrug-resistant organism. This includes enteric infection with Clostridium difficile. Measures used to prevent the spread of C. difficile are wearing gowns and gloves while in the room (not just during care) because the spores are on surfaces in the room. Washing with soap and water for hand hygiene is indicated because alcohol-based sanitizers are ineffective against the spores. The use of a mask by the nurse, or the client when outside the client's room, is unnecessary because C. difficile is not transmitted by the respiratory route. The door does not need to be kept shut.

*Question: Which data indicates to the nurse that a client is experiencing effective coping following the loss of a spouse? Select all that apply.*

** Rationale: Coping mechanisms are behaviors that are used to decrease stress and anxiety. Visiting a spouse's grave, visiting the senior citizens' center, and looking at snapshots of the family are effective coping mechanisms. Neglecting grooming and preferring to spend time alone and avoiding contact with others are behaviors that identify ineffective coping of the grieving process.

*Question: The nurse is caring for a 2-year-old child diagnosed with croup. The nurse collects data on the child, knowing that which are characteristics of this illness? Select all that apply.*

** Rationale: Croup often begins at night and may be preceded by several days of upper respiratory infection symptoms. It is characterized by a sudden onset of a harsh, metallic cough; sore throat; and inspiratory stridor. Symptoms usually worsen at night and are better in the day.

*Question: A client is diagnosed with disseminated intravascular coagulopathy (DIC). The nurse would become concerned with which laboratory values? Select all that apply.*

** Rationale: DIC laboratory studies will reveal a decreased hemoglobin and low platelet count. The prothrombin and activated partial thromboplastin times will be increased. The fibrinogen level is reduced, and the fibrin degradation products level is increased. The D-dimer result is elevated.

*Question: The medication prescribed is levodopa 1 g orally, daily. The medication label states levodopa, 500-mg tablets. The nurse prepares to administer how many tablets at the evening dose? Fill in the blank.*

** Rationale: Rationale not found

*Question: The nurse is assessing a client who has been diagnosed with Alzheimer's disease. The nurse knows that in the initial stages the client and family try to hide deficits in memory. Which are some of the defense mechanisms related to the progression of the disease? Select all that apply.*

** Rationale: Defense mechanisms related to the progression of Alzheimer's disease include denial, confabulation, perseveration, and avoidance of questions. Denial occurs fairly early in the disease process. Some people may have superior social graces and charm that give them the ability to hide severe deficits in memory, even from experienced health care professionals. Family members may also unconsciously deny that anything is wrong as a defense against the painful awareness that a loved one is deteriorating. Confabulation is the creation of stories or answers in place of actual memories to maintain self-esteem. Perseveration is also called the repetition of phrases or behavior. This defense mechanism is eventually seen and is often intensified under stress. The avoidance of answering questions is another mechanism by which the person is able to maintain self-esteem unconsciously in the face of severe memory deficits. Confusion is not a defense mechanism.

*Question: A client with cancer has undergone a total abdominal hysterectomy and has an indwelling Foley catheter in place. The nurse would expect to note which types of urinary drainage immediately following this surgery? Select all that apply.*

** Rationale: Depending on the type of surgical technique and the amount of intravenous fluid the client receives during surgery, the urine could be pale or light amber. Purulent urine indicates infection; blood-tinged and bright red urine indicate active bleeding. These are not expected findings.

*Question: The nurse determines that which clients are at high risk for metabolic acidosis? Select all that apply.*

** Rationale: Diabetes mellitus, kidney failure, and malnutrition lead to metabolic acidosis by increasing acids in the body. Asthma, pneumonia, and severe anxiety lead to respiratory, not metabolic, imbalances.

*Question: An elderly client is brought to the emergency department via ambulance after sustaining a fall. An x-ray indicates that the client sustained a femoral neck fracture. The nurse is collecting data from the client and knows that which disease processes increase the older adult's risk for hip fractures? Select all that apply.*

** Rationale: Disease processes like osteoporosis, foot disorders, bony metastases, and changes in cardiac function increase the older adults' risk for hip fracture. A history of carpal tunnel syndrome does not affect the elderly client's risk for hip fracture. Diminished visual acuity is a sensory, physiological change that can occur in the older adult and is not a disease process.

*Question: A client with endometrial cancer is receiving doxorubicin, an antineoplastic agent. The nurse would specifically collect data about which criteria? Select all that apply.*

** Rationale: Doxorubicin has adverse/side effects affecting the red and white blood cell counts and platelets. In addition, it is known to be cardiotoxic, causing dysrhythmias and electrocardiogram changes. Because of bone marrow suppression during therapy with antineoplastic agents, hematological laboratory values should be monitored closely. The incorrect options reflect neurological symptoms, which are not the concern with this medication.

*Question: Which statements made by the nursing student accurately reflect correct information about the hormone oxytocin? Select all that apply.*

** Rationale: Each obstetrical department should have a written protocol for the administration of oxytocin. Oxytocin is produced by the posterior pituitary, not the ovaries or the anterior pituitary gland, and stimulates the uterus to produce contractions during and after birth. The ovaries are the endocrine glands that produce estrogen and progesterone. The pancreas produces insulin and other enzymes that aid digestion. Oxytocin does not stimulate the pancreas to produce insulin. Oxytocin does stimulate contractions that assist with induction and augmentation of labor.

*Question: The nurse is preparing a list of client care activities to be done during the shift. For which of the following clients would the nurse instruct the assistive personnel (AP) to use an electric razor for shaving? Select all that apply.*

** Rationale: Electric razors need to be used for clients that are at risk for bleeding, which include clients with thrombocytopenia (a low platelet level), clients with bleeding or clotting disorders and clients taking certain medications, such as antiplatelet and anticoagulation medications. Therefore, options 3 and 4 are correct. Leukocytosis is not related to bleeding risk, as this indicates an elevated white blood cell count. Thrombocytosis indicates a higher than normal platelet level, which increases the risk for clotting. Finally, acetaminophen is not a medication that increases the clients risk for bleeding.

*Question: A client in the emergency department is diagnosed with Bell's palsy. The nurse collecting data on this client expects to note which observations? Select all that apply.*

** Rationale: Excessive tearing and an inability to furrow the brow are signs of Bell's palsy. The facial drooping associated with Bell's palsy makes it difficult for the client to close the eyelid on the affected side. Double vision and altered level of consciousness are signs of a cerebrovascular accident (CVA). Paroxysms of excruciating pain are seen with trigeminal neuralgia.

*Question: Which identifies accurate nursing documentation notations? Select all that apply.*

** Rationale: Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable because it can be misunderstood. The use of vague terms, such as seems or appears, is not acceptable because these words suggest the nurse is stating an opinion.

*Question: The nurse-midwife is conducting a session on the process of conception with a group of nursing students. Which statements reflect that the nursing students understand the process of conception? Select all that apply.*

** Rationale: Fallopian tubes, also called oviducts, are 8 to 14 cm long and are quite narrow. The fallopian tubes are a pathway for the ovum between the ovary and the uterus. Fertilization occurs in the outer third of the fallopian tube. After the sperm penetrates the ovum, a membrane is formed that blocks the entrance of additional sperm. Implantation usually occurs in the anterior or posterior fundal region. The corpus luteum found in the ovary is responsible for producing early hormones which maintain the pregnancy. The pre-embryonic period lasts until day 15.

*Question: Which interventions are appropriate for the care of an infant? Select all that apply.*

** Rationale: Holding, caressing, and swaddling provide warmth and tactile stimulation for the infant. To provide auditory stimulation, the nurse should talk to the infant in a soft voice and should instruct the mother to also do so. Additional interventions include playing a music box, radio, or television or having a ticking clock or metronome nearby. Hanging a bright, shiny object within 20 cm to 25 cm of the infant's face in the midline and hanging mobiles with contrasting colors (e.g., black and white) provide visual stimulation. Crying is an infant's way of communicating; therefore, the nurse would respond to the infant's crying. The mother is taught to do so also. An infant or child should never be allowed to fall asleep with a bottle containing milk, juice, soda, or sweetened water because of the risk of nursing (bottle-mouth) caries.

*Question: Which statements made by a nursing student indicate that the student has an appropriate knowledge base regarding the pregnancy hormone human chorionic gonadotropin (hCG)? Select all that apply.*

** Rationale: Human chorionic gonadotropin may be responsible for some of the nausea and vomiting associated with early pregnancy. Human chorionic gonadotropin is the hormone responsible for positive pregnancy tests. In early pregnancy as early as 8 to 10 days following conception, hCG is produced by trophoblastic cells that surround the developing embryo. This hormone is also responsible for maintaining the ovarian corpus luteum, which supplies estrogen and progesterone to help maintain the pregnancy until the placenta is fully functioning. Maximum levels of hCG are present from 50 to 70 days into the pregnancy and then this level declines.

*Question: Which interventions would the nurse implement for a child older than 2 years of age with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL? Select all that apply.*

** Rationale: Hypoglycemia is defined as a blood glucose level less than 70 mg/dL. Hypoglycemia occurs as a result of too much insulin, not enough food, or excessive activity. If able, the nurse should confirm hypoglycemia with a blood glucose reading. Glucose is administered orally immediately; the rapid-releasing sugar (such as honey) is followed by a complex carbohydrate and protein, such as a slice of bread or a peanut butter cracker. An extra snack is given if the next meal is not planned for more than 30 minutes or if activity is planned. If the child becomes unconscious, cake frosting or glucose paste can be squeezed onto the gums, and the blood glucose level is retested. If the child does not improve within 15 minutes, administration of glucagon may be necessary, and the nurse should be prepared for this intervention. In the hospital setting the nurse should be prepared to administer dextrose intravenously. Encouraging the child to ambulate and administering regular insulin wi

*Question: A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic and the respiratory rate is increased, and the primary health care provider diagnoses a pulmonary embolism. Which interventions apply to the care of this client? Select all that apply.*

** Rationale: If pulmonary embolism is suspected, oxygen is administered to decrease hypoxia. The client also is kept on bed rest, with the head of the bed slightly elevated, not supine, to reduce dyspnea. Morphine sulfate may be prescribed for the client to reduce pain and apprehension. An IV line also will be required, and vital signs must be monitored. Heparin therapy (not warfarin sodium) is administered.

*Question: The nurse reinforces instructions to a client diagnosed with impetigo. Which statements by the client indicate a need for further teaching? Select all that apply.*

** Rationale: Impetigo is a highly contagious skin infection caused by staphylococci or streptococci. The lesions commonly occur in children around the mouth. The sores contain fluid or pus and scab over with yellow brown crusts. Laundry should be washed separately from others in the household. The crusts need to be removed by gentle washing so topical antibiotics can penetrate into the skin. Thorough hand washing, separating laundry, and separate washing of the client's dishes are required because this infection is contagious as long as skin lesions are present. Antibiotics, topical and often oral, are administered and should be continued as prescribed.

*Question: The nurse is caring for a client who is diagnosed with anxiety. The nurse knows that according to Hildegard Peplau, there are different levels of anxiety that include which? Select all that apply.*

** Rationale: In 1968, Hildegard Peplau developed an anxiety model that consists of four levels: mild, moderate, severe, and panic. Rational and hallucinatory are not levels of anxiety in Peplau's model. The boundaries between these levels are not distinct, and the behaviors and characteristics of individuals experiencing anxiety can and often do overlap. Identification of the specific level of anxiety is essential because interventions are based on the degree of the patient's anxiety.

*Question: The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which actions would the nurse take? Select all that apply.*

** Rationale: In a clinical situation, the nurse must evaluate the vital signs of each postoperative client individually. If complications such as hemorrhage or shock are developing, early intervention is extremely important. Determining how the client feels and asking about dizziness lets the nurse evaluate how the client is tolerating these vital signs. Accessing the medical record to determine the most recent analgesic administration is pertinent because hypotension is a frequent side/adverse effect of analgesics, especially opioids. Reviewing the client's record gives the nurse data on the client's vital signs during and after surgery in the PACU, and the nurse can evaluate whether there has been a change. Giving the client oral fluids is an intervention if the client has a fluid volume deficit and this has not been established. Oral fluids would not correct the problem as quickly as administering IV fluids would. Collecting data about the client voiding is not directly related to

*Question: The advantages of using spinal anesthesia for delivery of a fetus include which reasons? Select all that apply.*

** Rationale: Keeping the woman in bed for at least 8 hours after receiving spinal anesthesia is thought to decrease the risk of headache. Advantages of spinal anesthesia include ease of administration, absence of fetal hypoxia, and onset of anesthesia in 1 to 3 minutes. A disadvantage is the intense blockade of sympathetic fibers resulting in a high incidence of hypotension; a potential decrease in voluntary expulsive efforts, increasing the incidence of the need of an operative birth; and an increased incidence of bladder and uterine atony.

*Question: The nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings would the nurse expect to note? Select all that apply.*

** Rationale: In a thoracotomy the lung is opened and exposed, and a wedge resection is the removal of part of the lung. The chest tube is placed during the surgery to remove fluid and air so the remaining lung can reinflate. The bubbling of water in the water-seal chamber should be gentle and indicates air drainage from the client. This is usually seen when intrathoracic pressure is greater than atmospheric pressure, and it may occur during exhalation, coughing, or sneezing. The fluctuation of water in the tube in the water-seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed, the lung has reexpanded, or no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction-control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room; however, drainage of more than 70 mL/hour to 100 mL/hour is considere

*Question: A client has been diagnosed with cataracts. Which signs and symptoms would the nurse expect to note? Select all that apply.*

** Rationale: In addition to the blurred vision that is typical of opacity of the lens, with cataracts there may be decreased color perception. Uncomplicated cataracts are usually painless, but the client may have photophobia (intolerance of light). Progressive loss of peripheral vision is a sign of glaucoma. Flashes of colored light accompanied by showers of floaters are signs of retinal detachment.

*Question: The nurse assisting with monitoring a client in labor is told that the client's cervix is 3 cm dilated with contractions occurring every 2 to 3 minutes. When monitoring the client's psychological status, the nurse anticipates the client will reflect which attitudes? Select all that apply.*

** Rationale: In early labor, contractions are usually mild. The woman feels able to cope with the discomfort and may be relieved that labor has begun. Excitement is high about the impending birth and she is often alert and talkative related to what she is experiencing. Options 2, 4, and 5 represent psychological states often noted late in labor when discomfort and fatigue are greater and coping ability may be reduced.

*Question: The nurse is checking a child for dehydration and documents that the child is moderately dehydrated. Which symptoms would be noted in determining this finding? Select all that apply.*

** Rationale: In moderate dehydration, thirst will be evident, the fontanels would be slightly sunken, the mucous membranes would be very dry, the skin color would be dusky, and oliguria would be present. Option 2 describes mild dehydration. In mild dehydration, slight thirst is present.

*Question: The home care nurse is collecting data from a client who has been diagnosed with an allergy to latex. In determining the client's risk factors associated with the allergy, the nurse would question the client about an allergy to which food items? Select all that apply.*

** Rationale: Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts are at risk for developing a latex allergy. This is thought to be due to a possible cross-reaction between the food and the latex allergen. The incorrect options are unrelated to latex allergy.

*Question: The nurse is reviewing the complete blood count (CBC) laboratory results of a female adult client suspected of having iron deficiency anemia. The nurse reviews the results and determines that which results are consistent with this diagnosis? Select all that apply.*

** Rationale: Iron deficiency anemia is a low red blood cell count caused by inadequate iron intake or absorption from the diet or blood loss. The low Hgb and Hct indicate an anemia. The normal hemoglobin level for an adult female is 12 to 16 g/dL, and the normal hematocrit is 37% to 47%. The low MCV (normal 80 to 95 fL) indicates a microcytic anemia (red blood cells smaller than normal), which is consistent with iron deficiency anemia. The platelet count and the WBC count are within the normal ranges. The normal platelet count is 150,000 to 400,000 mm3. The normal WBC count is 5000 to 10,000 mm3.

*Question: The nurse is caring for an older client who had surgery to repair a fractured hip. In the late evening the client becomes slightly confused and is moving about in bed. Which actions would the nurse take initially? Select all that apply.*

** Rationale: It is important that the nurse collects data about the client and institutes simple safety measures when an older client becomes restless and slightly confused. The nurse should turn on the bed alarm as a safety measure, ask the client about needing to void or move bowels, and turn on the night lights in the client room. The client should not receive pain medication without having pain assessed. The nurse should evaluate how the client responds to interventions before notifying the PHCP. Use of restraints should never be an initial intervention, and the nurse should try other interventions, including contacting the family to see if someone could stay with the client or obtaining a sitter.

*Question: The nurse is preparing to suction a client through a tracheostomy tube. The nurse would perform which actions when performing this procedure? Select all that apply.*

** Rationale: It is important that the nurse suctions the client sufficiently to clear the airway without making the client severely hypoxemic. Suction is not placed on the catheter when the catheter is introduced into the tracheostomy tube. Suction draws out oxygen, and placing suction on the catheter at this time could traumatize tracheal tissue. Suction should not be applied more than 10 seconds at a time to limit hypoxemia. It is correct technique to preoxygenate the client before suctioning, moistening the catheter with sterile saline, and using sterile technique.

*Question: The nursing student is assigned to care for an adolescent female client in the health care clinic who has the potential diagnosis of gonorrhea. Which signs/symptoms if found in this client support this diagnosis? Select all that apply.*

** Rationale: It is possible for gonorrhea to be asymptomatic. If signs/symptoms occur, the client may experience edema of the labia, chronic or acute severe pelvic or lower abdominal pain, a greenish-yellow purulent endocervical discharge, and menstrual irregularities. Generalized lymphadenopathy and maculopapular rash are associated with syphilis.

*Question: The medication prescribed is methylprednisolone acetate 60 mg intramuscularly. The medication label states methylprednisolone acetate 40 mg/1 mL. How many milliliters will the nurse prepare to administer to the client? Fill in the blank.*

** Rationale: Rationale not found

*Question: The nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric (NG) tube. The nurse checks the residual and obtains an amount of 200 mL. Which actions would the nurse take? Select all that apply.*

** Rationale: Large-volume aspirates in clients receiving intermittent tube feedings indicate delayed gastric emptying and place the client at risk for aspiration. The nurse should obtain data concerning the presence of nausea, bowel sounds, and abdominal distention indicating possible bowel obstruction. When 200 mL of residual formula is obtained, the feeding is held and the RN is notified because this is an indication that the feeding is not being absorbed. If the residual is less than 100 mL, the feeding is usually administered. If the feeding will be held, the tubing should be flushed with 30 mL saline to decrease the risk of the tube clogging from residual formula. In addition, the nurse should always check the PHCP's prescriptions and agency policy regarding residual amounts. The residual amount should be documented, but the residual aspirated is returned to the client to avoid electrolyte imbalance. There is no indication to give the client sips of water.

*Question: The nurse is assisting in performing Leopold's maneuvers. The client asks the purpose of the procedure. How would the nurse respond to the client? Select all that apply.*

** Rationale: Leopold's maneuvers are a systematic way to evaluate the maternal abdomen using inspection and palpation to determine fetal lie, attitude, position, and presentation. Leopold's maneuvers also assist in determining the degree of fetal descent into the pelvis and in locating the point of maximal fetal heart rate intensity. Fetal heart rate is not determined by the performance of Leopold's maneuvers. Contraction duration or frequency is not established by performing Leopold's maneuvers.

*Question: A client is receiving lithium carbonate. The client's lithium carbonate level is 1.5 mEq/L, which indicates an early sign of toxicity. Which are some early signs and symptoms of toxicity? Select all that apply.*

** Rationale: Lethargy, diarrhea, slurred speech, muscle weakness, nausea, vomiting, thirst, polyuria, and fine hand tremor are all early signs and symptoms of toxicity. The therapeutic serum level of lithium carbonate ranges from 0.6 to 1.2 mEq/L. Serum lithium carbonate levels above the therapeutic level will produce signs of toxicity. When early signs and symptoms of toxicity occur, lithium carbonate needs to be withheld, blood lithium levels measured, and dosage reevaluated. Weight gain is an expected side effect. Blurred vision is a severe sign of lithium carbonate toxicity.

*Question: The nurse is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse would include which items on a list of suggestions to be given to the client? Select all that apply.*

** Rationale: Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), relieve pain, and maintain tissue integrity (foot care and nutrition). Elastic stockings will not increase circulation. They are worn with peripheral vascular disease but not peripheral arterial disease. Application of heat directly to the extremity is contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Direct application of heat raises oxygen and nutritional requirements of the tissue even further.

*Question: The nurse is assessing a client with a diagnosis of bipolar affective disorder-mania. Which characteristics appropriately describe this client's diagnosis? Select all that apply.*

** Rationale: Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. It is a period when the mood is predominantly elevated, expansive, or irritable. Taking a shower every other day and occasional periods of depression are not symptomatic of mania.

*Question: The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which interventions would the nurse use to move this client? Select all that apply.*

** Rationale: Manually lifting or transferring clients can result in work-related injuries and back problems for health care workers. In addition, the shearing of the client's skin over bony prominences may occur when health care workers move clients independently. The nurse should get assistance from another caregiver and utilize correct body mechanics while utilizing mechanical aids such as a ceiling lift or friction-reducing slide sheet. Placing the client in Trendelenburg is not a useful technique for repositioning and could be harmful to the client because of the pressure this position places on the diaphragm. Administering oral pain medication is necessary, but oral medications need to be given at least 30 minutes before the activity to provide time for the medication to work and provide relief of pain.

*Question: In order to prevent mastitis, which discharge instructions should the breastfeeding postpartum client receive from the nurse? Select all that apply.*

** Rationale: Mastitis is an infection frequently associated with a break in the skin surface of the nipple. Measures to reduce the possibility of mastitis include changing breast pads frequently, avoiding the use of soap on the nipples, and exposing the nipples to the air to dry. Breastfeeding no more often than every 4 hours is too long a time period not to nurse and wearing an underwire bra may lead to the development of milk stasis and mastitis.

*Question: The nurse is reinforcing instructions to a client diagnosed with eczema about measures that decrease itching and moisturize the skin. Which would the nurse include in the instructions? Select all that apply.*

** Rationale: Measures that decrease itching and moisturize the skin help maintain skin integrity. Encourage the client to maintain the room temperature at 68°F to 75°F. New clothing should be washed before it is worn. Mild detergent should be used for laundry, and clothes should be rinsed twice. Recommend open-weave fabrics and loose clothing. Advise the use of moisturizers and sunscreens. The humidity should be kept at 45% to 55%.

*Question: Which nursing interventions would be implemented for a newborn receiving phototherapy for hyperbilirubinemia? Select all that apply.*

** Rationale: Phototherapy can cause changes in the newborn's temperature Therefore, the temperature should be closely monitored. The newborn's eyes are protected by an opaque eye mask to prevent overexposure to the light. The number and consistency of stools are monitored. Bilirubin breakdown increases gastric motility, which results in loose stools. Lotion should not be used during phototherapy because it absorbs heat and can cause burns. The newborn is unclothed, but a diaper is left on to protect the genitals.

*Question: The nurse notes the physical assessment findings for a client with a diagnosis of possible meningitis. Which findings would the nurse expect to observe because of meningeal irritation? Select all that apply.*

** Rationale: Meningitis is the inflammation of the meninges, the membranes covering the brain and spinal cord. It is caused by organisms such as bacteria, viruses, or fungi. The client with meningitis experiences discomfort when pressure is placed on certain areas that irritate the inflamed meninges. Neck stiffness (nuchal rigidity) is an early sign of meningitis. A positive Brudzinski's sign is observed if the supine client passively flexes the hip and knee in response to neck flexion by the examiner, and the client reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Unequal pupils and slowed pupillary response to light is a sign of increased intracranial pressure. This may occur in clients who are critically ill, but it is not a sign of meningeal irritation. Decorticate posturing is abnormal flexion and is

*Question: Which are the major roles the nurse can play in advocating for psychiatric evaluation and intervention for clients with a history of depression, schizophrenia, obsessive-compulsive disorder, generalized anxiety disorder, or bipolar disorder? Select all that apply.*

** Rationale: Nurses can play an important role in advocating for psychiatric evaluation and intervention by assisting with medication management, monitoring and documenting behavioral changes, notifying the primary health care provider of behavioral changes, and planning care for the needs of those clients with mental illness. It is very important for these clients to have ongoing treatment to prevent relapse and reemergence of symptoms. Administering antidepressants may not be appropriate for all client situations. Keeping the family involved in the client's plan of care may be a violation of client privacy.

*Question: The nurse is providing care to a client with increased intracranial pressure (ICP). Which approaches would be beneficial in controlling the client's ICP from an environmental viewpoint? Select all that apply.*

** Rationale: Nursing interventions should be spaced out over the shift to minimize the risk of a rise in ICP. If possible, activities known to raise ICP should be avoided when possible. Other interventions to control the ICP include keeping the lighting in the room dim or off; maintaining a calm, quiet environment; and avoiding emotional stress and interruption of sleep.

*Question: The nurse is encouraging an older client who has difficulties with incontinence to participate in recreational therapy. Which nursing interventions would the nurse consider performing before assisting the client to go to the recreational therapy session? Select all that apply.*

** Rationale: Older clients may find new activities stressful and become stressed over physiological problems such as incontinence. The nurse works with the client to make the new activity a positive experience even if the client has incontinence. The nurse plans to avoid the client becoming incontinent by promoting elimination just before the activity and assisting with hygiene (clean undergarment). Holding fluids for 4 hours before the activity is excessive and may harm the client. Telling the client that others also have problems belittles the client's concerns. Delaying a diuretic for an hour may be a reasonable adjustment to avoid incontinence for the client during recreational therapy. Basic physiological needs are a priority in administering nursing care. The priority would be to keep the client clean and dry and to avoid embarrassment.

*Question: The nurse is preparing to administer a medication through a nasogastric (NG) tube that is connected to suction. Which interventions would be included to accurately administer the medication? Select all that apply.*

** Rationale: Oral medications are sometimes administered to a client who is prescribed suction through a nasogastric (NG) tube. The nurse must verify that the tube has correct placement by checking drainage characteristics and pH to avoid aspiration of the medication into the trachea. The NG tube should be flushed with saline before and after medication administration to facilitate delivery and promote absorption. The suction must be stopped during administration, and then the tube is clamped for 30 minutes afterward. The client should be in an upright position at least 30 degrees, but higher is better to avoid aspiration. Medications should not be given in the supine position.

*Question: The nurse has given dietary instructions to a client to minimize the risk of osteoporosis. The nurse determines that the client understands the recommended changes if the client verbalizes the intention to increase intake of which foods? Select all that apply.*

** Rationale: Osteoporosis is a chronic metabolic disease in which there is bone loss resulting in decreased bone density and increased risk for fracture. Calcium intake is important to minimize the risk of osteoporosis. The major dietary source of calcium is from dairy foods, including milk, yogurt, and a variety of cheeses. Calcium also may be added to certain products, such as orange juice, which are then advertised as being "fortified" with calcium. Calcium supplements are also recommended to minimize the risk of osteoporosis. Fish, potatoes, chicken, and white bread are foods that are not high in calcium.

*Question: The nurse is caring for a client diagnosed with Paget's disease. The nurse plans care knowing that this condition usually affects which bones? Select all that apply.*

** Rationale: Paget's disease usually affects the axial skeleton, especially the vertebrae and skull. Besides the vertebrae and skull, the pelvis, femur, and tibia are other common sites of the disease. Skull involvement and deformed facial bones frequently occur.

*Question: A client rings the call light and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse would take which actions in the care of this client? Select all that apply.*

** Rationale: Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local infection and can cause the development of a clot (thrombophlebitis). The nurse should remove the IV at the phlebitic site and apply warm moist compresses to the area to speed resolution of the inflammation. Because phlebitis has occurred, the nurse also notifies the PHCP about the IV complication. The nurse should restart the IV in a vein other than the one that has developed phlebitis. Finally, the nurse documents the occurrence, actions taken, and the client's response.

*Question: The medication prescribed is heparin 5000 units subcutaneously, every 12 hours. The medication vial reads heparin 10,000 units/mL. The nurse prepares how many milliliters to administer one dose? Fill in the blank.*

** Rationale: Rationale not found

*Question: The nursing student is conducting a clinical conference regarding the hormones that are related to pregnancy, and the instructor asks the student about the function of progesterone. Which response made by the student indicates an understanding of the function of this hormone? Select all that apply.*

** Rationale: Progesterone decreases the mother's ability to utilize insulin. Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle, including the uterus. Prolactin is the primary hormone of milk production. Relaxin is the hormone that softens the muscles and joints of the pelvis during labor. Thyroxine increases during pregnancy to stimulate basal metabolic rate.

*Question: A primary health care provider has prescribed phytonadione 2.5 mg intramuscularly. The nurse reads the label on the medication vial and administers how many mL to the client? Refer to the figure and fill in the blank. Record your answer to two decimal places.View Figure*

** Rationale: Rationale not found

*Question: A primary health care provider prescribes 2000 mL of 5% dextrose in water to run over 24 hours. The drop (gtt) factor is 15 gtt/mL. The nurse plans to adjust the flow rate at how many drops per minute? Fill in the blank. Round answer to the nearest whole number.*

** Rationale: Rationale not found

*Question: A primary health care provider prescribes 3000 mL of 0.9% NaCl to run over 24 hours. The drop (gtt) factor is 15 gtts/mL. The nurse plans to adjust the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.*

** Rationale: Rationale not found

*Question: A primary health care provider prescribes 3000 mL of 5% dextrose to be administered over a 24-hour period. The nurse prepares to set the infusion rate knowing that how many milliliters per hour are to be administered? Fill in the blank.*

** Rationale: Rationale not found

*Question: A primary health care provider prescribes tetracycline hydrochloride 0.5 g orally 4 times daily. The medication label on the bottle of medication reads tetracycline hydrochloride 250-mg tablets. The nurse prepares how many tablet(s) to administer 1 dose? Fill in the blank.*

** Rationale: Rationale not found

*Question: A primary health care provider prescribes zolpidem tartrate 10 mg orally at bedtime daily. The medication bottle is labeled zolpidem tartrate 5-mg tablets. The nurse prepares how many tablet(s) to administer 1 dose? Fill in the blank.*

** Rationale: Rationale not found

*Question: A primary health care provider's prescription reads "cyanocobalamin 100 mcg intramuscular." The medication label reads "cyanocobalamin, 0.5 mg/mL." The nurse administers how many milliliters to the client? Fill in the blank. Record the answer to one decimal place.*

** Rationale: Rationale not found

*Question: A primary health care provider's prescription reads atenolol 0.025 grams orally daily. The medication bottle reads atenolol 50-mg tablets. The nurse prepares how many tablet(s) to administer the dose? Fill in the blank. Record the answer to one decimal place.*

** Rationale: Rationale not found

*Question: A primary health care provider's prescription reads ciprofloxacin 0.5 g orally twice daily. The medication label reads ciprofloxacin 500-mg tablets. The nurse prepares how many tablet(s) to administer 1 dose? Fill in the blank.*

** Rationale: Rationale not found

*Question: A primary health care provider's prescription reads theophylline 100 mg orally every 6 hours. The medication label reads 50-mg capsules. How many capsules will the nurse give to administer one dose? Fill in the blank.*

** Rationale: Rationale not found

*Question: A primary health care provider's prescription reads: tobramycin sulfate, 7.5 mg intramuscularly twice daily. The medication label states 10 mg/mL. How many milliliters (mL) will the nurse give to administer 1 dose? Fill in the blank. Record your answer to two decimal places.*

** Rationale: Rationale not found

*Question: Morphine sulfate, 2.5 mg subcutaneously, is prescribed for a child postoperatively. The medication label reads 2 mg/mL. How many milliliters should the nurse administer? Fill in the blank.*

** Rationale: Rationale not found

*Question: One unit of packed red blood cells is infusing into a client over a 4-hour period. The unit of blood contains 250 mL. The drop factor is 15 drops (gtts) per 1 mL. The nurse determines that the flow rate would be set at how many drops per minute? Fill in the blank and round answer to the nearest whole number.*

** Rationale: Rationale not found

*Question: Penicillin V potassium 250 mg orally every 8 hours is prescribed for a child with a respiratory infection. The medication label reads: Penicillin, 125 mg per 5 mL. The nurse has determined that the dosage prescribed is a safe dose for the child. How many milliliters (mL) will the nurse administer to the child per dose? Fill in the blank.*

** Rationale: Rationale not found

*Question: The intravenous prescription is 1000 mL of 0.9% NaCl (normal saline) to run over 12 hours. The drop factor is 15 gtts/1 mL. The nurse plans to adjust the flow rate to how many gtts/minute? Fill in the blank and record the answer to the nearest whole number.*

** Rationale: Rationale not found

*Question: The intravenous prescription is 3000 mL of 5% dextrose in water (D5W) to run over a 24-hour period. The drop factor is 10 gtts/1 mL. The nurse plans to adjust the flow rate to how many gtts/minute? Fill in the blank and record the answer to the nearest whole number.*

** Rationale: Rationale not found

*Question: The medication is an intramuscular dose of 400,000 units of penicillin G benzathine. The medication label reads penicillin G benzathine 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Fill in the blank and record the answer using one decimal place.*

** Rationale: Rationale not found

*Question: The medication prescribed is digoxin 0.25 mg orally, daily. The medication label reads digoxin 0.125 mg/tablet. The nurse would prepare how many tablet(s) to administer the dose? Fill in the blank.*

** Rationale: Rationale not found

*Question: The medication prescribed is haloperidol, 4 mg intramuscularly, immediately. The medication label states 5 mg/1 mL. The nurse prepares how much medication to administer the dose? Fill in the blank and round the answer to one decimal place.*

** Rationale: Rationale not found

*Question: The nurse on the mental health unit is collecting data on a client diagnosed with obsessive-compulsive disorder (OCD). The nurse expects to note which behavioral characteristics of OCD? Select all that apply.*

** Rationale: Rigidity, inflexibility, repetitive thoughts, and ritualistic behaviors are behavioral characteristics of the client with obsessive-compulsive disorder. Clients with OCD also frequently have difficulty sleeping. Clients are not usually hostile unless they are prevented from performing the obsession or compulsion because that is what decreases the anxiety. Clients with OCD definitely have problems trying to adapt.

*Question: A client with a diagnosis of tonic-clonic seizures is being admitted to the hospital, and the nurse needs to institute seizure precautions. During a seizure, which items are inappropriate to use and could cause harm to the client? Select all that apply.*

** Rationale: Seizure precautions include keeping side rails up and padded if the client has tonic-clonic seizures, ensuring that suction and oxygen equipment are available, and disabling the locks on the bathroom and room doors. The use of restraints can result in injury to the client because of their restrictive effect. No attempts should be made to open the client's clenched teeth during a seizure because this is likely to cause injury. A padded tongue blade should not be kept at the bedside.

*Question: An adult client with severe muscle spasticity is receiving intrathecal baclofen (ITB). The nurse knows that what adverse effects may occur if the medication is suddenly withdrawn. Select all that apply.*

** Rationale: Seizures and hallucinations may occur if ITB is suddenly withdrawn. Other centrally-acting skeletal muscular relaxants, such as tizanidine, may cause severe drowsiness and sedation in most clients and may not be effective in reducing spasticity. As an alternative to other centrally-acting skeletal muscular relaxants, intrathecal baclofen (ITB) therapy may be prescribed. This drug is administered through a programmable, implantable infusion pump and intrathecal catheter directly into the cerebrospinal fluid. The pump is surgically placed in a subcutaneous pouch in the lower abdomen. Common adverse effects include sedation, fatigue, dizziness, and possible changes in mental status.

*Question: A client is admitted to the hospital with a diagnosis of malnutrition. The nurse is told that blood will be drawn to determine whether the client has a protein deficiency. Which laboratory data indicate that the client is experiencing a protein deficiency? Select all that apply.*

** Rationale: Serum albumin, prealbumin, and transferrin are measures of visceral protein and provide objective data for determining protein deficiency in malnutrition. Albumin reflects protein over the last few weeks and is affected by the fluid status of the client. Normal albumin levels are 3.5 to 5.0 g/dL. Prealbumin is more sensitive and represents more recent protein levels since it has a half-life of 2 days. Normal prealbumin levels are 15 to 36 mg/dL. Serum transferrin is an iron transport protein that can be measured directly or calculated as an indirect measurement of total iron-binding capacity. It is a more sensitive indicator of protein status than albumin. When the serum transferrin level is less than 100 mg/dL, the level of visceral protein depletion is severe. Serum calcium and sodium levels reflect the levels of these electrolytes and are not related to protein levels.

*Question: A woman diagnosed previously with gestational hypertension is returning to the clinic for her scheduled prenatal appointment. During the assessment, the nurse is concerned that she is developing signs/symptoms that indicate that her mild gestational hypertension is progressing. What assessment findings indicate to the nurse that the mild gestational hypertension is progressing? Select all that apply.*

** Rationale: Severe gestational hypertension or preeclampsia may be forms of progression of mild gestational hypertension. In a worsening case, the blood pressure (BP) increases above 140/90 as does the proteinuria. The woman begins to have complaints of neurological symptoms. Elevated blood pressure and headaches are correct.

*Question: The nurse is assisting in caring for a client immediately following an abdominal surgical procedure who lost a significant amount of blood during surgery. Which findings would indicate a sign of a potential complication? Select all that apply.*

** Rationale: Shock that occurs after surgery is most often related to hypovolemia secondary to hemorrhage or inadequate fluid replacement. Increasing restlessness noted in a client is a sign that requires continuous and close monitoring because it could indicate shock. The client may have increasing pain from a buildup of blood internally. Vital sign changes that eventually occur include a drop in BP and an increased pulse rate. Absent bowel sounds are normal in the immediate postoperative period following abdominal surgery. The restlessness may progress to other signs of shock quickly. Remember that early treatment improves the outcome.

*Question: The nurse in the delivery room is assisting with the delivery of a newborn. Which observations indicate that the placenta has separated from the uterine wall and is ready for delivery? Select all that apply.*

** Rationale: Signs of placental separation include lengthening of the umbilical cord, a sudden trickle or gush of dark blood from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to globular shape. The client may experience vaginal fullness but not severe uterine cramping.

*Question: The nurse is reviewing the health care record of a newborn admitted to the nursery; the newborn is suspected of having an imperforate anus. The nurse understands that which documented findings are associated with this disorder? Select all that apply.*

** Rationale: Signs/symptoms of an imperforate anus include absence or stenosis of the anorectal canal, failure to pass meconium stool within 24 hours following birth, an external fistula to the perineum and an anal membrane. During neonatal assessment, the defect should be identified easily on sight. However, a rectal thermometer may be necessary to determine patency if meconium stool is not passed. The presence of stool in the urine, the vagina, or a skin dimple should be reported immediately as an indication of abnormal anorectal development. A bloody mucous stool is a clinical manifestation of intussusception.

*Question: A client is undergoing radiation therapy to treat lung cancer. Which instructions would the nurse reinforce to the client with regard to skin care? Select all that apply.*

** Rationale: Skin care during radiation therapy includes not removing markings, showering or washing the area once a day using warm water and mild soap, and using the hand to wash the affected area rather than a washcloth. The skin should not be subjected to cold, and lotions should not be used unless recommended by the radiologist.

*Question: The nurse is gathering data from a client diagnosed with a phobia. Which are some of the clinically recognized names of common phobias? Select all that apply.*

** Rationale: Social phobias are characterized by severe anxiety or fear provoked by exposure to a social situation or a performance situation. Agoraphobia is a fear of open spaces. Glossophobia is a fear of talking. Zoophobia is a fear of animals. Xenophobia is a fear of strangers. Mysophobia, not germophobia, is a fear of germs or dirt. Monophobia, not alonophobia, is fear of being alone.

*Question: A 0.9% intravenous (IV) solution is prescribed for a client. The IV is to run at 100 mL/hr. The nurse prepares the solution, understanding that which are characteristics of this type of solution? Select all that apply.*

** Rationale: Sodium chloride 0.9%, also referred to as normal saline 0.9%, is isotonic. Isotonic solutions frequently are used for intravenous infusion because they have the same osmolarity as blood. Isotonic IV solutions do not affect the plasma osmolarity. The solution is used for administration in blood transfusions because it will not affect the blood cells. Because the fluid stays in the circulation, isotonic fluids are given to treat hypotension.

*Question: A client delivers a viable neonate who is given Apgar scores of 8 and 9 at 1 and 5 minutes. The nurse recognizes that this score is based on which factors? Select all that apply.*

** Rationale: The Apgar scoring system was designed to evaluate the physical condition of the newborn at birth and determine the immediate need for resuscitation. The five components evaluated are color, heart rate, muscle tone, reflex irritability, and respiratory effort. Gestational age is not a part of Apgar scoring.

*Question: Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory results warrant a call to the primary health care provider (PHCP)? Select all that apply.*

** Rationale: The PHCP would be notified of significantly abnormal laboratory results that are helpful with diagnosing the medical problem, warrant further testing, and/or may put the client at risk for complications. The blood calcium is 7mg/dL, which is significantly low (normal calcium is 9 to 10.5 mg/dL). The blood magnesium is 1 mg/dL, which is also significantly low (normal magnesium is 1.8 to 2.6 mg/dL). The WBC count is somewhat decreased at 3000 cells/mm3 (normal WBC is 5,000 to 10,000 mm3). These laboratory results should be called to the PHCP. The TSH of 0.4 microunits/mL is normal (2 to 10 microunits/mL). The BUN of 10 mg/dL is normal (10 to 20 mg/dL). The serum creatinine of 1 mg/dL is normal (0.6 to 1.1 mg/dL). These values should be noted.

*Question: A transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with pain, and the nurse provides information to the client about the TENS unit. Which client statements indicate the need for further teaching? Select all that apply.*

** Rationale: The TENS unit is portable, and the client controls the system for relieving pain and reducing the need for analgesics. It is attached to the skin of the body by electrodes. The electrical current comes from batteries, and the voltage is controlled by the client. The current feels like "pins and needles," but needles are not used.

*Question: A nursing instructor instructs the nursing students that surfactant is a substance needed to facilitate neonatal breathing. Which statements made by the nursing students indicate understanding regarding the presence of surfactant? Select all that apply.*

** Rationale: The alveoli of the term infant's lungs are lined with surfactant. Surfactant, a substance needed to facilitate neonatal breathing, begins to be produced at approximately week 28. When surfactant is decreased or absent, more pressure will be needed to produce and maintain inspiration. Surfactant is responsible for lowering surface tension, which allows the alveoli to more easily remain open. Surfactant is produced by type 2 lung cells and is not a part of the clotting mechanism for the newborn.

*Question: The nurse is caring for a client with long-term Alzheimer's disease (AD). Which are some of the behavioral manifestations the nurse would expect to observe? Select all that apply.*

** Rationale: The behavioral manifestations of AD include apraxia, aphasia, agnosia, and hyperorality as well as confabulation and perseveration. Apraxia is loss of ability to perform purposeful movements, such as being unable to shave, dress, or perform other once-familiar and purposeful tasks. Aphasia is difficulty in the formulation of words, which may progress to the loss of language ability. Agnosia means loss of knowledge and refers to a wide range of cognitive losses. Hyperorality is the desire to taste everything, chew everything, and put everything into one's mouth. Somatization and operant conditioning are not behavioral manifestations of AD.

*Question: The nurse is teaching a client how to walk with a cane. Which information would the nurse include? Select all that apply.*

** Rationale: The cane should create no more than 30 degrees of flexion of the elbow, and the top of the cane should be parallel to the greater trochanter of the femur or stylus of the wrist. A straight leg cane is sometimes used if the client needs only minimal support for an affected leg. A hemi-cane or quad-cane provides a broader, not narrower, base for the cane and therefore more support. The cane is placed on the unaffected side and not the affected side.

*Question: The nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is in a cephalic presentation. Which findings while performing Leopold's maneuvers support the identification of a cephalic presentation? Select all that apply.*

** Rationale: The cephalic presentation is more favorable than others and is the most common. Abnormal presentations result in prolonged labor and are likely to necessitate a cesarean birth. Small parts may be located on either side of the uterus. In the cephalic presentation, the round, ballottable head is located just above the symphysis pubis. If the round, ballottable shape is located in the fundus or if a soft, irregular shape is present over the symphysis pubis, the fetus is in a breech presentation.

*Question: The nurse is assisting in planning care for a client with a chest tube. The nurse would suggest including which interventions in the plan? Select all that apply.*

** Rationale: The chest tube system must be maintained as a closed system in order for the air to be removed by suction and for the lungs to reexpand to a normal state. The connections should be airtight (no leaks), and all connections should be taped and secure. It is important that the tubes to the suction and the chest tube be patent (without kinks or obstructions). Chest-tube tubing is never pinned to the bed linens because this presents the risk of accidental dislodgment of the tube when the client moves. The chest tube system is not opened and emptied, because a closed system must be maintained; if the system is opened, air pressure causes air to rush in, and lung collapse can occur.

*Question: The nurse is reinforcing instructions to a client about the types of fluids that assist in prevention and treatment of urinary tract infections (UTIs). The nurse instructs the client to consume which fluids? Select all that apply.*

** Rationale: The client at risk for UTIs should be instructed to consume adequate amounts (2000 to 2500 mL/day) of fluids. Certain fluids such as prune juice, apple juice, cranberry juice, and water can be used to minimize the risk for development of UTI. Dairy products and carbonated beverages should be avoided because they are alkylating agents.

*Question: A client with myasthenia gravis is having difficulty speaking. The client's speech is dysarthric and has a nasal tone. The nurse would use which communication strategies when working with this client? Select all that apply.*

** Rationale: The client has speech that is nasal in tone and dysarthric because of cranial nerve involvement of the muscles governing speech. The nurse listens attentively and verbally, verifies what the client has said, asks questions requiring a yes or no response, and develops alternative communication methods (e.g., letter board, picture board, pen and paper, flash cards). Encouraging the client to speak quickly is an ineffective communication strategy and is counterproductive.

*Question: A client admitted to the hospital with a neurological problem indicates to the nurse that magnetic resonance imaging (MRI) may be done. Which findings noted in the client history indicates that the client may be ineligible for this diagnostic procedure? Select all that apply.*

** Rationale: The client having an MRI must have all metallic objects removed because of the magnetic field generated by the device. A careful history is done to determine if any metal objects are inside the client, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may heat up, become dislodged, or malfunction during this procedure. The client may be ineligible if there is significant risk.

*Question: The nurse is developing a teaching plan for a client following a radical mastectomy and includes measures that will assist in preventing lymphedema of the affected arm. The nurse would include which interventions when reviewing instructions with the client to prevent this complication? Select all that apply.*

** Rationale: The client needs to be aware of the signs of lymphedema and ways to prevent this complication. Following mastectomy, the arm should be elevated above the level of the heart per primary health care provider's prescription. Simple arm exercises should be encouraged. The client should inspect the arm daily and notify the primary health care provider if signs of infection or swelling occur. No blood pressure readings, injections, IV lines, or blood draws should be performed on the affected arm. Cool compresses or ice bags are not a suggested measure for lymphedema prevention. The client should not wear constrictive sleeves, and ace wraps are used as treatment, not prevention.

*Question: A client with ovarian cancer is scheduled to receive chemotherapy with cisplatin. The nurse assisting in caring for the client reviews the plan of care, expecting to note which interventions? Select all that apply.*

** Rationale: The client should receive prehydration before and during the infusion of this medication to minimize the risk of renal damage. The BUN and creatinine should be monitored to determine if renal impairment is occurring. Fluids are not restricted. Encouraging adequate dietary intake is appropriate, but a high-protein or low-fat diet is not necessary.

*Question: The nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. The client has been prescribed hip precautions. The nurse plans to implement which activities in the care of the client? Select all that apply.*

** Rationale: The client who has undergone ORIF will be placed on hip precautions per the surgeon's preference. In general, guidelines the nurse should plan to follow include ensuring the client doesn't bend his/her hips beyond 90 degrees and not 120 degrees, doesn't sit or stand for long periods of time, and doesn't cross his/her legs past the midline of the body. The nurse should ensure that the client engages in walking and mild, not rigorous, exercise to maintain strength and that the client uses assistive/adaptive devices when performing activities of daily living.

*Question: The nurse is caring for a client admitted with fat embolism syndrome (FES). Which are some of the early manifestations of this syndrome? Select all that apply.*

** Rationale: The earliest manifestations of FES are a low arterial oxygen level (hypoxemia), dyspnea, and tachypnea (increased respirations). FES is a serious complication that usually results from fractures or fracture repair. In this syndrome, fat globules are released from the yellow bone marrow into the bloodstream within 12 to 48 hours after an injury or other illness (mechanical theory). Headache, lethargy, agitation, confusion, decreased level of consciousness, seizures, and vision changes may follow. Petechiae may appear over the neck, upper arms, and/or chest. Although this rash is a classic manifestation, it is usually the last sign to develop.

*Question: A 39-year-old man learned today that his 36-year-old wife has an incurable cancer and is expected to live not more than a few weeks. The nurse identifies which responses by the husband as indicative of effective individual coping? Select all that apply.*

** Rationale: The expression of anger is known to be a normal response to impending loss, and the anger may be directed toward the self, the dying person, God or other spiritual being, or the caregivers. The options mentioning not allowing his wife to die at home and having children live with out-of-state relatives indicate possibly rash and unilateral decisions without taking into consideration anyone else's feelings. Not visiting his wife at the hospital is strong evidence of denial, as he refuses to see or discuss his wife. The expected responses by the husband are expressing anger at God, bargaining for more time, and making funeral arrangements. These actions indicate progression through the Kubler-Ross stages of dying.

*Question: The nurse is reading about the four different levels of anxiety. Which different categories distinguish and describe each level? Select all that apply.*

** Rationale: The four levels of anxiety are compared and contrasted in relation to the effects on one's perceptual field, effects on one's problem solving, and physical and other defining characteristics. Effects on environment mean the same as effects on perceptual field. Dysfunctional behavior is not a category that defines anxiety but a defense against anxiety. Healthy reaction necessary for survival defines normal anxiety and is not one of the diagnostic levels of anxiety.

*Question: The nurse is reviewing the medical history of a client admitted to the hospital with a diagnosis of colorectal cancer. The nurse understands that which information documented in the medical history are risk factors of this type of cancer? Select all that apply.*

** Rationale: The incidence of colorectal cancer increases with age. Colorectal cancer most often occurs in populations with diets low in fiber and high in refined carbohydrates, fats, and meats. Other risk factors include a family history of the disease, rectal polyps, and active inflammatory disease of at least 10 years' duration. A diet high in fiber is considered protective again colorectal cancer.

*Question: A maternity nurse is providing an in-service educational session to nursing students regarding the process of conception. The nurse determines that successful learning has occurred if the nursing students correctly identify which statements as true? Select all that apply.*

** Rationale: The mature ovum is transported through the fallopian tube by the muscular action of the tube and the movement of the cilia within the tube. The blastocyst typically implants in the anterior or posterior fundal region. Fertilization normally occurs in the distal third of the fallopian tube near the ovary. The ovum, fertilized or not, enters the uterus about 3 days after its release from the ovary. Human chorionic gonadotropin is the hormone responsible for a positive pregnancy test. The stage of the embryo starts about day 15 and lasts to week 8. After this time, the product of conception is referred to as a fetus. Implantation begins 6 to 10 days following fertilization.

*Question: The nurse collects data from a client with a diagnosis of macular degeneration of the eye. The nurse would expect the client to report which symptoms? Select all that apply.*

** Rationale: The most common symptom of macular degeneration is blurred central vision that often occurs suddenly. Clients complain of difficulty with reading and seeing fine detail. Formation of a central scotoma (blind spot) occurs in some clients. Clients may complain of visual distortion usually described as a bending or irregularity of straight lines. Peripheral vision is spared, so although affected persons cannot see to read, drive, watch television clearly, or distinguish faces, they do have the ability to walk. The client may be unable to see the vividness of colors or to see details.

*Question: The nurse reviews a client's serum sodium level and notes that the level is 150 mEq/L (150 mmol/L). The primary health care provider prescribes dietary instructions for the client based on the sodium level. Which food items would the nurse instruct the client to avoid? Select all that apply.*

** Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 150 mEq/L (150 mmol/L) is indicative of hypernatremia. Based on this finding, the nurse should instruct the client to avoid foods high in sodium, such as processed foods including cereals and meats (bacon and salami). Summer squash and tomatoes are low in sodium.

*Question: The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse would include which activities in the nursing care plan for the client on the day of surgery? Select all that apply.*

** Rationale: The nurse caring for clients who will be having surgery must ensure that the client is properly identified and prepared according to the prescription(s) by the surgeon and anesthesiologist. The nurse should assist the client with voiding before surgery so that the bladder is empty at the beginning of the procedure. The nurse should verify that the client has signed the consent for the procedure. If the client has not signed a consent, no preoperative medications should be given, and the surgeon can obtain the consent before proceeding. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 8 hours before surgery rather than 24 hours (often NPO after midnight). A slight increase in blood pressure and pulse is common during the preoperative period; this is generally the result of anxiety. The nurse should verify what the normal blood pressure and pulse rate are for this client.

*Question: The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. Which client data are pertinent and would be reported to the primary health care provider before the surgery? Select all that apply.*

** Rationale: The nurse conducts an interview and reviews current health practices and health history preoperatively with clients. Specific client data that are likely to affect a surgery are communicated promptly. The nurse reports any client allergies, especially an antibiotic allergy, to avoid an allergic reaction perioperatively. The fact that the client was a smoker until recently is pertinent because it may affect how the client tolerates and recovers from anesthesia. The nurse should communicate any client concerns about the effects of the surgery so that the matter can be discussed and understood clearly before the surgery (informed consent). A history of a deep venous thrombosis (DVT) is pertinent because of an increased risk for DVT after the planned surgery, and precautions should be prescribed. A history of a childhood tonsillectomy and routine vitamin and mineral supplementation are part of the client history but are not pertinent data that need to be reported specificall

*Question: The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques would the nurse use when communicating with the family? Select all that apply.*

** Rationale: The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know that they will not be abandoned. The nurse should touch and hold the client's or family member's hand, if appropriate.

*Question: The nurse is assigned to care for a client experiencing episodes of postural hypotension who will be discharged home soon. Which actions would the nurse take to ensure safety while transferring the client from the bed to the chair? Select all that apply.*

** Rationale: The nurse needs to take precautions to ensure safe transfer, especially with clients experiencing postural hypotension. The nurse should ask whether the client is experiencing dizziness before beginning the transfer. The client should be wearing stable footwear to avoid sliding when the client stands. Allowing the client to sit on the side of the bed before transfer allows the body to adjust to position changes, thereby avoiding a fall resulting from postural hypotension. The nurse should remain with the client and assist in the transfer to the chair. A transfer board and a hydraulic lift are not necessary and will not be available after discharge.

*Question: The nurse is reinforcing instructions for a client on how to perform a testicular self-examination (TSE). Which instructions would the nurse include? Select all that apply.*

** Rationale: The nurse needs to teach the client how to perform a testicular self-examination (TSE). The nurse should instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. This will provide ease in palpating, and the client will be better able to identify any abnormalities. The nurse should instruct the client to select a day of the month and perform the examination on the same day each month to avoid forgetting to do the examination. TSE is done by the client rolling each testicle between the thumb and fingers. The client should seek medical attention if a lump, mass, or swelling of the testicle is detected. The bladder does not have to be empty to complete the examination. There is no connection between urethral discharge and TSE.

*Question: The nurse is discharging a client with a diagnosis of gout. Which best practice guidelines would the nurse teach the client? Select all that apply.*

** Rationale: The nurse needs to teach the client to drink plenty of fluids to prevent the formation of urinary stones. Increasing fluid intake helps dilute urine and prevent sediment formation. The client also needs to avoid taking diuretics because this would limit the amount of fluid in the body and would not help prevent sediment formation. Excessive physical or emotional stress can also exacerbate the disease. The nurse needs to teach the client stress-management techniques to help prevent future attacks of gout. A strict low-purine diet is recommended, and clients should avoid foods such as organ meats, shellfish, and oily fish with bones (e.g., sardines). Excessive alcohol intake and fatty meats should also be avoided. The nurse needs to also teach the client to determine which foods precipitate acute attacks and try to avoid them. In addition to food and beverage restrictions, clients with gout should avoid all forms of aspirin and diuretics because they may precipitate an att

*Question: The nurse is caring for a client with osteoporosis who is being discharged with instructions to take calcium with vitamin D. Which instructions would the nurse give the client about taking this medication? Select all that apply.*

** Rationale: The nurse needs to tell the client to take a third of the daily dose at bedtime because no weight-bearing activity to build bone occurs while sleeping. Fluids should be increased, and the medication should be taken with 6 to 8 ounces of water.

*Question: The nurse is caring for a client who underwent a spinal fusion with a metal implant. The nurse notes that the back dressing is wet with clear drainage. Which actions would the nurse take? Select all that apply.*

** Rationale: The nurse observes the surgical dressing following spinal fusion, with or without instrumentation. If clear drainage is observed on or about the surgical dressing, the client likely has a cerebrospinal fluid leak from a dural tear (tear in the covering of the spinal cord). The nurse should place the client flat and notify the registered nurse, who will assess the client and notify the surgeon. The client usually is kept on flat bed rest for several days while the tear heals over. The dressing is not reinforced, but will be changed and a dry dressing applied. Checking the Jackson-Pratt drain for patency and reassessing extremity strength and sensation are not indicated at this time.

*Question: The nurse is assisting with planning care for a client with an internal radiation implant. Which would be included in the plan of care? Select all that apply.*

** Rationale: The nurse should follow standard precautions when caring for any client and wear gloves when emptying a bedpan. Linens are kept in the room as a safety precaution in case there is contamination or part of the implant is lost. The film badge dosimeter allows the nurse to visualize the estimated amount of radiation exposure during the shift. The nurse wears a lead apron to protect oneself and block the radiation waves emitted when close to the client. A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent the accidental exposure of other clients to radiation.

*Question: A client is receiving anticonvulsant therapy with phenytoin. The nurse plans to monitor the results of which laboratory tests closely? Select all that apply.*

** Rationale: The nurse would monitor the client's complete blood cell counts because hematological side effects of this therapy include aplastic anemia, agranulocytosis, leukopenia, and thrombocytopenia. Other values that warrant monitoring include serum calcium levels and the results of urinalysis, and hepatic and thyroid function tests. Serum sodium is not affected by phenytoin.

*Question: The nurse assists a primary health care provider (PHCP) with the insertion of a nasogastric tube. Which positions would the nurse place the client in to prepare for the procedure? Select all that apply.*

** Rationale: The nurse, while assisting the PHCP with the insertion of the nasogastric tube insertion, should place the client in a high-Fowler's position (sitting at a 90-degree angle) with neck slightly extended. This position will assist the use of gravity and straighten the pathway for the tube. Supine and low-Fowler's positions and slight neck flexion will not facilitate the procedure.

*Question: The nurse is preparing to discontinue an indwelling urinary catheter. Which pieces of equipment would the nurse obtain to perform this procedure? Select all that apply.*

** Rationale: The nurse, while preparing to discontinue an indwelling urinary catheter, should obtain nonsterile gloves, a clean towel, and a sterile syringe to remove the saline from the catheter balloon. The client is positioned similarly to the position used with insertion. The nurse dons the gloves and places the towel between the legs to protect the client and bed from any drainage. The balloon of a urinary catheter is filled with 10 mL of sterile saline during the insertion process. The nurse needs to use a 10- or 12-mL syringe to aspirate and remove all the saline through the self-sealing port of the urinary catheter. The nurse then asks the client to take a deep breath and slowly and smoothly withdraws the catheter. The nurse assists the client with perineal care after discontinuing the catheter.

*Question: The maternity nurse is describing the ovarian cycle to a group of nursing students and asks a nursing student to identify the phases of the cycle. Which phases stated by the nursing student indicate a need for further teaching in this area? Select all that apply.*

** Rationale: The ovarian cycle consists of three phases: preovulatory, ovulatory, and luteal. The secretory and proliferative phases are part of the endometrial cycle.

*Question: The nursing instructor has taught a lecture on the reproductive cycle of the female and asks a nursing student to identify the functions of the vagina. The student correctly responds by identifying which functions? Select all that apply.*

** Rationale: The pelvis is a bony structure that supports and protects the lower abdominal and internal reproductive organs. The vagina is the female organ of coitus, allows discharge of the menstrual flow, and assists in the passage of the fetus from the uterus to outside the mother's body during childbirth. The fallopian tubes are lined with folded epithelium containing cilia that beat rhythmically toward the uterine cavity to propel the ovum through the tube. The functions of the ovaries include sex hormone production and maturation of an ovum during each reproductive cycle.

*Question: The nurse is reinforcing instructions about psoriasis to a client with a high risk of the disorder. The nurse explains to the client the plaques of psoriasis most often appear in which areas? Select all that apply.*

** Rationale: The plaques most often appear on the skin of the elbows, knees, and base of the spine of a client with psoriasis. The plaques do not often appear on the face or the abdomen.

*Question: A pregnant woman visiting a health care clinic for the first prenatal visit hears the primary health care provider discuss the preembryonic period of development with the nurse. The woman asks the nurse what this means. What information would the nurse share related to this stage of development? Select all that apply.*

** Rationale: The preembryonic period is the first 2 weeks after conception. Around the fourth day after conception, the fertilized ovum, now called a zygote, enters the uterus. The preembryonic period includes blastocyst formation, initial development of the embryonic membranes, and establishment of the primary germ layers. The embryonic period of development extends from the beginning of the third week through the eighth week after conception. Basic structures of all major body organs are completed during the embryonic period. The fetal period is the longest part of prenatal development. It begins 9 weeks after conception and ends with birth. All major systems are present in their basic form.

*Question: The nurse is preparing a client for surgery. Which would be components of the plan of care? Select all that apply.*

** Rationale: The preoperative preparation is important to ensure that the surgery gets done with everything ready to ensure a successful outcome. The client may brush teeth and rinse with mouthwash but must not swallow any water. Any specific medications that the client was instructed to take on the day of surgery need to be administered and documented. This may include insulin or a blood pressure medication. The nurse cannot just verify that the preoperative testing was done. The nurse needs to review the results of the preoperative laboratory studies and notify the surgeon of any abnormal results. Some increase in both blood pressure and pulse is common because of client anxiety regarding surgery. The client usually has a restriction of food and fluids for 8 hours before surgery instead of 24 hours.

*Question: The nurse is caring for a postpartum client who is being treated for thrombophlebitis. The client is receiving an anticoagulant by intravenous infusion. The nurse monitors for adverse effects of the anticoagulant by checking the client for which signs/symptoms? Select all that apply.*

** Rationale: The treatment for thrombophlebitis is anticoagulant therapy. Adverse effects of anticoagulants include bleeding and would be recognized by the presence of epistaxsis, hematuria, and ecchymosis. Dysuria may indicate a bladder infection. Headache is not an adverse effect of an anticoagulant.

*Question: The nurse is assisting in providing surgical instructions to a preoperative client who will have abdominal surgery. Which instructions would be appropriate to include in the preoperative plan of care? Select all that apply.*

** Rationale: The type of planning and instruction required varies with each individual and type of surgery. Preoperative education, including rationales related to a client's expected postoperative behavior, has a positive outcome on recovery and prevention of postoperative complications. Postoperatively, the client will be monitored closely with vital signs and the client should understand this is routine. General anesthesia predisposes clients to respiratory problems that can lead to atelectasis and pneumonia in the postoperative period. Therefore, coughing and deep breathing are important exercises to be taught in the preoperative period. Addressing that pain will be monitored and controlled with prescribed analgesia should allay client fears regarding pain. Specific instructions that the client needs to receive before discharge should include wound care, activity restrictions, dietary instructions, postoperative medication instructions, personal hygiene, and follow-up appointment

*Question: The nurse is administering mouth care to an unconscious client. The nurse would avoid doing which actions? Select all that apply.*

** Rationale: The unconscious client needs oral hygiene to avoid infection, but it must be implemented in a way to avoid aspiration. The unconscious client is positioned on the side, not supine, during mouth care to prevent aspiration. The use of products with lemon or alcohol should be avoided because they have a drying effect. The teeth are brushed at least twice daily using a small soft toothbrush. The gums, tongue, roof of mouth, and oral mucous membranes are cleansed with tooth sponges to avoid encrustation and infection. The lips are coated with water-soluble lubricant to prevent drying, cracking, and encrustation. Suction equipment should be at the bedside and turned on during the mouth care.

*Question: A nursing student is asked to identify the layers of tissue found within the uterus. Which student responses are correct with regard to the tissue layers of the uterus? Select all that apply.*

** Rationale: The uterus has three divisions: the corpus, the isthmus, and the cervix. The upper division is the corpus or the body of the uterus. The uppermost part of the uterine corpus, above the area where the fallopian tubes enter the uterus, is the fundus of the uterus. The tissue layers of the uterus include the myometrium, perimetrium, and endometrium.

*Question: The nurse provides information to the mother of a toddler regarding toilet-training. The nurse would tell the mother what information? Select all that apply.*

** Rationale: Waiting until the child is 24 to 30 months old makes the task considerably easier because toddlers of this age are less negative and usually more willing to control their sphincters to please their parents. Bowel control typically occurs before bladder control. The child should not be forced to sit for long periods. The ability to remove clothing is one of the physical signs of readiness.

*Question: A primary health care provider is caring for a client who is human immunodeficiency virus (HIV) positive and has delivered a newborn baby. The nurse anticipates which interventions would be employed for the newborn to decrease the risk of HIV? Select all that apply.*

** Rationale: There are known methods to decrease the risk of transmission of HIV from a positive mother to the infant, including caesarian section delivery and treatment of the mother with antiretroviral medications. A newborn of a mother who is HIV positive should be tested within 48 hours of delivery and then at set intervals until the age of 6 months. The infant may test positive due to transmission of maternal antibodies and not be truly HIV positive. Antiretroviral prophylaxis for newborns testing HIV positive is started and continues for 6 weeks. Breast-feeding is not recommended for the HIV-positive mother. Airborne precautions are not indicated for the newborn.

*Question: The student nurse is learning about leadership and management. The student knows that which are the main styles of group leadership? Select all that apply.*

** Rationale: There are three main styles of group leadership, and a leader selects the style that is best suited to the therapeutic needs of a particular group. The autocratic leader exerts control over the group and does not encourage much interaction among members. In contrast, the democratic leader supports extensive group interaction in the process of problem solving. Psychotherapy groups most often employ this empowering leadership style. A laissez-faire leader allows the group members to behave in any way they choose and does not attempt to control the direction of the group. In any group, the leader must be thoughtful about communication techniques since these can have a tremendous impact on group content and process.

*Question: The nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which interventions are included in the plan of care? Select all that apply.*

** Rationale: Thrombosis that is limited to the superficial veins of the saphenous system is treated with analgesics, rest, and elastic support stockings. Elevation of the lower extremity improves venous return and may be recommended. Warm packs may be applied to the affected area to promote healing. Anticoagulants or anti-inflammatory agents are not needed unless the condition persists. After 5 to 7 days of bed rest, and when signs/symptoms disappear, the woman may gradually begin to ambulate.

*Question: A nursing student is conducting a clinical conference regarding the hormones related to pregnancy. The instructor asks the student about the function of thyroxine. Which statements by the student indicate an understanding of this hormone? Select all that apply.*

** Rationale: Thyroxine may lead to a mild enlargement of the thyroid gland while still allowing the pregnant woman to remain euthyroid. Thyroxine increases during pregnancy to stimulate basal metabolic rate. It may also function to assist in the neural development of the fetus. Relaxin is the hormone that softens the muscles and joints of the pelvis. Prolactin is the primary hormone of milk production. Progesterone maintains uterine lining for implantation and relaxes all smooth muscle including the uterus.

*Question: The nurse is teaching the paraplegic client measures to promote skin integrity. Which instructions would be helpful to the client? Select all that apply.*

** Rationale: To avoid developing skin breakdown, the paraplegic client must diligently follow a self-care routine that includes both assessing for skin breakdown and incorporating preventive measures into daily routines. The paraplegic client should have a nutritious diet with adequate protein, use a pressure relief pad in the wheelchair and while in bed, and the bottom sheet should be free of wrinkles and wetness. The client should shift weight in the wheelchair at least every 2 hours and use a mirror to inspect the skin twice a day (morning and evening) to assess for redness, edema, and breakdown.

*Question: The nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which information is accurate regarding depression and the older client? Select all that apply.*

** Rationale: To work most effectively with an older client with depression, the nurse should be aware of the implications of depression, such as physical manifestations, the possibility of dementia, and suicide risk. Suicide is a frequent cause of death among the older population and some indications of dementia may actually originate as depression. Depression in an older person is also likely to have physical manifestations. Depression is treatable in an older client. Depression is never a normal finding, regardless of the client's age.

*Question: The nurse is performing an environmental assessment in the home of an older client. Which observations require immediate attention? Select all that apply.*

** Rationale: Trauma to the older client in the home may be caused by a variety of factors. Some of these factors include an unsteady gait, the presence of unsecured scatter rugs, cluttered passageways, inoperable smoke detectors, or a history of previous falls. The scatter rugs need to be removed or secured. Smoking in bed is the cause of most house fires. The client should be advised to smoke outside and never in bed. Observing a clear exit, working smoke detector, and a secure prefilled medication cassette are evidence of a safe environment.

*Question: The nurse has given medication instructions to the client receiving phenytoin. The nurse determines that the client understands the instructions if the client makes which comments? Select all that apply.*

** Rationale: Typical anticonvulsant medication instructions include taking the prescribed dose daily to keep the blood level of the drug constant, having a serum drug level drawn before taking the morning dose, avoiding abruptly stopping the medication, avoiding alcohol, checking with the primary health care provider before taking over-the-counter medications, avoiding activities in which alertness and coordination are required until medication effects are known, providing good oral hygiene and getting regular dental care, and wearing a Medic-Alert bracelet or tag.

*Question: The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What would the nurse do? Select all that apply.*

** Rationale: Unless otherwise instructed or if the residual contents appear abnormal, an amount of less than 100 mL is reinstilled; then a normal amount of prescribed tube feeding is administered. The amount of residual should be documented. It is important to return the contents to the stomach to prevent electrolyte imbalances. The feeding is not held, and the residual is not sent to the laboratory. The tube feeding should continue at the prescribed rate.

*Question: A client is suspected of having a myocardial infarction. The nurse would expect elevations in which laboratory values to support the diagnosis? Select all that apply.*

** Rationale: When a myocardial infarction occurs, the heart muscle is damaged and enzymes (cardiac markers) are released into the bloodstream. Laboratory testing can detect elevations to support the diagnosis. Troponin I levels elevate as early as 3 hours after myocardial injury and may remain elevated for 7 to 10 days. The CPK-MB reflects the isoenzyme from cardiac muscle, which is the level that increases with myocardial infarction. TSH is not affected with heart damage and is elevated with clients who are hypothyroid. The CPK-MM reflects the isoenzyme from skeletal muscle. The CPK-BB reflects the isoenzyme from the brain.

*Question: The nurse is planning to begin a continuous tube feeding on a client with a nasogastric (NG) tube. Which interventions would the nurse perform before initiating the feeding? Select all that apply.*

** Rationale: When a tube feeding is initiated, the most important intervention is to make sure the NG tube is properly placed in the stomach to prevent aspiration of the formula. After explaining the procedure to the client and assessing placement of the tube, the nurse should irrigate the tube with saline to ensure the formula flows well through the tube. When a tube feeding is administered, the client is placed in a high-Fowler's position for a bolus feeding and in a semi-Fowler's position (30-45 degrees) for a continuous feeding to allow gravity to help the flow of formula and to prevent reflux and aspiration. There is no need to aspirate contents because the formula has not been given and the contents are gastric secretions. Scissors are not kept at the bedside with an NG tube but with the Sengstaken-Blakemore tube used to treat bleeding esophageal varices. The correct placement for the end of the NG tube is in the stomach, not the esophagus.

*Question: A client is admitted to the mental health unit with a diagnosis of possible somatic symptom disorder. Besides anxiety, the nursing assessment is especially important in identifying which client signs/symptoms are contributing to the somatic symptom disorder? Select all that apply.*

** Rationale: When admitting a client with a possible somatic symptom disorder, it is especially important for the nursing assessment to identify signs/symptoms of depression, substance abuse, adverse childhood events, and PTSD. Often, the client has a comorbid psychiatric disorder such as depression, anxiety, and/or a personality disorder. Potential for violence and OCD are not signs/symptoms that contribute to a somatic symptom disorder.

*Question: The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which actions would the nurse take? Select all that apply.*

** Rationale: When suctioning a client with an endotracheal tube, the nurse removes the secretions and clears the airway. If a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm, the nurse must discontinue suctioning until the client is stabilized. The nurse would also notify the RN. It is also important to monitor the vital signs and the pulse oximetry. If the client's condition continues to deteriorate, then the respiratory department and PHCP may need to be notified. There is no data in the question that indicates that the rapid response team needs to be notified.

*Question: The nurse is assisting in caring for a client with a diagnosis of bladder cancer who recently received chemotherapy. The nurse receives a telephone call from the laboratory, which reports that the client's platelet count is 20,000 mm3. Based on this laboratory value, the nurse revises the plan of care and suggests including which interventions? Select all that apply.*

** Rationale: When the platelet count is decreased, the client is at risk for bleeding. A high risk of hemorrhage exists when the platelet count is less than 20,000 mm3. Fatal central nervous system hemorrhage or massive gastrointestinal hemorrhage can occur when the platelet count is less than 10,000 mm3. The client should be assessed for signs of bleeding. Petechiae are tiny red or purple dots noted on the skin due to ruptured capillaries. Many petechiae are noted with low platelet counts. Bleeding precautions are instituted and include no intramuscular injections and limited venipunctures, using small gauge needles only. Options 1, 3, and 4 are specific interventions related to the risk of infection: fresh flowers, fruits, and vegetables should be eliminated and signs of infection should be monitored.

*Question: The nurse is caring for a client who had a total knee replacement and was put on a continuous passive motion (CPM) machine in the postanesthesia care unit (PACU). What are some of the actions the nurse needs to monitor to operate this machine? Select all that apply.*

** Rationale: While not as commonly used today, the CPM machine keeps the prosthetic knee in motion and may prevent the formation of scar tissue which could decrease knee mobility and increase postoperative pain. It should be used as much as the client can tolerate. The nurse needs to make sure that the machine is well padded and assess the client's response to the machine. Also, the machine needs to be turned off while the client is having a meal in bed. It is very important that the nurse ensures that the joint being moved is positioned properly on the machine. The cycle and range-of-motion settings must be checked every 8 hours and not once a day. When the machine is not in use, it should not be stored on the floor. If the client is confused, place the controls to the machine out of his or her reach.

*Question: A client is being discharged to home following spinal laminectomy and fusion with insertion of a metal implant. The nurse includes which instructions about activity after discharge? Select all that apply.*

** Rationale: With a laminectomy with spinal fusion (arthrodesis), part of the bony process lamina is removed and then the spine is fused to stabilize the affected area with a bone graft and insertion of a metal implant. This limits spinal flexibility. The client has some mobility restrictions while the bone fuses. It is important that the client does not fall and disturb the surgery. The client should avoid activities that involve pulling or pushing because these actions put pressure on the spine. The client should not lift over 5 pounds. Stair climbing may be restricted or limited for several weeks following spinal fusion with instrumentation. Clients are encouraged to walk to gain strength and avoid complications. Clients are not allowed to drive until seen by and given approval from the surgeon.

*Question: TThe nurse is assessing a client bladder cancer who has a cystectomy and creation of a ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care?*

*Answer: "I empty the urinary collection bag when it is two-thirds full."* Rationale: The urinary collection bag needs to be changed when it is one-third full to prevent pulling of the appliance and leakage. The remaining options identify correct statements about the care of a urinary stoma.

*Question: The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which actions would the nurse take to deal with this event? Select all that apply.*

** Rationale: Wound dehiscence is the separation of the wound edges at the suture line. Signs and symptoms include increased drainage and the appearance of underlying tissues. It usually occurs as a complication 6 to 8 days after surgery. The client should be instructed to remain quiet and avoid coughing or straining, and he or she should be positioned to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline should be used to cover the wound. The registered nurse (RN) and primary health care provider (PHCP) need to be notified. The client should assume a low-Fowler's position with knees bent to avoid further stress on the incision. Obesity is a risk factor for dehiscence, but now is not the appropriate time for this teaching. The nurse should not explore the incision because this may actually cause evisceration, a more serious complication.

*Question: Surgery has been recommended for the client with otosclerosis. The client tells the nurse that she would prefer not to have surgery and asks the nurse about alternative methods to improve hearing. The nurse would make which appropriate response to the client?*

*Answer: "A hearing aid may improve your hearing."* Rationale: Clients with otosclerosis who do not desire surgery may have their hearing loss relieved by the use of a hearing aid. Options 2, 3, and 4 are inappropriate responses.

*Question: A nursing instructor asks a nursing student to describe accountability. Which statement by the student indicates an inaccurate description of accountability?*

*Answer: "Accountability can be delegated."* Rationale: Accountability refers to the process of answering or being responsible for what occurs and carries legal implications for task performance. Accountability cannot be delegated; one must answer for the care given and for the care one asks others to complete.

*Question: The parents of a 16-year-old child tell the nurse that they are concerned because the child sleeps until noon every weekend. Which is the most appropriate nursing response?*

*Answer: "Adolescents love to sleep late in the morning."* Rationale: The sleep patterns of the adolescent vary some according to individual needs. However, in general, adolescents love to sleep late in the morning, but they should be encouraged to be responsible for waking themselves, particularly in time to get ready for school. Options 2, 3, and 4 are incorrect.

*Question: The nurse provides instructions to a client about the use of an incentive spirometer. The nurse determines that the client needs further teaching about its use if the client makes which statement?*

*Answer: "After maximal inspiration, I will hold my breath for 10 seconds and then exhale."* Rationale: For optimal lung expansion with the incentive spirometer, the client should assume a semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. When maximal inspiration is reached, the client should hold the breath for 5 seconds and then exhale slowly through pursed lips.

*Question: The nurse is preparing a client for an intravesical instillation of an alkylating chemotherapeutic agent into the bladder for the treatment of bladder cancer. The nurse provides instructions to the client regarding the procedure. Which client statement indicates an understanding of this procedure?*

*Answer: "After the instillation is done, I will need to change position every 15 minutes from side to side."* Rationale: Normally the medication is injected into the bladder through a urethral catheter, the catheter is clamped or removed, and the client is asked to retain the fluid for 2 hours. The client is to change position every 15 to 30 minutes from side to side, and from supine to prone, or to resume all activity immediately during this time period. This allows the chemotherapeutic agent to be in contact with all areas inside the bladder. The client then voids and is instructed to drink water to flush the bladder.

*Question: A mother of a 3-year-old is concerned because the child is still insisting on a bottle at nap time and at bedtime. The nurse would make which suggestion to the mother?*

*Answer: "Allow the bottle if it contains water."* Rationale: A toddler should not be allowed to fall asleep with a bottle because of the risk of dental caries. If the bottle is allowed in bed, it should contain only water.

*Question: A client with glaucoma asks the nurse if complete vision will return. The nurse would make which response to the client?*

*Answer: "Although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan."* Rationale: Vision loss to glaucoma is irreparable. The client needs to be reassured that although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan. Options 1, 2, and 3 are incorrect.

*Question: A hospitalized 2-year-old child with croup is receiving corticosteroid therapy. The mother asks the nurse why the primary health care provider did not prescribe antibiotics. The nurse makes which response to the mother?*

*Answer: "Antibiotics are not indicated unless a bacterial infection is present."* Rationale: Antibiotics are not indicated in the treatment of croup unless a bacterial infection is present. Options 1, 2, and 4 are incorrect. In addition, the question does not include any supporting data to indicate that the child may be allergic to antibiotics.

*Question: A 6-month-old infant receives a diphtheria, tetanus, and pertussis (DTaP) immunization at the well-baby clinic. The mother returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which is the appropriate response by the nurse?*

*Answer: "Apply an ice pack to the injection site."* Rationale: Occasionally, tenderness, redness, or swelling may occur at the site of the injection. This can be relieved with ice packs for the first 24 hours followed by warm compresses if the inflammation persists. It is not necessary to bring the infant back to the clinic. Option 1 may be an appropriate intervention but is not specific to the subject of the question.

*Question: The nurse notes that a client is taking lansoprazole. On data collection the nurse would ask the client which question to determine medication effectiveness?*

*Answer: "Are you experiencing any heartburn?"* Rationale: Lansoprazole is a gastric acid pump inhibitor used to treat gastric and duodenal ulcers, erosive esophagitis, and hypersecretory conditions. It also is used to treat gastroesophageal reflux disease (GERD). It is not used to treat visual problems, problems with appetite, or leg pain.

*Question: The parents of an 8-year-old child tell the nurse that they are concerned about the child because the child seems to be more attentive to friends than anyone else. Which is the appropriate nursing response?*

*Answer: "At this age, the child is developing his or her own personality."* Rationale: According to Erikson, at ages 7 to 12 years, the child begins to move toward receiving support from peers and friends and away from that of parents. The child also begins to develop special interests that reflect his or her own developing personality instead of those of the parents. Therefore, the other options identify incorrect responses.

*Question: A nursing instructor asks a nursing student about the use of bacillus Calmette-Guerin vaccine (BCG). Which response made by the nursing student is correct?*

*Answer: "BCG is administered to asymptomatic human immunodeficiency virus (HIV)-infected children who are at increased risk for developing TB."* Rationale: The BCG vaccine is used mainly for children with a negative chest x-ray and skin test results who have had repeated exposures to TB and for asymptomatic HIV-infected children who are at increased risk for developing TB.

*Question: The nurse has reinforced instructions to the client with a cystocele about Kegel exercises. The nurse determines that the client has not fully understood the directions if the client makes which statement?*

*Answer: "Begin voiding and then stop the stream, holding residual urine for an hour."* Rationale: Kegel exercises strengthen the perineal floor and are useful to prevent and manage cystocele, rectocele, and enterocele. There are several acceptable ways to perform Kegel exercises. These involve starting and stopping the flow of urine either once for up to 5 minutes, or several times during a single voiding for about 5 seconds. Because the muscles that control urination also are involved in defecation, these exercises also can be done once during defecation. Otherwise, they may be done by holding perineal muscles taut for up to 10 seconds several times a day, or for 5 minutes three or four times a day. Option 1 is not a correct method for performing Kegel exercises. Residual urine should not be held in the bladder for lengthy periods because it could promote urinary tract infection.

*Question: A client asks the nurse to describe the preferred provider organization model of care because the client is unsure of the procedure involved in this form of health care. Which statement by the nurse indicates an inaccurate description of this form of organization?*

*Answer: "Beneficiaries are limited to those providers that are participating primary health care providers for any required health care services."* Rationale: Options 1, 2, and 3 are accurate descriptions of the preferred provider organization. In the exclusive provider organization, beneficiaries are limited to those providers that are participating primary health care providers for any required health care services. If members elect to see primary health care providers outside the exclusive provider organization, services may not be covered.

*Question: The nurse is providing a teaching session to an adolescent female regarding sexual maturation. The nurse recognizes that successful teaching has occurred if the adolescent female makes which statement?*

*Answer: "Breast changes most commonly occur before growth of pubic and axillary hair."* Rationale: Clinical findings associated with sexual maturation typically occur in an orderly pattern. Breast changes usually occur before the development of pubic and axillary hair. Height and weight increase when puberty is experienced. Menstruation usually occurs about 2 years following the beginning of breast development.

*Question: A postpartum client with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. Which would the nurse tell the client?*

*Answer: "Breast-feed from the left breast and gently pump the right breast."* Rationale: In most cases, the mother can continue to breast-feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. If an abscess forms and ruptures into the ducts of the breasts, breast-feeding should be discontinued and a pump used to empty the breast (but the milk should be discarded). The remaining statements are incorrect options.

*Question: A pregnant client is positive for the human immunodeficiency virus (HIV). The nurse educates the client and determines that there is a need for further teaching if the client makes which statement?*

*Answer: "Breastfeeding my newborn will be the best option for my baby."* Rationale: It is very important that the nurse assess that the client has correct knowledge regarding the transmission of HIV and needed precautions to prevent the transmission of HIV.

*Question: The nurse is reviewing the treatment plan with the parents of a newborn infant with hypospadias. Which statement by the parents indicates their understanding of the plan?*

*Answer: "Circumcision has been delayed to save tissue for surgical repair."* Rationale: Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. The infant should not be circumcised because the dorsal foreskin tissue will be used for surgical repair of the hypospadias. The incorrect statements are unrelated to this disorder.

*Question: A client who was started on anticonvulsant therapy with clonazepam tells the nurse of increasing clumsiness and unsteadiness since starting the medication. The client is visibly upset by these manifestations and asks the nurse what to do. How would the nurse respond to the client's concerns?*

*Answer: "Clumsiness and unsteadiness are worse during initial therapy and decrease or disappear with long-term use."* Rationale: Drowsiness, unsteadiness, and clumsiness are expected effects of the medication during early therapy. They are dose related and usually diminish or disappear altogether with continued use of the medication. It does not indicate that a severe side effect is occurring. It is also unrelated to interaction with another medication. The client is encouraged to take this medication with food to minimize gastrointestinal upset.

*Question: A myringotomy is performed on a client in the ambulatory care center. The ambulatory care nurse calls the client 24 hours after the procedure to evaluate the status of the client. The client reports to the nurse that a small amount of brownish drainage has been coming from the ear. Which instruction would the nurse provide to the client?*

*Answer: "Continue to monitor the drainage because this is normal and may occur for 24 to 48 hours following the surgery."* Rationale: A small amount of brownish or reddish drainage is normal for 24 to 48 hours following the surgery. Excessive drainage, especially clear fluid, should be reported immediately. Options 1, 2, and 3 are inaccurate instructions.

*Question: The nurse has reinforced client instructions regarding crutch safety. Which comment by the client would indicate a need for further teaching?*

*Answer: "Crutch tips will not slip, even when wet."* Rationale: There is a need for further teaching when the client says that crutch tips won't slip even when wet. Crutch tips should remain dry. Water could cause slipping by decreasing the surface friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The client should use only crutches measured for the client. The tips should be inspected for wear, and spare crutches and tips should be available if needed.

*Question: The nurse reinforces instructions to a client who is to return to the primary health care provider's office in 1 week for a patch test to identify the allergen causing the dermatitis. The nurse provides which instruction to the client?*

*Answer: "Discontinue the prescribed antihistamine 2 days before the test."* Rationale: Client preparation for a patch test includes informing the client to discontinue systemic corticosteroids or antihistamines for at least 48 hours before the test. To prevent suppression of the inflammatory response to an allergen, these medications must be discontinued. A client does not need to be NPO, may consume fluids, and may take a shower with antibacterial soap before a patch test.

*Question: A mother of a child brings the child to a clinic and reports that the child has a fever and has developed a rash on the neck and trunk. Roseola is diagnosed, and the mother is concerned that her other children will contract the disease. Which instruction would the nurse reinforce to the mother to prevent the transmission of the disease?*

*Answer: "Disease transmission is unknown."* Rationale: The method of transmission of roseola is unknown. Options 2, 3, and 4 are not correct transmission routes of roseola.

*Question: The nurse reviews the medication history of a client admitted to the hospital and notes that the client is taking leflunomide. During data collection, the nurse asks which question to determine if the medication is effective?*

*Answer: "Do you have any joint pain?"* Rationale: Asking the client, "do you have any joint pain?" is the question to ask to determine if the medication is effective. Leflunomide is an immunosuppressive agent and has an anti-inflammatory action. The medication provides symptomatic relief of rheumatoid arthritis. Diarrhea can occur as a side effect of the medication. The other questions are unrelated to medication effectiveness.

*Question: The nurse is obtaining data from a client admitted with a diagnosis of bladder cancer. Which question would the nurse ask the client to determine if the client experienced the most common symptom associated with this type of cancer?*

*Answer: "Do you notice any blood in the urine?"* Rationale: The most common symptom in clients with cancer of the bladder is hematuria. The client may also experience irritative voiding symptoms such as frequency, urgency, and dysuria, which often are associated with cancer in situ. The nurse's question in option 4 will elicit information from the client regarding the most common symptom associated with bladder cancer.

*Question: The nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which nursing response would be therapeutic?*

*Answer: "Do you recall needing to be hospitalized because you stopped your medication?"* Rationale: Noncompliance with antipsychotic medication is one of the chief reasons that clients with schizophrenia have relapses. Asking the client, "Do you recall needing to be hospitalized because you stopped your medication?" is a therapeutic response. The nurse teaches the client with schizophrenia to identify the causes of relapse. In option 1 the nurse is employing restating, which, although therapeutic, is not useful to this client and to this client's situation. In option 2 the nurse is again using restating. In option 4 the nurse is using an illogical, judgmental, and biased response, which is not therapeutic.

*Question: The nurse is collecting data from a client suspected of having ovarian cancer. Which question would the nurse ask the client to elicit information specifically related to this disorder?*

*Answer: "Does your abdomen feel as though it is swollen?"* Rationale: Signs/symptoms of ovarian cancer include abdominal distention, urinary frequency and urgency, pleural effusion, malnutrition, pain from pressure caused by the growing tumor and the effects of urinary or bowel obstruction, and constipation. Ascites with dyspnea and ultimately general severe pain will occur as the disease progresses. Abnormal bleeding, often resulting in hypermenorrhea, is associated with uterine cancer.

*Question: A client is somewhat nervous about having magnetic resonance imaging (MRI). Which statement by the nurse would provide reassurance to the client about the procedure?*

*Answer: "Even though you are alone in the scanner, you will be in voice communication with the technologist during the procedure."* Rationale: The MRI scanner is a hollow tube, which gives some clients a feeling of claustrophobia. Metal objects must be removed before the procedure so that they are not drawn into the magnetic field. The client may eat and take all prescribed medications before the procedure. If a contrast medium is used, the client may wish to eat lightly if there is a tendency to get nauseated easily. The client lies supine on a padded table, which moves into the imager. The client must lie still during the procedure. The imager makes tapping noises while scanning. The client is alone in the imager, but the nurse can reassure the client that the technician is in voice communication with the client at all times during the procedure.

*Question: The nurse reinforces instructions to parents regarding the methods that will decrease the risk of recurrent otitis media in infants. Which would the nurse include in the instructions?*

*Answer: "Feed the infant in an upright position."* Rationale: To decrease the risk of recurrent otitis media, parents should be encouraged to breast-feed during infancy, discontinue bottle-feeding as soon as possible, feed the infant in an upright position, and avoid giving the infant a bottle in bed. Parents should be told not to smoke in the child's presence because passive smoking increases the incidence of otitis media.

*Question: The nurse educator determines that a newly hired licensed practical nurse (LPN) in a local hospital demonstrates an accurate understanding of professional liability insurance when which statement is made?*

*Answer: "I should obtain my own malpractice insurance."* Rationale: Nurses need their own liability insurance for protection against malpractice lawsuits. Nurses erroneously assume that they are protected by an agency's professional liability policies. Usually when the nurse is sued, the employer is also sued for the nurse's actions or inactions. Even though this is the norm, nurses are encouraged to have their own malpractice insurance.

*Question: A client reports to the health care clinic for an eye examination, and a diagnosis of primary open-angle glaucoma is suspected. Which question will elicit information regarding the signs/symptoms associated with this disorder?*

*Answer: "Have you had difficulty with peripheral vision?"* Rationale: Because glaucoma is usually symptom free, the client may first note changes in peripheral visual acuity. If pain occurs with glaucoma, it is usually late in the course of structural changes with an intraocular pressure of 40 to 50 mm Hg or higher. More severe pain is characteristic of absolute glaucoma (total vision loss). Glare from bright lights is a complaint of a client with a cataract. Blurred central vision occurs with macular degeneration.

*Question: The nurse is collecting data from a client who is admitted to the hospital for diagnostic studies to rule out the presence of Hodgkin's disease. Which question would the nurse ask the client to elicit information specifically related to this disease?*

*Answer: "Have you noticed any swollen lymph nodes?"* Rationale: Hodgkin's disease is a chronic progressive neoplastic disorder of lymphoid tissue characterized by the painless enlargement of lymph nodes with progression to extra-lymphatic sites, such as the spleen and liver. Weight loss is most likely to be noted. Fatigue and weakness may occur but are not significantly related to the disease.

*Question: The nurse determines that an adolescent client with diabetes mellitus needs further teaching about A1c levels and their purpose if the client made which statement when told that a level will be drawn?*

*Answer: "I already had a complete blood cell count drawn an hour ago, so this test is not necessary."* Rationale: A1c reflects the average blood glucose levels during the previous 3 to 4 months. It assesses glucose control in the client with diabetes mellitus. Glucose molecules attach to the hemoglobin A molecules found in red blood cells (RBCs) and remain there for the lifetime of the RBCs, approximately 120 days.

*Question: A pregnant client tests positive for hepatitis B virus (HBV). The nurse determines that the client understands this infection when the client makes which statement?*

*Answer: "I am so glad that I can breastfeed my baby after she has been vaccinated."* Rationale: To reduce the possibility of hepatitis B virus being spread to the newborn, neonates routinely are vaccinated at birth. Although HBV is transmitted in breast milk, once serum immune globulin has been administered, the mother may breastfeed without risk to the newborn. Option 2 is incorrect because the baby is not provided immunity to this condition. HBV does not cause a severe eye infection in the newborn, and this newborn does not need to be isolated.

*Question: The nurse is reinforcing dietary instructions to the mother of a child with celiac disease. Which statement by the mother indicates a need for further teaching?*

*Answer: "I am so pleased that I won't have to eliminate oatmeal from my child's diet."* Rationale: Dietary management is the mainstay of treatment for the child with celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early period of treatment to correct deficiencies.

*Question: The student nurse is being taught by the registered nurse (RN) how to collect data from a client and is attempting to obtain subjective data regarding the client's sexual reproductive status. The client states, "I don't want to discuss this; it's private and personal." Which response by the student nurse indicates a need for further teaching?*

*Answer: "I am the nurse and, as such, I'll have you know that all information is kept confidential."* Rationale: There is a need for further teaching when the student nurse responds to the client about obtaining personal sexual reproductive data that "I am the nurse and, as such, I'll have you know that all information is kept confidential". The nursing student is acting pompously, and the response is not therapeutic. The other responses are therapeutic and acknowledge the client's discomfort with the questions and assure the confidentiality of the client's response.

*Question: The nurse is reinforcing preoperative instructions to a client scheduled for cataract surgery and prepares a written list of instructions for the client. Which statement by the client indicates a need for further teaching?*

*Answer: "I can drink any liquids that I want to on the morning of the surgery."* Rationale: The client should be instructed that no oral intake is permitted for 6 to 12 hours before the surgical procedure. Local or general anesthesia will be administered, and the client may receive medication to produce relaxation. Eyelashes may be cut before surgery and will grow back but will grow slowly. Eye medications such as mydriatics, cycloplegics, or beta blockers may be administered before the surgical procedure.

*Question: A nurse discussing options with a mother of a child with cystic fibrosis (CF) asks if she understands the education. Which statement by the mother indicates a need for further teaching?*

*Answer: "I can give my child whatever foods he likes to eat, since he gets enzymes anyway."* Rationale: A diet of high-protein, high-calorie, moderate-fat is prescribed. Option 4 is incorrect. Cystic fibrosis is a genetic disease in which excess mucous production occurs because of exocrine gland dysfunction. The lungs, intestine, sinuses, reproductive tract, sweat glands, and pancreas are all affected. Treatment includes gene therapy, bronchodilators, expectorants, oral pancreatic enzymes, double doses of fat-soluble vitamins and mucolytics. Lung transplant is an option for these clients.

*Question: A client seeking treatment for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client makes which statement?*

*Answer: "I can resume a full activity level immediately."* Rationale: Discharge instructions for the client hospitalized for hyperthermia include prevention of heat-related disorders, increased fluid intake for 24 hours, self-monitoring of voiding, and the importance of staying in a cool environment and resting.

*Question: During a group meeting, a client diagnosed with posttraumatic stress disorder (PTSD) verbalizes difficulty with maintaining realistic behavior. Which response by the nurse would be therapeutic?*

*Answer: "I can see that you are upset about this. Let's talk about this some more."* Rationale: The correct response is "I can see that you are upset about this. Let's talk about this some more." This response acknowledges the client's feelings. The remaining responses do not use therapeutic communication skills. Options 1 and 2 are clichés that do not acknowledge the client's feelings. Option 4 is nontherapeutic and requires an explanation from the client.

*Question: The nurse is assigned to care for a client who is agitated. On entering the room, the client screams, "Why don't you just leave me alone?" The nurse would make which therapeutic response to the client?*

*Answer: "I can see that you are upset. I'll be back in a few minutes to see how you are doing."* Rationale: The correct response, "I can see that you are upset. I'll be back in a few minutes to see how you are doing," gives the client space and personal control. Asking the client, "Why do you feel this way?" may place the client on the defensive and is not a facilitative technique. Telling the client not to yell at you is confrontational and nonfacilitative and imposes control by the nurse. Telling the client that you'll contact the psychiatrist is belittling, does not include the client, and does not provide a clear sense of direction.

*Question: The nurse working the evening shift is assisting clients in getting ready to go to sleep. A client diagnosed with obsessive-compulsive disorder (OCD) becomes upset and agitated and asks the nurse to sit down and talk. Which response by the nurse would be best at this time?*

*Answer: "I can see that you're upset. I'm willing to listen."* Rationale: The best response acknowledges the client's feelings and provides a forum for release of anxieties. The other responses are incorrect because they do not use therapeutic communication techniques. Each of them contains a block to communication by putting the client's feelings on hold.

*Question: The nurse is reinforcing instructions to a postpartum cesarean delivery client who is preparing for discharge. Which statement by the client indicates a need for further teaching?*

*Answer: "I can start doing abdominal exercises as soon as I get home."* Rationale: Abdominal exercises should not start following abdominal surgery until 3 to 4 weeks postoperatively to allow for healing of the incision. Options 1, 2, and 4 reflect proper understanding of self-care after discharge.

*Question: The nurse reinforces instructions to a client with glaucoma regarding measures that will prevent an increase in intraocular pressure in the eyes. Which statement by the client indicates a need for further teaching?*

*Answer: "I can tie my shoelaces by bending over slowly."* Rationale: Activities such as bending over or straining at stool will increase intraocular pressure. The client must be instructed to maintain a diet high in bulk and fiber and to consume a high intake of liquids, unless contraindicated, to prevent constipation and straining at stools. The client should tie shoelaces by bending the knee, raising the thigh, and bringing the foot within hand reach. Objects weighing 20 pounds or more can be moved by pushing the object on the floor using the feet or with a mechanical dolly.

*Question: A client with arthritis is scheduled for a surgical knee joint replacement. The client will be admitted to the hospital on the day of the surgical procedure, and the nurse is reinforcing instructions with the client regarding preparation for the surgical procedure. Which client statement indicates an understanding of the preoperative instructions?*

*Answer: "I cannot drink or eat anything after midnight on the night before surgery."* Rationale: Preoperative instructions are important so that the client is readied adequately for surgery and all has been done to achieve a successful outcome. The client must understand the importance of following the timing of being NPO to lower the risk of aspiration associated with the anesthetic. Antiplatelet medications such as aspirin alter normal clotting factors and increase the risk of hemorrhage. Aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. Prednisone, a corticosteroid, should not be discontinued abruptly. In fact, additional dosages of the corticosteroid may be necessary before stressful situations, such as surgery. There is no reason to discontinue prescribed exercises, and discontinuing exercises in this client may be harmful.

*Question: The nurse is assisting in developing a plan of care for a client in the fourth stage of labor who received an epidural. Which statement by the mother is most likely to occur at this time related to her birth experience?*

*Answer: "I do not feel any urges yet to empty my bladder."* Rationale: The fourth stage of labor is the period of time from 1 to 4 hours after delivery, when the woman's body begins to readjust and relax. An epidural may lead to loss of bladder sensation and resulting rapid bladder filling. The remaining options relate to earlier stages in the labor process.

*Question: A client is seen in the health care clinic, and a diagnosis of conjunctivitis is made. The nurse reinforces discharge instructions to the client regarding care of the disorder while at home. Which statement by the client indicates a need for further teaching?*

*Answer: "I do not need to be concerned about spreading this infection to others in my family."* Rationale: Conjunctivitis is inflammation or infection of the lining of the eyelids. Conjunctivitis is highly contagious and clients must follow strict hand washing and avoid touching their eyes and others. Antibiotic drops usually are administered four times a day. When purulent discharge is present, saline eye irrigations or eye applications of warm compresses may be necessary before instilling the medication. Ophthalmic analgesic ointment or drops may be instilled, especially at bedtime, because discomfort becomes more noticeable when the eyelids are closed.

*Question: A hospitalized client who is experiencing delusions and has a diagnosis of schizophrenia says to the nurse, "I know that the doctor is talking to the CIA to get rid of me." Which would be the nurse's best response?*

*Answer: "I don't know anything about the CIA. Do you feel afraid that people are trying to hurt you?"* Rationale: The nurse's best response relates to the nurse not knowing anything about the CIA and asking if the client is afraid that people are trying to hurt him or her. It is most therapeutic for the nurse to empathize with the client's experience. When delusional, a person truly believes that what he or she thinks to be real is real. The person's thinking often reflects feelings of great fear and aloneness. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate.

*Question: The nurse is gathering data from a 16-year-old pregnant client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which client statement indicates a need for further investigation?*

*Answer: "I don't like my face anymore. I always look like I have been crying."* Rationale: Options 1, 2, and 3 are dealing with body image. Although these comments should not be ignored, the need for follow-up is not urgent. Option 4 is an implication of periorbital and facial edema, which could be indicative of gestational hypertension (GH). Because this is an adolescent who has not sought early prenatal care, she is at higher risk for the development of gestational hypertension.

*Question: The nurse is collecting data from a client who is suspected of having mittelschmerz. Which statement supports this probable diagnosis?*

*Answer: "I experience a sharp pain located on my low right side midway through my cycle."* Rationale: Some women will experience slight vaginal bleeding at the time they experience mittelschmerz. Mittelschmerz (middle pain) refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain is caused by growth of the dominant follicle within the ovary, or rupture of the follicle and subsequent spillage of follicular fluid and blood into the peritoneal space. The pain is fairly sharp and is felt on the right or left side of the pelvis. It generally lasts a few hours to 2 days. Mittelschmerz is not related to menstrual flow, pain during intercourse, or pain associated with menstruation.

*Question: Which statement by the client would cause the nurse to suspect that the thyroid test results drawn on the client this morning may be inaccurate?*

*Answer: "I had a radionuclide test done 3 days ago."* Rationale: Recent radionuclide scans performed before the test can affect thyroid laboratory results. There are no food, fluid, or activity restrictions required for this test.

*Question: A client hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is an appropriate response by the nurse?*

*Answer: "I hear what you are saying, but I don't share your belief."* Rationale: Paranoid beliefs are coping mechanisms and therefore not easily relinquished. It is important not to support the belief and not ridicule, argue, or criticize it. Asking the client "why" places the client in a defensive position. Encouraging the client to expound on the belief when discussion would be limited is also inappropriate. Threatening the client by denying a privilege is unethical.

*Question: Griseofulvin is prescribed for a child with tinea capitis. The nurse reinforces instructions to the family regarding administration of the medication. Which statement by the mother indicates a need for further teaching?*

*Answer: "I need to administer the medication 2 hours before meals."* Rationale: Griseofulvin is given with or after meals to avoid gastrointestinal (GI) irritation and to increase absorption. Oral suspensions should be shaken well. Parents are instructed to continue therapy as prescribed and not to miss a dose. Exposure to the sun is avoided during treatment.

*Question: A client with a diagnosis of otosclerosis is admitted to the ambulatory care unit for stapedectomy, and the nurse reinforces instructions to the client regarding home care following the procedure. Which statement by the client indicates a need for further teaching?*

*Answer: "I need to avoid air travel for at least 6 months."* Rationale: Following stapedectomy, the client is instructed to keep water out of the ear canal for at least 3 weeks and to avoid swimming for 6 weeks. The client is also instructed to avoid coughing and sneezing and to avoid bending and lifting heavy objects or other strenuous activities for at least 3 weeks. Air travel is avoided for 4 weeks. If the client develops sudden hearing loss, fever, or severe persistent vertigo or dizziness, the primary health care provider should be notified.

*Question: The nurse has provided instructions about measures to clean the penis to the mother of a newborn who is not circumcised. Which statement by the mother indicates an understanding of this procedure?*

*Answer: "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions."* Rationale: In newborn males, the prepuce is continuous with the epidermis of the glans and is not retractable. If retraction is forced, adhesions can develop. It is best to allow separation of the foreskin to occur naturally, which usually occurs between 3 years and puberty. Most foreskins are retractable by 3 years of age and should be pushed back gently at this time for cleaning once a week.

*Question: The nurse reinforces discharge instructions to the mother of a child following a myringotomy with insertion of tympanostomy tubes. Which statement by the mother indicates a need for further teaching?*

*Answer: "I need to be sure my child uses soft tissues to blow his nose."* Rationale: Parents need to be instructed that the child should not blow the nose for 7 to 10 days. Bath and lake water are potential sources of bacterial contamination. Diving and swimming deeply under water are prohibited. The child's ears need to be kept dry. Options 1, 2, and 3 are appropriate statements.

*Question: The nurse is reinforcing instructions to a client following mastectomy who will be discharged with an axillary drain in place. The client will be receiving home care visits from the nurse to monitor drainage and perform dressing changes. Which client statement indicates a need for further teaching?*

*Answer: "I need to begin full range-of-motion (ROM) exercises to my upper arm as soon as I get home."* Rationale: The client should be instructed to limit upper arm ROM to the level of the shoulder only. After the axillary drain is removed, the client can begin full ROM exercises to the upper arm as prescribed by the primary health care provider. Elevating the arm above the heart level while sitting or lying down, massaging the area with cocoa butter after the incision is completely healed if prescribed by the primary health care provider, and having pain in the absent breast (phantom pain) are correct measures following a mastectomy.

*Question: The client who received a kidney transplant is taking azathioprine, and the nurse reinforces instructions about the medication. Which statement by the client indicates a need for further teaching?*

*Answer: "I need to discontinue the medication after 14 days of use."* Rationale: Azathioprine is an immunosuppressant medication that is taken for life. Because of the effects of the medication, the client must watch for signs of infection, which are reported immediately to the PHCP. The client should also call the PHCP if more than one dose is missed. The medication may be taken with meals to minimize nausea.

*Question: The nurse reinforces medication instructions to the client who had a kidney transplant about therapy with cyclosporine. Which statement by the client should indicate a need for further teaching?*

*Answer: "I need to obtain a yearly influenza vaccine."* Rationale: Cyclosporine is an immunosuppressant medication. Because of the medication's effects, the client should not receive any vaccinations without first consulting the PHCP. The client should report decreased urine output or cloudy urine, which could indicate kidney rejection or infection, respectively. The client must be able to self-monitor blood pressure to check for the side effect of hypertension. The client needs meticulous oral care and dental cleaning every 3 months to help prevent gingival hyperplasia.

*Question: The nurse reinforces home care instructions to a client after cataract removal and placement of an intraocular implant in the right eye. Which statement by the client indicates a need for further teaching?*

*Answer: "I need to remove the eye dressing as soon as I get home and place a warm pack on my eye."* Rationale: After cataract surgery, a dressing is applied to the eye. It usually is removed later on the day of surgery or the following day. The client should not place a warm pack on the eye unless this is specifically prescribed because of the risk of infection and increased edema in the surgical area. The client is instructed to wear a metal or plastic eye shield to protect the eye from accidental injury and is instructed not to rub the eye. Glasses may be worn during the day. The client is instructed not to sleep on the side of the body that was operated on to prevent pressure and edema in the affected eye. The use of stool softeners is recommended to prevent constipation and straining.

*Question: The nurse is giving discharge instructions to the client with varicose veins. The nurse realizes there is a need for further teaching when the client makes which statement?*

*Answer: "I need to sit as much as possible with my legs elevated."* Rationale: Treatment of varicose veins includes using elastic support hose, exercising the legs and feet periodically throughout the day, and elevating the legs whenever possible. Prolonged standing, sitting, or crossing the legs is to be avoided. Weight reduction is recommended for patients who are obese.

*Question: The nurse is reinforcing instructions to an adolescent with type 1 diabetes mellitus regarding insulin administration and rotation sites. Which statement made by the adolescent would indicate an understanding of the instructions?*

*Answer: "I need to use one major site for the morning injection and another major site for the evening injection for 2 to 3 weeks before changing major sites."* Rationale: To help decrease variations in absorption from day to day, the child should use one location within a major site for the morning injection. The child should then rotate to another site for the evening injection, and a third site for the bedtime injection. The child should follow this pattern for a period of 2 to 3 weeks before changing major sites.

*Question: Moxifloxacin is prescribed for the client with a diagnosis of community-acquired pneumonia. The client needs to take the medication for 10 days, and the nurse reinforces instructions to the client about the medication. Which statement by the client best indicates an understanding of the medication instructions?*

*Answer: "I need to wear sunscreen and protective clothing when outdoors."* Rationale: Moxifloxacin is a fluoroquinolone. Increased sensitivity of the skin to sunlight can occur, and the client is instructed to avoid excessive sunlight and artificial ultraviolet light. The client should wear sunscreen and protective clothing when outdoors. The client should also drink fluids liberally and avoid the use of antacids because antacids will decrease absorption of the medication. The medication can cause inflamed and ruptured tendons, and the client is instructed to notify the primary health care provider if inflammation or tendon pain occurs.

*Question: The nurse reinforces instructions to a client regarding the use of tretinoin. Which statement by the client indicates the need for further teaching?*

*Answer: "I should apply a very thin layer to my skin."* Rationale: Tretinoin is applied liberally to the skin. The hands are washed thoroughly immediately after applying. Therapeutic results should be seen after 2 to 3 weeks but may not be optimal until after 6 weeks. The skin needs to be cleansed thoroughly before applying the medication.

*Question: The nurse provides home care instructions to a client undergoing hemodialysis with regard to care of an arteriovenous (AV) fistula. Which statement by the client indicates an understanding of the instructions?*

*Answer: "I should check the fistula every day by feeling it for a vibration."* Rationale: An arteriovenous fistula provides access to the client's bloodstream for the dialysis procedure. The client is instructed to monitor fistula patency daily by palpating for a vibration known as a thrill. The client is instructed to avoid compressing the fistula with tight clothing or when sleeping and that blood pressure measurements and blood draws should not be performed on the arm with the fistula. The client also is instructed to assess the fistula for signs and symptoms of infection, including pain, redness, swelling, and excessive warmth.

*Question: The nurse is reinforcing instructions to a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse instructs the client to consume an adequate intake of fluid on a daily basis. Which statement by the client indicates an understanding of the daily fluid requirement?*

*Answer: "I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement."* Rationale: The nurse should instruct the client to drink an adequate fluid intake on a daily basis to assist in digestion and in the management of constipation: 8 to 12 glasses of liquids (1500 to 2000 mL) in addition to the daily milk requirement are recommended every day. This fluid should be water or fruit and vegetable juices rather than carbonated soft drinks or caffeinated beverages.

*Question: The nurse provides instructions to a parent of a toddler experiencing physiological anorexia. The nurse determines the need for further teaching if the parent makes which statement?*

*Answer: "I should feed my child if she will not eat."* Rationale: Toddlers have the skills required to feed themselves. Children who can feed themselves should not be fed or force fed. To increase nutritious intake, juice intake is limited to 6 ounces per day, and milk intake to 16 to 24 ounces per day. In addition, the nurse instructs the mother to limit nutritious snacks to two per day and to give them only at the toddler's request.

*Question: The nurse has provided instructions to a client scheduled for a mammography regarding the procedure. Which statement by the client indicates an understanding of the procedure?*

*Answer: "I should not wear deodorant on the day of the test."* Rationale: Mammography takes about 15 to 30 minutes to complete. Some discomfort may be experienced because of the breast compression required to obtain a clear image. Maintaining a nothing-by-mouth (NPO) status before the procedure is not necessary. A sports bra is not required; the test is performed without clothing. Deodorants, powders, and lotions should not be worn on the day of the test because it will affect the testing process and affect the imaging of the breasts.

*Question: The nurse has given the client diagnosed with hepatitis instructions about post discharge management during convalescence. The nurse determines a need for further teaching if the client makes which statement?*

*Answer: "I should resume a full activity level within 1 week."* Rationale: The client with hepatitis is easily fatigued and may require several weeks to resume a full activity level. It is important for the client to get adequate rest so that the liver may heal. The client should take in a high-carbohydrate and low-fat diet. The client should avoid hepatotoxic substances, such as aspirin and alcohol. If prescribed for prolonged clotting times the client should take vitamin K.

*Question: The nurse has reinforced discharge instructions regarding home care to a client following a prostatectomy for cancer of the prostate. He is being discharged with an indwelling urinary catheter. Which statement by the client indicates a need for further teaching?*

*Answer: "I should use the leg bag when I am in bed during the night."* Rationale: The post prostatectomy client who is discharged with an indwelling urinary catheter needs to be instructed in maintaining the catheter at home. The nurse reviews the printed instructions with the client and caregiver. They need to understand and know how to empty the catheter and keep it aseptic. The client will attach the leg bag, which can be worn under pants, to drain urine while he is up and about. The drainage bag needs to be kept lower than the bladder to facilitate proper drainage. The urine may have some small blood clots, but there should be no frank bleeding. The catheter will be removed by the urologist during a postoperative office visit by deflating the balloon of the catheter.

*Question: Collagenase is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication?*

*Answer: "I will apply the ointment once a day and cover it with a sterile dressing."* Rationale: Collagenase is used to promote debridement of dermal lesions and severe burns. It is usually applied once daily and covered with a sterile dressing.

*Question: The nurse is assigned to care for a client with a diagnosis of Ménière's disease. After reinforcing discharge instructions, which client statement indicates a need for further teaching?*

*Answer: "I will become totally deaf if I don't follow instructions."* Rationale: Ménière's disease is a disorder of the labyrinth of the inner ear. The hearing loss is unilateral, meaning that only one ear is affected. Biofeedback, self-hypnosis, and relaxation techniques may be recommended to help the client learn to live with Ménière's disease. A low-salt diet is sometimes prescribed for people with Ménière's disease. Caffeine, alcohol, chocolate, and nicotine may aggravate or trigger an attack.

*Question: The nurse reinforces home care instructions to the postcraniotomy client. Which statement by the client indicates the need for further teaching?*

*Answer: "I will not hear sounds clearly unless they are loud."* Rationale: Seizures are a complication that can occur for up to 1 year after surgery. For this reason, the client must diligently take anticonvulsant medications. The client and family are encouraged to keep track of doses administered. The family should learn seizure precautions and accompany the client while ambulating if dizziness or seizures tend to occur. The suture line is kept dry until sutures are removed to prevent infection. The postcraniotomy client can hear sounds, is typically sensitive to loud noises, and can find them irritating (e.g., loud television). Awareness control of environmental noise by others is helpful to this client.

*Question: A client with chronic atrial fibrillation is being started on amiodarone as maintenance therapy for dysrhythmia suppression. The nurse reinforces instructions to the client about the medication. Which statement by the client indicates a need for further teaching?*

*Answer: "I will stop taking the prescribed anticoagulant after starting this new medication."* Rationale: Amiodarone is used for the dysrhythmia, atrial fibrillation. The medication will have no effect in preventing thrombus formation within the atria, so anticoagulants need to be continued. The medication increases sun sensitivity so protective measures are essential. Thyroid function studies should be monitored because the medication can affect thyroid function. Because the medication can cause corneal microdeposits, follow-up with the ophthalmologist is important.

*Question: The nurse is providing discharge instructions for a client who has had a fenestration procedure for the treatment of otosclerosis. Which statement by the client indicates an understanding of the instructions?*

*Answer: "I will take stool softeners as prescribed by my doctor."* Rationale: Following ear surgery, clients need to avoid straining when having a bowel movement. Clients need to be instructed to avoid drinking with a straw for 2 to 3 weeks, air travel, and coughing excessively. Clients need to avoid getting their head wet, washing their hair, and showering for 1 week. Clients need to avoid rapidly moving the head, bouncing, and bending over for 3 weeks.

*Question: The instructor is quizzing the student nurse concerning care of a visually impaired client. Which statement indicates a need for further teaching?*

*Answer: "I will take the client's arm to lead while we are walking."* Rationale: Measures to support the client with impaired vision and to prevent injury include announcing yourself when entering or leaving the room and speaking in a normal tone of voice. People tend to act as if those who cannot see also cannot hear, so a tendency exists to raise one's voice when talking to the visually impaired. Advise the client what to expect during procedures. Keep doors either open or closed so that the ambulatory client does not run into a partially closed door. To lead a blind person, have him or her take your arm.

*Question: A client is being discharged from the ambulatory care unit following cataract removal, and the nurse provides instructions regarding home care. Which statement by the client indicates an understanding of the instructions?*

*Answer: "I will wear my eye shield at night and my glasses during the day."* Rationale: The client is instructed to wear a metal or plastic shield to protect the eye from accidental injury and is instructed not to rub the eye. Glasses may be worn during the day. Aspirin or medications containing aspirin are not to be administered or taken by the client, and the client is instructed to take acetaminophen as needed for pain. The client is instructed not to sleep on the same side of the body that underwent surgery. The client is not to lift more than 5 pounds.

*Question: The nurse is discharging a client who had conventional open back surgery. Which comment by the client indicates a need for further teaching?*

*Answer: "I'll be careful not to lift anything heavier than 20 pounds."* Rationale: There is a need for further teaching when the client states that "I'll be careful not to lift anything heavier than 20 pounds." The client should not lift anything heavier than 5 pounds. After conventional open back surgery, the client may have activity restrictions for the first 4 to 6 weeks, such as restricting or limiting driving, limiting daily stair climbing, avoiding bending and twisting at the waist, taking a daily walk, and restricting pushing-and-pulling activities like dog walking.

*Question: The nurse has reinforced instructions to the client returning home after arthroscopy of the knee. The nurse determines that the client understands the instructions if the client makes which statement?*

*Answer: "I'll report fever or site inflammation to the primary health care provider."*

*Question: The nurse has given a client instructions on how to do active range-of-motion exercises on her contracted right hand. The nurse determines that the client understands the rationale for this procedure when the client makes which statement?*

*Answer: "I'm doing these exercises so I can begin to fasten my buttons and dress myself again."* Rationale: The client understands the purpose of the therapy and provides an incentive to comply with the exercises when the client states, "I'm doing these exercises so I can begin to fasten my buttons and dress myself again." The statement, I'm doing this, so I can go home soon" may or may not be true and could relate to a number of factors other than use of the right hand. Saying it hurts but things always hurt at my age is an inaccurate statement. Saying the therapist will get mad if I don't do this is incorrect because it indicates imposition of staff values on the client and is suggestive of possible abuse.

*Question: The clinic nurse is teaching a client who has just been diagnosed with osteoporosis about nutritional therapy. Which comment by the client indicates a need for further teaching?*

*Answer: "I'm glad I can still drink as much coffee as I want."* Rationale: There is a need for further teaching when a client with osteoporosis says "I'm glad I can still drink as much coffee as I want." The nurse needs to teach clients to avoid excessive alcohol and caffeine consumption and about the need for adequate amounts of calcium and vitamin D for bone remodeling. The nutritional considerations for the treatment of a client with a diagnosis of osteoporosis are the same as those for preventing the disease. The nurse needs to help the client develop a nutritional plan that is most beneficial in maintaining bone health. The plan should emphasize fruits and vegetables, low-fat dairy and protein sources, increased fiber, and moderation in alcohol and caffeine.

*Question: Carisoprodol is been prescribed for a client to relieve muscle spasms. The client is being discharged and the nurse is instructing the client and family about the medication. What comment by the client indicates a need for further teaching?*

*Answer: "I'm glad there are no withdrawal problems when I stop taking this medication."* Rationale: There is a need for further teaching when the client states, "I'm glad there are no withdrawal problems when I stop taking this medication." There is a risk for withdrawal problems when carisoprodol is stopped. The client needs to be taught to report withdrawal symptoms such as syncope, tachyarrhythmia, excessive fatigue or unusual mental status changes. The client needs to avoid tasks that require alertness and motor skills until response to the medication is established, and also avoid alcohol. Carisoprodol would only be used for short periods of time (2 to 3 weeks).

*Question: A resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." An appropriate response by the nurse is which?*

*Answer: "I'm glad you told me that. Let's have a cup of coffee and you can tell me about your father."* Rationale: The correct response acknowledges the client's comment and feelings. Option 1 fails to protect the client from possible harm. Option 2 is inappropriate and is inconsistent with legal aspects of care based on the information given. Option 3 does not preserve the client's dignity.

*Question: A client has been hospitalized and has participated in substance abuse therapy group sessions. The client has consented to participate in Alcoholics Anonymous (AA) community groups after discharge. Which statement by the client best indicates to the nurse that the client has assimilated therapy session topics and coping response styles and has processed information effectively for self-use?*

*Answer: "I'm looking forward to leaving here; I know that I will miss all of you. So, I'm happy and I'm sad, I'm excited and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you people."* Rationale: The statement by the client that best indicates to the nurse that the client has assimilated therapy session topics and coping response styles and has processed information effectively for self-use is "I'm looking forward to leaving here; I know that I will miss all of you. So, I'm happy and I'm sad, I'm excited and I'm scared." The client is expressing real concern and ambivalence about discharge from the hospital. The client also demonstrates reality in the statement. Option 1 indicates client denial. In option 4 the client is relying heavily on others. Finally in option 2 the client is concrete and procedure oriented; again, the client denies that "nothing will go wrong that way" if the client follows all the directions.

*Question: The nurse informs a client that a Papanicolaou smear will be done at the next scheduled clinic visit, and the nurse provides instructions to the client regarding preparation for this test. Which statement by the client indicates an understanding of the procedure?*

*Answer: "If I have my period at the time of my next scheduled visit, I will not be able to have the test done."* Rationale: A Papanicolaou smear cannot be performed during menstruation. The test is usually painless. The client needs to be instructed to avoid douching for at least 24 hours before the test. There is no reason to restrict fluids on the day of the test.

*Question: A nursing instructor asks a student nurse assigned to care for an infant with a diagnosis of tricuspid atresia to describe the infant's disorder. Which statement by the student indicates the need to further research this disorder?*

*Answer: "The disorder means there is no communication from the right atrium to the right ventricle of the heart."* Rationale: In tricuspid atresia, there is no communication from the right atrium to the right ventricle. Option 1 describes truncus arteriosus. Option 4 describes transposition of the great arteries. Frequent episodes of hypercyanotic spells occur in tetralogy of Fallot.

*Question: The nurse is evaluating the parent's understanding of discharge care regarding the functioning of the infant's ventricular peritoneal shunt. Which statement by a parent indicates an understanding of the shunt complications?*

*Answer: "If my baby has a high-pitched cry, I should call the primary health care provider."* Rationale: If the shunt is broken or malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial area. The result is intracranial pressure, which then causes a high-pitched cry in the infant. The baby should not have pressure when on the shunt side. Skin breakdown and possible compression to the apparatus could result. This type of shunt affects the gastrointestinal system, not the genitourinary system. Option 1 is only a concern if the baby becomes malnourished or dehydrated, which could then raise the body temperature. Otherwise, refusal to eat purees has no direct relationship to the shunt functioning.

*Question: A client receives a prescription for methocarbamol, and the nurse reinforces instructions to the client regarding the medication. Which client statement would indicate a need for further teaching?*

*Answer: "If my vision becomes blurred, I don't need to be concerned about it."* Rationale: There is a need for further teaching when the client says, "If my vision becomes blurred, I don't need to be concerned." The client needs to be told that the urine may turn brown, black, or green. Other adverse effects include blurred vision, nasal congestion, urticaria, and rash. The client needs to be instructed that if these adverse effects occur, the primary health care provider needs to be notified. The medication is used to relieve muscle spasms.

*Question: The nurse has reinforced instructions with the client with a nonplaster (fiberglass) leg cast about cast care at home. The nurse determines that the client needs further teaching if the client makes which statement?*

*Answer: "If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting."* Rationale: The client needs further teaching if the client states that if the cast gets wet, drying it with a hair dryer turned to the warmest setting is an option. If the cast gets wet, it can be dried with a hair dryer set to a cool setting to prevent skin breakdown. Client instructions should include avoidance of walking on wet, slippery floors to prevent falls. Surface soil on a cast may be removed with a damp cloth. If the skin under the cast itches, cool air from a hair dryer may be used to relieve it. The client should never scratch under a cast because of risk of skin breakdown and ulcer formation.

*Question: The nurse reinforces discharge instructions to a client following patch testing. Which statement by the client indicates the need for further teaching?*

*Answer: "If the patch comes off, I need to reapply it."* Rationale: The nurse instructs the client to keep the test site dry at all times. The nurse also discourages excessive physical activity that will result in sweating. Reapplying the patch can interfere with an accurate interpretation of the allergic reactions. The nurse reinforces the necessity of removing loose or nonadherent test patches for reapplication at a later date. The initial reading is performed 2 days after application, and the final reading is performed 2 to 5 days later.

*Question: The nurse is reinforcing instructions to the mother of an 8-year-old child who had a tonsillectomy. The mother tells the nurse that the child loves tacos and asks when the child can safely eat one. The nurse would make which response to the mother?*

*Answer: "In 3 weeks"* Rationale: Rough, scratchy foods or spicy foods are to be avoided for 3 weeks. Citrus juices, which irritate the throat, need to be avoided for 10 days. Red liquids are avoided because they will give the appearance of blood if the child vomits. A full-liquid diet is allowed on the second postoperative day, and soft foods are allowed as the child tolerates them.

*Question: The nurse is told by an older woman that she has begun to be incontinent of urine at night and now drinks no fluids after 6.00 pm. Which is the nurse's best response?*

*Answer: "Incontinence at any age should be evaluated by your primary health care provider."* Rationale: Urinary incontinence requires evaluation as to the cause so that appropriate treatment can begin. Incontinence is not expected in old age, and the statement about expecting incontinence represents stereotypical thinking. It is not correct to say that older adults do not need as much fluid intake as younger adults. This is also stereotypical thinking. The idea that most adults are able to judge fluid needs may be true generally but may not apply because of the development of this new problem.

*Question: Which statement by a nursing student about Kohlberg's theory of moral development indicates the need for further teaching about the theory?*

*Answer: "Individuals move through all six stages in a sequential fashion."* Rationale: Kohlberg's theory states that individuals move through the six stages of development in a sequential fashion but that not everyone reaches stages 5 or 6 as part of their development of personal morality. The other options are correct statements regarding Kohlberg's theory.

*Question: The mother of a toddler tells the nurse that she has a difficult time getting the child to go to bed at night. The nurse would make which suggestion to the mother?*

*Answer: "Inform the child of bedtime a few minutes before it is time for bed."* Rationale: Most toddlers take an afternoon nap, and until approximately age 2 some also require a morning nap. Toddlers often resist going to bed. Firm, consistent limits are needed for temper tantrums or when toddlers try stalling tactics. Bedtime protests may be reduced by warning the child of bedtime a few minutes before the time.

*Question: The nurse educator is providing an in-service education to the nursing staff regarding transcultural nursing care. A staff member asks the nurse educator to describe the concept of acculturation. Which response is appropriate?*

*Answer: "It is a process of learning a different culture to adapt to a new or changing environment."* Rationale: Acculturation is a process of learning a different culture to adapt to a new or changing environment. Ethnic identity is the subjective perspective of belonging to the group of one's heritage. An ethnic group is a group of persons in a society that is culturally distinct and has a unique identity. A subculture is sharing some of the characteristics of a larger population group.

*Question: Which statement made by the nursing student indicates a need for further teaching by the nursing instructor on the concept of ethnocentrism?*

*Answer: "It is imposing one's beliefs on individuals from another culture."* Rationale: Ethnocentrism is a tendency to view one's own ways of life as the most desirable, acceptable, or best, and to act in a superior manner toward another culture. Cultural imposition is the tendency to impose one's own beliefs, values, and patterns of behavior on individuals from another culture.

*Question: A client with possible rib fracture has never had a chest x-ray. The nurse would tell the client which statement about the procedure?*

*Answer: "It is necessary to remove jewelry and any other metal objects."* Rationale: An x-ray is a photographic image of a part of the body on a special film that is used to diagnose a wide variety of conditions. The x-ray itself is painless. Any discomfort would arise from repositioning a painful part for filming. The nurse may want to premedicate a client who is at risk for pain. Any radiopaque objects such as jewelry or other metal must be removed. The client is asked to breathe in deeply and then hold the breath while the chest x-ray is taken. To minimize risk of radiation exposure, the x-ray technologist stands in a separate area protected by a lead wall. The client also wears a lead shield over the genital area.

*Question: A child is diagnosed with lactose intolerance. The child's mother asks the nurse about the disease. Which statement is the appropriate nursing response?*

*Answer: "It is the inability to tolerate sugar found in dairy products."* Rationale: Lactose intolerance is the inability to tolerate lactose, the sugar found in dairy products. It results from absence or deficiency of lactase, an enzyme found in the secretions of the small intestine required for the digestion of lactose. Option 2 describes Hirschsprung's disease. Option 3 describes irritable bowel syndrome. Option 4 describes celiac disease.

*Question: A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse would make which therapeutic response to the client?*

*Answer: "It must be frightening to you. Has something made you feel that your food is poisoned?"* Rationale: The response, "It must be frightening to you. Has something made you feel that your food is poisoned?" validates the client's feelings. Asking the client "Why do you think this way?" may place the client on the defensive and is not a facilitative technique. The response, "Here, I'll taste the food for you," involves the nurse in the client's delusion. Finally, the statement, "Your food is not poisoned. Our kitchen staff are nice people, and they are not allowed to poison people," is an incorrect response because the statement is defensive and therefore nontherapeutic.

*Question: A client says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house ready to plan our activities for the day." Which is the therapeutic nursing response?*

*Answer: "It must be hard to accept that she has passed away."* Rationale: The therapeutic nursing response is the one that recognizes the difficulties of grieving the loss of a loved one and facilitates expression of feelings. The remaining responses are not therapeutic and do not encourage expression of feelings.

*Question: The nurse asks a nursing student to describe case management. Which student response indicates a lack of understanding about this concept?*

*Answer: "It represents a primary health prevention focus managed by a single case manager."* Rationale: Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources to maximize hospital revenues while providing for optimal outcome of care. Options 1, 3, and 4 identify the components of managed care.

*Question: The nurse provides explanation to a client prescribed methylergonovine maleate in the immediate postpartum period. Which statement made by the client demonstrates understanding of the rationale for administration?*

*Answer: "It will help prevent bleeding and control bleeding if it occurs."* Rationale: Methylergonovine maleate is an ergot alkaloid that stimulates smooth muscles. Because the smooth muscle of the uterus is especially sensitive to the medication, it is used in the postpartum period to stimulate the uterus to contract and prevent or control postpartum hemorrhage. Options 1, 2, and 3 are incorrect actions of the medication.

*Question: A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his slippers from where he always kept them under his side of our bed. She doesn't know how much I'm hurting." Which statement by the nurse would be therapeutic?*

*Answer: "It's okay to grieve and be angry with your daughter and anyone else for a time."* Rationale: The therapeutic statement is the one that gives the client permission to grieve and acknowledges that anger is part of loss and that it may be aimed at the people who are trying most to help and are closest. The remaining statements are nontherapeutic because they do not encourage the client to express feelings.

*Question: An older client confides to the visiting nurse the fear of falling while going to the bathroom at night. Considering the visual changes affecting the older client, the nurse would make which recommendation?*

*Answer: "Keep a red light on in the bathroom at night."* Rationale: Because it takes longer to adapt to changes from dark to light and vice versa, older people are at greater risk for falls and injuries. Any place where there is a sudden change from dark to light or from light to dark can be dangerous. Getting up during the night is hazardous for an older client. Eyes adapt to the dark by using the rod receptors, which are sensitive to short blue-green wavelengths. Red wavelengths are longer and are perceived by the cones. Thus, a red light in the bathroom at night allows for adequate vision to function in the dark without the need for adaptation.

*Question: Intravenous (IV) lactated Ringer's (LR) solution is prescribed for a postoperative abdominal surgery client. A nursing student is caring for the client, and the nursing instructor asks the student about why this IV solution is prescribed. Which student response is correct?*

*Answer: "LR is isotonic to plasma and contains electrolytes"* Rationale: Lactated Ringer's solution is an isotonic solution. It contains calcium, potassium, sodium, chloride, and lactate in small amounts. Other isotonic solutions include 5% dextrose in water, 0.9% normal saline, and 5% dextrose in 0.225% normal saline. Isotonic solutions are used for fluid replacement in surgical clients. The fluid will remain in the vascular space.

*Question: The nurse is planning to teach a client with a left arm cast about measures to keep the left shoulder from becoming stiff. Which suggestion would the nurse include in the teaching plan?*

*Answer: "Lift the left arm up over the head."* Rationale: The shoulder of a casted arm should be lifted over the head periodically as a preventive measure. Immobility and the weight of a casted arm may cause the shoulder above an arm fracture to become stiff. The use of slings further immobilizes the shoulder and may be contraindicated. Making fists with the left hand provides isometric exercise to maintain muscle strength. Range of motion of the affected fingers is also a useful general measure. Lifting the right arm is of no particular value.

*Question: A client is brought to the ambulatory care department by the spouse 1 day following a cataract extraction procedure. A diagnosis of hyphema is made, which occurred as a result of the surgical procedure. The nurse reinforces instructions to the client and spouse regarding the treatment for the complication and makes which statement?*

*Answer: "Maintain bed rest and patching of both eyes."* Rationale: Hyphema is bleeding into the anterior chamber of the eye that occurs postoperatively as a complication of cataract surgery. Treatment includes bed rest and bilateral eye patching for 2 to 5 days during which absorption occurs. The client should be instructed to monitor for signs of increased intraocular pressure, which commonly causes sudden ocular pain. Miotics and cycloplegics may be prescribed. Occasionally, irrigation of the anterior chamber may be done to remove the blood.

*Question: A client with a diagnosis of human immunodeficiency virus (HIV) who was prescribed an oral solution of ritonavir complains about the taste of the solution. Which response would the nurse give the client?*

*Answer: "Mix the oral solution with chocolate milk."* Rationale: Ritonavir oral solution is preferably administered with a food substance. It may be mixed with chocolate milk or a dietary supplement to improve the taste. The client also is instructed to consume the dose within 1 hour of mixing. It is not necessary to notify the primary health care provider. Taking the medication at bedtime or refrigeration of the medication will not have an effect on the taste of the oral solution.

*Question: The nurse is assigned to care for a client who received methylergonovine maleate in the immediate postpartum period. The nurse determines the medication is effective when the client makes which statement?*

*Answer: "My afterpains are really strong."* Rationale: Methylergonovine maleate is an ergot alkaloid that stimulates smooth muscles. Because the smooth muscle of the uterus is especially sensitive to the medication, it is used postpartally to stimulate the uterus to contract and control excessive blood loss. The client statements in options 1, 2, and 3 are not related to this medication.

*Question: The nurse tells a client she is now beginning the second stage of labor. The nurse realizes the client understands the occurrences of this stage when the client makes which statement?*

*Answer: "My cervix is completely dilated."* Rationale: The second stage of labor begins when the cervix is completely dilated and ends with the birth of the infant. Bloody show, intense contractions and rupture of membranes can occur any time in labor.

*Question: The nurse is teaching a client about crutch walking. Which comment by the client indicates a need for further teaching?*

*Answer: "My crutches must rest up underneath my arm for extra support."* Rationale: There is a need for further teaching when the client states that crutches need to rest up underneath the arm. Crutches must not rest underneath the client's arm, because it could cause injury to the nerves of the brachial plexus. Crutches must be measured so that the tops are three or four fingerbreadths or 1 to 2 inches from the axilla. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the body.

*Question: The nurse is monitoring a client with anorexia nervosa. Which statement by the client would indicate to the nurse that treatment has been effective?*

*Answer: "My friends and I went out to lunch today."* Rationale: Treatment has been effective if the client says, "My friends and I went out to lunch today." In anorexia nervosa, the client tries to establish identity and control by self-imposed starvation. The first three comments are verbalizations of the client's intentions. Option 4 is a measurable action that can be verified.

*Question: The new breastfeeding mother has been seen in the clinic for the treatment of mastitis. Which comment by the mother indicates a need for further teaching?*

*Answer: "My left breast is sore, so I will offer only my right breast frequently for breastfeeding."* Rationale: Failure to nurse equally on both sides will decrease the flow of milk through the breast, causing engorgement of the breast that has been offered less frequently. Options 1, 2, and 3 are appropriate measures.

*Question: The nurse is collecting data from a client admitted to the hospital with a diagnosis of suspected gastric ulcer and is asking the client questions about pain. Which statement made by the client would the nurse recognize as best supporting the diagnosis of gastric ulcer?*

*Answer: "My pain comes shortly after I eat, maybe a half hour or so later."* Rationale: Gastric ulcer pain often occurs in the upper epigastrium, with localization to the left of the midline, and may be exacerbated by food. The pain occurs a half hour to an hour after a meal and rarely occurs at night. Duodenal ulcer pain is usually located to the right of the epigastrium. The pain associated with a duodenal ulcer occurs 90 minutes to 3 hours after eating and often awakens the client at night.

*Question: A client has been examined in the clinic and has been diagnosed with pelvic inflammatory disease. The client asks the nurse to describe this condition. Which description of pelvic inflammatory disease by the nurse is accurate?*

*Answer: "Pelvic inflammatory disease is an infectious process that involves the uterine, tubes and uterus."* Rationale: Pelvic inflammatory disease (PID) is an infectious process that most commonly involves the uterine (fallopian) tubes (salpingitis), and uterus. Multiple organisms have been found to cause PID, and most cases are associated with more than one organism. Mittelschmerz refers to pelvic pain that occurs midway between menstrual periods. Primary dysmenorrhea refers to menstrual pain without identified pathology. Amenorrhea is the cessation of menstruation for a period of at least 3 cycles or 6 months in a woman who has established a pattern of menstruation and can be due to a variety of causes.

*Question: A client is being encouraged to attend music therapy as part of the individual plan of care. The client refuses to attend and states that he "cannot sing." Which response by the nurse is therapeutic?*

*Answer: "Perhaps you could just enjoy the music without singing."* Rationale: The correct response "perhaps you could just enjoy the music without singing" encourages the client to socialize and deflects the client's attention away from the subject of singing. Option 2 uses a cliché, which is not therapeutic. Option 1 ignores client rights, and option 3 challenges the client.

*Question: Efavirenz, an antiviral medication, is prescribed for a client diagnosed with human immunodeficiency virus (HIV) infection. Which time would the nurse instruct the client is best to take this medication?*

*Answer: At bedtime* Rationale: Because the medication causes temporary nervous system side effects during the first 2 to 4 weeks of therapy, the client is instructed to take the medication at bedtime. Because of the nervous system effects, options 2, 3, and 4 are not recommended administration times.

*Question: The nurse has instructed the client with myasthenia gravis about ways to manage his or her own health at home. The nurse determines that the client needs further teaching if the client makes which statement?*

*Answer: "Resting in a sauna will be a relaxing form of activity."* Rationale: Most ongoing treatment for myasthenia gravis is done in outpatient settings, and the client needs to be aware of the lifestyle changes needed to maintain independence. Taking medications 1 hour before mealtime gives greater muscle strength for chewing and is indicated. The client should have portable suction equipment and a portable resuscitation bag available in case of respiratory distress. The client should carry medical identification about the condition. The client should avoid activities that could worsen the symptoms, including stress, infection, heat (including saunas, staying out of the sun at the beach), surgery, or alcohol.

*Question: The pediatric nursing instructor asks a nursing student to describe the cause of the symptoms that occur in sickle cell disease. Which is the correct response by the nursing student?*

*Answer: "Sickled cells are unable to flow easily through the microvasculature, and their clumping obstructs blood flow."* Rationale: All the clinical manifestations of sickle cell disease are a result of the sickled cells being unable to flow easily through the microvasculature, and their clumping obstructs blood flow. With reoxygenation, most of the sickled red blood cells resume their normal shape. Options 1, 2, and 3 are inaccurate.

*Question: The nurse is caring for a client who says, "I don't want you to touch me. I'll take care of myself!" The nurse would make which therapeutic response to the client?*

*Answer: "Sounds like you're feeling pretty troubled by all of us. Let's work together so you can do everything for yourself as you request."* Rationale: The therapeutic response "Sounds like you're feeling pretty troubled by all of us. Let's work together so you can do everything for yourself as you request," is the one that reflects the client's feelings and offers the client control of care.

*Question: Zidovudine is prescribed for an adult client diagnosed with human immunodeficiency virus (HIV). Which statement by the nurse would provide the best instruction to the client about the medication?*

*Answer: "Space the medication doses evenly around the clock."* Rationale: Zidovudine interferes with HIV replication, slowing the progression of HIV infection. The client is instructed to space the doses of the medication evenly around the clock. Food or milk does not affect the gastrointestinal absorption of the medication. The client is instructed to continue therapy for the full length of treatment. The client also is instructed not to take any medication, including aspirin, without the primary health care provider's approval.

*Question: The nurse is providing discharge instructions to a client following a keratoplasty. Which statement by the client indicates the need for further teaching?*

*Answer: "Sutures are removed in 2 weeks."* Rationale: Depending on the type of procedure performed, the client is told that sutures are usually left in place for as long as 6 months. After the sutures are removed and complete healing has occurred, prescription glasses or contact lenses will be prescribed. Options 1, 3, and 4 are correct discharge instructions for the client following keratoplasty.

*Question: A film-coated form of diflunisal has been prescribed for a client for the treatment of chronic rheumatoid arthritis. The client calls the clinic nurse because of difficulty swallowing the tablets. Which initial instruction would the nurse reinforce to the client?*

*Answer: "Swallow the tablets with large amounts of water or milk."* Rationale: The initial instruction the nurse would reinforce to the client is to swallow the tablets with large amounts of water or milk. Taking the medication with a large amount of water or milk should be tried before contacting the primary health care provider. Diflunisal may be given with water, milk, or meals. The tablets would not be crushed or broken open.

*Question: A client taking carbamazepine asks the nurse what to do if he misses one dose. Which response would the nurse give?*

*Answer: "Take the medication as long as it is not immediately before the next dose."* Rationale: Carbamazepine is an anticonvulsant that should be taken around the clock, precisely as directed. If a dose is omitted, the client should take the dose as soon as it is remembered, as long as it is not immediately before the next dose. The medication should not be double dosed. If more than one dose is omitted, the client should call the primary health care provider.

*Question: A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse would make which therapeutic response to the client?*

*Answer: "Tell me about your difficulty sleeping."* Rationale: Option 4 identifies the therapeutic communication technique of restatement. Although it is a technique that has a prompting component to it, it repeats the client's major theme and addresses the problem from the client's perspective. Options 1 and 2 allow the client to direct the discussion when it needs to be more focused at this point. Option 3 focuses on the number of nights rather than the specific problem of sleep.

*Question: A client in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week, yet is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern about not being able to continue the tube feedings at home with family caregivers. Which nursing response would be appropriate at this time?*

*Answer: "Tell me more about your concerns with your feedings after going home."* Rationale: A client often has fears about leaving the secure, cared-for environment of the health care facility. This client has a fear about not being able to provide self-care at home and not being able to handle the tube feedings at home. An open communication statement such as, "Tell me more about..." often leads to valuable information about the client and the client's concerns. Giving false assurance, giving advice, and dismissing client feelings are nontherapeutic statements.

*Question: A child with leukemia is hospitalized and is receiving chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase for the flowers. Which response by the nurse is appropriate?*

*Answer: "The flowers from your garden are beautiful, but they should not be placed in the child's room at this time."* Rationale: For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas organisms, to which these children are very susceptible. In addition, fruits and vegetables that are not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises.

*Question: A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse would respond by making which appropriate statement?*

*Answer: "Tell me what you know about complementary therapies."* Rationale: Complementary (alternative) therapies include a wide variety of treatment modalities that are used in addition to conventional treatment to treat a disease or illness. These therapies complement conventional treatment, but they should be approved by the person's primary health care provider (PHCP) to ensure that the treatment does not interact with prescribed therapy. Although the PHCP should approve the use of a complementary therapy, it is important for the nurse to explore the complementary therapies first with the client, which would eliminate option 4. The statement in option 2 is inappropriate. Similarly, option 1 is an inappropriate response to the client. Option 3 addresses the client's question and encourages discussion.

*Question: A client has been admitted to the maternity unit for a scheduled cesarean section. As she is getting into bed for preliminary preparation for surgery, the client states, "I don't need the cesarean section after all because I think my baby has moved around." Which is the appropriate response by the nurse?*

*Answer: "Tell me what you mean when you say that your baby has moved."* Rationale: Anxiety is an expected and normal reaction to surgery and within limits is functional. The nurse should remain with the client and let the client express her fears and concerns. Option 1 encourages the client to express concerns because it uses the therapeutic communication tool of paraphrasing that validates and clarifies. Options 2, 3, and 4 do not and are blocks to communication.

*Question: The nurse is caring for a client hospitalized with an acute attack from Ménière's disease. The client verbalizes concern because the client has experienced a hearing loss as a result of the attack. Which response would the nurse make to the client regarding the hearing loss?*

*Answer: "The attack leaves a hearing loss in the involved ear."* Rationale: After the acute phase, remission occurs, but symptoms will recur with 2 or 3 acute attacks per year. As this pattern of attacks and remissions develops, fewer symptoms occur during the acute phase. A complete remission eventually occurs with some degree of hearing loss varying from slight to complete. It takes several weeks before all symptoms subside after an attack leaving a loss of hearing in the involved ear. Options 1, 3, and 4 are incorrect.

*Question: A pregnant client is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. Which response is appropriate for the nurse to make?*

*Answer: "The breast changes are a result of the secretion of estrogen and progesterone."* Rationale: During pregnancy the breasts change in both size and appearance. The increase in size is a result of the effects of estrogen and progesterone on maternal tissue and structures. Estrogen stimulates the growth of mammary ductal tissue, and progesterone promotes the growth of lobes, lobules, and alveoli. A delicate network of veins is often visible just beneath the surface of the skin. This is the most direct, comprehensive response.

*Question: A child with croup is placed in a cool-mist tent. The mother asks if the child may have her security blanket inside the tent. Which is the most appropriate response by the nurse?*

*Answer: "The child may have the security blanket inside the tent."* Rationale: Familiar objects provide a sense of security for children in the strange hospital environment. The child is allowed to have a favorite toy or blanket while in the mist tent. Options 2, 3, and 4 are inappropriate statements.

*Question: A child is diagnosed with bacterial conjunctivitis, and antibiotic eye drops are prescribed for the child. The parent asks the nurse when the child can return to school. The nurse would make which response to the parent?*

*Answer: "The child should be kept home until the antibiotic eye drops have been administered for 24 hours."* Rationale: Bacterial conjunctivitis is extremely contagious. The child should be kept home from school or day care until the child has received antibiotic eye drops for 24 hours. Immediately, after 1 week of treatment, and until re-examined by the PHCP are incorrect time intervals for the child to return to school.

*Question: The nurse is reinforcing instructions to the mother of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement would the nurse make to the mother?*

*Answer: "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."* Rationale: It is essential that children with cystic fibrosis be adequately protected from communicable diseases by immunization. It is recommended that in addition to the basic series of immunizations, children with cystic fibrosis also should receive yearly influenza vaccines.

*Question: Several children have contracted rubeola (measles) in a local school, and the school nurse conducts a teaching session for the parents of the school children. Which statement, if made by a parent, indicates a need for further teaching regarding this communicable disease?*

*Answer: "The communicable period ranges from 10 days before the onset of symptoms to 15 days after the rash appears."* Rationale: The communicable period for rubeola ranges from 4 days before to 5 days after the rash appears, mainly during the prodromal (catarrhal) stage. Options 1, 2, and 3 are accurate descriptions of rubeola. The small blue-white spots found in this communicable disease are called Koplik spots. Option 3 describes the incubation period for rubella, not rubeola.

*Question: The nurse is caring for a newborn in the nursery and notes that the primary health care provider has documented that the child has gastroschisis. The parents ask the nurse about the treatment for the disorder. Which statement would the nurse make to the parents?*

*Answer: "The defect will be closed surgically after all of the contents have been returned to the abdominal cavity."* Rationale: Gastroschisis is an abdominal wall defect. It involves an embryonal weakness in the abdominal wall causing herniation of the gut on one side of the umbilical cord during development. The defect will be closed surgically after all of the contents have been returned to the abdominal cavity. Even if the defect is small, immediate surgical repair may be done in several stages. Options 1, 2, and 3 describe therapeutic management for an umbilical hernia.

*Question: A primary health care provider is planning to administer a skeletal muscle relaxant to a client with a spinal cord injury. The medication is going to be administered intrathecally. Which medication would the nurse expect to be prescribed and administered by this route?*

*Answer: Baclofen* Rationale: Baclofen is a skeletal muscle relaxant that can be administered intrathecally. The other medications are incorrect.

*Question: A mother brings her child to the clinic because the child has developed a rash on the trunk and scalp. The child is diagnosed with varicella. What will the nurse tell the mother about the infectious period?*

*Answer: "The infectious period is 1 to 2 days before the onset of the rash to 5 days after the onset of lesions and the crusting of lesions."* Rationale: Varicella is known as chickenpox. The infectious period for varicella is 1 to 2 days before the onset of the rash to 5 days after the onset of lesions and the crusting of lesions. In roseola, the infectious period is unknown. Option 2 describes diphtheria. Option 3 describes rubella.

*Question: The nurse informs a client with an eating disorder about group meetings with Overeaters Anonymous. Which statement by the client indicates a need for further teaching about this self-help group?*

*Answer: "The leader of this self-help group is the nurse or psychiatrist."* Rationale: There is a need for further teaching when the client with an eating disorder at an Overeaters Anonymous group meeting states that the leader of this self-help group is the nurse or psychiatrist. The leader of a self-help group is an experienced member of the group. The nurse or psychiatrist may be asked by the group to serve as a resource but would not be the leader of the group. The remaining statements contain characteristics of a self-help group.

*Question: A client scheduled for a skin biopsy asks the nurse how painful the procedure is. The nurse would make which response to the client?*

*Answer: "The local anesthetic may cause a burning or stinging sensation."* Rationale: Depending on the size and location of the lesion, a biopsy is usually a quick and almost painless procedure. The most common source of pain is the initial local anesthetic, which can produce a burning or stinging sensation. Options 1, 3, and 4 are incorrect.

*Question: Coal tar has been prescribed for a client with a diagnosis of psoriasis, and the nurse reinforces instructions to the client about the medication. Which statement by the client indicates a need for further teaching?*

*Answer: "The medication can cause systemic effects."* Rationale: Coal tar is used to treat psoriasis and other chronic disorders of the skin. It suppresses DNA synthesis, mitotic activity, and cell proliferation. It has an unpleasant odor, can frequently stain the skin and hair, and can cause phototoxicity. Systemic toxicity does not occur.

*Question: The nurse determines a child is in the "preoperational" phase of Piaget's cognitive developmental theory when the child makes which statement?*

*Answer: "The moon follows me, and goes to bed when I go to bed".* Rationale: In the preoperational stage, the child is demonstrating egocentric thinking by believing the moon's actions revolve around the child. In the sensorimotor stage, a child does not believe an object exists if it is not in sight. A child in the concrete operations stage is able to classify, order, and sort facts, such as the multiplication tables. A child in the formal operations stage is able to solve more complex problems, such as using a map to determine location and directions.

*Question: After surgical evacuation and repair of a vaginal hematoma, a 3-day postpartum mother is discharged. The nurse determines that the mother needs further teaching if the new mother makes which statement?*

*Answer: "The only medications that I will take are prenatal vitamins and stool softeners."* Rationale: After surgical evacuation and repair of a vaginal hematoma, the client will need an antibiotic because she is at increased risk for infection because of the break in skin integrity and collection of blood at the hematoma site. The client statements in options 1, 2, and 3 indicate that the client understands the necessary home care measures.

*Question: Prescriptive glasses are prescribed for a client with bilateral aphakia, and the nurse reinforces instructions to the client regarding the use of the glasses. Which statement by the client indicates the need for further teaching?*

*Answer: "The prescriptive glasses will correct my visual field of sight."* Rationale: Aphakia (absence of the lens of the eye) can be corrected by prescriptive glasses, contact lenses, or intraocular lenses. Only central vision is corrected with these prescriptive glasses, and the peripheral vision is distorted. Prescriptive glasses provide approximately 30% magnification of central vision. This requires adjustment to daily activities and safety precautions. Because of the magnification, objects viewed centrally appear distorted, and it is difficult to judge distances such as when driving a car.

*Question: Several children have contracted measles (rubeola) in a local school, and the nurse provides information to the mothers of the children about this communicable disease. Which statement by a mother indicates a need for further teaching?*

*Answer: "The symptoms increase in severity after the rash appears."* Rationale: Symptoms gradually increase in severity until second day after rash appears, when they begin to subside. Options 1, 2, and 4 are accurate descriptions of rubeola. Option 3 is not true for the rubeola disease.

*Question: Family members of an elderly client ask the nurse if there is any test to determine if a person will eventually get Alzheimer's disease. Which appropriate response would the nurse make?*

*Answer: "There are no tests to determine if a person will get Alzheimer's disease, but research for new diagnostic tests will continue."* Rationale: Currently there are no diagnostic tests for providers to use in making the diagnosis of preclinical Alzheimer's disease. But research does continue. The other tests are used for diagnosing other cognitive or neurological disorders.

*Question: Which statement by a pregnant client who is human immunodeficiency (HIV) positive indicates her understanding of the risk to her newborn during delivery?*

*Answer: "There is a risk of transmission from HIV-positive mothers to their newborn, although the newborn may be asymptomatic at birth."* Rationale: There is a risk of transmission of HIV to a newborn at the time of delivery if the pregnant woman is HIV positive. With appropriate pharmacologic intervention for the HIV-positive mother, transmission of the virus to the newborn has minimal risk. Newborns may not exhibit symptoms for 18 months or more.

*Question: A client with glaucoma has suffered significant eye damage before diagnosis and now has impaired vision. The nurse determines that the client needs further assistance in adapting to this situation if the client makes which statement?*

*Answer: "There is no difficulty driving at dusk."* Rationale: The client with impaired vision that may accompany glaucoma needs to take action to maintain safety in dim lighting. This includes moving carefully in dim lighting, using nightlights along paths traveled in the home at night, and not driving at dusk or dawn. Satisfactory adjustment also is indicated by recognition of the need for ongoing eye examinations and the presence of a supportive family.

*Question: A nursing instructor asks a nursing student to describe Montgomery's tubercles of the breast. Which response by the student indicates successful learning regarding Montgomery's tubercles?*

*Answer: "These are sebaceous glands that are located in the areola."* Rationale: Montgomery's tubercles are sebaceous glands in the areola. They are inactive and not obvious except during pregnancy and lactation, when they enlarge and secrete a substance that keeps the nipple soft. Within each breast are lobes of glandular tissue that secrete milk. Alveoli are small sacs that contain acinar cells to secrete milk. The alveoli drain into lactiferous ducts, which connect to drain milk from all areas of the breast.

*Question: The nurse in the primary health care provider's office is measuring vital signs on a postoperative client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. Which statement is appropriate for the nurse to tell the client?*

*Answer: "These sensations lessen over several months and usually are gone after 1 year."* Rationale: Numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow occurs in women after mastectomy. It is a result of injury to the nerves that provide sensation to the skin in those areas. These sensations may be described as heaviness, pain, tingling, burning, or "pins and needles." These sensations dissipate over several months and usually resolve 1 year after surgery.

*Question: A nursing instructor asks a nursing student to describe the standards of care formulated by the American Nurses Association. Which statement by the student indicates an inaccurate description of these statements?*

*Answer: "They are specific guidelines."* Rationale: Standards of care are authoritative statements that describe a common or acceptable level of client care or performance that have some similarity to policies and procedures. Thus, standards of care define professional practice. The American Nurses Association has formulated general standards and guidelines for nursing practice. They are broad and general in nature and apply across the nation.

*Question: A 13-year-old child is diagnosed with osteogenic sarcoma of the femur. Following a course of chemotherapy, it is decided that leg amputation is necessary. Following the amputation, the child becomes very frightened because of aching and cramping felt in the missing limb. Which statement made by the nurse will best assist in alleviating the child's fear?*

*Answer: "This aching and cramping are normal and temporary and will subside."* Rationale: Following amputation, phantom limb pain is a temporary condition that some children may experience. This sensation of aching or cramping in the missing limb is most distressing to the child. The child needs to be reassured that the condition is normal and only temporary.

*Question: The nurse has reinforced prior teaching of a school-age child who was given a brace to wear for the treatment of scoliosis. The child needs further teaching if which statement is made?*

*Answer: "This brace will correct my curve."* Rationale: Bracing can halt the progression of most curvatures, although it is not curative for scoliosis. The statements in options 2, 3, and 4 represent correct understanding on the part of the child.

*Question: The nurse is teaching a male client with osteomalacia about this disorder. Which comment by the client indicates a need for further teaching?*

*Answer: "This condition is primarily due to my lack of calcium and testosterone."* Rationale: There is a need for further teaching when the client says that lack of calcium and testosterone cause osteomalacia. Osteomalacia is caused by a lack of vitamin D. It is the softening of bone tissue characterized by inadequate mineralization of osteoid. Osteoporosis is caused by a lack of calcium and estrogen in women and testosterone in men.

*Question: A nursing student is asked to discuss juvenile idiopathic arthritis (JIA) at a clinical conference scheduled for the end of the clinical day. Which statement by the nursing student indicates the need for further research of this disorder?*

*Answer: "This disease is twice as likely to occur in boys as in girls."* Rationale: JIA is twice as likely to occur in girls as in boys. The cause of JIA is unknown. JIA has two peak ages of onset: between 1 and 3 years of age and between 8 and 10 years of age. This autoimmune inflammatory disease causes painful inflammation of joints.

*Question: A woman at 20 weeks of gestation calls the primary health care provider's office and speaks to the nurse. The client states that she is having subtle but persistent changes in her vaginal discharge, menstrual-like cramps, and diarrhea. Which is the least helpful response to the client?*

*Answer: "This is an emergency; you should come to the clinic within the hour."* Rationale: The nurse needs to determine if this client is experiencing preterm labor or uterine irritability. The woman should be instructed to lie on her side, drink fluids, and keep her bladder empty. This will decrease uterine activity and prevent uterine hypoxia. Option 3 addresses the process of data collection and is an important initial component of care. If the woman continues to have persistent uterine activity after 1 hour or counts four or more contractions in less than an hour, she should be seen for further evaluation. Telling the client that this is an emergency without first attempting the other options places undue stress on the pregnant client.

*Question: The parent of a 4-year-old child expresses concern because her hospitalized child has started sucking his thumb. The mother states that this behavior began 2 days after hospital admission. Which is the appropriate nursing response?*

*Answer: "This is common during hospitalization"* Rationale: In the hospitalized preschooler, it is best to accept regression, such as thumb sucking if it occurs, because it is most often caused by the stress of the hospitalization. Parents may be overly concerned about regression and should be told that their child may continue the behavior at home. There is no need to call the health care provider. Telling the parents the child is acting like a baby or being too old to act this way is inappropriate.

*Question: Antibiotics are prescribed for a child and the nurse provides instructions to the parents regarding the administration of the antibiotics. Which statement made by a parent would indicate that the instructions were understood?*

*Answer: "We will administer the antibiotics until they are gone."* Rationale: Antibiotics need to be taken as prescribed, and the full course needs to be completed. It is important that parents are instructed regarding the administration of antibiotics. Options 2, 3, and 4 are incorrect. Antibiotics are not tapered but administered until they are completed.

*Question: The nurse is reinforcing discharge instructions to the parents of a 2-year-old child who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement?*

*Answer: "We will be sure not to leave hot liquids unattended."* Rationale: Toddlers, with their increased mobility and developing motor skills, can reach hot water, open fires, or hot objects placed on counters and stoves above their eye level. Parents should be encouraged to remain in the kitchen when preparing a meal and reminded to use the back burners of the stove. Pot handles should be turned inward and toward the middle of the stove. Hot liquids should never be left unattended, and the toddler should always be supervised. The other options do not reflect an adequate understanding of the principles of safety.

*Question: The nurse is reinforcing instructions to the parents of a child with a hernia regarding measures that will promote reducing the hernia. The nurse determines that the parents understand these measures if they make which statement?*

*Answer: "We will provide comfort measures to reduce any crying periods by our child."* Rationale: A warm bath and comfort measures to reduce crying periods are all simple measures to promote reducing a hernia. Coughing and crying increase the strain on the hernia. Likewise, physical activities and enemas of any type would increase the strain on the hernia.

*Question: A client is undergoing electronic fetal monitoring (EFM), and the nurse informs the client about the procedure. Which statement indicates to the nurse that the client correctly understands this procedure?*

*Answer: "What an efficient way to record my baby's heart rate."* Rationale: EFM is a method of recording the fetal heart rate. The woman is asked to assume a semi-sitting position or a lateral position when undergoing this procedure. The ultrasound transducer acts through the reflection of high-frequency sound waves from a moving interface; in this case, the fetal heart and valves. EFM does not need to be shut off when talking on the telephone.

*Question: The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" Which response made by the nurse would be most appropriate?*

*Answer: "What do you and your husband believe is the right thing for your children?"* Rationale: The most appropriate response is the one that encourages open expression of feelings and empowers the grieving individual. Values, beliefs, and practices will differ with ethnic and spiritual backgrounds, and the nurse would not push a decision based on his or her own personal belief system. The remaining statements are nontherapeutic because they provide incorrect information related to postmortem grieving or offer the nurse's opinion and impose the nurse's beliefs.

*Question: Which statement would the nurse include when providing safety instructions to the parents of an infant with a diagnosis of hydrocephalus?*

*Answer: "When picking up your infant, support the infant's neck and head with the open palm of your hand."* Rationale: Hydrocephalus is a condition characterized by an enlargement of the cranium caused by an abnormal accumulation of cerebrospinal fluid within the cerebral ventricular system. This characteristic causes the increase in the weight of the infant's head. The infant's head becomes top heavy. Supporting the infant's head and neck when picking it up prevents hyperextension of the neck area and prevents the infant from falling backward. The infant should be fed with the head elevated for proper motility of food processing. A helmet could suffocate an unattended infant during rest and sleep times, and hyperextension of the infant's head can put pressure on the neck vertebrae, causing injury.

*Question: A stillborn was delivered in the birthing suite a few hours ago. After the birth, the family has remained together, touching the baby. Which statement by the nurse would further assist the family in their initial period of grief?*

*Answer: "Would you like to hold your baby?"* Rationale: Nurses should explore measures that assist the family in creating memories of an infant so that the existence of the child is confirmed and the parents can complete the grieving process. Asking the family if they would like to hold the baby meets this goal and demonstrates a caring and empathetic response. The remaining options are blocks to communication and devalue the parents' feelings.

*Question: A postpartum client who delivered at 32 weeks of gestation would like to breastfeed her preterm infant. At this time, the infant is receiving tube feedings only. What is the nurse's best response to the mother?*

*Answer: "You can begin pumping as soon as possible after delivery with an electric breast pump."* Rationale: Prematurity usually causes a delay before the baby can be fed at the breast. Mothers must initiate and maintain their milk supply with an electric breast pump. Milk expression by electric pump needs to begin as soon as possible after delivery and be done 8 or more times each 24 hours. Hand expression is not as effective as using an electric pump.

*Question: The nurse in the outpatient unit is preparing a client who is scheduled for a laser trabeculoplasty for the treatment of primary open-angle glaucoma. Which instructions would the nurse reinforce to the client?*

*Answer: "You may return to work 1 or 2 days following the procedure."* Rationale: Laser trabeculoplasty is performed in the outpatient setting and requires about 30 minutes. The client will experience little discomfort and may resume all normal activities including returning to work within 1 or 2 days. The treatment prevents further visual loss, but the lost vision cannot be restored.

*Question: The nurse is reinforcing discharge instructions with a client who is being discharged following a fenestration procedure for the treatment of otosclerosis. Which would be included on the list of instructions prepared for the client?*

*Answer: "You need to avoid air travel."* Rationale: Following ear surgery, clients need to avoid straining when having a bowel movement. Clients must be instructed to avoid drinking with a straw for 2 to 3 weeks, air travel, and coughing excessively. Clients need to avoid getting their head wet, washing their hair, and showering for 1 week. Clients also must avoid rapidly moving the head, bouncing, and bending over for 3 weeks.

*Question: The nurse who is assisting in a weight loss program prepares to monitor a client's weight. The client receives education about caloric intake and weight reduction. In order to lose 2 pounds per week the caloric intake should be decreased by how many calories per day?*

*Answer: 1000 calories* Rationale: The amount of weight loss in a client in a weight loss program is based on food intake, energy expenditure, and fluid loss. To obtain a weight loss of 1 pound per week the client needs a decrease in daily caloric intake of 500 calories. To lose 2 pounds per week the client needs to decrease intake by 1000 calories per day.

*Question: A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?*

*Answer: "You seem very distressed over learning you have asthma."* Rationale: It is important for the nurse to convey an accepting attitude to enhance mutual respect and trust. Clients who have learned they have a chronic illness may exhibit denial, anger, or sarcasm because of the fear associated with the chronic illness. Asking the client if asthma will kill them paraphrases the client's words but is somewhat sarcastic. Telling the client that you will not work with them is punitive in its approach and threatens the client. Informing the client that asthma is a treatable condition lectures the client and does not deal directly with the client's expressed concerns.

*Question: A mother tells the pediatrician's office nurse that she is concerned because her children must let themselves into the house after school each day while she is at work, and they feel isolated and fearful. The nurse would suggest which to the mother?*

*Answer: "You should seek community after-school programs or activities for your children."* Rationale: Most communities have free or low-cost after-school programs or activities that would minimize the amount of time that school-age children are at home alone. These programs should include adult supervision, which is needed by school-age children.

*Question: A pregnant woman in her second trimester calls the prenatal clinic nurse to report a recent exposure to a child with rubella. Which response by the nurse is appropriate?*

*Answer: "You were wise to call. I will check your rubella titer screening results, and we can identify immediately if interventions are needed."* Rationale: Rubella virus is spread by aerosol droplet transmission through the upper respiratory tract and has an incubation period of 14 to 21 days. Rubella titer screening is a standard antenatal test for women during their initial screening. The results of this screening test need to be checked to determine if interventions are necessary. Options 1, 2, and 3 are inappropriate statements and do not address the subject of the question.

*Question: A client with depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The nurse would make which therapeutic response to the client?*

*Answer: "You've been feeling like a failure for a while?"* Rationale: Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct response is an example of the use of restating. The incorrect responses block communication because they minimize the client's feelings and do not facilitate exploration of his or her expressed feelings.

*Question: A child with diabetes mellitus is brought to the emergency department by her mother, who states that her daughter has been complaining of abdominal pain and has a fruity odor on the breath. Diabetic ketoacidosis (DKA) is diagnosed. The nurse assisting with care for the child checks the intravenous (IV) and medication supply area for which item?*

*Answer: 0.9% normal saline IV infusion* Rationale: Rehydration is the initial step in resolving DKA. Normal saline is the initial IV rehydration fluid. NPH insulin is never administered by the IV route. Dextrose solutions are added to the treatment when the blood glucose levels reach an acceptable level. IV potassium may be required depending on the potassium level, but it would not be part of the initial treatment.

*Question: A client asks, "What does it mean that the baby is at minus one?" The nurse would explain to the client that the fetal presenting part is which?*

*Answer: 1 cm above the ischial spines* Rationale: Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line. Options 1, 2, and 4 are incorrect.

*Question: A client has been diagnosed as having syndrome of inappropriate antidiuretic hormone (SIADH) secretion following cranial surgery. The nurse interprets that this complication is not resolving if which urine specific gravity measurement is obtained?*

*Answer: 1.030* Rationale: The normal range for urine specific gravity, the comparison of urine concentration to water is from 1.016 to 1.022. Elevations may occur with SIADH because the kidneys are stimulated to reabsorb water, thus causing a higher concentration of the urine. The client retains water in the circulating blood volume leading to hyponatremia and low sodium levels, which cause decreased mental alertness and functioning. Specific gravities of 1.016, 1.018, and 1.020 are all within the normal range.

*Question: The nurse is planning to suction a client through a tracheostomy tube. Which is the amount of time for application of suction during withdrawal of the catheter?*

*Answer: 10 seconds* Rationale: During suctioning, the nurse should apply suction during the withdrawal of the catheter for a period of 5 to 10 seconds. Suction applied longer than this can cause hypoxia in the client.

*Question: A client is receiving a maintenance dose of oral dantrolene sodium for the treatment of spasticity. The nurse reviews the medication record, expecting which dose to be prescribed?*

*Answer: 100 mg twice daily* Rationale: For treatment of spasticity, dantrolene is administered orally. The initial dosage in adults is 25 mg once daily. The usual maintenance dosage is 100 mg 2 to 4 times daily. If beneficial effects do not develop within 45 days, dantrolene therapy should be discontinued.

*Question: The nurse determines that a student in a basic cardiac life support (BCLS) course correctly performs cardiopulmonary resuscitation (CPR) on an infant when the nurse observes which rate of chest compressions delivered to the infant mannequin?*

*Answer: 100 times per minute* Rationale: In an infant, the rate of chest compressions is at least 100 per minute. All other options are incorrect rates of compression based on current recommendations.

*Question: A client is brought to the emergency department following a smoke inhalation injury. The initial nursing action is to prepare the client to receive which treatment?*

*Answer: 100% humidified oxygen by face mask* Rationale: If the client sustains a smoke inhalation injury, the client is treated immediately with 100% humidified oxygen delivered by face mask. Oxygen via nasal cannula will not provide adequate oxygenation. Endotracheal intubation is needed if the client exhibits respiratory stridor, which then indicates airway obstruction. Pain management is necessary but is not the initial concern.

*Question: A mother of a child with cystic fibrosis asks the nurse when the postural drainage should be performed. The mother states that the child eats meals at 8:00 a.m., 12 noon, and at 6:00 p.m. What times would the nurse tell the mother to perform postural drainage?*

*Answer: 10:00 a.m., 2:00 p.m., and 8:00 p.m.* Rationale: Respiratory treatments should be performed at least 1 hour before meals or 2 hours after meals to prevent vomiting. In some children with cystic fibrosis, treatments are prescribed every 2 hours, particularly if infection is present. It is also important to perform these treatments before bedtime to clear airways and facilitate rest.

*Question: A pregnant client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse responds by telling the client that the gender of the fetus can usually be determined by which range of weeks?*

*Answer: 12 to 16* Rationale: By the end of the twelfth week, the fetal gender can be determined by the appearance of the external genitalia on ultrasound.

*Question: An infant, weighing 12 kg, is receiving diuretic therapy, and the nurse is closely monitoring the intake and output. Which is the amount of hourly urine output that the nurse would expect to be adequate?*

*Answer: 12 to 24 mL/hour* Rationale: Normal urinary output for an infant is 1 to 2 mL/kg/hr. Therefore for an infant weighing 12 kg, 12 to 24 mL/hour would be the expected adequate amount.

*Question: A client has been admitted for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?*

*Answer: 15 mg/dL* Rationale: The normal blood urea nitrogen value for the adult is 10 to 20 mg/dL. Thus the value of 15 mg/dL is correct. Values of 29 and 35 mg/dL reflect continued dehydration. Option 1 reflects a lower than normal value, which may occur with fluid overload, among other conditions.

*Question: Isotretinoin is prescribed for a client to treat severe cystic acne. The nurse tells the client that the length of the usual prescribed course of treatment is which?*

*Answer: 15 to 20 weeks* Rationale: Isotretinoin is usually administered 2 times daily for a period of 15 to 20 weeks. The usual adult dosage is 0.5 to 1 mg/kg/day. If needed, a second course may be administered but not until 2 months have elapsed after completing the first course.

*Question: The nurse is preparing to feed a 1-year-old hospitalized child. The nurse prepares the amount of formula to be given to this child, knowing that generally a 1-year-old consumes approximately which amount?*

*Answer: 175 mL per feeding* Rationale: A 1-year-old child consumes approximately 175 mL (6 ounces) of formula per feeding. Options 1, 2, and 4 are incorrect.

*Question: A nulliparous woman asks the nurse when she will feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately which week of gestation?*

*Answer: 18* Rationale: The first recognition of fetal movements, or "feeling life," by the multiparous woman may occur as early as the fourteenth to sixteenth week of gestation. The nulliparous woman may not notice these sensations until the 18th week of gestation or later. The first recognition of fetal movement is called quickening.

*Question: The nurse is preparing to hang an intravenous (IV) solution of 1000 mL 5% dextrose in lactated Ringer's to flow at 80 mL/hour. The nurse time-tapes the bag with a start time of 07.00. After making hourly marks on the time-tape, the nurse notes that the completion time for the bag would be what?*

*Answer: 19.30* Rationale: At a rate of 80 mL/hour, the 1000-mL bag will be finished infusing in 12.5 hours. This brings the end time to 19.30, using military time.

*Question: The nurse is reinforcing instructions regarding cardiopulmonary resuscitation (CPR) to a group of nursing students. The nurse tells the group that when performing chest compressions on adults, the sternum would be depressed to at least which depth?*

*Answer: 2 inches* Rationale: When performing CPR on adults, the sternum is depressed at least 2 inches. The remaining depths of compression could be ineffective or harmful.

*Question: A client with multiple sclerosis is receiving dantrolene for relief of muscle spasticity. When would this medication be discontinued if there is no relief of spasticity?*

*Answer: 2 months* Rationale: Dantrolene is discontinued if no relief of spasticity is achieved in 6 to 8 weeks.

*Question: A client with Parkinson's disease has begun therapy with carbidopa/levodopa. The nurse determines that the client understands the action of the medication if the client verbalizes that results may not be apparent for which length of time?*

*Answer: 2 to 3 weeks* Rationale: Signs and symptoms of Parkinson's disease usually begin to resolve within 2 to 3 weeks of starting therapy, although in some clients marked improvement may not be seen for up to 6 months. Clients need to understand this concept to aid in compliance with medication therapy. Options 1, 2, and 3 are incorrect because of the short time frames.

*Question: The nurse is preparing a small dose of a medication for administration to an infant. The nurse selects which syringe for preparing the medication? Refer to figure.View Figure*

*Answer: 2* Rationale: The tuberculin syringe has a long, thin barrel. The syringe, calibrated in sixteenths of a minim and hundredths of a milliliter, has a capacity of 1 mL. It is used to prepare small amounts of medication such as small, precise doses for infants or young children. Option 1 is a 3-mL syringe that is used to administer intramuscular and subcutaneous injections. Option 3 is a 5-mL syringe, and option 4 is an insulin syringe. Insulin syringes are used to administer insulin.

*Question: The nurse is checking the date of an intravenous (IV) insertion in a client. The insertion date on the dressing is 2/9 (February 9). The nurse calculates that the site should be changed on which date?*

*Answer: 2/12* Rationale: The IV site should be changed very 72 to 96 hours based on the Center for Disease Control guidelines. With an insertion date of 2/9, the due date for change should be 2/12. Changing the IV site every 5 to 7 days would place the client at risk for site infection.

*Question: The nurse is assisting in preparing a diet plan for a client who is taking the anticoagulant, warfarin. The nurse instructs the client to limit which food from the diet?*

*Answer: Broccoli* Rationale: Anticoagulant medications act to prevent coagulation by antagonizing the action of vitamin K. When a client is taking an anticoagulant, foods high in vitamin K are often omitted from the diet. Vitamin K is found in large amounts in green, leafy vegetables. Pasta, oranges, and potatoes are very low in vitamin K.

*Question: The nurse volunteering at the health screening clinic reinforces instructions to a 22-year-old client that diet and exercise would be used as tools to keep the total cholesterol level under at least which level?*

*Answer: 200 mg/dL* Rationale: The cholesterol level should be at least less than 199 mg/dL. The client should be counseled to keep the total cholesterol level under 200 mg/dL. This will aid in prevention of atherosclerosis, which can lead to a number of cardiovascular disorders later in life. The option of 130 mg/dL is abnormally low, and the options of 250 mg/dL and 300 mg/dL are too high.

*Question: The nurse is preparing to auscultate a client's abdomen for bowel sounds. The nurse listens for bowel sounds in which abdominal quadrant first? Refer to the figure.View Figure*

*Answer: 3* Rationale: When auscultating the abdomen, the nurse begins in the right lower quadrant (RLQ), in the ileocecal valve area, because bowel sounds are normally always present here. The nurse then proceeds to the other quadrants, 1, 2, and 4.

*Question: The nurse is caring for a client with myasthenia gravis who has received edrophonium intravenously to test for myasthenic crisis. The client asks the nurse how long the improvement in muscle strength will last. The nurse's response is based on the understanding that the duration is usually how many minutes?*

*Answer: 30* Rationale: Edrophonium may be given to test for myasthenic crisis. If the client is in myasthenic crisis, muscle strength improves after administration of the medication and lasts for about 30 minutes.

*Question: The nurse is assigned to a hospitalized client with chronic pancreatitis. The nurse reviews the client's record and expects to note a serum amylase level that is most likely which value?*

*Answer: 300 units/L* Rationale: Chronic pancreatitis is inflammation of the pancreas that occurs long term. It is a progressive destructive disease and is often caused by alcoholism or chronic biliary tract disease including cholecystitis and cholelithiasis. The normal serum amylase level is 25 to 151 units/L. In chronic cases of pancreatitis, the rise in the serum amylase level usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Therefore, 300 units/L is correct because the remaining options are normal values.

*Question: A client with rheumatoid arthritis is taking acetylsalicylic acid on a daily basis. Which medication dose would the nurse expect the client to be taking?*

*Answer: 4 g daily* Rationale: Clients with rheumatoid arthritis are treated with 3.6 to 5.4 g/day in divided doses. Acetylsalicylic acid may be used to treat a client with rheumatoid arthritis. It may also be used to reduce the risk of recurrent transient ischemic attack (TIA) or stroke (brain attack) or reduce the risk of myocardial infarction (MI) in clients with unstable angina or a history of a previous MI. The normal dose for clients being treated with aspirin to decrease thrombosis and MI is 300 to 325 mg/day. Clients being treated to prevent TIAs are usually prescribed 1.3 g/day in 2 to 4 divided doses.

*Question: The nurse is preparing to administer a continuous tube feeding to a client with a nasogastric tube. The primary health care provider has prescribed an amount of 100 mL/hr. The tube feeding setup is an open system, a bag that has formula added at intervals. How much formula would the nurse plan to add to fill the feeding bag?*

*Answer: 400 mL of formula* Rationale: Feeding can be hung at room temperature for a period of 4 hours. If 100 mL/hr is prescribed, the nurse should fill the feeding bag with a maximum amount of 400 mL. Feeding hung longer than 4 hours at room temperature creates the risk of bacterial invasion in the formula.

*Question: A primary health care provider instructs a client with rheumatoid arthritis to take ibuprofen. The nurse reinforces the instructions, knowing that the normal adult dose for this client is which?*

*Answer: 400 mg orally 3 times a day* Rationale: For acute or chronic rheumatoid arthritis or osteoarthritis, the normal oral adult dose is 400 to 800 mg 3 or 4 times daily.

*Question: A client who takes theophylline for chronic obstructive pulmonary disease (COPD) is seen in the urgent care center for respiratory distress. Just before initiating treatment for the respiratory distress, a sample for a theophylline level is drawn. The nurse notes the therapeutic range for the serum theophylline level is 10 to 20 mcg/mL and determines that the client may not be taking the medication as prescribed if which result is obtained?*

*Answer: 6 mcg/mL* Rationale: A therapeutic range for a medication is the level at which the medication is enough to produce the desired physiological effect without any symptoms of excess or toxicity. A level of 6 mcg/mL is below the therapeutic range, indicating the client may not be taking the medication as frequently as prescribed. With a low level, the client may experience frequent exacerbations of the disorder. If the level is within the therapeutic range as indicated by the results of 11 and 15 mcg/mL, the client is most likely compliant with medication therapy. An elevated level such as 25 mcg/mL is greater than normal, and the client may be taking too great or frequent a dose than prescribed or physiologically does not metabolize the medication normally. Theophylline is metabolized in the liver.

*Question: The nurse is caring for a child receiving carbamazepine who has a carbamazepine level drawn. Which result indicates a therapeutic level?*

*Answer: 6 mcg/mL* Rationale: When carbamazepine is administered, blood levels need to be drawn periodically to check for the child's absorption of the medication. The amount of the medication prescribed is based on the blood level achieved. The therapeutic serum level for this medication is 4 to 12 mcg/mL.

*Question: A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Based on the client's behavior, the nurse would suspect the client is how far dilated?*

*Answer: 8 to 10 cm* Rationale: During the transition phase of the first stage of labor, cervical dilation progresses from 8 to 10 cm. As contractions intensify, women often doubt their ability to cope with labor and fear abandonment.

*Question: The nurse is caring for a 5-year-old child who has been placed in traction after a fracture of the femur. Which is the most appropriate activity for this child?*

*Answer: A 10-piece puzzle* Rationale: In the preschooler, play is simple and imaginative, and it includes activities such as dressing up, paints, crayons, and simple board and card games. Ten-piece puzzles are also appropriate and aid with fine motor development. Blocks are most appropriate for the toddler. A music video is most appropriate for the adolescent. Large picture books are most appropriate for the infant.

*Question: A licensed practical nurse (LPN) asks an assistive personnel (AP) to gather supplies in preparation for administering a tepid bath to a child with an elevated temperature. The LPN intervenes if the AP obtains which unnecessary item(s)?*

*Answer: A bottle of alcohol* Rationale: Alcohol should never be used for bathing a child with an elevated temperature because it can cause rapid cooling, peripheral vasoconstriction, and chilling, thus elevating the temperature further. Washcloths can be used to squeeze water over the child's body. Towels are used to dry the child. Toys, especially water toys, can be used to provide distraction during the bath. Lightweight clothing should be placed on the child after the child is dried.

*Question: The nurse is providing instructions to a pregnant client with genital herpes about the measures that need to be implemented to protect the fetus. Which instruction should the nurse provide to the client?*

*Answer: A cesarean section will be necessary if vaginal lesions are present at the time of labor.* Rationale: For women with active lesions, either recurrent or primary at the time of labor, delivery should be by cesarean section to prevent the fetus from being in contact with the genital herpes. The safety of acyclovir has not been established during pregnancy and should be used only for a life-threatening infection. Clients should be advised to abstain from sexual contact while the lesions are present. If this is an initial infection, they should continue to abstain until they become culture-negative because prolonged viral shedding may occur in such cases. Keeping the genital area clean and dry will promote healing.

*Question: The nursing student is presenting a clinical conference and discusses the causative factors related to beta-thalassemia. Which group is at greatest risk of developing this disorder?*

*Answer: A child of Mediterranean descent* Rationale: Beta-thalassemia is an autosomal recessive disorder. This disorder is found primarily in individuals of Mediterranean descent. The disease also has been reported in Asian and African populations. Options 1, 3, and 4 are not risk factors for this disorder.

*Question: The nurse in charge of a rehabilitation center is planning the client assignments for the day. Which client would the nurse assign to the assistive personnel (AP)?*

*Answer: A client on strict bed rest and a 24-hour urine collection* Rationale: The nurse is legally responsible for client assignments and must assign tasks based on the guidelines of nurse practice acts and the job description of the employing agency. A newly admitted client who had a below-the-knee amputation will require physiological and psychosocial care and initiation of rehabilitation. A client scheduled to be discharged home will require reinforcement of home care management. A client scheduled for a cardiac catheterization requires physiological needs. The AP has been trained to care for a client on bed rest and on urine collections. The nurse should provide instructions to the AP regarding the tasks, but the task required for this client is within the role description of a AP.

*Question: The nurse is assigned to care for four clients. In planning client rounds, which client would the nurse collect data on first?*

*Answer: A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift* Rationale: Airway and breathing are always a high priority, and the nurse should attend to the client who had been experiencing a breathing problem first. The clients described in options 1, 2, and 3 would be intermediate priorities.

*Question: The nurse is planning the client assignments for the shift. Which client would the nurse assign to the assistive personnel (AP)?*

*Answer: A client requiring frequent ambulation with a walker* Rationale: Assignment of tasks needs to be implemented based on the job description of the AP, the level of clinical competence, and state law. Options 1, 3, and 4 involve care that requires the skill of a licensed nurse. Although an AP may be trained to administer an enema (depending on the state practice act and agency policies), a rectal suppository needs to be administered by a licensed nurse. Option 2 is the most appropriate assignment for the AP.

*Question: The nurse is checking her clients for skin breakdown. Which client would have the lowest priority for concern in the development of skin breakdown?*

*Answer: A client with a lowered mental awareness status* Rationale: Bed or chair confinement, inability to move, loss of bowel or bladder control, poor nutrition, absent or inconsistent caregiving, and a lowered mental awareness can contribute to the development of skin breakdown. However, the least likely risk as presented in the options is the lowered mental awareness status. Options 1, 2, and 4 identify physiological conditions, which are the highest-risk priorities.

*Question: A client had a colon resection. A Salem tube was in place when a regular diet was brought into the client's room. The client did not want to eat solid food and asked that the primary health care provider be called. The nurse persisted in the belief that the solid food was the correct diet. The client ate two meals and subsequently had additional surgery due to complications. The nurse understands that the determination of negligence in this situation is based on what?*

*Answer: A duty existed and it was breached* Rationale: Proven negligence requires a duty, a breach of duty, the breach of duty must cause the injury, and damages or injury must be experienced. Options 1, 3, and 4 do not fall under the criteria for negligence. Option 2 is the only option that fits the criteria of negligence.

*Question: The nurse is newly employed in a health agency. The nurse is told that the decision-making process of the organization is based on a centralized structure. The nurse determines that this means that the authority to make decisions is vested in whom?*

*Answer: A few individuals such as the board of directors* Rationale: With regard to the decision-making process, organizations may be described as having a centralized or decentralized structure. An organization is depicted as centralized when the authority to make decisions is vested in a few individuals. Conversely, when the decision-making involves a number of individuals and filters down to the individual employee, the organization is said to operate in a decentralized fashion.

*Question: A client receiving therapy with carbidopa/levodopa is upset and tells the nurse that his urine has turned a darker color since he began to take the medication. The client wants to discontinue its use. In formulating a response to the client's concerns, how does the nurse interpret this development?*

*Answer: A harmless side effect of the medication* Rationale: With carbidopa/levodopa therapy, a darkening of the urine or sweat may occur. The client should be reassured that this is a harmless effect of the medication, and its use should be continued. Options 1, 2, and 4 are incorrect interpretations.

*Question: The nurse is providing care to a client with this type of cast. (Refer to figure.) The nurse documents that the client has which type of cast?View Figure*

*Answer: A hip spica cast* Rationale: A hip spica cast is used to treat pelvic and femoral fractures. The cast covers the lower torso and extends to one or both lower extremities. If only one lower extremity is included it is called a single hip spica. If two are included it is called a double hip spica. Short and long leg casts are applied to the leg. A body jacket cast is applied to the upper torso.

*Question: The nurse is collecting data from a prenatal client. The nurse determines that which situation places the client in the high-risk category for contracting human immunodeficiency virus (HIV)?*

*Answer: A history of intravenous (IV) drug use in the past year* Rationale: HIV is transmitted by intimate sexual contact and by the exchange of body fluids, exposure to infected blood, and the transmission from an infected woman to her fetus. Women who fall into the high-risk category for HIV infection include those with persistent and recurrent sexually transmitted infections or a history of multiple sexual partners and those who use or have used IV drugs. The remaining options are not situations that contribute to contracting HIV infection.

*Question: A 4-year-old child is diagnosed with otitis media, and the mother asks the nurse about the causes of this illness. The nurse responds, knowing that which is an unassociated risk factor related to otitis media?*

*Answer: A history of urinary tract infections* Rationale: Factors that increase the risk of otitis media include exposure to illness, household smoking, bottle-feeding, and congenital conditions such as Down syndrome and cleft palate. The use of a pacifier beyond age 6 months has also been identified as a risk factor. Allergies are also thought to precipitate otitis media. Urinary tract infections are not a risk factor for otitis media.

*Question: The nurse is told in intershift report that a client has been appointed a legal guardian. The nurse looks for what evidence that supports this information?*

*Answer: A judicial decision in a court of law* Rationale: Appointment of a guardian must be done through due legal process. It cannot be done by a primary health care provider's prescription. Options 1 and 4 could support the decision that a legal guardian is necessary if the client is incompetent to make his or her own decisions, but they are not sufficient by themselves.

*Question: The nurse finds the client lying on the floor. The nurse calls the registered nurse, who checks the client and then calls the nursing supervisor and the primary health care provider to inform them of the occurrence. The nurse completes the incident report for which purpose?*

*Answer: A method of promoting quality care and risk management* Rationale: Proper documentation of unusual occurrences, incidents, accidents, and the nursing actions taken as a result of the occurrence are internal to the institution or agency. Documentation on the incident report allows the nurse and administration to review the quality of care and determine any potential risks present. Options 1, 3, and 4 are incorrect.

*Question: The nurse is assigned to administer the prescribed eye drops for a client preparing for cataract surgery. Which type of eye drops would the nurse expect to be prescribed?*

*Answer: A mydriatic medication* Rationale: A mydriatic medication produces mydriasis or dilation of the pupil. Mydriatic medications are used preoperatively in the cataract client. These medications act by dilating the pupils. They also constrict blood vessels. A miotic agent would constrict the pupil. An osmotic agent would act to decrease intraocular pressure. A thiazide diuretic would promote the excretion of body fluid. A thiazide diuretic is not likely to be prescribed for a client with a cataract.

*Question: The nurse is caring for an older client who is reminiscing about past life experiences in a positive manner. The nurse plans care with the understanding that this behavior indicates which?*

*Answer: A normal psychosocial response* Rationale: According to Erikson, the later years of life are from 65 years of age until death. The adult reminisces about past life experiences, often viewing them in a positive way. The adult needs to feel good about his or her accomplishments, see successes in his or her life, and feel that he or she has made a contribution to society.

*Question: The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse would check the client's room to ensure that which priority item is at the bedside?*

*Answer: A pair of scissors* Rationale: When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the client's bedside at all times. If the gastric balloon of the tube ruptures, the tube will move upward and potentially occlude the client's airway. The client needs to be observed for sudden respiratory distress. If this occurs, the RN is notified immediately, and the balloon lumens will be cut. An obturator and a Kelly clamp are kept at the bedside of a client with a tracheostomy. An irrigation set may also be kept at the bedside, but it is not the priority item.

*Question: The nurse receives a client in the surgical unit who was transferred from the postanesthesia care unit. The nurse checks the client for which data first?*

*Answer: A patent airway* Rationale: After transfer from the postanesthesia care unit, the nurse performs an assessment on the client. Airway must be established first. Urine output, surgical dressing, and orientation to the surroundings also may be checked, but these are not the first actions.

*Question: The nurse is assisting in developing a plan of care for a client preparing to breastfeed. In planning care, which factor is most significant in teaching a client to breastfeed?*

*Answer: A positive nurse-client relationship* Rationale: The nurse-client relationship is most significant. Option 4 is the opposite of what needs to happen. Brief separation decreases the chance of correct latch and suck in the immediate postpartum period. Infants should be placed at the breast immediately after delivery. Previous breastfeeding experience and a primary health care provider who encourages clients to breastfeed are not the most significant factors.

*Question: A client with spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. Which is the best response by the nurse?*

*Answer: Acknowledge the client's anger and continue to encourage participation in care.* Rationale: Adjusting to paralysis is difficult both physically and psychosocially for the client and family. The nurse recognizes that the client goes through the grieving process in adjusting to the loss and may move back and forth among the stages of grief. The nurse acknowledges the client's feelings while continuing to meet the client's physical needs and encouraging independence.

*Question: The nurse is assisting in reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which indicates the need for further action and analysis?*

*Answer: A postoperative client who develops a cough and a fever* Rationale: Variances are actual deviations or detours from the critical paths. Variances can be positive or negative, avoidable or unavoidable, and can be caused by a variety of factors. Positive variance occurs when the client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs when untoward events prevent a timely discharge. Variance analysis occurs continually to anticipate and recognize negative variance early so that appropriate action can be taken. A postoperative client who develops a cough and a fever identifies a negative outcome.

*Question: An alkaline-ash diet is prescribed for a client with renal calculi. Which diet menu does the nurse advise the client to select?*

*Answer: A spinach salad, milk, and a banana* Rationale: In an alkaline-ash diet, all fruits are allowed except cranberries, prunes, and plums. The fruits in options 1, 3, and 4 are eliminated in an acid-ash diet.

*Question: A client with myasthenia gravis verbalizes complaints of feeling much weaker than normal. The primary health care provider plans to implement a diagnostic test to determine if the client is experiencing a myasthenic crisis and administers edrophonium. Which data would indicate that the client is experiencing a myasthenic crisis?*

*Answer: A temporary improvement in the condition* Rationale: Edrophonium is administered to determine whether the client is reacting to an overdose of a medication (cholinergic crisis) or to an increasing severity of the disease (myasthenic crisis). When the edrophonium injection is given and the condition improves temporarily, the client is in myasthenic crisis. This is known as a positive test. Increasing weakness would occur in cholinergic crisis. Options 2 and 3 would not occur in either crisis.

*Question: The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation?*

*Answer: A urinary output of 20 mL/hour* Rationale: Urine output is maintained at a minimum of at least 30 mL/hour for an adult. An output of less than 30 mL/hour for each of 2 consecutive hours should be reported to the surgeon. A temperature more than 37° C (100° F) or less than 36.1° C (97° F) and a falling systolic blood pressure less than 90 mm Hg are to be reported. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.

*Question: When caring for a 3-year-old child, the nurse would provide which toy for the child?*

*Answer: A wagon* Rationale: Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, trucks, and dolls are some appropriate toys. A puzzle, with large pieces only, may be appropriate. A miniature farm set and a golf set may contain items that the child could swallow.

*Question: A child is brought to the emergency department for treatment of an acute asthma attack. The nurse prepares to administer which medication first?*

*Answer: A β2-agonist* Rationale: In treating an acute asthma attack, a short-acting β2-agonist such as albuterol will be given to produce bronchodilation. Options 2, 3, and 4 are long-term control (preventive) medications.

*Question: The nurse is caring for a client following a craniotomy in which a large tumor was removed from the left side. In which position can the nurse safely place the client? Refer to the Figure.View Figure*

*Answer: A* Rationale: Clients who have undergone craniotomy should have the head of the bed elevated 30 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion, and the head is maintained in a midline, neutral position. If a large tumor has been removed, the client should be placed on the nonoperative side to prevent displacement of the cranial contents. A flat position or Trendelenburg's position would increase intracranial pressure. A reverse Trendelenburg's position would not be helpful and may be uncomfortable for the client.

*Question: A pregnant client in the second trimester of pregnancy is admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which finding would the nurse expect to note if this condition is present?*

*Answer: Abdominal pain* Rationale: Classic signs and symptoms of abruptio placentae include vaginal bleeding, abdominal pain, uterine tenderness, and contractions. Mild to severe uterine hypertonicity is present. Pain is mild to severe and either is localized over one region of the uterus or is diffuse over the uterus, with a boardlike abdomen. Painless vaginal bleeding and a soft, nontender uterus in the second or third trimester of pregnancy are signs of placenta previa.

*Question: The nurse is caring for a client who has been treated with long-term antipsychotic medication. The nurse plans to monitor for tardive dyskinesia. Which signs would the nurse observe with tardive dyskinesia?*

*Answer: Abnormal movements and involuntary movements of the mouth, tongue, and face* Rationale: Tardive dyskinesia is a severe reaction associated with the long-term use of antipsychotic medication. The clinical manifestations are abnormal movements (dyskinesia) and involuntary movements of the mouth, tongue, and face. In its more severe form, tardive dyskinesia involves the fingers, arms, trunk, and respiratory muscles. When this occurs, the medication is discontinued.

*Question: A confused and disoriented client is admitted to the psychiatric unit diagnosed with posttraumatic stress disorder (PTSD). The nurse initially plans to take which action with this client?*

*Answer: Accept the client as a person and make the client feel safe.* Rationale: The nurse initially plans to accept the client as a person and make the client feel safe. It is important to make a confused and disoriented client feel safe. Orientation and explaining the unit rules are part of any admission process and do not meet the individual needs of this client. Stabilizing psychiatric needs is a long-term goal.

*Question: A client is taking ticlopidine hydrochloride. The nurse tells the client to avoid which substance while taking this medication?*

*Answer: Acetylsalicylic acid* Rationale: Ticlopidine hydrochloride is a platelet aggregation inhibitor. It is used to decrease the risk of thrombotic strokes in clients with precursor symptoms. Because it is an antiplatelet agent, other medications that precipitate or aggravate bleeding should be avoided during its use. Therefore, aspirin or any aspirin-containing product should be avoided.

*Question: The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the emergency department. Which would be the initial nursing action?*

*Answer: Activate the agency emergency response plan.* Rationale: During a widespread disaster, many people will be brought to the emergency department for treatment. Health care institutions are required to have an emergency response plan in place and perform practice drills. The initial nursing action should be to activate the emergency response plan. The plan entails the other options, which include preparing triage rooms to take casualties and obtaining sufficient supplies and medical personnel.

*Question: The nurse enters a client's room and finds that the wastebasket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action?*

*Answer: Activate the fire alarm.* Rationale: The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire is then confined by closing all doors. Finally, the fire is extinguished.

*Question: A client who suffered a crush injury to the leg has a highly positive urine myoglobin level. The nurse plans to monitor this particular client carefully for signs of which complication?*

*Answer: Acute tubular necrosis* Rationale: The normal urine myoglobin level is negative. After extensive muscle destruction or damage, myoglobin is released into the bloodstream where it is cleared from the body by the kidneys. When a large amount of myoglobin is being cleared from the body, the renal tubules may become clogged with myoglobin, which causes acute tubular necrosis. This is one form of acute kidney injury.

*Question: The nurse is caring for a child who is scheduled for an appendectomy. When the nurse reviews the primary health care provider's preoperative prescriptions, which would be questioned?*

*Answer: Administer a Fleet enema.* Rationale: In the preoperative period, enemas or laxatives should not be administered. No heat should be applied to the abdomen because this may increase the chance of perforation secondary to vasodilation. IV fluids would be started and the child would be NPO. Prescribed preoperative medications most likely would be administered on call to the operating room.

*Question: A client who has had a total knee replacement tells the nurse that there is pain with extension of the knee. Which action would the nurse implement?*

*Answer: Administer an analgesic.* Rationale: Pain with knee extension is a common complaint of clients after knee replacement. This is because preoperatively the client placed the knee in flexion to reduce pain, and flexion contracture has resulted. The nurse should encourage the client to keep the knee extended and administer analgesics as needed.

*Question: The goal for a postpartum client with deep thrombophlebitis is to prevent the complication of pulmonary embolism. In planning care to assist in meeting this goal, the nurse would perform which action?*

*Answer: Administer anticoagulants as prescribed.* Rationale: The purpose of anticoagulant therapy is to prevent the clot from moving to another area. Options 1, 2, and 3 will not prevent pulmonary embolism.

*Question: A client in labor has an underlying diagnosis of sickle cell anemia. During labor the client is at high risk for sickling crisis. The nurse would take which action to assist in preventing a crisis from occurring during labor?*

*Answer: Administer oxygen as prescribed.* Rationale: During the labor process, the client is at high risk for being unable to meet the oxygen demands of labor and becoming unable to prevent sickling. An intervention to prevent sickle cell crisis during labor includes administering oxygen as needed. Options 1, 2, and 3 are accurate information but not for the situation described in the question.

*Question: The nurse is told that an assigned client will have the chest tubes removed. The nurse plans to do which in preparation for the procedure?*

*Answer: Administer pain medication 15 to 30 minutes before the procedure.* Rationale: Removal of chest tubes can be uncomfortable for a client. The nurse should medicate the client 15 to 30 minutes before the chest tube is removed. The remaining options are inappropriate actions and would not be performed by the nurse.

*Question: The nurse prepares to administer digoxin to a 3-year-old with a diagnosis of heart failure and notes that the apical heart rate is 120 beats per minute. Which nursing action is appropriate?*

*Answer: Administer the digoxin.* Rationale: The normal apical heart rate for a 3-year-old is 80 to 125 beats per minute. Because the apical heart rate is within normal range, options 1, 3, and 4 are inappropriate.

*Question: The medication prescription states to administer acetaminophen 650 mg orally for a temperature of more than 38° C. The medication bottle states acetaminophen, 325 mg tablets. The nurse takes the client's temperature and notes that it is 101° F. The nurse plans to take which action?*

*Answer: Administer two tablets.* Rationale: Convert Fahrenheit to Celsius, and then calculate the dose to be administered.

*Question: The nurse is providing care for a client following a bone biopsy. Which action by the nurse is unnecessary in the care of this client?*

*Answer: Administering intramuscular opioid analgesics* Rationale: Administering intramuscular opioid analgesics to a client following a bone biopsy is an unnecessary action for the nurse. Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, and hematoma formation. The biopsy site is elevated for 24 hours to reduce edema. The vital signs are monitored every 4 hours for 24 hours. The client usually requires mild analgesics; more severe pain usually indicates that complications are arising.

*Question: The nurse is reviewing the plan of care developed by a nursing student for a client scheduled for keratoplasty. The nurse discusses the plan with the student if which incorrect intervention is listed in the plan?*

*Answer: Administering medications that will dilate the pupil* Rationale: Keratoplasty is done by removing damaged corneal tissue and replacing it with corneal tissue from a human donor (live or cadaver). Preoperative preparation of the recipient's eye may include obtaining a culture and sensitivity with conjunctival swabs, instilling antibiotic ophthalmic medication, and cutting the eyelashes. Some ophthalmologists prescribe a medication such as 2% pilocarpine to constrict the pupil before surgery.

*Question: The nurse notes that a client who is attached to a cardiac monitor suddenly develops atrial fibrillation at a rate of 130 beats per minute. The nurse immediately notifies the registered nurse and prepares the client for which initial intervention?*

*Answer: Administration of a calcium channel blocker* Rationale: The initial treatment goal when atrial fibrillation suddenly occurs is to control the rate of impulses with the administration of a calcium channel blocker or a beta blocker. Defibrillation is indicated when a client is in pulseless ventricular tachycardia or ventricular fibrillation. Electrical cardioversion is an option for atrial fibrillation if the client is clinically unstable or if the client has not responded to chemical cardioversion after a 6-week period of anticoagulant therapy. Anticoagulant therapy, for example, with a continuous heparin infusion, is indicated to prevent development of thrombus formation in the atria but is not the priority over rate control.

*Question: The nurse in the postpartum unit notes that the result of a rubella titer drawn on a postpartum client during the antepartum period is 1.8. Which would the nurse anticipate to be prescribed by the primary health care provider?*

*Answer: Administration of a subcutaneous rubella virus vaccine* Rationale: A blood sample for rubella titer is done on all women in the antepartum or postpartum period. A postpartum woman with a titer of 1.8 or less should receive a subcutaneous rubella virus vaccine (Meruvax II) following the birth of her baby. This stimulates active immunity against the rubella virus. The woman should be counseled to avoid pregnancy for 3 months after receiving the vaccine.

*Question: The nurse caring for an adolescent client recently diagnosed with bone cancer is monitoring the client for depression. To best recognize these symptoms in the adolescent, the nurse would distinguish which attribute of normal adolescents from an adolescent with depression?*

*Answer: Adolescents like to stay up late but rarely have insomnia.* Rationale: The signs of depression include crying spells, insomnia, eating disorders, social isolation and withdrawal, serious acting-out behavior, feelings of hopelessness, unexplained physical symptoms, loss of interest in appearance, and giving away things or possessions. Staying up late is the only option that represents normal adolescent behavior.

*Question: A hospitalized client with severe seborrheic dermatitis is receiving treatments of topical glucocorticoid applications followed by the application of an occlusive dressing. The nurse monitors the client for which systemic effect that can occur as a result of this treatment?*

*Answer: Adrenal suppression* Rationale: Topical glucocorticoids can be absorbed in sufficient amounts to produce systemic toxicity. Primary concerns are growth retardation (in children) and adrenal suppression in all age groups. Systemic toxicity is more likely under extreme conditions such as with prolonged therapy in which extensive surfaces are treated with high doses of high-potency agents in conjunction with occlusive dressings.

*Question: The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When would the nurse inflate the balloon?*

*Answer: Advance the catheter to the bifurcation and inflate the balloon.* Rationale: Urinary catheterization is a sterile procedure. When inserting an indwelling catheter, the nurse should ensure the balloon is in the bladder before inflating it. If the balloon is inflated in the urethra of the male client, trauma may occur. When catheterizing a male client, the nurse observes the tubing for the flow of urine, continues to advance the catheter to the point of bifurcation, and then inflates the balloon. The nurse then pulls the catheter back until slight resistance is felt and applies a tube holder onto the thigh to hold the catheter in place. The balloon should not be inflated when urine is first observed, after advancing several more centimeters, or when resistance is felt.

*Question: The nurse is providing information to assistive personnel (AP) regarding caring for an older adult. The nurse determines the AP understands the information provided if the AP identifies which situation portrays ageism?*

*Answer: Advising older adults to forgo aggressive treatment* Rationale: Ageism is a form of prejudice in which older adults are stereotyped by characteristics found in only a few members of their group. Fundamental to ageism is the view that older people are different from "me" and will remain different from "me." Therefore, they are portrayed as not experiencing the same desires, needs, and concerns. Options 1, 2, and 3 identify supportive roles of the nurse when dealing with the older adult. Option 4 suggests that the older adult is not worthy of aggressive treatment and demonstrates ageism.

*Question: Exemestane 25 mg orally daily is prescribed for a client with advanced breast cancer. When reinforcing instructions to the client about the medication, which time does the nurse tell the client to take the medication?*

*Answer: After a meal* Rationale: The best time for a client to take the daily dosage of exemestane is after a meal. Therefore, options 2, 3, and 4 are incorrect.

*Question: The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. Which is the next action the nurse would perform?*

*Answer: Aim at the base of the fire.* Rationale: A fire can be extinguished by using a fire extinguisher. To use the extinguisher, the pin is pulled first. The extinguisher should then be aimed at the base of the fire. The handle of the extinguisher is squeezed, and the fire is extinguished by sweeping from side to side to coat the area evenly. Remember that the safety of anyone present is more important than extinguishing the fire. Remember the mnemonic RACE: R (Rescue) A (Alarm) C (Confine) E (Extinguish).

*Question: A client who has been receiving total parenteral nutrition by way of a central venous access device complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that the pulse rate has increased and that the blood pressure has dropped. The nurse determines that the client is most likely experiencing which sign?*

*Answer: Air embolism* Rationale: The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety, tachycardia, and hypotension. The nurse also should hear a loud churning sound over the pericardium on auscultation of the chest. The signs and symptoms of sepsis include fever, chills, and general malaise. The signs and symptoms of a fluid imbalance depend on the type of imbalance that the client is experiencing. Fluid overload causes increased intravascular volume, which increases the blood pressure and the pulse rate as the heart tries to pump the extra fluid volume. Fluid overload also causes neck vein distention and the shifting of fluid into the alveoli, resulting in lung crackles. Complications should be reported to the registered nurse and/or the primary health care provider immediately.

*Question: The nurse obtains a health history from a mother of a 15-month-old child before administering a measles, mumps, and rubella (MMR) vaccine. Which is essential information to obtain before the administration of this vaccine?*

*Answer: Allergy to eggs* Rationale: Before the administration of a measles, mumps, and rubella vaccine, a thorough health history needs to be obtained. The MMR vaccine is used with caution in a child with a history of allergy to gelatin or eggs because the live measles vaccine is produced by chick embryo cell culture. The MMR vaccine also contains a small amount of the antibiotic neomycin. Options 1, 3, and 4 are not contraindications to administering this immunization.

*Question: The nurse is preparing a client who is scheduled to have cerebral angiography performed. Which would the nurse check before the procedure?*

*Answer: Allergy to iodine or shellfish* Rationale: A client undergoing cerebral angiography is assessed for possible allergy to the contrast dye, which can be determined by questioning the client about allergies to iodine or shellfish. Allergy to salmon is not associated with this procedure. Claustrophobia and excessive weight are areas of concern with magnetic resonance imaging.

*Question: The nurse is caring for a client who is going to have an arthrogram using a contrast medium. Which data collected by the nurse would be of highest priority?*

*Answer: Allergy to iodine or shellfish* Rationale: Because of the risk of allergy to contrast dye, the nurse places highest priority on identifying whether the client has an allergy to iodine or shellfish. The nurse also reinforces information about the test, tells the client about the need to remain still during the procedure, and encourages the client to void before the procedure for comfort.

*Question: The nurse has obtained a personal and family history from a client with a neurological disorder. Which finding in the client's history is least likely associated with a risk for neurological problems?*

*Answer: Allergy to pollen* Rationale: Previous neurological problems such as headaches or back injuries place the client more at risk for development of a neurological disorder. Chronic diseases such as hypertension and diabetes mellitus also place the client at greater risk. Assessment of allergies is a routine part of the health history, regardless of the nature of the client's problem. In addition, an allergy to pollen would not place the client at risk for a neurological problem.

*Question: Following a tonsillectomy, which of the primary health care provider's prescriptions would the nurse question?*

*Answer: Allow ice cream when awake.* Rationale: Clear, cool liquids are encouraged. Milk and milk products are avoided initially because they coat the throat, which causes the child to clear the throat, increasing the risk of bleeding. Options 1 and 2 are important nursing interventions following any type of surgery.

*Question: A 16-year-old child is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which intervention is most appropriate to facilitate normal growth and development?*

*Answer: Allow the child to participate in activities with other individuals in the same age group when the condition permits.* Rationale: Adolescents are not often sure they want their parents with them when they are hospitalized. Because of the importance of the peer group, separation from friends is a source of anxiety. Ideally, the peer group will support the ill friend. The other options isolate the child from the peer group.

*Question: The nurse is providing instructions to a new parent regarding the psychosocial development of the infant. Using Erikson's psychosocial development theory, which instruction would the nurse reinforce to the parents?*

*Answer: Allow the infant to signal a need.* Rationale: According to Erikson, the caregiver should not try to anticipate the infant's needs at all times but rather allow the infant to signal his or her needs. If an infant is not allowed to signal a need, the infant will not learn how to control the environment. Erikson believed that a delayed or prolonged response to an infant's signal would inhibit the development of trust and lead to the mistrust of others. Therefore, the remaining options are incorrect.

*Question: The nurse would plan which to encourage autonomy in the client who is a resident in a long-term care facility?*

*Answer: Allowing the client to choose social activities* Rationale: Autonomy is the personal freedom to direct one's own life as long as it does not impinge on the rights of others. An autonomous person is capable of rational thought. This individual can identify problems, search for alternatives, and choose solutions that allow for continued personal freedom as long as the rights and property of others are not harmed. The loss of autonomy—and, therefore, independence—is a very real fear among older clients. The correct option is the only choice that allows the client to be a decision maker.

*Question: An older adult couple requests to room together at a long-term care facility. When some members of the staff question this, the nurse would provide which response?*

*Answer: Although responses may be slower, sexual ability is present in later years of life.* Rationale: The option regarding slower response time represents a true statement about sexuality in the older client. The other options indicate stereotypes with no foundation in fact.

*Question: The nurse is caring for a client with kidney failure. The serum phosphate level is reported as 7 mg/dL. Which medication would the nurse plan to administer as prescribed to the client?*

*Answer: Aluminum hydroxide gel* Rationale: The normal serum phosphate level is 3 to 4.5 mg/dL. The client in this question is experiencing hyperphosphatemia. Certain medications can be given to increase fecal excretion of phosphorus by binding phosphorus from the food in the gastrointestinal tract. Aluminum hydroxide gel is one such medication. Calcium gluconate and calcium chloride are medications used in the treatment of tetany that occurs from acute hypocalcemia. Calcitonin, a thyroid hormone, decreases the plasma calcium level by increasing the incorporation of calcium into the bones, thus keeping it out of the serum.

*Question: An 84-year-old client in an acute state of disorientation was brought to the emergency department by the client's daughter. The daughter states that this is the first time that the client experienced confusion. The nurse determines from this piece of information that which is unlikely to be the cause of the client's disorientation?*

*Answer: Alzheimer's disease* Rationale: Alzheimer's disease is a chronic disease with progression of memory deficits over time. The situation presented in the question represents an acute problem. Medication use, hypoglycemia, and impaired cerebral circulation require evaluation to determine if they play a role in causing the client's current symptoms.

*Question: The clinic nurse is reviewing the records of the pregnant clients who will be seen in the clinic. Which client profile presents the greatest risk for human immunodeficiency virus (HIV) infection?*

*Answer: An adolescent with multiple heterosexual contacts* Rationale: Although all women are at risk for developing HIV during their reproductive years, it is believed that adolescents are particularly at risk because they engage in high-risk behaviors. The client profiles in options 1, 3, and 4 identify at-risk situations for a variety of obstetric risk factors but not necessarily HIV infection.

*Question: A client is suspected of having myasthenia gravis, and the primary health care provider administers edrophonium to determine the diagnosis. After administration of this medication, which sign/symptom would indicate the presence of myasthenia gravis?*

*Answer: An increase in muscle strength* Rationale: Edrophonium is a short-acting acetylcholinesterase inhibitor used as a diagnostic agent. When a client with suspected myasthenia gravis is given the medication intravenously, an increase in muscle strength would be seen in 1 to 3 minutes. If no response occurs, another dose is given over the next 2 minutes, and muscle strength is again tested. If no increase in muscle strength occurs with this higher dose, the muscle weakness is not caused by myasthenia gravis. Clients receiving injections of this medication commonly demonstrate a drop of blood pressure, feel faint and dizzy, and are flushed.

*Question: Which individual is least likely to be at risk for the development of Kaposi's sarcoma?*

*Answer: An individual working in an environment in which exposure to asbestos is possible* Rationale: Kaposi's sarcoma is a vascular malignancy that presents as a skin disorder. It is a common acquired immunodeficiency syndrome (AIDS) indicator. Malignancy is seen most frequently in men with a history of same-sex partners. Although the cause of Kaposi's sarcoma is not known, it is considered to be the result of an alteration or failure in the immune system. The renal transplant client and the client receiving antineoplastic medications are at risk for immunosuppression. Exposure to asbestos is not related to the development of Kaposi's sarcoma but could be related to mesothelioma.

*Question: The nurse will be caring for several older adults who will be undergoing general anesthesia. Which older adult will require the closest monitoring for a prolonged effect of anesthesia?*

*Answer: An older adult with increased amount of fatty tissue* Rationale: An older person needs fewer anesthetic agents to produce anesthesia, and it takes longer for the older person to eliminate anesthetic agents. One reason for the reduction of dosage is that the percentage of fatty tissue increases as people age. Anesthetic agents that have an affinity for fatty tissue concentrate in body fat and the brain. Another reason is that older clients may have low plasma proteins, particularly when malnourished. With decreased plasma proteins, more of the anesthetic agent remains free or unbound, which results in a more potent action. Reduction in liver size decreases the rate at which the liver can inactivate many anesthetic agents. The decreased functioning of kidney cells reduces excretion of waste products and anesthetic agents.

*Question: The nurse is caring for a client who has had a spinal fusion with insertion of hardware. The nurse would be especially concerned with which finding?*

*Answer: An oral temperature of 101°F orally* Rationale: For this specific type of surgery, the nurse monitors the neurovascular status of the lower extremities, watches for signs/symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear, tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101°F or higher should be reported because it might indicate infection or require that the hardware be removed.

*Question: The nurse in the emergency department is caring for a client with a fractured arm. The nurse understands that which item is least likely needed before reduction of the fracture in the casting room?*

*Answer: Anesthesia consent* Rationale: The item that is least likely needed before reduction of a fracture in the casting room is an anesthesia consent. Before a fracture is reduced, the client is informed about the procedure and consent is obtained. An analgesic is given as prescribed because the procedure is painful. Anesthesia may or may not be administered, depending on severity. Closed reductions may be done in the emergency department without anesthesia. If anesthesia is used, the procedure is done in the operating room.

*Question: A mother of a 5-year-old child tells the nurse that the child scolds the floor or table if the child hurts herself on the object. The nurse identifies the child as displaying signs of which stage of Piaget's theory of cognitive development?*

*Answer: Animism* Rationale: Animism means that all inanimate objects are given living meaning. Object permanence, the realization that something out of sight still exists, occurs in the later stages of the sensorimotor stage of development. Egocentric speech occurs when the child talks just for fun and cannot see another's point of view. Global organization means that if any part of an object or situation changes, the whole thing has changed. Egocentric speech and global organization occur during the preoperational stage.

*Question: A licensed practical nurse (LPN) attends a session about bioterrorism agents including anthrax. Which statement by an attendee demonstrates the need for further teaching about anthrax?*

*Answer: Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis.* Rationale: Anthrax is caused by Bacillus anthracis, and it can be contracted through the digestive system, abrasions in the skin, or inhalation. Antibiotics are administered. Botulism is caused by a neurotoxin that causes severe paralysis and can be fatal.

*Question: The nurse is caring for a child with a suspected diagnosis of rheumatic fever (RF). The nurse reviews the laboratory results. Which laboratory study would assist in confirming the diagnosis of RF?*

*Answer: Antistreptolysin O titer* Rationale: A diagnosis of RF is confirmed by the presence of two major manifestations or one major and two minor manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is confirmed by a positive antistreptolysin O titer, streptozyme, or an anti-DNase B assay. Options 1, 2, and 4 will not assist in confirming the diagnosis of RF.

*Question: An infant is seen in a clinic and is diagnosed with unilateral hip dysplasia. Which finding is associated with this condition?*

*Answer: Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table* Rationale: Asymmetry of the gluteal folds when the infant is placed prone would be a finding in hip dysplasia in infants beyond the newborn period. Options 1, 2, and 3 are inaccurate assessment findings in this disorder.

*Question: A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with the early stage of cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse would expect which assessment finding?*

*Answer: Appearance of reddish-blue lesions on the lower extremities* Rationale: Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They also can spread to the lymphatic system, lungs, and gastrointestinal (GI) tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and GI lesions.

*Question: The nurse prepares to administer a pancreatic enzyme powder to a child with cystic fibrosis (CF). Which food item would the nurse mix with the medication?*

*Answer: Applesauce* Rationale: Pancreatic enzyme powders are not to be mixed with hot foods or foods containing tapioca or other starches. Enzyme powder should be mixed with nonfat, nonprotein foods such as applesauce. Pancreatic enzymes are inactivated by heat and are partially degraded by gastric acids.

*Question: A client who was hit in the eye with a baseball bat sustains a contusion of the eyeball. The emergency department nurse implements which immediate action?*

*Answer: Applies ice to the affected eye* Rationale: Treatment for a contusion ideally begins at the time of injury and includes applying ice to the site. The client also should receive a thorough eye examination to rule out the presence of other eye injuries. An eye patch will not assist in treating this type of injury. Irrigating the eye with cool water may be implemented for injuries that involve a splash of an irritant into the eye.

*Question: The nurse has a prescription to get the client out of bed to a chair on the first postoperative day after total knee replacement. The nurse plans to do which to protect the knee joint?*

*Answer: Apply a knee immobilizer before getting the client up, and elevate the client's surgical leg while sitting.* Rationale: The nurse assists the client to get out of bed on the first postoperative day after putting a knee immobilizer on the affected joint for stability. The surgeon prescribes the weight-bearing limits on the affected leg. The leg is elevated while the client is sitting in the chair to minimize edema.

*Question: The nurse is changing the abdominal dressing on a client following abdominal surgery. The nurse notes that the incision line is separated and the appearance of underlying tissue is noted. Wound dehiscence is suspected. Which is the appropriate initial nursing action?*

*Answer: Apply a sterile dressing soaked with sterile normal saline to the wound.* Rationale: Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the appearance of underlying tissues. It usually occurs 6 to 8 days after surgery. The client should be instructed to remain quiet and to avoid coughing or straining. The client should be placed in semi-Fowler's position to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline should be used to cover the wound. The primary health care provider needs to be notified immediately.

*Question: The nurse is reinforcing instructions to a client with a diagnosis of hordeolum regarding the treatment plan. Which instruction would the nurse include in the teaching plan for the client?*

*Answer: Apply a warm compress for 15 minutes 4 times daily.* Rationale: Hordeolum is commonly known as a sty. Therapeutic management includes the application of a warm compress for 15 minutes 4 times daily and installation of an ophthalmic antibiotic ointment to combat the infectious organism and prevent the spread of infection to surrounding lid glands. The warm compress promotes comfort and aids in bringing purulent contents to a head causing rupture with drainage. If a sty does not rupture spontaneously, it can be incised with a small sterile instrument by the primary health care provider. The client should be told not to press on or squeeze the sty to induce rupture because such pressure could force infectious material into the venous system and transmit infection to the brain.

*Question: A client arrives in the emergency department with a foreign body in the eye. Which action would the nurse plan to perform first?*

*Answer: Apply an eye patch to both eyes.* Rationale: If a foreign body is in the eye, no attempt to remove it should be made. Both eyes should be patched to prevent further eye movement, until the primary health care provider can see the client. The eye should not be irrigated with any solution, and no ointment should be applied. The primary health care provider may eventually check for corneal abrasions once the object is removed.

*Question: Which nursing action would avoid pressure on the popliteal nerve when applying the safety strap across the client's legs on the operating table?*

*Answer: Apply the safety strap 2 inches above the knees.* Rationale: The safety strap is applied to prevent the client from falling off the surgery table. The strap should be applied 2 inches above the knees to avoid pressure on the popliteal nerve. Options 1, 3, and 4 are inappropriate and unsafe.

*Question: The nurse is assigned to care for a client with a leg ulcer. Sutilains treatments are prescribed. The nurse would avoid which action when performing the treatment?*

*Answer: Applying the sutilains immediately followed by a dry sterile dressing* Rationale: The wound should be cleansed with a sterile solution before treatment. The nurse then should thoroughly moisten the wound with sterile normal saline or sterile water and apply a loose thin dressing after applying a thin film of sutilains extending ¼ to ½ inch beyond the area to be debrided. The ointment should be refrigerated.

*Question: The nurse is assisting in caring for a newborn whose mother is Rh negative. Which is important for the nurse to include when planning the newborn's care?*

*Answer: Ask about the newborn's blood type and direct Coombs.* Rationale: To further assess and plan for the newborn's care, the newborn's blood type and direct Coombs must be known. If the newborn's blood type is Rh negative, or if the newborn's blood type is Rh positive with a negative direct Coombs' test, then there is no concern for Rh incompatibility. If the newborn's blood type is Rh positive and the direct Coombs is positive, then Rh incompatibility exists. Options 1 and 2 are inappropriate at this time because additional data are needed. Option 4 is incorrect because vitamin K is given to prevent hemorrhagic disease in the newborn.

*Question: The nurse is caring for a client who is scheduled for surgery. The client states concern about the surgical procedure. How would the nurse initially address the client's concerns?*

*Answer: Ask the client to discuss information known about the planned surgery.* Rationale: The client is concerned about having surgery and needs to discuss it. This will offer the client the opportunity to verbalize his or her current and specific understanding. Explanations should begin with the information that the client knows. Option 1 is a block to communication and minimizes the client's feelings. Giving unsolicited explanations may produce additional anxiety and not address the real concerns of the client.

*Question: A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry. The nurse performs which best action to ensure accurate readings on the oximeter?*

*Answer: Ask the client to limit motion in the hand attached to the pulse oximeter.* Rationale: Several factors can interfere with the reading of accurate oxygen saturation levels on a pulse oximeter. To ensure accurate readings, the nurse should ask the client to limit motion of the area attached to the sensor. The nurse should apply the device to a warm area because hypotension, hypothermia, and vasoconstriction interfere with blood flow to the area. If possible, the nurse should avoid placing the sensor distal to any invasive arterial or venous catheters, pressure dressings, or blood pressure cuffs. The nurse needs to know that very dark nail polish (black, brown-red, blue, green) interferes with accurate measurement.

*Question: A client with sickle cell anemia has vaso-occlusive pain. After noting that the client is of preschool age, the nurse plans to use which method to determine the adequacy of pain control?*

*Answer: Ask the client to point to faces (smiling to very sad) that best describe the pain.* Rationale: A client of preschool age has the level of cognitive ability to recognize happy and sad faces and to correlate them with the level of pain experienced. Using descriptive words to communicate varying intensities of pain may be too complicated for some preschoolers. Some preschool children may not be able to count or understand the value of numbers in relation to other numbers. Children of preschool age are too young to control a PCA pump.

*Question: A client in skeletal leg traction with an overbed frame is not allowed to turn from side to side. Which action by the nurse would be most useful in trying to provide good skin care to the client?*

*Answer: Asking the client to pull up on a trapeze to lift the hips off the bed* Rationale: The nursing action that would be most useful if the client in skeletal traction may not turn from side to side is to have the client pull up on a trapeze and try to lift the hips off the bed for skin care, bedpan use, and linen changes. If the client is unable to pull up on a trapeze, the nurse can push down on the mattress with one hand while administering care with the other.

*Question: The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?*

*Answer: Aspiration of gastric contents occurs when suctioning.* Rationale: Necrosis of the tracheal wall in a client with a tracheostomy can lead to an artificial opening between the posterior trachea and esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the stomach causing abdominal distention. It also causes aspiration of gastric contents. Options 1, 3, and 4 are not signs of this complication.

*Question: A client with a headache arrives in the emergency department and is staggering, confused, smells of alcohol, and is verbally abusive. The nurse explains to the client that the primary health care provider will need to perform an assessment before the administration of medication. When the client becomes verbally abusive, the nurse threatens to place the client in restraints. With what can the client legally charge the nurse as a result of this nursing action?*

*Answer: Assault* Rationale: An assault occurs when a person puts another person in fear of a harmful or offensive contact. For this intentional tort to be actionable, the victim must be aware of the threat of harmful or offensive contact. Battery is the actual contact with one's body. Negligence involves actions below the standards of care. When the individual's private affairs are unreasonably intruded upon, invasion of privacy occurs.

*Question: A client arrives to the surgical nursing unit after surgery. What would be the initial nursing action after surgery?*

*Answer: Assess patency of the airway.* Rationale: If the airway is not patent, immediate measures must be taken for the survival of the client. After checking the client's airway, the nurse would then check the client's vital signs, followed by the dressings, tubes, and drains.

*Question: A client receiving chemotherapy asks the nurse, "What will I do when my hair starts to fall out?" Which action by the nurse is therapeutic?*

*Answer: Assist her to express feelings.* Rationale: The nurse should encourage the client to express her feelings initially. Selecting a wig before the hair falls out will enable the client to better match hair color and texture of the wig with her natural hair. A new hairstyle will not be beneficial to the client because the hair will have fallen out. Option 3 is nontherapeutic, and option 4 can be considered false reassurance.

*Question: The nurse is planning the client assignments. Which is the least appropriate assignment for the assistive personnel (AP)?*

*Answer: Assisting a child who is profoundly developmentally disabled to eat lunch* Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the least appropriate assignment for the AP would be assisting a profoundly developmentally disabled child with feeding. The child is likely to have difficulty eating and therefore has a higher potential for complications, such as choking and aspiration. The remaining options do not include data indicating that these tasks carry any unforeseen risk.

*Question: The nurse is assisting in planning client assignments. Which is the most appropriate assignment for the assistive personnel (AP)?*

*Answer: Assisting a client to ambulate after an appendectomy* Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a AP would be assisting a client to ambulate after an appendectomy. Options 1, 2, and 4 would require assessment and teaching, so they cannot be delegated to a AP.

*Question: A client with narcolepsy has been prescribed a central nervous system (CNS) stimulant. The client complains to the nurse that he cannot sleep well anymore at night and does not want to take the medication any longer. Before making any specific comment, the nurse plans to investigate whether the client takes the medication at which time schedule?*

*Answer: At least 6 hours before bedtime* Rationale: A central nervous system (CNS) stimulant acts by releasing norepinephrine from nerve endings. The client should take the medication at least 6 hours before going to bed at night to prevent disturbances with sleep. Taking the medication at the time frames indicated in options 1, 2, and 3 will prevent the client from sleeping because of the stimulant properties of the medication.

*Question: A urinalysis has been prescribed for an infant and the nurse plans to collect the specimen. The nurse implements which appropriate method to collect the specimen?*

*Answer: Attaches a urinary collection device to the infant's perineum* Rationale: Although many methods have been used to collect urine from an infant, the most reliable method is the urine collection device. This device is a plastic bag that has an opening lined with adhesive so that it may be attached to the perineum. Urine for certain tests, such as specific gravity, may be obtained from a diaper. Urinary catheterization is not to be done unless specifically prescribed because of the risk of infection. It is not reasonable to monitor urinary patterns and attempt to collect the specimen in a cup when the infant voids.

*Question: The nurse discovers that one of her assigned clients is bleeding excessively from an abdominal incision. The nurse gives specific prescriptions to an assistive personnel (AP) to attend to the other clients and tells another nurse to call the primary health care provider immediately. In this situation, the nurse is implementing which leadership style?*

*Answer: Autocratic* Rationale: Autocratic leadership, also called "directive leadership," involves the leader in assuming complete control over the decisions and activities of the group. In this situation, the nurse assumed the autocratic style of leadership so that all necessary tasks would be accomplished immediately. Democratic leadership, also called "participative leadership," is characterized by a sense of equality among the leader and other participants. Situational leadership is a comprehensive approach that incorporates the leader's style, the maturity of the work group, and the situation at hand. Laissez-faire is a permissive style of leadership in which the leader gives up control and delegates all decision-making to the work group.

*Question: The client recovering from a third-degree burn asks the nurse about grafts. The nurse explains to the client that the best type of graft is which?*

*Answer: Autograft* Rationale: It is most desirable to graft the client's own skin (autograft), but when this is not possible, a homograft (the skin of another person [allograft], obtained from a cadaver), a heterograft (xenograft, usually obtained from a pig), or artificial (biosynthetic) skin, such as Biobrane, can be used as a temporary measure.

*Question: A perinatal client is at risk for toxoplasmosis. Which instruction would the nurse reinforce with the client to prevent exposure to this disease?*

*Answer: Avoid exposure to litter boxes used by cats.* Rationale: Infected house cats transmit toxoplasmosis through feces. Handling litter boxes can transmit the disease to the maternity client. Meats that are undercooked can harbor microorganisms that can cause infection. Hands should be washed throughout the day when items that could be contaminated are handled. Topical corticosteroid treatment is not the pharmacological treatment of choice for toxoplasmosis.

*Question: The nurse is providing health care information to a pregnant client who is human immunodeficiency virus (HIV) positive. The nurse instructs the client that it is important to avoid alcohol and cigarettes during pregnancy and to get adequate rest primarily to accomplish which goal?*

*Answer: Avoid further stress on the maternal immune system.* Rationale: The use of alcohol and cigarettes during the pregnancy of an HIV-infected client, as well as not getting appropriate rest, can compromise the maternal immune system and interfere with medical treatments that may be in place. Collectively, such factors may place both the mother and fetus at additional risk during the pregnancy. Option 3 identifies the primary nursing management subject for the HIV-infected client.

*Question: The nurse is preparing discharge instructions for a client receiving baclofen. Which instruction would be included in the teaching plan?*

*Answer: Avoid the use of alcohol.* Rationale: Baclofen is a skeletal muscle relaxant. The client should be cautioned against the use of alcohol and other central nervous system depressants because baclofen potentiates the depressant activity of these agents. Constipation rather than diarrhea is an adverse side effect. Restriction of fluids is not necessary, but the client should be warned that urinary retention can occur. Fatigue is related to a central nervous system effect that is most intense during the early phase of therapy and diminishes with continued medication use. The client does not need to notify the PHCP about fatigue.

*Question: The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. Which best intervention would the nurse include when formulating a plan of care?*

*Answer: Avoid using a whisper voice in front of the client.* Rationale: Disturbed thought process related to paranoid personality disorder is the client's problem, and the plan of care must address this problem. The client is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client with this disorder.

*Question: The nurse is preparing to perform an abdominal assessment on a client. The nurse places the client in which best position to perform the assessment? Refer to figure.View Figure*

*Answer: B* Rationale: The dorsal recumbent position is the best position used for abdominal assessment because it promotes relaxation of abdominal muscles. In addition, clients with painful disorders are more comfortable with the knees flexed. The sitting upright position in option 1 provides full expansion of the lungs and visualization of the upper body parts. In option 3, the Sims' position is used for assessment of the rectal and vaginal area. The lithotomy position in option 4 is used for assessment of the female genitalia.

*Question: A primary health care provider has told the mother of a newborn diagnosed with strabismus that surgery will be necessary to realign the weakened eye muscles. The mother asks the nurse when the surgery might be performed. Which time frame for the surgery would the nurse explain to the mother?*

*Answer: Before the child is 3 years old* Rationale: In a child diagnosed with strabismus, surgery may be indicated to realign the weakened muscles. It is most often indicated when amblyopia (decreased vision in the deviated eye) is present. The surgery would be performed before the child is 3 years old.

*Question: The nursing student is preparing a conference on Freud's psychosexual stages of development, specifically the anal stage. Which appropriately relates to this stage?*

*Answer: Beginning of toilet training* Rationale: Toilet training generally occurs during this period. According to Freud, the child gains pleasure from both the elimination and retention of feces. Self-gratification relates to the oral stage. Tapering off of conscious biological and sexual urges relates to the latency period. Association with pleasurable and conflicting feelings about genital organs relates to the phallic stage.

*Question: A client is complaining of low back pain with radiation down the left posterior thigh. The nurse continues to collect data from the client to see if the pain is worsened or aggravated with which action?*

*Answer: Bending or lifting* Rationale: Low back pain with radiation into one leg (sciatica) is consistent with herniated lumbar disk. The nurse continues to collect data from the client to see if the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, coughing, or lifting the leg straight up while supine (straight leg raise test). The other actions assist in alleviating pain.

*Question: The nurse is assigned to care for a client 1 hour after delivery. The nurse palpates a firm, uterine fundus 2 cm above the umbilicus and displaced to the right. The nurse recognizes that this finding indicates which condition?*

*Answer: Bladder distention* Rationale: Immediately following expulsion of the placenta, the fundus is firmly contracted, midline, and located one half to two thirds of the way between the symphysis pubis and the umbilicus. Because the uterine ligaments are still stretched, a full bladder can move the uterus upward and to the side. Options 1, 3, and 4 are complications not usually indicated by a firm and displaced uterus.

*Question: The nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. How would the nurse explain compartment syndrome?*

*Answer: Bleeding and swelling cause increased pressure in an area that cannot expand.* Rationale: Compartment syndrome is caused by bleeding and swelling within a compartment lined by fascia that does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment, triggering the signs and symptoms.

*Question: A client diagnosed with portosystemic encephalopathy is receiving oral lactulose daily. The nurse would check which to determine medication effectiveness?*

*Answer: Blood ammonia level* Rationale: Lactulose is a hyperosmotic laxative and ammonia detoxicant. It is used to prevent or treat portosystemic encephalopathy, including hepatic precoma and coma. It also is used to treat constipation. The medication retains ammonia in the colon (decreases the blood ammonia concentration), producing an osmotic effect. It promotes increased peristalsis and bowel evacuation, expelling ammonia from the colon.

*Question: Methylergonovine is prescribed for a client with postpartum hemorrhage caused by uterine atony. Before administering the medication the nurse checks which important client parameter?*

*Answer: Blood pressure* Rationale: Methylergonovine is an ergot alkaloid used for postpartum hemorrhage. It stimulates contraction of the uterus and causes arterial vasoconstriction. Ergot alkaloids are avoided in clients with significant cardiovascular disease, peripheral disease, hypertension, eclampsia, or preeclampsia. These conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. The nurse should check the client's blood pressure before administering the medication and should follow agency protocols regarding withholding of the medication. Temperature, lochial flow, and urine output are items that are checked in the postpartum period, but they are unrelated to the use of this medication.

*Question: A client with angina pectoris is experiencing chest pain that radiates down the left arm. The nurse administers a sublingual nitroglycerin tablet to the client. The client's pain is unrelieved, and the nurse determines that the client needs another nitroglycerin tablet. Which vital sign is most important for the nurse to check before administering a second dose of the medication?*

*Answer: Blood pressure* Rationale: Nitroglycerin acts directly on the smooth muscle of the blood vessels, causing relaxation and dilation. As a result, hypotension can occur. The nurse should check the client's blood pressure before administering the second nitroglycerin tablet. Although the respirations, apical pulse, and temperature may be checked, these vital signs are not the most important assessments related to administration of this medication.

*Question: The nurse caring for an infant with bronchiolitis is monitoring for signs of dehydration. The nurse monitors which method as reliable for determining fluid loss?*

*Answer: Body weight* Rationale: Body weight is the most reliable method of measurement of body fluid loss or gain. One kilogram of weight change represents 1 L of fluid loss or gain. Although options 1, 2, and 3 may be used to determine fluid status, they are not the most reliable determinants.

*Question: The nurse is administering an intravenous dose of methocarbamol to a client with multiple sclerosis. For which adverse effect would the nurse monitor?*

*Answer: Bradycardia* Rationale: Intravenous administration of methocarbamol can cause hypotension and bradycardia. The nurse needs to monitor for these adverse effects. Options 1, 2, and 4 are not effects with administration of this medication.

*Question: A client with advanced ovarian cancer is being treated with paclitaxel. The nurse monitors the client closely for which side effect of the medication?*

*Answer: Bradycardia* Rationale: Side effects of paclitaxel include alopecia, pain in the joints and muscles, diarrhea, nausea, vomiting, peripheral neuropathy, hypotension, mucositis, pain and redness at the injection site, cardiac disturbances (bradycardia), and an abnormal electrocardiogram. Insomnia is not associated with the medication.

*Question: Neuroleptic malignant syndrome is suspected in a client who is taking chlorpromazine. Which medication would the nurse prepare in anticipation of the prescription to treat this adverse effect related to the use of chlorpromazine?*

*Answer: Bromocriptine* Rationale: Bromocriptine is an antiparkinsonian prolactin inhibitor used in the treatment of neuroleptic malignant syndrome. Protamine sulfate is the antidote for heparin overdose. Vitamin K is the antidote for warfarin overdose. Enalapril maleate is an antihypertensive used in the treatment of hypertension.

*Question: The nurse is caring for a client who has been taking diuretics on a long-term basis. The nurse reviews the medication record, knowing that which medications if prescribed for this client would place the client at risk for hypokalemia?*

*Answer: Bumetanide* Rationale: Bumetanide is a potassium-losing loop diuretic. The client on this medication would be at risk for hypokalemia. Spironolactone, triamterene, and amiloride hydrochloride are potassium-retaining diuretics.

*Question: A client on the nursing unit has a prescription for a central nervous (CNS) stimulant orally daily. The nurse collaborates with the dietitian to limit the amount of which item on the client's dietary trays?*

*Answer: Caffeine* Rationale: Caffeine is a stimulant and should be limited in the client taking a central nervous system (CNS) stimulant. The client should also be taught to limit caffeine intake as well.

*Question: The nurse receives a telephone call from a neighbor who states that her child was found sitting on the floor near the kitchen sink playing with several bottles of cleaning fluids. The bottles of cleaning fluid were opened and spilled on the child and the floor, and the mother suspects that the child may have consumed some of the cleaning fluid. Which action would the nurse tell the mother to do immediately?*

*Answer: Call the area poison control center.* Rationale: The area poison control center should be called if an unknown toxic agent has been ingested or if it is necessary to identify an antidote for a known toxic agent. Syrup of ipecac is not recommended for home use. It may be prescribed in a hospitalized setting under medical supervision. It induces vomiting, but vomiting is not induced in an unconscious client or after ingestion of caustic substances (acid or alkaline) or petroleum distillates. Calling an ambulance or calling the primary health care provider will delay necessary lifesaving measures.

*Question: A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. Which action would the nurse instruct the mother to take first?*

*Answer: Call the poison control center.* Rationale: If a suspected poisoning occurs, the poison control center should be contacted immediately. The nurse can assist the mother with contacting the poison control center. Vomiting should not be induced without instructions from the poison control center. Inducing vomiting is not done if the client is unconscious or the substance ingested is a strong corrosive or petroleum product. Bringing the child to the emergency department or calling an ambulance would delay treatment. The poison control center may advise the mother to bring the child to the emergency department; if this is the case, the mother should call an ambulance.

*Question: The nurse discusses emergency nursing measures that are implemented at the site of an injury with a nursing student. Which initial action does the nurse tell the student to perform in the event of carbon monoxide poisoning?*

*Answer: Carry the client to fresh air.* Rationale: Whenever a victim inhales a poison, the victim is carried immediately to fresh air. Any tight clothing is then loosened and CPR is initiated if necessary. Oxygen is administered as soon as possible. Chilling is prevented, and the victim is wrapped in blankets and kept as quiet as possible.

*Question: The nurse is caring for a child recently diagnosed with cerebral palsy. The parents of the child ask the nurse about the disorder. The nurse bases the response to the parents on the understanding that cerebral palsy is best described by which statement?*

*Answer: Cerebral palsy is a chronic disability characterized by a difficulty in controlling the muscles.* Rationale: Cerebral palsy is a chronic disability characterized by difficulty in controlling the muscles as a result of an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infection. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.

*Question: The nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which assessment finding most likely indicates a hematoma?*

*Answer: Changes in vital signs* Rationale: Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with vulvar hematoma. Options 3 and 4 are inaccurate for a client who is anesthetized. Heavy bruising may be noted, but vital sign changes are most likely to indicate the presence of a hematoma.

*Question: The emergency department nurse is gathering initial data on a child suspected of epiglottitis. Which is the nurse's highest priority?*

*Answer: Check for a patent airway.* Rationale: When epiglottitis is suspected, the priorities are to maintain a patent airway and to next obtain an x-ray to confirm the diagnosis. If epiglottitis is present, the child is taken promptly to the operating room for tracheal intubation. Although options 2, 3, and 4 may be components of care, they are not the priority.

*Question: The nurse is caring for a newborn with a diagnosis of spina bifida (myelomeningocele). Which would the nurse perform to monitor for a major symptom of this condition?*

*Answer: Check for responses to painful stimuli from the torso downward.* Rationale: Newborns with spina bifida (myelomeningocele type) demonstrate lack of nerve innervation from below the site of the gibbus (sac containing the meninges and spinal cord). They therefore show diminished or no responses to painful stimuli in the areas below the gibbus. Options 1, 2, and 4 are incorrect because the area above the gibbus is not affected. The capillary refill would be normal. The urine would not have blood present. If the kidneys are affected, proteinuria could be present, but this is not generally noted in the newborn period. No abdominal masses are present.

*Question: A client in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The client tells the nurse that she frequently has leg cramps, primarily when she is reclining. On the basis of the client's complaint, which would the nurse do first?*

*Answer: Check for signs of thrombophlebitis.* Rationale: Leg cramps may be a result of compression of the nerves supplying the legs because of the enlarging uterus, a reduced level of diffusible serum calcium, an increase in serum phosphorus, or the presence of thrombophlebitis. In the pregnant client who complains of leg cramps, the nurse should first check for signs of thrombophlebitis and notify the registered nurse. If thrombophlebitis is not present, the nurse may be instructed to place heat on the affected area, dorsiflex the foot until the spasm relaxes, or have the client stand on a cold surface. The primary health care provider may prescribe oral supplementation with calcium carbonate tablets or calcium hydroxide gel with each meal to increase the calcium level and lower the phosphorus level. Although the nurse may check for edema and check the pedal pulses, these should not be the first actions.

*Question: Atenolol hydrochloride is prescribed for a hospitalized client. The nurse would perform which as a priority action before administering the medication?*

*Answer: Check the client's blood pressure.* Rationale: Atenolol hydrochloride is a beta blocker used to treat hypertension. Therefore, the priority nursing action before administration of the medication is to check the client's blood pressure. The nurse also checks the client's apical heart rate. If the systolic blood pressure is below 90 mm Hg or the apical pulse is 60 beats per minute or lower, the medication is withheld and the registered nurse and/or health care provider is notified. The nurse should check baseline renal and liver function tests. The medication may cause weakness, and the nurse should assist the client with activities if weakness occurs.

*Question: The nurse is caring for a client during the immediate recovery phase or fourth stage of labor. Which action is most important for the nurse to take at this time?*

*Answer: Check the uterine fundus and lochia.* Rationale: A potential complication following delivery is hemorrhage. The most significant source of bleeding is the site where the placenta is implanted. It is critical that the uterus remain contracted, and vaginal blood flow is monitored every 15 minutes for the first 1 to 2 hours to maintain physiological integrity. Options 1, 2, and 4 are nursing actions that would follow.

*Question: A client who is on lithium carbonate will be discharged at the end of the week. In reinforcing a discharge teaching plan, the nurse would include which instructions?*

*Answer: Check with the psychiatrist before using any over-the-counter (OTC) medications or prescription medications.* Rationale: The client needs to check with the psychiatrist before using any over-the-counter (OTC) medications or prescription medications. Many OTC medications interact with lithium, and the client is instructed to avoid OTC medications while taking lithium. Lithium is the medication of choice to treat manic-depressive illness. Lithium is not addicting, and although serum lithium levels need to be monitored, it is not necessary to check these levels every week. A tyramine-free diet or one including soy sauce, wine, and aged cheese, is associated with monoamine oxidase inhibitors.

*Question: The nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy. A wound drain is in place in the abdominal wound. Which nursing action would be appropriate during the dressing change?*

*Answer: Checking the wound site for drainage from the drain* Rationale: The wound site needs to be checked for drainage from the drain; the drainage can excoriate the skin. Usually the drainage from the wound is pale, red, and watery. Active bleeding is bright red. Aseptic technique must be used when changing the dressing to avoid contamination of the wound, and sterile gloves are worn. The drain should be checked for patency to provide an exit for the fluid and blood to promote healing. The drainage needs to flow freely, and there should be no kinks in the drains. Curling, folding, or taping the drain prevents the flow of drainage. The tube is not advanced.

*Question: The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data indicate to the nurse a favorable resolution of the fat embolus?*

*Answer: Clear chest x-ray* Rationale: A clear chest x-ray is a favorable indicator that the fat embolus is resolving. When fat embolism occurs, the chest x-ray has a "snowstorm" appearance. Eupnea (unlabored breathing), not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be greater than 95%.

*Question: The nursing instructor asks a nursing student about the points to document if the client has had a seizure. The instructor determines that the student needs to research seizures and related documentation points if the student states which assessment is important?*

*Answer: Client's diet in the 2 hours preceding seizure activity* Rationale: Typically, seizure assessment includes the time the seizure began, part(s) of the body affected, the type of movements and progression of the seizure, changes in pupil size, eye deviation or nystagmus, client condition and vital signs during the seizure, and postictal status.

*Question: A client with a history of simple partial seizures is taking clorazepate, and asks the nurse if there is a risk of addiction. The nurse's response is based on which fact?*

*Answer: Clorazepate leads to physical and psychological dependence with prolonged high-dose therapy.* Rationale: Clorazepate is classified as an anticonvulsant, antianxiety agent, and sedative-hypnotic. One of the concerns with clorazepate therapy is that the medication can lead to physical or psychological dependence with prolonged therapy at high doses. For this reason, the amount of medication that is readily available to the client at any one time is restricted. Options 1, 2, and 4 are incorrect.

*Question: Levalbuterol via inhalation is prescribed for a client with a diagnosis of emphysema. The nurse reinforces instructions to the client regarding the medication and teaches the client about the dietary restrictions that must be implemented while taking this medication. The nurse determines that the client understands the dietary instructions when the client states he will avoid which food choice?*

*Answer: Cocoa* Rationale: Levalbuterol is a bronchodilator. This medication stimulates the beta receptors in the lungs, relaxes bronchial smooth muscle, increases vital capacity, and decreases airway resistance. Central nervous system (CNS) stimulation can occur with the use of this medication. The client is instructed to avoid caffeine-containing products such as coffee, tea, colas, and chocolate because these products can cause further CNS stimulation. Options 2, 3, and 4 are food items that are high in potassium.

*Question: The nurse is preparing to give a postcraniotomy client medication for incisional pain. The family asks the nurse why the client is receiving codeine sulfate and not "something stronger." The nurse would formulate a response based on which understanding of codeine?*

*Answer: Codeine does not alter respirations or mask neurological signs as do other opioids.* Rationale: Codeine sulfate is the opioid analgesic often used for clients after craniotomy. It is frequently combined with a nonopioid analgesic such as acetaminophen for added effect. It does not alter the respiratory rate or mask neurological signs as do other opioids. Side effects of codeine include gastrointestinal upset and constipation. The medication can lead to physical and psychological dependence with chronic use. It is not the strongest opioid analgesic available.

*Question: A primary health care provider prescribes auranofin for a client with rheumatoid arthritis. Which data would indicate to the nurse that the client is experiencing toxicity related to the medication?*

*Answer: Complaints of a metallic taste in the mouth* Rationale: Early symptoms of toxicity of auranofin include a rash, purple blotches, pruritus, mouth lesions, and a metallic taste in the mouth. Auranofin is the one gold preparation that is given orally rather than by injection. Gastrointestinal reactions including diarrhea, abdominal pain, nausea, and loss of appetite are common early in therapy, but these usually subside in the first 3 months of therapy.

*Question: The nurse is assisting in collecting subjective and objective data from a client admitted to the hospital with tuberculosis (TB). The nurse would expect to note which finding?*

*Answer: Complaints of night sweats* Rationale: The client with TB usually experiences a low-grade fever, weight loss, pallor, chills, and night sweats. The client also will complain of anorexia and fatigue. Pulmonary symptoms include a cough that is productive of a scant amount of mucoid sputum. Purulent, blood-stained sputum is present if cavitation occurs. Dyspnea and chest pain occur late in the disease.

*Question: The nurse assists the nurse-midwife in examining the client. The midwife documents the following data: cervix 80% effaced and 3 cm dilated, vertex presentation minus (-) 2 station, membranes ruptured. The nurse anticipates that the midwife will prescribe which activity for the client?*

*Answer: Complete bed rest* Rationale: Rupture of the membranes with the presenting part not engaged and firmly down against the cervix can increase the risk of prolapsed cord. Activity and the downward force of gravity with the client upright can also increase the risk. Options 1, 2, and 4 are incorrect activity prescriptions.

*Question: The nurse is trying to communicate with a stroke (brain attack) client with aphasia. Which action by the nurse would be least helpful to the client?*

*Answer: Completing the sentences that the client cannot finish* Rationale: Clients with aphasia after stroke often fatigue easily and have a short attention span. General guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner. The nurse should avoid shouting (because the client is not deaf), appearing impatient for a response, and completing responses for the client.

*Question: A client has several fractures of the lower leg and has been placed in an external fixation device. The client is upset about the appearance of the leg, which is very edematous. The nurse determines that the client is experiencing which problem?*

*Answer: Concerns about body image* Rationale: The client is expressing concerns about body image. The data in the question are unrelated to isolation and inability to tolerate activity. Although the client is unable to physically move about, this is not associated with what the client is upset about.

*Question: The nurse is preparing to initiate a tube feeding for a client, and the primary health care provider has prescribed that the feeding be infused at 50 mL per hour. The nurse brings an electronic feeding pump to the bedside and discovers that there is no available outlet in the wall socket to plug the pump into. Which action would the nurse implement?*

*Answer: Contact the electrical maintenance department for assistance.* Rationale: The nurse needs to use hospital resources for assistance. A regular extension cord should not be used because it poses the risk of fire. The use of electrical appliances near a sink also presents a hazard. If the use of a pump is required to administer the feeding as prescribed, the nurse must provide safe means for its use.

*Question: The nurse employed in a long-term care facility calls the primary health care provider (PHCP) regarding a new medication prescription because the dose prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action would the nurse take?*

*Answer: Contact the nursing supervisor.* Rationale: If the PHCP writes a prescription that requires clarification, it is the nurse's responsibility to contact the PHCP for clarification. If there is no resolution regarding the prescription because the PHCP cannot be located or because the prescription remains as it was written after talking with the PHCP, the nurse should then contact the nurse manager or supervisor for further clarification as to what the next step would be. Under no circumstances should the nurse proceed to carry out the prescription until clarification has been obtained.

*Question: The nurse is reinforcing instructions to a maternity client on how to keep a fetal activity diary. Which instruction would the nurse provide the client?*

*Answer: Contact the primary health care provider if the baby's movements are fewer than 10 times in 2 hours.* Rationale: Most healthy fetuses move at least 10 times in 2 hours. Slowing or stopping of fetal movement may be an indication that the fetus needs some attention and evaluation. In general, women are advised to count fetal movements for 30 minutes three times a day. The woman should lie on her left side during the procedure because it provides optimal circulation to the uterus-placenta-fetus unit. The time of day may affect fetal movement, which is lower in the morning and higher in the evening.

*Question: A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric (NG) tube. Which action would the nurse take?*

*Answer: Continue to monitor the drainage.* Rationale: Following gastrectomy, drainage from the NG tube is normally bloody for 24 hours postoperatively, changing to brown-tinged and then to yellow or clear. Because bloody drainage is expected in the immediate postoperative period, the nurse should continue to monitor the drainage. There is no need to notify the PHCP at this time. Measuring abdominal girth is performed to detect the development of distention. Following gastrectomy, an NG tube should not be irrigated.

*Question: The nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action would be appropriate?*

*Answer: Continue to monitor.* Rationale: The presence of fluctuations in the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. The apparatus and all connections must remain airtight at all times, and the drainage is never emptied because of the risk of disruption in the closed system, which can result in lung collapse. Encouraging the client to deep breathe is unrelated to this observation. The client is not told to hold his or her (client) breath.

*Question: A client with vascular headaches is taking ergotamine. Which client complaint would the nurse monitor?*

*Answer: Cool, numb fingers and toes* Rationale: Ergotamine produces vasoconstriction, which suppresses vascular headaches when given at a therapeutic dose range. The nurse monitors for hypertension; cool, numb fingers and toes; muscle pain; and nausea and vomiting. Options 1, 2, and 3 are not associated with this medication.

*Question: The home care nurse is selecting dressing supplies for a client who has an allergy to latex. The nurse would ask the medical supply personnel to deliver which items?*

*Answer: Cotton pads and silk tape* Rationale: Cotton pads and plastic or silk tape are latex-free products. The items identified in the incorrect options are products that contain latex.

*Question: The nurse is giving a bed bath to an assigned client. An assistive personnel (AP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The nurse would do which?*

*Answer: Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.* Rationale: The nurse is responsible for the care provided to the assigned clients. The appropriate action is to provide safety to the client that is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the AP.

*Question: The home care nurse is assigned to care for a client who returned home following treatment for a sprained ankle. The nurse notes that the client was sent home with crutches that have rubber axillary pads, and the nurse needs to reinforce instructions regarding crutch walking. On data collection, the nurse discovers that the client has an allergy to latex. Before providing instructions regarding crutch walking, the nurse would do which action?*

*Answer: Cover the crutch pads with cloth.* Rationale: The rubber pads used on crutches may contain latex. If the client requires the use of crutches, the nurse can cover the pads with a cloth to prevent cutaneous contact. Telling the client that the crutches must be immediately removed from the house is inappropriate and may alarm the client. The nurse cannot prescribe a cane for a client. In addition, this type of assistive device may not be appropriate considering this client's injury. No reason exists to contact the PHCP at this time.

*Question: A client is receiving topical corticosteroid therapy in the treatment of psoriasis. The nurse expects the primary health care provider to prescribe which measure to maximize the effectiveness of this therapy?*

*Answer: Covering the application with a warm, moist dressing and an occlusive outer wrap* Rationale: The nurse can enhance penetration of topical corticosteroid therapy to the client with psoriasis by applying warm moist heat and an occlusive outer wrap. The wrap may consist of a plastic film, glove, bootie, or a similar item. If large surface areas of skin are involved, the occlusive therapy may be limited to 12 hours per day to minimize local and systemic side effects. The remaining options are not measures that will enhance the effectiveness of therapy.

*Question: The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. The nurse understands that assessment of which cranial nerve would identify a complication specifically associated with this surgery?*

*Answer: Cranial nerve VII, facial nerve* Rationale: Treatment for acoustic neuroma is surgical removal via a craniotomy. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve. Acoustic neuromas rarely reoccur following surgical removal.

*Question: An older client is taking multiple medications for a variety of health problems. The nurse would monitor the results of which most important laboratory test(s) when evaluating adverse effects of medication therapy in the older adult?*

*Answer: Creatinine* Rationale: Creatinine should be most closely monitored because it relates to kidney function. Because many medications are excreted by the kidneys, that makes this the laboratory test of choice for ongoing monitoring. The hemoglobin and hematocrit are part of the complete blood cell count, whereas arterial blood gases are not generally measured unless there is a specific problem with oxygenation.

*Question: The nurse is collecting data from an older adult client. Which indicates a potential complication associated with the skin of this client?*

*Answer: Crusting* Rationale: The normal physiological changes that occur in the skin of older adults include thinning of the skin, loss of elasticity, deepening of expression lines, and wrinkling. Crusting noted on the skin indicates a potential complication.

*Question: The nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed to touch down the affected leg. How would the nurse teach the client to use the crutches?*

*Answer: Crutches and the left leg, then advance the right leg* Rationale: A three-point gait requires good balance and arm strength. The crutches are advanced with the affected leg, and then the unaffected leg is moved forward. Putting the crutches down and then moving both legs simultaneously describes a swing-to gait. Putting the crutches and the right leg down then advancing the left leg describes the three-point gait used for a right-leg problem. Putting the left leg and right crutch down and then the right leg and left crutch down describes a two-point gait.

*Question: A mother of a child with cystic fibrosis asks the clinic nurse about the disease. How would the nurse respond to the mother about the disease?*

*Answer: Cystic fibrosis is a chronic multisystem disorder affecting the exocrine glands.* Rationale: Cystic fibrosis is a chronic multisystem disorder affecting the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and the pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait.

*Question: A mother brings her 4-month-old infant to the well-baby clinic for immunizations. Which immunizations would be administered to this infant?*

*Answer: DTaP, Hib, IPV, pneumococcal vaccine (PCV)* Rationale: DTaP, Hib, IPV, and PCV are administered at 4 months of age. DTaP is administered at 2 months, 4 months, 6 months, between 12 and 18 months, and between 4 and 6 years of age. Hib is administered at 2 months, 4 months, 6 months, and between 12 and 15 months of age. IPV is administered at 2 months, 4 months, 6 months, and between 4 and 6 years of age. The first dose of MMR is administered between 12 and 15 months of age; the second dose is administered at 4 to 6 years of age (if the second dose was not given by 4 to 6 years of age, it should be given at the next visit). The first dose of hepatitis B vaccine is administered between birth and 2 months, the second dose is administered between 1 and 4 months, and the third dose is administered between 6 and 18 months of age. Varicella zoster vaccine is administered between 12 and 18 months of age. PCV is administered at 2, 4, and 6 months of age and between 12 and 15 months of

*Question: The licensed practical nurse (LPN) is assisting a school nurse in conducting a session with female adolescents regarding the menstrual cycle. The LPN tells the adolescents that the most likely day for ovulation in a 30-day menstrual cycle is which day?*

*Answer: Day 16* Rationale: The normal duration of the menstrual cycle is about 28 days. However, in a longer menstrual cycle, ovulation typically occurs 14 days before day 1 of the next cycle. Thirty days minus 14 days would be day 16.

*Question: The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action?*

*Answer: Decline to sign the will.* Rationale: Living wills are required to be in writing and signed by the client. The client's signature either must be witnessed by specified individuals or notarized. Many states prohibit any employee from being a witness, including the nurse in a facility in which the client is receiving care.

*Question: An adult client with suspected meningitis has undergone lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis of a bacterial infection. The nurse checks for which value indicating a bacterial infection of the CSF?*

*Answer: Decreased glucose level* Rationale: Findings that indicate a bacterial infection of the cerebrospinal fluid include presence of a bacterial organism, elevated WBC count, elevated protein level, and decreased glucose level. Red blood cells should not be present in CSF.

*Question: An older client has been prescribed digoxin. The nurse determines that which age-related change would place the client at risk for digoxin toxicity?*

*Answer: Decreased lean body mass and glomerular filtration rate* Rationale: The older client is at risk for medication toxicity because of decreased lean body mass and an age-associated decreased glomerular filtration rate. Although the other changes identify age-related changes that occur in the older client, they are not specifically associated with this risk.

*Question: A client with multiple sclerosis is receiving baclofen. The nurse monitoring this client would look for which outcome to indicate a primary therapeutic response from the medication?*

*Answer: Decreased muscle spasms* Rationale: A primary therapeutic response from baclofen is to decrease the frequency and amplitude of muscle spasms in clients with spinal cord injuries or diseases and multiple sclerosis. Baclofen is a skeletal muscle relaxant and acts at the spinal cord level. Increased muscle tone and strength and increased range of motion of all extremities are not directly related to the effects of this medication. Decreased nausea is incorrect.

*Question: A 10-year-old child with asthma is treated for acute exacerbation. Which finding would indicate that the condition is worsening?*

*Answer: Decreased wheezing* Rationale: Decreased wheezing in a child who is not improving clinically may be interpreted incorrectly as a positive sign, when in fact it may signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With treatment, increased wheezing may actually signal that the child's condition is improving. Warm, dry skin indicates an improvement in the condition because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats per minute.

*Question: An abdominal postoperative client has been tolerating a full liquid diet, and the nurse plans to advance the diet to solid food as prescribed. The nurse collects data regarding which important item before advancing the diet to solids?*

*Answer: Dentition and ability to chew* Rationale: It may be necessary to modify a client's diet to a soft or mechanical chopped diet if the client has difficulty chewing. Food and cultural preferences should have been determined on admission. Bowel sounds should be present before introducing any diet to a postoperative client.

*Question: When teaching a client who is being started on imipramine hydrochloride, when would the nurse tell the client that the medication would have the desired effects?*

*Answer: Desired effects do not occur for 2 to 3 weeks of administration.* Rationale: The therapeutic effects of administration of imipramine hydrochloride may not occur for 2 to 3 weeks after the antidepressant therapy has been initiated. Therefore, the other times are incorrect.

*Question: The nurse learns in report that a client is exhibiting Cheyne-Stokes respirations. Based on this data, which action is most appropriate for the nurse to take initially?*

*Answer: Determine the client's ability to follow verbal commands.* Rationale: Cheyne-Stokes respirations, rhythmic respirations with periods of apnea, occur with disorders affecting the respiratory center of the pons in the central nervous system such as a metabolic dysfunction in the cerebral hemisphere or basal ganglia. The nurse should initially obtain data about neurological functioning, starting with determining the client's ability to respond to verbal stimuli. Listening to heart sounds is important but is secondary to determining the neurological status. There is no information related to the need to check for a pulse deficit (difference between the apical and radial pulse). The use of incentive spirometry is indicated for shallow breathing and postoperatively.

*Question: A client has just delivered a viable newborn. The first nursing action to initiate attachment is which?*

*Answer: Determine the parents' desires for contact with the newborn.* Rationale: Although immediate contact may be important for attachment or breastfeeding, the parents' wishes concerning contact with their newborn must be supported and determined first. The remaining options would follow the initial intervention.

*Question: The nurse is assisting in developing a plan of care for a paranoid client who experiences religious delusions. Which short-term goal would be most appropriate?*

*Answer: Develops a relationship to help reduce the frequency of the delusions* Rationale: The short-term goal that would be most appropriate in this situation is develops a relationship to help reduce the frequency of the delusions. Paranoid clients feel anxious and threatened as a result of a lack of trust. Increasing the ability to trust will help decrease delusional thinking. Defending the delusion is not therapeutic, and relinquishing the need for delusional thinking is not realistic at this time. Verbalizing the reasons for the delusion may also not be realistic in the short term.

*Question: The nurse would check for vision loss in a client with which condition?*

*Answer: Diabetes mellitus* Rationale: Elevated blood glucose levels can cause temporary blurred vision. Over time, permanent retinal changes can occur in clients with diabetes mellitus. Options 1, 2, and 4 are not conditions that cause eye damage.

*Question: Capecitabine is prescribed for a client with metastatic breast cancer. The nurse reinforces information to the client about the medication including what frequent side effect?*

*Answer: Diarrhea* Rationale: Capecitabine is an antineoplastic medication. Diarrhea is a frequent side effect associated with the medication. Headache, myalgia, and dyspepsia can occur with the use of this medication, but these are not frequent side effects.

*Question: A child is hospitalized with a diagnosis of lead poisoning. The nurse caring for the child would prepare to assist in administering which medication?*

*Answer: Dimercaprol* Rationale: Dimercaprol is a chelating agent that is administered to remove lead from the circulating blood and from some tissues and organs for excretion in the urine. Sodium bicarbonate may be used in salicylate poisoning. Syrup of ipecac is used in the hospital setting in poisonings to induce vomiting. Activated charcoal is used to decrease absorption in certain poisoning situations. Note that dimercaprol is prepared with peanut oil, and hence should be avoided by clients with known or suspected peanut allergy.

*Question: A client who excessively uses alcohol and who is motivated to stop tells the nurse, "I know that there is a medication that can help people like me quit drinking." Which medication would the nurse explain is available for this purpose?*

*Answer: Disulfiram* Rationale: Disulfiram is a medication used for alcoholism that aids in the maintenance of sobriety. An adverse reaction occurs if the client drinks while taking this medication. The client should be motivated to stop drinking before being given this medication. The other medications are incorrect. Pyridoxine, vitamin B6, is a vitamin supplement. Chlordiazepoxide is a benzodiazepine used to manage anxiety disorders and alcohol withdrawal symptoms. Clonidine is an antihypertensive and is also used in opioid withdrawal.

*Question: The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and primary health care provider (PHCP) are notified of the incident. Which is the next nursing action regarding the incident?*

*Answer: Document a complete entry in the client's record concerning the incident.* Rationale: The incident report is confidential and privileged information, and it should not be copied, placed in the chart, or have any reference made to it in the client's record. The incident report is not a substitute for a complete entry in the client's record concerning the incident.

*Question: The nurse in the labor room is caring for a client in the first stage of labor. When monitoring the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Which is the appropriate nursing action?*

*Answer: Document the findings and continue to monitor the fetal patterns.* Rationale: Early deceleration of the FHR is a gradual decrease in and return to baseline FHR in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are not necessary. The remaining options are unnecessary.

*Question: Upon palpation of the fontanel of a 3-month-old newborn, the nurse notes that the anterior fontanel has not closed and is soft and flat. Which action would the nurse take?*

*Answer: Document the findings.* Rationale: The anterior fontanel is diamond shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. The posterior fontanel closes by 2 to 3 months of age. Therefore, because the findings are normal, the nurse should document the findings.

*Question: The nurse checks the vital signs of an infant with a respiratory infection and notes that the respiratory rate is 50 breaths per minute. Which action is appropriate?*

*Answer: Document the findings.* Rationale: The normal respiratory rate in an infant is 30 to 60 breaths per minute. The nurse would document the findings.

*Question: The nurse is checking the capillary refill of a child with a cast applied to the left arm. The nurse compresses the nail bed of a finger, and it returns to its original color in 2 seconds. Which action would be taken by the nurse?*

*Answer: Document the findings.* Rationale: When checking capillary refill, the nurse would expect to note that a compressed nail bed will return to its original color in less than 3 seconds. Options 2, 3, and 4 are unnecessary actions.

*Question: A student nurse has received the client assignment for the day and is organizing the required tasks. The nursing instructor reviews the plan for time management with the student and determines that the student needs assistance with the plan if the student indicated that which activity would be part of it?*

*Answer: Documenting task completion at the end of the day* Rationale: The nurse should document task completion continually throughout the day. Options 1, 2, and 3 identify accurate components of time management.

*Question: A client who is paraplegic after spinal cord injury has been taught muscle-strengthening exercises for the upper body. The nurse determines that the client will derive the least muscle-strengthening benefit from which activity?*

*Answer: Doing active range of motion to finger joints* Rationale: Range-of-motion exercises of the finger joints prevent contractures but do not actively strengthen muscle groups needed for self-mobilization with paraplegia. Other activities that are more effective include push-ups from a prone position, sit-ups from a sitting position, extending the arms while holding weights, and squeezing rubber balls or crumpling newspaper.

*Question: A child is hospitalized with Rocky Mountain spotted fever (RMSF). The health record reveals documentation that the child was bitten by a tick 2 weeks ago. The child presents with complaints of headache, fever, and anorexia, and the nurse notes a rash on the palms of the hands and soles of the feet. The nurse reviews the primary health care provider's prescriptions and anticipates that which medication would be prescribed?*

*Answer: Doxycycline* Rationale: The care of a child with RMSF caused by the bacterium Rickettsia rickettsii will include the administration of the antibacterial doxycycline. Amphotericin B is used for fungal infections. Ganciclovir is used to treat cytomegalovirus. Amantadine is used to treat influenza A virus.

*Question: A client has had a bone scan procedure. The nurse determines that the client understands the elements of follow-up care if the client states which postprocedural care?*

*Answer: Drink plenty of water for a day or two following the procedure.* Rationale: There are no special restrictions following a bone scan. The client is encouraged to drink large amounts of water for 24 to 48 hours to flush the radioisotope from the system. The minimal amount of radioactivity of the isotope poses no hazards to the client or staff. Postprocedural care does not include reporting nausea or flushing, eating small meals, or ambulating on the day the test is done.

*Question: The nurse is reviewing the record of a client admitted to the hospital for treatment of bladder cancer. Which risk factor related to this type of cancer would the nurse likely note in the client's record?*

*Answer: Drinks coffee and smokes cigarettes* Rationale: The incidence of bladder cancer is greater in men than in women and affects the white population twice as often as African Americans. It most often occurs after the age of 40 years. Environmental health hazards have been attributed as causes. Cigarette smoking and drinking coffee are some factors associated with bladder cancer.

*Question: The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions?*

*Answer: Droplet* Rationale: A major priority in nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is prescribed. The child also is placed in a private room, with droplet precautions, for at least 24 hours after antibiotics are given. Contact, enteric, and neutropenic precautions are not associated with the mode of transmission of meningitis. Contact precautions are instituted when contact with infectious items or materials is likely. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Neutropenic precautions are instituted when the client has a low neutrophil count.

*Question: A client with a history of spinal cord injury is receiving baclofen for muscle spasms. The nurse determines that the client is experiencing a side effect of this medication if the client experiences which sign/symptom?*

*Answer: Drowsiness* Rationale: Baclofen is a centrally acting skeletal muscle relaxant. Side effects of baclofen include drowsiness, dizziness, weakness, and nausea. Occasional side effects include headache, paresthesias of the hands and feet, constipation or diarrhea, anorexia, hypotension, confusion, and nasal congestion. The other signs/symptoms are incorrect.

*Question: A client with multiple sclerosis is receiving diazepam, a centrally acting skeletal muscle relaxant. Which data would indicate that the client is experiencing a side effect related to this medication?*

*Answer: Drowsiness* Rationale: Incoordination and drowsiness are common side effects resulting from this medication. The other side effects are incorrect.

*Question: A client with Parkinson's disease has been prescribed benztropine. The nurse monitors for which gastrointestinal (GI) side effect of this medication?*

*Answer: Dry mouth* Rationale: Common GI side effects of benztropine therapy include constipation and dry mouth. Other GI side effects include nausea and ileus. These effects are the result of the anticholinergic properties of the medication.

*Question: The nurse suspects that the client has a pulmonary embolism when the client exhibits which signs and symptoms?*

*Answer: Dyspnea, tachypnea, and tachycardia* Rationale: Pulmonary embolism is the passage of a thrombus into the lungs. The usual signs and symptoms are dyspnea, tachypnea, tachycardia, a congested cough (not a dry cough), hemoptysis (not hematemesis), pleuritic chest pain, and a feeling of impending doom. Back pain, edema, skin tenderness, hematemesis, and increased skin temperature are not associated with pulmonary embolism.

*Question: The nurse is assisting in caring for a client with an inoperable lung tumor and helps develop a plan of care by addressing complications related to the disorder. The nurse includes monitoring for the early signs of vena cava syndrome in the plan. Which early sign of this oncological emergency would the nurse include monitoring for in the plan of care?*

*Answer: Edema of the face and eyes* Rationale: Vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms. Mental status changes and cyanosis are late signs.

*Question: The nurse prepares to explain the purpose of effleurage to a client in early labor. Which explanation by the nurse describes effleurage?*

*Answer: Effleurage is light stroking of the abdomen to facilitate relaxation during labor.* Rationale: Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before transition to promote relaxation and relieve mild to moderate pain. Options 1, 3, and 4 are incorrect descriptions.

*Question: A diagnostic workup is performed on a 1-year-old child suspected of a diagnosis of neuroblastoma. Which finding specifically associated with this type of tumor would the nurse expect to find documented in the child's record?*

*Answer: Elevated vanillylmandelic acid (VMA) levels in the urine* Rationale: Neuroblastoma is a solid tumor found only in children. It arises from neural crest cells that develop into the sympathetic nervous system and the adrenal medulla. Typically the tumor infringes on adjacent normal tissue and organs. Neuroblastoma cells may excrete catecholamines and their metabolites. Urine samples will indicate elevated VMA levels. The presence of blast cells in the bone marrow occurs in leukemia. Projectile vomiting occurring most often in the morning and a positive Babinski's sign are signs/symptoms of a brain tumor.

*Question: A mother of a child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child has discomfort on the right side and that the acetaminophen is not very effective. Which is the best suggestion by the nurse?*

*Answer: Encourage the child to lie on the right side.* Rationale: Splinting of the affected side by lying on that side may decrease discomfort. It is inappropriate to advise the mother to increase the dose or frequency of the acetaminophen. Lying on the left side will not be helpful in alleviating discomfort.

*Question: A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention would the nurse suggest to alleviate the child's fears?*

*Answer: Encourage the child's parents to stay with the child.* Rationale: Although the preschooler may already be spending some time away from parents at a day care center or preschool, illness adds a stressor that makes separation more difficult. The child may repeatedly ask when parents will be coming for a visit or may constantly want to call the parents. The option of encouraging the child to play with other children is unrelated to the subject of the question and may not be appropriate for a child at risk for immunocompromise. Advising the parents to visit only during visiting hours will increase stress related to separation anxiety. A private room may be necessary, but this does not alleviate the child's fear.

*Question: A client is scheduled to have an elective cesarean delivery. How would the nurse allay the client's feelings of anxiety?*

*Answer: Encourage the client to discuss her concerns and desires regarding anesthesia options.* Rationale: Emotional needs of the client and family are best met by assessing their feelings and allowing for verbalization of concerns. Options 1, 2, and 3 involve actions by the nurse that do not involve client input. A woman undergoing cesarean delivery often feels disappointment and guilt, even if the procedure is elective. Providing the opportunity for discussion and input into decisions can help alleviate these feelings. Too much technical information may increase the client's anxiety. The presence of a support person is helpful.

*Question: The nurse is assisting in caring for a newborn with respiratory distress syndrome. Which initial action would the nurse plan to best facilitate bonding between the newborn and parents?*

*Answer: Encourage the parents to touch their newborn.* Rationale: The best initial action to begin the attachment process and promote bonding is to encourage the parents to touch their newborn. The parents' initial need is to become acquainted with their newborn. Explaining equipment is important but is not specific to parent-newborn bonding activities. Identifying specific caregiving tasks to be assumed by the parents may be frightening because of the condition of the newborn and the unfamiliarity of high-risk newborn care practices. This option will be appropriate as the newborn's condition becomes stable. Providing pamphlets related to the newborn's condition is inappropriate initially. Requiring parents to focus on pamphlets or literature does not enhance the parent-newborn bond.

*Question: The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approach by the nurse would be least helpful in assisting this client?*

*Answer: Encouraging multiple visitors at one time* Rationale: Clients with cognitive impairment from neurological dysfunction respond best to a stable environment that is limited in the amounts and type of sensory input. The nurse can provide sensory cues and give clear, simple directions in a positive manner. Confusion and agitation can be minimized by reducing environmental stimuli (such as television, multiple visitors) and keeping familiar personal articles (such as family pictures) at the bedside.

*Question: A client with right leg hemiplegia is experiencing difficulty with mobility. The nurse determines that there is a need for further teaching if the nurse observes which action by the family?*

*Answer: Encouraging the client to stand unassisted on the leg* Rationale: The question is worded to elicit an unsafe action on the part of the family. Depending on the client's functional ability, either passive or active ROM is indicated to keep the joint moving freely. Application of a premolded splint would also keep the limb aligned and in good position. The client should not attempt to stand unsupported on a weak or paralyzed limb. The inability to bear weight will cause the client to fall.

*Question: A client who has been seen in the clinic has been diagnosed with endometriosis and asks the nurse to describe this condition. Which is the best response for the nurse to provide?*

*Answer: Endometriosis is the presence of tissue outside the uterus that resembles the lining of the uterus.* Rationale: Endometriosis is defined as the presence of tissue outside the uterus that resembles the endometrium in structure and function. The response of this tissue to the stimulation of estrogen and progesterone during the menstrual cycle is identical to that of the endometrium. Primary dysmenorrhea refers to menstrual pain without identified pathology. Mittelschmerz refers to pelvic pain that occurs midway between menstrual periods. Amenorrhea is the cessation of menstruation for a period of at least 3 cycles or 6 months in a woman who has established a pattern of menstruation. It can result from a variety of causes.

*Question: A client has a prescription for valproic acid orally once daily. How would the nurse plan to administer the medication?*

*Answer: Ensure that the medication is administered at the same time each day.* Rationale: Valproic acid is an anticonvulsant, antimanic, and antimigraine medication. It may be administered with or without food. It should not be taken with an antacid or carbonated beverage because these products will affect medication absorption. The medication is administered at the same time each day to maintain therapeutic serum levels.

*Question: Sodium hypochlorite is prescribed for a client with a leg wound containing purulent drainage. The nurse is assisting in developing a plan of care for the client and includes which in the plan?*

*Answer: Ensure that the solution is freshly prepared before use.* Rationale: Sodium hypochlorite solution is a chloride solution that is used for irrigating and cleaning necrotic or purulent wounds. It can be used for packing necrotic wounds. It cannot be used to pack purulent wounds because the solution is inactivated by copious pus. It should not come into contact with healing or normal tissue, and it should be rinsed off immediately if used for irrigation. Solutions are unstable, and the nurse must ensure that the solution has been prepared fresh before use.

*Question: The nurse assists in administering first aid to a client who has been bitten by a snake on the right leg. The nurse would take which action?*

*Answer: Ensure that the victim is lying down, and remove restrictive items.* Rationale: Initial first aid at the site of a snakebite includes having the victim lie down, removing constrictive items such as clothing or rings, providing warmth, cleansing the wound, covering the wound with a light sterile dressing, and immobilizing the injured body part below the level of the heart. Ice or a tourniquet is not applied during the acute stage.

*Question: The licensed practical nurse employed in the ambulatory clinic is assisting the registered nurse in preparing to administer a dose of intravenous immune globulin (IVIG). The licensed practical nurse would ensure that which medication is readily available before the medication is administered?*

*Answer: Epinephrine* Rationale: IVIG is an immune serum that increases antibody titer and antigen-antibody reaction, providing passive immunity against infection. Anaphylactic reactions, although rare, can occur, and the nurse ensures that epinephrine is readily available when administering this medication. Protamine sulfate is the antidote for heparin. Vitamin K is the antidote for oral anticoagulants. Acetylcysteine is used to treat acetaminophen overdose.

*Question: The nurse is assigned to care for a client who had a Sengstaken-Blakemore tube inserted when more conservative treatment failed to alleviate the condition. The nurse would most likely suspect that the client has which diagnosis?*

*Answer: Esophageal varices* Rationale: A Sengstaken-Blakemore tube is inserted in a client with a diagnosis of cirrhosis with ruptured esophageal varices when other measures used to treat the varices are unsuccessful or contraindicated for the client. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The gastric balloon holds the tube in the correct position and prevents migration of the esophageal balloon, which could harm the client. This tube is not used to treat the conditions noted in the remaining options.

*Question: In the prenatal clinic, the nurse is gathering data from a new client for the health history information. Which action is the best way for the nurse to elicit correct responses to questions that refer to sexually transmitted infections?*

*Answer: Establish a therapeutic relationship between the nurse and pregnant client.* Rationale: Utilizing therapeutic communication skills is necessary when sensitive information is needed. The initial assessment interview establishes the therapeutic relationship between the nurse and the pregnant woman. It is planned, purposeful communication that focuses on specific content. Using closed-ended questions, omitting assessment of this area, or apologizing for any embarrassment the questioning may cause are incorrect options and would not elicit correct client responses.

*Question: The nurse is assigned to assist in the care of a client with obsessive-compulsive disorder (OCD). The nurse would place priority on which action when planning care for this client?*

*Answer: Establish a trusting nurse-client relationship.* Rationale: The nurse's priority is to establish a trusting nurse-client relationship. A trusting relationship indicates to the client that the he or she is important. After a therapeutic relationship has been developed, other work can begin. The nurse would not demand anything from the client.

*Question: A client with a neurological impairment experiences urinary incontinence. Which nursing action would help the client adapt to this alteration?*

*Answer: Establishing a toileting schedule* Rationale: A bladder retraining program, such as use of a toileting schedule, may be helpful to clients experiencing urinary incontinence. An indwelling urinary catheter should be used only when necessary because of risk of infection. Use of diapers or pads is the least acceptable alternative because the risk of skin breakdown exists.

*Question: The nurse determines that a client with which history is most at risk for endometrial cancer?*

*Answer: Estrogen replacement therapy* Rationale: Endometrial cancer is related to the hormone estrogen because estrogen is the primary stimulant of endometrial proliferation. Steroid replacement therapy, occupational exposure to dust, and surgical interventions are not considered to be risk factors for endometrial cancer.

*Question: The nurse is preparing the client for eye testing, and the examiner is planning to test the eyes using the confrontational method. What would the nurse tell the client about the purpose of the test?*

*Answer: Examines visual fields or peripheral vision* Rationale: The confrontational method of eye testing is used to examine visual fields or peripheral vision. Tonometry is used to check for glaucoma. An Ishihara chart is used to check color vision. A flashlight is used to test pupillary response to light.

*Question: The nurse is performing a vaginal check of a pregnant client in labor. The nurse notes that the umbilical cord is protruding from the vagina. Which action would the nurse immediately perform?*

*Answer: Exert upward pressure against the presenting part with gloved fingers.* Rationale: If the umbilical cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and further reduce blood flow. The nurse should place a gloved hand into the vagina toward the cervix and exert upward pressure against the presenting part to relieve compression of the cord. The nurse also should wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline solution. Oxygen, 8 to 10 L/minute by face mask, is administered to the mother to increase fetal oxygenation, and the client is prepared for immediate delivery. However, the immediate action is to relieve pressure on the cord. The client would already have an external fetal monitor in place.

*Question: The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention would the nurse plan to incorporate into the care routine for the client?*

*Answer: Explaining equipment and procedures on an ongoing basis* Rationale: Families often need assistance to cope with the sudden, severe illness of a loved one. The nurse can help the family of an unconscious client by assisting them to work through their feelings of grief. The nurse should explain all equipment, treatments, and procedures, and supplement or reinforce information given by the primary health care provider. The family should be encouraged to touch and speak to the client and to become involved in the client's care to the extent that they are comfortable. The nurse should allow the family to stay with the client as much as possible and should encourage them to eat and sleep adequately to maintain their strength.

*Question: An adolescent client is admitted to the hospital following an accidental gunshot wound to the foot. The nurse would plan to do which as a first step for the prevention of future injury?*

*Answer: Explore the adolescent's knowledge of gun safety.* Rationale: One of the leading causes of accidental deaths in the adolescent population is improper use of firearms. Before implementing firearm safety goals, the nurse needs to obtain baseline data about a firearm safety history, which is done in option 2. Option 3 may then be indicated. Option 4 may or may not be effective at some point for this client. Option 1 is unreasonable.

*Question: The nurse assists in monitoring for early signs of meningitis in a child and assists with attempting to elicit Kernig's sign. Which is the appropriate procedure to elicit a Kernig's sign?*

*Answer: Extend the leg and knee and check for pain.* Rationale: Kernig's sign is pain that occurs with extension of the leg and knee. Brudzinski's sign occurs when flexion of the head causes flexion of the hips and knees. Chvostek's sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Trousseau's sign is a sign for tetany in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally.

*Question: The nurse is providing emergency measures to a pregnant client with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which appropriately describes the mother's problem at this time?*

*Answer: Fear about what is happening* Rationale: The mother is anxious and frightened and the most appropriate problem for the client at this time is fear about what is happening. No data in the question support the problems noted in the other options although they may be a consideration for this client at some point during the hospitalized experience.

*Question: The nurse observes that a client in the transition stage of labor is crying out in pain with pushing efforts. The nurse recognizes this behavior as indicative of which response?*

*Answer: Fear of losing control* Rationale: Pains, helplessness, and fear of losing control are possible client responses in the transition stage of labor. Whimpering, high-pitched cries, and crying out in pain are indicative of losing control, and low-pitched grunting sounds usually indicate a woman is working effectively with contractions. The Valsalva maneuver is performed by attempting to forcibly exhale while keeping the mouth and nose closed. This maneuver is used to evaluate the condition of the heart and is sometimes done as a treatment to correct abnormal heart rhythms or relieve chest pain.

*Question: A client has just been told by the primary health care provider about her diagnosis of breast cancer. The client responds, "Oh no, does this mean I'm going to die?" The nurse interprets which response as the client's initial reaction?*

*Answer: Fear* Rationale: The client's response is one of fear. The client has verbalized the object of fear (dying), which makes anxiety incorrect. The client's statement contains no evidence of denial or rage.

*Question: A 1-year-old child with hypospadias is scheduled for surgery to correct this condition. The nurse is asked to assist in preparing a plan of care for this child. During this developmental time period, which factor would the nurse take into account?*

*Answer: Fears of separation and mutilation are present.* Rationale: At the age of 1 year, a child's fears of separation and mutilation are present because the child is facing the developmental task of trusting others. As the child gets older, fears about virility and reproductive ability may surface. The question does not provide enough data to determine that siblings exist. Options 3 and 4 may be issues if the child were older.

*Question: The nurse is monitoring a client who is receiving oxytocin to augment labor. The nurse determines that the dosage would be decreased and notifies the registered nurse if which is noted?*

*Answer: Fetal tachycardia* Rationale: Acute hypoxia is a common cause of fetal tachycardia. The dosage of oxytocin should be decreased in the presence of fetal tachycardia because of excessive uterine activity. The nurse should also ensure that the uterus maintains an adequate resting tone between contractions. Options 2, 3, and 4 are not indications of a problem.

*Question: The nurse is assigned to assist in caring for a client who is receiving parenteral nutrition with fat emulsion. The nurse is instructed to monitor the client for signs of fat overload. The nurse monitors for which signs and symptoms of this complication?*

*Answer: Fever and pruritic urticaria* Rationale: IV fat emulsions are sometimes administered with parenteral nutrition to supply needed calories and essential fatty acids. This fat emulsion must be infused by pump at a set rate, usually over 10 to 12 hours. Signs and symptoms of fat overload include fever, leukocytosis, hyperlipidemia, and pruritic urticaria, and focal seizures are possible. Hepatosplenomegaly also may be present. Bradycardia, altered taste, muscle weakness, hypertension, and decreased urine output are not signs of this complication.

*Question: The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which observation is indicative of the signs/symptoms associated with withdrawal from opioids?*

*Answer: Fever, yawning, irritability, diaphoresis, and diarrhea* Rationale: Opioids are central nervous system (CNS) depressants. Fever, yawning, irritability, diaphoresis, and diarrhea identify some of the signs/symptoms associated with withdrawal from opioids. The signs/symptoms in option 2 characterize withdrawal from nicotine, whereas option 3 describes withdrawal from cocaine, and option 4 describes withdrawal from alcohol.

*Question: A client admitted to the hospital gives the nurse a bottle of clomipramine. The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication?*

*Answer: Frequent hand washing with hot, soapy water* Rationale: Frequent hand washing is a common obsessive-compulsive behavior. Clomipramine is commonly used in the treatment of obsessive-compulsive disorder. Weight gain is a common side effect of this medication. Tachycardia and sedation are also side effects. Insomnia may occur but is seldom a side effect.

*Question: The nurse is instructing a pregnant client on dietary sources of iron. Which client food selection demonstrates an understanding of teaching?*

*Answer: Fresh spinach* Rationale: Dietary sources of iron include lean meats; liver; shellfish; dark green, leafy vegetables such as spinach; legumes; whole grains and enriched grains; cereals; and molasses. Milk is high in calcium and also contains phosphorus. Potatoes and cantaloupe are high in vitamin C.

*Question: While collecting data related to the cardiac system on a client, the nurse hears a murmur. Which best describes the sound of a heart murmur?*

*Answer: Gentle, blowing or swooshing noise* Rationale: A heart murmur is an abnormal heart sound and is described as a gentle, blowing, swooshing sound. It occurs from increased or abnormal blood flow through the valves of the heart. Lub-dub sounds are normal and represent the S1 (first heart sound) and S2 (second heart sound), respectively. A pericardial friction rub is described as a scratchy, leathery heart sound that occurs with pericarditis. A click is described as an abrupt, high-pitched snapping sound.

*Question: A client is being treated for depression with amitriptyline hydrochloride. During the initial phases of treatment, which is the most important nursing intervention?*

*Answer: Getting baseline postural blood pressures before administering the medication and each time the medication is administered* Rationale: The most important nursing intervention is getting baseline postural blood pressures before administering the medication and each time the medication is administered. Amitriptyline hydrochloride is a tricyclic antidepressant often used to treat depression. It causes orthostatic changes and can produce hypotension and tachycardia. This can be frightening to the client and dangerous because it can result in dizziness and client falls. The client must be instructed to move slowly from a lying to a sitting to a standing position to avoid injury if these effects are experienced. The client may also experience sedation, dry mouth, constipation, blurred vision, and other anticholinergic effects, but these are transient and will diminish with time.

*Question: An adolescent with diabetes mellitus becomes flushed and complains of hunger and dizziness. A blood glucose level is drawn, and the results indicate a glucose level of 60 mg/dL. Which is the appropriate intervention?*

*Answer: Give the child a glass of fruit juice.* Rationale: A blood glucose less than 70 mg/dL indicates hypoglycemia. When signs of hypoglycemia occur, the child needs an immediate source of glucose. Options 1, 3, and 4 do not address the hypoglycemic condition.

*Question: A mother of a child who underwent a myringotomy with insertion of tympanostomy tubes calls the nurse and reports that the child is complaining of discomfort. Which would the nurse instruct the mother to do?*

*Answer: Give the child acetaminophen for the discomfort as per discharge instructions.* Rationale: Following myringotomy with insertion of tympanostomy tubes, the child may experience some discomfort. Acetaminophen or ibuprofen can be given to relieve the discomfort. Aspirin should not be administered to the child. The child should rest if discomfort is present.

*Question: A client with a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse would avoid which action?*

*Answer: Giving the client thin liquids* Rationale: Before a client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration.

*Question: The nurse is preparing a care plan for the client with obsessive-compulsive disorder (OCD). The nurse would focus on which as the primary means to accomplish work with this client?*

*Answer: Goals and objectives* Rationale: Goals and objectives are the primary means to accomplish work between the client and the nurse and provide the foundation for the accomplishment of work. The other means to accomplish work are not specific to the nurse-client working relationship.

*Question: The nurse witnesses an automobile accident and provides care at the scene of the accident to an open wound on a young child. The family is extremely grateful and insists that the nurse accept monetary compensation for the care provided to the child. Because of the family's insistence, the nurse accepts the compensation to avoid offending the family. The child develops an infection and sepsis and is hospitalized. The family files suit against the nurse who provided care to the child at

*Answer: Good Samaritan laws will not provide immunity from suit if the nurse accepted compensation for the care provided.* Rationale: A Good Samaritan law is passed by a state legislature to encourage nurses and other primary health care providers to provide care to a person when an accident, emergency, or injury occurs, without fear of being sued for the care provided. Called "immunity from suit," this protection usually applies only if all the conditions of the law are met; for example, the primary health care provider receives no compensation for the care provided, and the care given is not willfully or wantonly negligent.

*Question: A child remarks, "I share my toys and snacks with my friends so they will like me more." The nurse determines the child is in which stage of moral development?*

*Answer: Good boy-nice girl orientation* Rationale: According to Kohlber's theory of moral development, during the good boy-nice girl orientation, the child acts in a way to please other people. Sharing is an example of this behavior. A child in the egocentric judgment stage has no awareness of right or wrong. A person in the law-and-order orientation stage obeys laws to maintain social order. During the social contract and legalistic orientation stage, a person is aware that others may have another set of values and opinions.

*Question: The nurse prepares to give a bath and change the bed linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse use during the bathing of this client?*

*Answer: Gown and gloves* Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items, such as wound drainage on bed linens. Masks are not required unless droplet or airborne precautions are necessary.

*Question: A nursing student is asked to discuss human immunodeficiency virus (HIV) during a clinical conference. The nursing student would include which correct item in the discussion?*

*Answer: HIV virus attacks the immune system by destroying T lymphocytes.* Rationale: The virus attacks the immune system by destroying T lymphocytes. Children born to HIV-positive women test positive for HIV antibody, not HIV virus. This is actually a measure of maternal antibody and not indicative of true infection. T4 cells are depleted in number and cannot signal B cells to form protective antibodies to fight off the invading virus.

*Question: The nurse is assigned to assist in preparing a woman who is gravida VI for delivery. In planning care for this client, the nurse places which item(s) at the client's bedside?*

*Answer: Intravenous (IV) supplies* Rationale: The client who is a gravida VI is at risk for possible uterine atony. An IV access is needed so that blood and medication can be administered if necessary. Options 1, 2, and 3 are unnecessary items.

*Question: The community health nurse is conducting a research study and is identifying clients in the community who are at risk for latex allergy. The nurse would determine that which client population is at risk for developing this type of allergy?*

*Answer: Hairdressers* Rationale: Individuals at risk for developing a latex allergy include health care workers; individuals who work in the rubber industry; individuals having multiple surgeries; individuals with spina bifida; individuals who wear gloves frequently such as food handlers, hairdressers, and auto mechanics; and individuals allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts.

*Question: The nurse is asked to assist the primary health care provider in performing Leopold's maneuvers on a client. Which nursing intervention would be implemented before this procedure is performed?*

*Answer: Have the client empty her bladder.* Rationale: An empty bladder contributes to a woman's comfort during the examination. Drinking water to fill the bladder and warming sonogram gel may be performed before a sonogram (ultrasound). Often, Leopold's maneuvers are performed to aid the examiner in locating the fetal heart tones.

*Question: A client has just undergone spinal fusion after suffering a herniated lumbar disk. The nurse would avoid which action to maintain client safety after this procedure?*

*Answer: Having the client use an overhead trapeze* Rationale: Following spinal fusion, the head of the bed is generally kept in a flat position. The client is logrolled from side to side as prescribed. Pillows may be placed under the entire length of the legs by surgeon preference to relieve tension on the lower back. The use of an overhead trapeze is contraindicated because its use could promote twisting of the spine after surgery.

*Question: A client has been prescribed amikacin. Which priority baseline function would the nurse determine needs to be monitored?*

*Answer: Hearing acuity* Rationale: Amikacin is an antibiotic. This medication can cause ototoxicity and nephrotoxicity; therefore, hearing acuity tests and kidney function studies should be performed before the initiation of therapy. Apical pulse, liver function studies, and blood pressure are not specifically related to the use of this medication.

*Question: The nurse is reviewing the laboratory results of a client scheduled for surgery. Which laboratory result would indicate to the nurse that the surgery might be postponed?*

*Answer: Hemoglobin, 8.4 g/dL* Rationale: Routine screening tests include a complete blood cell count, serum electrolyte analysis, coagulation studies, and serum creatinine tests. The complete blood count includes the hemoglobin analysis. All these values are within normal range except the hemoglobin. If a client has a low hemoglobin level, the surgery may be postponed.

*Question: The nurse is reviewing the health record of an infant with a diagnosis of gastroesophageal reflux. Which signs/symptoms of this disorder would the nurse expect to note documented in the record?*

*Answer: Hiccupping and spitting up after a meal* Rationale: Clinical manifestations of all types of gastroesophageal reflux include vomiting (spitting up) after a meal, hiccupping, and recurrent otitis media related to pooled secretions in the nasopharynx during sleep. Option 1 is a clinical manifestation of esophageal atresia and tracheoesophageal fistula. Option 2 is a clinical manifestation of congenital diaphragmatic hernia. Option 4 is a clinical manifestation of hiatal hernia.

*Question: The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse would place the client in which position for insertion?*

*Answer: High-Fowler's position* Rationale: Before insertion of a nasogastric tube the nurse places the client in a sitting or high-Fowler's position to reduce the risk of pulmonary aspiration if the client should vomit. A pillow may be placed behind the head and shoulders to promote the client's ability to swallow during procedure. Options 1, 2, and 4 do not facilitate the insertion of the tube or prevent aspiration.

*Question: A client has a diagnosis of asymptomatic diverticular disease. Which type of diet would the nurse anticipate being prescribed?*

*Answer: High-fiber diet* Rationale: A high-fiber diet is the diet of choice for asymptomatic diverticular disease to help prevent straining from constipation. A high-iron diet is for clients with anemia to help make hemoglobin. A low-purine diet is for clients with gout to prevent formation of stones and crystals. Hypertensive clients and clients with cardiac problems may require a low-sodium diet to prevent increased fluid volume.

*Question: The nurse is preparing to reinforce instructions to a client with Addison's disease regarding diet therapy. The nurse understands that which diet would be prescribed for this client?*

*Answer: High-sodium, high-carbohydrate diet* Rationale: A high-sodium, high-complex carbohydrate, and high-protein diet will be prescribed for the client with Addison's disease. To prevent excess fluid and sodium loss, the client is instructed to maintain an adequate salt intake of up to 8 g of sodium daily and to increase salt intake during hot weather; before strenuous exercise; and in response to fever, vomiting, or diarrhea.

*Question: The nurse is reviewing the serum electrolyte laboratory results of a client and finds that the client has an elevated magnesium level. Which part of the client's history is likely associated with this problem?*

*Answer: History of chronic laxative use* Rationale: Magnesium is contained in many foods, but most cases of hypermagnesemia are not dietary related. Clients, who have problems with severe constipation, may abuse laxatives that contain magnesium such as magnesium hydroxide. A history of breast cancer, parathyroid tumor, or lactose intolerance is not associated with hypermagnesemia. The client who avoids milk products because of lactose intolerance may be prone to hypocalcemia.

*Question: The nurse is reviewing the record of a client with a diagnosis of cervical cancer. Which would the nurse expect to note in the client's record related to a risk factor associated with this type of cancer?*

*Answer: History of human papillomavirus infection* Rationale: Risk factors associated with cervical cancer include smoking, intercourse with uncircumcised males, early frequent intercourse with multiple sexual partners, multiparity, chronic cervicitis, and history of genital herpes or human papillomavirus infection. Incidence of cervical cancer is also higher in African Americans.

*Question: The nurse notes that a client is receiving lamivudine. The nurse would determine that this medication has been prescribed to most likely treat which condition?*

*Answer: Human immunodeficiency virus (HIV) infection* Rationale: Lamivudine is a nucleoside reverse transcriptase inhibitor and antiviral medication. It slows HIV replication and reduces the progression of HIV infection. It also is used to treat chronic hepatitis B and is used for prophylaxis in health care workers at risk of acquiring HIV after occupational exposure to the virus. This medication is not used to treat pancreatitis, pharyngitis, or seizures.

*Question: The nurse is taking a health history on a client seen in the health care clinic for the first time. When the nurse asks the client about current prescribed medications, the client tells the nurse that amprenavir is prescribed twice daily. Based on this finding, the nurse would elicit data from the client regarding the presence of which condition?*

*Answer: Human immunodeficiency virus (HIV)* Rationale: Amprenavir is an antiretroviral agent, classified as a protease inhibitor, used to treat HIV infection. It is not used to treat peptic ulcer disease, inflammatory bowel disease, or CAD.

*Question: The nurse is assigned to care for a client admitted with a diagnosis of systemic lupus erythematosus (SLE). The nurse reviews the primary health care provider's prescriptions. Which medication would the nurse expect to be prescribed to aid in long-term control?*

*Answer: Hydroxychloroquine* Rationale: Hydroxychloroquine, an antimalarial drug, aids in long-term control of SLE. Aspirin is not used in the treatment of SLE. Dehydroepiandrosterone (DHEA), a mild male hormone, is given to treat hair loss, joint pain, fatigue, and memory issues. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to reduce inflammation and control pain.

*Question: The nurse is collecting medication information from a client, and the client states that she is taking garlic as an herbal supplement. The nurse understands that the client is most likely treating which condition?*

*Answer: Hyperlipidemia* Rationale: Garlic is an herbal supplement that is used to treat hyperlipidemia and hypertension. An herbal supplement that may be used to treat eczema is evening primrose. Insomnia has been treated with both valerian root and chamomile. Migraines have been treated with feverfew.

*Question: Which cardiovascular sign would the nurse expect to note in a client with a diagnosis of hypocalcemia?*

*Answer: Hypotension* Rationale: Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the ECG, the nurse should note a prolonged ST segment and a prolonged QT interval.

*Question: The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs and symptoms of infection. The nurse understands that there may be damage to the client's thermoregulatory center which is located in which part of the brain?*

*Answer: Hypothalamus* Rationale: Hypothalamic damage causes hyperthermia, which may also be called "central fever." It is characterized by a persistent high fever with no diurnal variation. There is also an absence of sweating. Options 1, 2, and 3 are not associated with temperature regulation.

*Question: A client who sustained an inhalation injury arrives in the emergency department. On data collection, the nurse notes that the client is very confused and combative. The nurse determines that the client is experiencing which problem?*

*Answer: Hypoxia* Rationale: After a burn injury, clients are normally alert. If a client becomes confused or combative, hypoxia may be the cause. Hypoxia occurs after inhalation injury and may occur after an electrical injury. The data in the question is not specifically related to options 1, 2, or 4.

*Question: The nurse is reviewing a primary health care provider's prescription for a child who was just admitted to the hospital with a diagnosis of Kawasaki disease. Which prescription would the nurse anticipate being part of the treatment plan?*

*Answer: Immune globulin* Rationale: Intravenous immune globulin is administered to the child with Kawasaki disease to decrease the incidence of coronary artery lesions and aneurysms and to decrease fever and inflammation. Options 1, 2, and 3 are not components of the treatment plan for this disease.

*Question: The nurse is assigned to care for a client who has experienced uterine rupture. The nurse plans care knowing that which is the priority concern in caring for the client?*

*Answer: Impaired gas exchange* Rationale: The priority should always deal with airway. Although options 1, 2, and 3 are also appropriate concerns for this client, they are not the priority and assume a lesser priority than impaired gas exchange.

*Question: A client who was admitted to the mental health unit 1 month ago with agoraphobia is cooperative, sharing with peers, and makes appropriate suggestions during group discussions. The nurse concludes that this client's behavior is most consistent with which behavior?*

*Answer: Improvement* Rationale: The behavior exhibited by the client is appropriate and is most consistent with improvement. Acting out is attention-seeking behavior. All clients have a desire to be accepted. There is no pattern of manipulation exhibited.

*Question: A client with Parkinson's disease is experiencing a Parkinsonian crisis. The nurse would immediately place the client where?*

*Answer: In a quiet, dim room with respiratory and cardiac support available* Rationale: Parkinsonian crisis can occur with emotional trauma or sudden withdrawal of medications. The client exhibits severe tremors, rigidity, and bradykinesia. The client also displays anxiety, is diaphoretic, and has tachycardia and hyperpnea (tachypnea). The client should be placed in a quiet, dim room, and respiratory and cardiac support should be available.

*Question: The nurse is collecting data on a pregnant client and is preparing to take the client's blood pressure. In which position would the nurse place the client?*

*Answer: In a sitting position* Rationale: Because position affects blood pressure in the pregnant woman, the method for obtaining blood pressure should be standardized as much as possible. The blood pressure should be obtained in the sitting position with the arm supported in a horizontal position at heart level. Lying down or positioning on the left or right side is incorrect, and these positions may cause physiological stress that will affect the blood pressure.

*Question: The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest to minimize the pain. The nurse plans to put the bed in which position?*

*Answer: In semi-Fowler's position with the knee gatch slightly raised* Rationale: Clients with low back pain are often more comfortable when placed in semi-Fowler's position with the knee gatch slightly raised or with pillows under the knees. The bed is placed in semi-Fowler's position with the knee gatch raised sufficiently to flex the knees. This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root. Keeping the foot of the bed flat will enhance extension of the spine. Keeping the client flat with the knee gatch raised stretches the lower back.

*Question: A client arrives at the emergency department after experiencing a traumatic blow to the eye, and a hyphema is diagnosed. In which position would the nurse place the client?*

*Answer: In semi-Fowler's position* Rationale: A hyphema is the presence of blood in the anterior chamber of the eye. It is caused by an event that ruptures blood vessels in the eye, such as a penetrating injury from a BB pellet or indirectly from a blow to the forehead. The client is treated with bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea. The positions identified in options 1, 2, and 4 will be harmful to the client.

*Question: A client is receiving diazepam for its skeletal muscle relaxant effects. The nurse would monitor this client for which side effect of this medication?*

*Answer: Incoordination* Rationale: Diazepam is a centrally acting skeletal muscle relaxant. Incoordination and drowsiness are common side effects resulting from this medication. The other side effects of diazepam are incorrect.

*Question: Indinavir is prescribed for the client with a diagnosis of human immunodeficiency virus (HIV). Which medication instruction would the nurse reinforce to the client?*

*Answer: Increase fluid intake to at least 1.5 L/day.* Rationale: Indinavir is an antiretroviral agent. This medication can cause kidney stones; therefore, the client is instructed to increase fluid intake to at least 1.5 L/day. The client is also instructed to report sharp back pain or the presence of blood in the urine. The client is instructed to take the medication 1 hour before or 2 hours after a large meal. If the medication needs to be taken with food, the client should consume a light meal, such as dry toast, juice, or a bowl of cereal with milk. Unexplained weight loss must be reported to the primary health care provider.

*Question: A client arrives at the birthing center in active labor. Her membranes are still intact and the nurse-midwife performs an amniotomy. The nurse explains to the client that this procedure will most likely have which effect?*

*Answer: Increased efficiency of contractions* Rationale: Rupturing of membranes, if they do not rupture spontaneously, allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Rupturing of the membranes does not create the need for increased monitoring of the BP.

*Question: The nurse is providing instructions to a client newly diagnosed with diabetes mellitus. The nurse gives the client a list of the signs of hyperglycemia. Which specific signs of this complication would be included on the list?*

*Answer: Increased thirst* Rationale: The classic signs of hyperglycemia include polydipsia, polyuria, and polyphagia. Profuse sweating and shakiness would be noted in a hypoglycemic condition.

*Question: The nurse is caring for a client with a diagnosis of osteoarthritis. Which actions would be least helpful for the client?*

*Answer: Increasingly vigorous and high-impact exercise* Rationale: Vigorous or high-impact exercise could be damaging to articulating surfaces within joints and should be avoided by clients with osteoarthritis. The other actions may be helpful in promoting joint mobility.

*Question: The nurse notes documentation that a postcraniotomy client is having difficulty with body image. The nurse determines that the client is still working on the postoperative outcome criteria when the client indicates which altered personal appearance?*

*Answer: Indicates that facial puffiness will be a permanent problem* Rationale: After craniotomy, the client may experience difficulty with altered personal appearance. The nurse can help by listening to the client's concerns and by clarifying any misconceptions about facial edema, periorbital bruising, and hair loss, which are temporary. The nurse can encourage the client to participate in self-grooming and use personal articles of clothing. Finally, the nurse can suggest the use of a turban, followed by a hairpiece, to help the client adapt to the temporary change in appearance.

*Question: Mannitol is being administered to a client with increased intracranial pressure following a head injury. The nurse assisting in caring for the client knows that which indicates the therapeutic action of this medication?*

*Answer: Induces diuresis by raising the osmotic pressure of glomerular filtrate, thereby inhibiting tubular reabsorption of water and solutes* Rationale: Mannitol is an osmotic diuretic that induces diuresis by raising the osmotic pressure of glomerular filtrate, thereby inhibiting tubular reabsorption of water and solutes. It is used to reduce intracranial pressure in the client with head trauma.

*Question: The nurse is assisting in developing a plan of care for a client with immunodeficiency. The nurse would determine that which problem is a priority for the client?*

*Answer: Infection* Rationale: The client with immunodeficiency has inadequate or an absence of immune bodies and is at risk for infection. The priority problem is infection. The question presents no data indicating that inability to cope, lack of information about the disease, and feeling uncomfortable about body changes are problems.

*Question: A client receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On data collection, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which has occurred?*

*Answer: Infiltration* Rationale: An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling at the IV site result when IV fluid is deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of IV solution will slow down or stop. The corrective action is to remove the catheter and start a new IV line at another site. Infection, phlebitis, and thrombosis are likely to be accompanied by warmth at the site, not coolness.

*Question: A client diagnosed with diabetes mellitus has a foot infection and is prescribed antibiotic therapy with an aminoglycoside. The nurse collects data from the client and notes that the client has a hearing loss. The nurse would take which action next?*

*Answer: Inform the registered nurse (RN) about the hearing loss.* Rationale: A preexisting hearing loss is a contraindication for the administration of aminoglycosides because these medications can cause ototoxicity and irreversible hearing loss. The nurse should report the findings to the RN to protect the client's safety. The RN will in turn notify the primary health care provider. Options 3 and 4 are not beneficial because hearing loss has already occurred in this client. Nurses do not change medication prescriptions independently.

*Question: During the emergent phase of a client with severe burns the nurse expects to perform which action?*

*Answer: Insert a Foley catheter.* Rationale: In the emergent phase of severe burns, a Foley catheter is inserted to monitor hourly urine output and provide data to determine whether fluid resuscitation is adequate. The minimum acceptable urine flow for an adult is 30 mL/hr. The other options would not be implemented in the emergent phase.

*Question: A child is admitted to the burn unit with partial- and full-thickness burns over 35% of the body. The nurse assisting in caring for the child develops the plan of care. Which nursing intervention is the priority?*

*Answer: Inserting a Foley catheter* Rationale: A Foley catheter is inserted into the child's bladder so that urine output can be accurately measured hourly. Although pain medication may be required, the child should not be sedated. IV fluids are not restricted and are administered at a rate sufficient to maintain adequate tissue perfusion. A nasogastric tube may be required but would not be the priority intervention.

*Question: A client has Buck's extension traction applied to the right leg. The nurse would plan which intervention to prevent complications of the device?*

*Answer: Inspecting the skin on the right leg at least once every 8 hours* Rationale: Buck's extension traction is a type of skin traction. The nurse inspects the skin of the limb in traction at least once every 8 hours for irritation or inflammation. Massaging the skin with lotion is not indicated. The nurse never releases the weights of traction unless specifically prescribed by the primary health care provider. Skin traction does not involve pin care.

*Question: A hospitalized client is having the dosage of clonazepam adjusted. The nurse would plan to implement which action?*

*Answer: Instituting seizure precautions* Rationale: Clonazepam is a benzodiazepine used as an anticonvulsant. During initial therapy and during periods of dosage adjustment, the nurse should initiate seizure precautions for the client. Options 1, 2, and 4 are not associated with the use of this medication.

*Question: A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions, and the nurse determines that the client is experiencing Braxton Hicks contractions. Which nursing action would be appropriate?*

*Answer: Instruct the client that these are common and may occur throughout the pregnancy.* Rationale: Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. Because Braxton Hicks contractions may occur and are normal in some women during pregnancy, contacting the primary health care provider, maintaining bed rest, and admitting the client to the labor unit are unnecessary and inaccurate interventions.

*Question: The nurse prepares to reinforce instructions to a client who is taking allopurinol. The nurse would include which instruction in the plan?*

*Answer: Instruct the client to drink 3000 mL of fluid per day.* Rationale: Clients taking allopurinol are encouraged to drink 3000 mL of fluid a day. Allopurinol is an antigout medication used to decrease uric acid levels. A full therapeutic effect may take 1 week or longer. Allopurinol is to be given with or immediately following meals or milk to prevent gastrointestinal irritation. If the client develops a rash, irritation of the eyes, or swelling of the lips or mouth, he or she should contact the primary health care provider because this may indicate hypersensitivity.

*Question: Which instructions would be included in the teaching plan for a mother whose newborn is human immunodeficiency virus (HIV) positive?*

*Answer: Instruct the mother and family to provide meticulous skin care to the newborn and to change the newborn's diaper after each voiding or stool.* Rationale: Meticulous skin care helps protect the HIV-infected newborn from developing secondary infections. Feeding the newborn in an upright position, using a special nipple, and bulging fontanels are unrelated to the pathology associated with HIV.

*Question: The nurse is collecting data on a client who is 6 hours postpartum following delivery of a full-term healthy newborn. The client tells the nurse that she feels faint and dizzy. Which nursing action is appropriate?*

*Answer: Instruct the mother to request help when getting out of bed.* Rationale: Orthostatic hypotension may occur during the first 8 hours after birth. Feelings of faintness and dizziness are signs that caution the nurse to be aware of the client's safety. The nurse should advise the mother to get help the first few times getting out of bed. Option 1 is not a helpful action and could cause increased dizziness. Option 2 requires a primary health care provider's prescription. Option 4 is unnecessary.

*Question: A client is placed on hydrate sedative-hypnotic for short-term treatment. Which nursing action indicates an understanding of the major side effect of this medication?*

*Answer: Instructing the client to call for ambulation assistance* Rationale: A sedative-hypnotic causes sedation and impairment of motor coordination; therefore, safety measures need to be implemented. The client is instructed to call for assistance with ambulation. Options 1 and 2 are not specifically associated with the use of this medication. Although option 4 is an appropriate nursing intervention, it is most important to instruct the client to call for assistance with ambulation.

*Question: The nurse is assisting in administering beractant to a premature infant who has respiratory distress syndrome. The nurse understands that the medication would be administered by which route?*

*Answer: Intratracheal* Rationale: Respiratory distress is common in premature neonates and may be due to lung immaturity as a result of surfactant deficiency. The mainstay of treatment is the administration of exogenous surfactant, which is administered by the intratracheal route. Options 1, 3, and 4 are not routes of administration for this medication.

*Question: The nurse is reinforcing instructions to a pregnant client about the warning signs in pregnancy that require the need to notify the primary health care provider. The nurse determines that further teaching is needed if the client states that it is necessary to call the primary health care provider if which occurs?*

*Answer: Irregular, painless contractions* Rationale: Clients should be educated regarding the danger signs of pregnancy. Generalized or facial edema, rapid weight gain and visual disturbances are warning signs in pregnancy. Braxton Hicks contractions are the normal, irregular, painless contractions of the uterus that may occur throughout the pregnancy. Additional warning signs in pregnancy include vaginal bleeding, premature rupture of the membranes, preterm uterine contractions that are normal and regular, change in or absence of fetal activity, severe headache, epigastric pain, persistent vomiting, abdominal pain, and signs of infection.

*Question: A client arrives in the emergency department with a chemical eye injury. The nurse immediately performs which action?*

*Answer: Irrigates the eye with copious amounts of sterile normal saline* Rationale: Emergency care following a chemical injury to the eye includes irrigating the eye immediately with water, sterile normal saline, or ocular irrigating solution. The irrigation should be maintained for at least 10 minutes. Following this emergency treatment, visual acuity is checked. Antibiotics and eye patching may be prescribed, but these are not the initial actions.

*Question: A child with a fractured femur is placed in Buck's skin traction, and the nurse is planning care for the client. Which information about this type of traction is correct?*

*Answer: Is a type of skin traction that pulls the hip and leg into extension* Rationale: Buck's skin traction is a type of skin traction used in fractures of the femur and in hip and knee contractures. It pulls the hip and leg into extension. Countertraction is applied by the child's body. Options 1, 2, and 3 describe skeletal traction.

*Question: A nursing student is assigned to care for a client with a diagnosis of schizophrenia. Haloperidol is prescribed for the client, and the nursing instructor asks the student to describe the action of the medication. Which statement by the nursing student indicates an understanding of the action of this medication?*

*Answer: It blocks the binding of dopamine to the postsynaptic dopamine receptors in the brain.* Rationale: Haloperidol acts by blocking the binding of dopamine to the postsynaptic dopamine receptors in the brain. Imipramine hydrochloride blocks the reuptake of norepinephrine and serotonin. Donepezil hydrochloride inhibits the breakdown of released acetylcholine. Fluoxetine hydrochloride is a potent serotonin reuptake blocker.

*Question: The nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately?*

*Answer: It helps to make sure that the primary health care provider is aware of all of the medications the client is taking and has been taking at home.* Rationale: Medication reconciliation is an organized process to avoid medication errors by comparing the client's medication prescriptions to all of the medications that the client has been taking. Primary health care providers must review this list and prescribe appropriate medications. This process is not used to educate clients and families on current medications or to determine if the client has medication allergies. Notifying the pharmacy of the medications the client is taking while in the hospital is not a specific purpose of the medication reconciliation process.

*Question: The nurse is caring for a child with a diagnosis of Kawasaki disease. The mother of the child asks the nurse about the disorder. Which statement by the nurse most accurately describes Kawasaki disease?*

*Answer: It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause.* Rationale: Kawasaki disease, also called mucocutaneous lymph node syndrome, is a febrile generalized vasculitis of unknown etiology. Option 1 describes human immunodeficiency virus (HIV) infection. Option 2 describes systemic lupus erythematosus. Option 4 describes rheumatic fever.

*Question: The nurse prepares to assist in instructing a client about Lyme disease. Which would the nurse include in the instructions?*

*Answer: It is caused by a tick carried by deer.* Rationale: Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. Persons bitten by the Ixodes ticks are infected with the spirochete Borrelia burgdorferi. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. Toxoplasmosis is caused by the ingestion of cysts from contaminated cat feces. Lyme disease cannot be transmitted from one person to another.

*Question: The family of an unconscious client with increased intracranial pressure is talking at the client's bedside. They are discussing the gravity of the client's condition and wondering if the client will ever recover. How would the nurse interpret the client's situation?*

*Answer: It is possible the client can hear the family.* Rationale: Some clients who have awakened from an unconscious state report that they remember hearing specific voices and conversations. Family and staff should assume that the client's sense of hearing is still intact and act accordingly. Research has also demonstrated that positive outcomes are associated with coma stimulation, that is, speaking to and touching the client.

*Question: A new nurse is employed at a local community hospital and is attending an orientation session. The nurse educator conducting the session asks the new nurse to describe an organization's mission statement. The new nurse appropriately responds with which statement?*

*Answer: It outlines what the organization plans to accomplish.* Rationale: All organizations have a purpose or reason for existing. The purpose typically is expressed in the form of a mission statement. The mission statement outlines what the organization plans to accomplish. Sometimes mission statements incorporate statements of philosophy (beliefs), purpose(s), and goals or objectives into a single statement; other times the philosophy, purpose(s), and goals are addressed in addition to the mission statement. These statements serve as benchmarks against which an organization's performance can be evaluated.

*Question: A client has undergone fasciotomy to treat compartment syndrome of the leg. Which type of wound care would the nurse anticipate will be prescribed for the fasciotomy site?*

*Answer: Moist, sterile saline dressings* Rationale: The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with moist sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. The other types of wound care are incorrect.

*Question: The nurse is reviewing medications with the client receiving colchicine for the treatment of gout. The nurse determines that the medication is effective if the client reports a decrease in which?*

*Answer: Joint inflammation* Rationale: Colchicine is effective if the client has a decrease in joint inflammation. This medication is classified as an antigout agent. It interferes with the ability of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client would also report a decrease in pain as well as inflammation in the affected joints. There will also be a decrease in the number of gout attacks. Colchicine has no effect on the client's blood glucose or blood pressure and is not used to treat a headache.

*Question: A child seen in the clinic is found to have rubeola (measles), and the mother asks the nurse how to care for the child. Which instruction would the nurse provide to the mother?*

*Answer: Keep the child in a room with dim lights.* Rationale: A nursing consideration in rubeola is eye care. The child usually has photophobia, so the nurse should suggest that the parent keep the child out of brightly lit areas. Children with viral infections are not to be given aspirin because of the risk of Reye's syndrome. Warm baths and the sun will aggravate itching. In addition, the child needs to rest.

*Question: The nurse receives a telephone call from a male client who states that he wants to kill himself and has a bottle of sleeping pills in front of him. Which would be the best response by the nurse?*

*Answer: Keep the client talking and signal to another staff member to send help to the client.* Rationale: Keeping the client on the phone and getting help to the client is the best response by the nurse. In a crisis, the nurse must take an authoritative, active role to promote the client's safety. A bottle of sleeping pills in front of a client who verbalizes he wants to kill himself is a "crisis." The client's safety is of prime concern. The word "insist" could anger the client, and he might hang up. Keeping the client talking and allowing the client to vent his feelings lacks the authoritative action stance of securing the client's safety. Using therapeutic communication is important, but overuse of "reflection" may sound uncaring or superficial and is lacking direction and solutions to the immediate problem of the client's safety.

*Question: A cooling blanket is prescribed for a child with a fever. The nurse prepares to use the cooling blanket and would avoid which action?*

*Answer: Keeping the child uncovered to assist in reducing the fever* Rationale: While on a cooling blanket, the child should be covered lightly to maintain privacy and reduce shivering. Options 2, 3, and 4 are important interventions to prevent shivering, frostbite, and skin breakdown.

*Question: A client who has recently been started on enteral feedings begins to complain of abdominal cramping, followed by passage of two liquid stools. The nurse notes that the client has abdominal distention as well. The nurse reviews the nutritional content on the label of the can to see if it contains which ingredient?*

*Answer: Lactose* Rationale: Several tube feeding formulas contain lactose. A client with an unreported history of lactose intolerance would develop symptoms such as these in response to nutritional therapy with these formulas. If the client is diagnosed as lactose intolerant, a lactose-free formula should be prescribed by the primary health care provider. This will resolve the client's symptoms and promote adequate nutrition for the client.

*Question: The nurse is assisting in caring for a client who has sustained a nasal fracture. The nurse monitors for which priority finding specifically related to this injury?*

*Answer: Leakage of clear fluid from the nose* Rationale: When a nasal fracture is suspected or diagnosed, the nurse should monitor the client for leakage of clear fluid from the nose as the priority. This could be cerebrospinal fluid (CSF) and may be indicative of cerebral injury. Any discharge of fluid from the nose should be tested to determine whether it is CSF. Inability to breathe through one nare is important to address, but is not the priority in this question because the client is still able to breathe through the other nare and through the mouth. Hematoma formation around the eyes and edema around the nose and eyes are common manifestations of nasal fracture.

*Question: A client is seen in the clinic for complaints of skin itchiness that has been persistent over the past several weeks. Following data collection, it has been determined that the client has scabies. Lindane is prescribed, and the nurse is asked to provide instructions to the client regarding the use of the medication. How would the nurse teach the client to apply the cream?*

*Answer: Leave the cream on for 8 to 12 hours and then remove by washing.* Rationale: Lindane is applied in a thin layer to the entire body below the head. No more than 30 g (1 oz) should be used. The medication is removed by washing 8 to 12 hours later. Usually, only one application is required.

*Question: A client with right-sided weakness needs to learn how to use a cane. How would the nurse teach the client to position the cane?*

*Answer: Left hand, and 6 inches lateral to the left foot* Rationale: The client is taught to hold the cane on the opposite side of the weakness. This is done because with normal walking, the opposite arm and leg move together (called reciprocal motion). The cane is placed 6 inches lateral to the fifth toe.

*Question: The nurse is preparing to monitor a fetal heart rate. The nurse locates a round, ballottable shape just above the symphysis pubis. Fetal small parts are located on the right side of the uterus with a concave shape located on the left side of the uterus. Where would the nurse listen to hear the strongest fetal heart tones?*

*Answer: Left lower quadrant* Rationale: The fetal heart rate is best detected through the fetal back. The findings in this situation support a cephalic presentation. The extremities are on the right side, and the back is on the left side. The fetal heart rate is best heard in the left lower quadrant.

*Question: Letrozole is prescribed for a postmenopausal client with advanced breast cancer. Which side effect of this medication would the nurse reinforce in the instructions to the client?*

*Answer: Leg pain* Rationale: Letrozole is an aromatase inhibitor used to treat advanced breast cancer in postmenopausal women whose disease progressed after antiestrogen therapy. The most frequent side effects include skeletal, back, arm, and leg pain. Less frequent side effects include nausea, headache, fatigue, constipation, vomiting, and dyspnea.

*Question: The nurse is caring for a 14-year-old boy who is hospitalized and placed in Crutchfield traction. The child is having difficulty adjusting to the length of the hospital confinement. Which nursing action would be appropriate to meet the child's needs?*

*Answer: Let the child wear his own clothing when friends visit.* Rationale: Adolescents need to identify with their peers and have a strong need to belong to a group. They like to dress like the group and wear similar hairstyles. Because Crutchfield traction uses skeletal pins, hair dye is not appropriate. The boy should be allowed to wear his own clothes to feel a sense of belonging to the group. Loud music may disturb others in the hospital. The boy's request for a darkened room is indicative of a possible problem with depression that may need further evaluation and intervention.

*Question: A child with croup is placed in a cool-mist tent. The mother becomes concerned because the child is frightened, consistently crying, and tries to climb out of the tent. Which is the appropriate nursing action?*

*Answer: Let the mother hold the child and direct a cool mist over the child's face.* Rationale: Crying aggravates laryngospasm and increases hypoxia, which may cause airway obstruction. If the use of a tent or hood is causing distress, treatment may be more effective if the child is held by the parent and a cool mist is directed toward the child's face. A mild sedative would not be administered to the child. Options 1 and 2 will not alleviate the child's fear.

*Question: The nurse has reinforced instructions to a client regarding the method for instilling eye drops into the left eye. The nurse determines that the client needs further teaching if the client does which during a return demonstration?*

*Answer: Lies supine, pulls up on the upper lid, and puts the drop in the upper lid* Rationale: It is correct procedure for the client to either lie down or sit with the head tilted back. The thumb or finger is used to pull down on the lower lid. The client holds the bottle like a pencil (tip facing downward) and squeezes the bottle so that the drop falls into the sac. The client then gently closes the eye. An alternative method for clients who blink very easily is to place the client in the supine position with the head turned to one side. The eye to be used is uppermost. The client squeezes the drop onto the inner canthus. The client turns from this side to the other while blinking. Surface tension and gravity then cause the drop to move into the conjunctival sac.

*Question: After a client undergoes a liver biopsy, the nurse places the client in the prescribed right-side lying position. The nurse understands that the purpose of this intervention is to accomplish which?*

*Answer: Limit bleeding from the biopsy site* Rationale: After a liver biopsy, the client is assisted with assuming a right side-lying position with a small pillow or folded towel under the puncture site for at least 3 hours to apply pressure and limit bleeding from the biopsy site. The liver produces bile that flows through the common bile duct; client discomfort may be decreased; and the liver does store glucose as glycogen, but this is not the purpose of the right side-lying position.

*Question: A client who has developed paralysis of the lower extremities is admitted to the hospital. The client shares information with the nurse regarding a severe emotional trauma that occurred 6 weeks ago. The nurse develops a plan of care, knowing which action is the priority?*

*Answer: Look for organic causes of the paralysis.* Rationale: The first priority is to rule out any neurological disorders. After it has been determined that the paralysis has no physiological basis, then further psychiatric evaluation can be done. The client would be encouraged to talk about feelings, but this is not the priority. Encouraging the client to move the arms has no beneficial or associated effect in this situation.

*Question: The nurse is caring for a client with glaucoma who is receiving acetazolamide daily. Which sign/symptom indicates to the nurse that the client is experiencing an adverse effect related to the medication?*

*Answer: Low back pain and dysuria* Rationale: Acetazolamide is a carbonic anhydrase inhibitor. Nephrotoxicity and hepatotoxicity can occur and are manifested by dark urine and stools, jaundice, pain in the lower back, dysuria, crystalluria, renal colic, and calculi. Bone marrow depression also may occur. The remaining options are not adverse effects of the medication.

*Question: A client has been diagnosed with acute gastroenteritis. Which diet would the nurse anticipate to be prescribed for the client?*

*Answer: Low fiber* Rationale: A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. This diet is prescribed for clients with inflammatory bowel disease, ileostomy, colostomy, partial obstructions of the intestinal tract, acute gastroenteritis, or diarrhea.

*Question: The nurse is communicating with a client who is hard of hearing in both ears. To facilitate communication with this client, the nurse would perform which?*

*Answer: Lower the voice pitch and face the client when speaking.* Rationale: The nurse should lower the pitch of the voice and face the client while speaking. Lower tones are heard better with hearing loss, and facing the client allows the client to pick up visual cues from the nurse's face. Option 1 requires that the client and nurse understand sign language. Option 2 can be interpreted as hostility, whereas option 3 invades the client's personal space.

*Question: The nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin. The nurse would include which in the plan of care?*

*Answer: Maintain continuous electronic fetal monitoring.* Rationale: Maternal and fetal well-being is monitored before and during oxytocin administration; this includes monitoring fetal heart rate, uterine contractions and tone, and maternal blood pressure. No data in the question indicate the presence of maternal or fetal complications that would require antibiotics, complete bed rest, or notifying the neonatal resuscitation team.

*Question: The nurse is caring for a neonate with fetal alcohol syndrome (FAS). The nurse includes which priority intervention in the plan of care for this newborn?*

*Answer: Monitor neonate response to feedings and the weight gain pattern.* Rationale: A primary nursing goal for the neonate diagnosed with FAS is to establish nutritional balance following delivery. These neonates may exhibit hyperirritability, vomiting, diarrhea, or an uncoordinated sucking and swallowing ability. A quiet environment with minimal stimuli and handling also will help establish appropriate sleep/rest patterns in the neonate.

*Question: The nurse is caring for a newborn with spina bifida (myelomeningocele type) who is scheduled for the removal of the gibbus (sac on the back filled with cerebrospinal fluid, meninges, and some of the spinal cord). Which is the priority nursing action in the preoperative period?*

*Answer: Maintain moisture of the normal saline dressing on the gibbus area.* Rationale: The newborn is at risk for infection before closure of the gibbus. A sterile normal saline dressing is placed over the gibbus to maintain moisture of the gibbus and its contents. This prevents tearing or breakdown of the skin integrity at the site. Blood pressure is difficult to determine during the newborn period and is not the best indicator of infection. Urine concentration is not well developed in the newborn stage of development. Depression of the anterior fontanel is a sign of dehydration. With spina bifida, an increase in intracranial pressure is more of a priority. A complication of spina bifida would demonstrate a bulging or taut anterior fontanel.

*Question: The nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which is a primary prevention measure?*

*Answer: Maintaining body weight at or above minimum recommended levels* Rationale: Maintaining body weight at or above minimum recommended levels is a primary prevention measure. Additional prevention measures include achieving optimal calcium intake, performing regular exercise, avoiding smoking and alcohol consumption, avoiding a high-sodium and high-protein diet, and consuming adequate amounts of vitamin D. The other prevention measures are secondary and not primary prevention measures.

*Question: The nurse observes that a client with Parkinson's disease has very little facial expression. The nurse attributes this piece of data to which information?*

*Answer: Masklike facies is a component of Parkinson's disease.* Rationale: A masked facial expression is typical of the client with Parkinson's disease. There are no data to support the assumption provided in option 2. Option 3 is not a true statement. Option 4 places a false interpretation on the client's expression.

*Question: The nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring, and the nurse is asked to obtain a fetal monitor strip. Which is the most important information for the nurse to document on the strip?*

*Answer: Maternal vital signs* Rationale: Maternal vital signs can influence circulatory exchange with the placenta. Fetal oxygenation depends on a normal flow of oxygenated maternal blood into the placenta and normal uteroplacental exchange. A temporary interruption is noteworthy but not as important as option 2, which is the correct option. Options 1 and 3 are irrelevant.

*Question: Which is the primary goal that would be included in the plan of care for a child who has cerebral palsy?*

*Answer: Maximize the child's assets and minimize the limitations.* Rationale: The goal of managing the child with cerebral palsy is early recognition and intervention to maximize the child's abilities. The cause of the disease cannot be eliminated. It is best to minimize emotional disturbances, if possible, but not to prevent them because it is healthy for the child to express emotions. Improvement of muscle control and coordination is a component of the plan, but the primary goal is to maximize the child's assets and minimize the limitations caused by the disease.

*Question: A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How would the nurse interpret this?*

*Answer: Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.* Rationale: Depression is frequently seen in clients with spinal cord injuries and may be exhibited as a loss of appetite. The client should be allowed to choose the types of food eaten and to eat as much as is feasible because it is one of the few areas of control that the client has left.

*Question: The nurse is collecting data from a client with a suspected diagnosis of gastric ulcer. The client tells the nurse that oral antacids are taken frequently throughout the day. The nurse continues to collect data from the client, understanding that the client is at risk for which acid-base disturbance?*

*Answer: Metabolic alkalosis* Rationale: Increases in base components occur as a result of oral or parenteral ingestion of bicarbonates, carbonates, acetates, citrates, and lactates. Excessive use of oral antacids containing sodium or calcium bicarbonate can cause metabolic alkalosis. Eliminate the options dealing with respiratory problems. Eliminate acidosis because of the ingestion of antacids.

*Question: The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term neonate admitted to the newborn nursery. The nurse determines that which additional sign would be consistent with fetal alcohol syndrome (FAS)?*

*Answer: Microcephaly and increased respiratory effort* Rationale: Features associated with FAS include craniofacial abnormalities, cleft lip or palate, abnormal palmar creases, and irregular hair distribution. Microcephaly, limb anomalies, and increased respiratory effort during the transition to extrauterine life also are noted frequently in the neonate with FAS.

*Question: An oral powder form of nelfinavir is prescribed for a client diagnosed with human immunodeficiency virus (HIV). The nurse would reinforce instructions regarding the preparation of the medication and instruct the client to mix the powder with which substance?*

*Answer: Milk* Rationale: Nelfinavir is an antiviral medication used in the treatment of HIV infection when antiretroviral therapy is warranted. It is available in tablet and powder form. The powder form is prepared by mixing the dose with a small amount of water, milk, formula, soy milk, or dietary supplements. The powder is not mixed with acidic foods or juices such as apple juice or applesauce, orange juice, or grapefruit juice.

*Question: The nurse is assisting in preparing to administer acetylcysteine to a client with an overdose of acetaminophen. How would the nurse administer the medication?*

*Answer: Mix the medication in a flavored ice drink, and allow the client to drink the medication through a straw.* Rationale: Because acetylcysteine has a pervasive odor of rotten eggs, it must be disguised in a flavored ice drink. It is consumed preferably through a straw to minimize contact with the mouth. It is not administered by the intramuscular or subcutaneous route.

*Question: The nurse reinforces instructions to the parents of a newborn infant regarding car travel and safety seats. Which information related to the safety of the infant is correct?*

*Answer: Restrain in a car seat in the back seat in a semi-reclined, rear-facing position.* Rationale: The infant should be placed in a car safety seat restraint in the back seat of the car, in a rear-facing position. The infant should never be placed in a forward-facing position or in the front seat.

*Question: The nurse is assisting in developing a plan of care for a newborn with spina bifida (myelomeningocele type). The nurse includes measures in the plan to monitor for increased intracranial pressure (ICP). Which action will detect the presence of an increase in ICP?*

*Answer: Monitoring the anterior fontanel for bulging* Rationale: A bulging or taut anterior fontanel indicates the presence of increased ICP. Monitoring for signs of dehydration will not provide data related to increased ICP. Urine concentration is also not well developed in the newborn stage of development. Blood pressure is difficult to assess during the newborn period and is not the best indicator of increased ICP.

*Question: The nurse is planning care for a client in spinal shock. Which action would be least helpful in minimizing the effects of vasodilation below the level of the injury?*

*Answer: Moving the client quickly as one unit* Rationale: Reflex vasodilation below the level of spinal cord injury places the client at risk of orthostatic hypotension, which may be profound. Actions to minimize this include measuring vital signs before and during position changes, use of a tilt table in early mobilization, and changing the client's position slowly. Venous pooling can be reduced by using compression stockings, if prescribed. Vasopressor medications are used as per protocol and as prescribed.

*Question: A client with a herniated intervertebral lumbar disk complains of a knifelike, stabbing pain in the lower back, as well as pain radiating into the right buttock. The nurse interprets that the sharp, stabbing pain is probably a result of which reason?*

*Answer: Muscle spasm in the area of the herniated disk* Rationale: The pain of muscle spasm is continuous, knifelike, and localized in the affected area. Compression of a nerve results in inflammation, which then irritates adjacent muscles, putting them into spasm. The other interpretations of the pain are incorrect.

*Question: A client receives a dose of edrophonium. The client shows improvement in muscle strength for a period of time following the injection. The nurse would interpret this finding as indicative of which disease process?*

*Answer: Myasthenia gravis* Rationale: Myasthenia gravis can often be diagnosed based on clinical signs and symptoms. The diagnosis can be confirmed by injecting the client with a dose of edrophonium. This medication inhibits the breakdown of an enzyme in the neuromuscular junction, so more acetylcholine binds to receptors. If the muscle is strengthened for 3 to 5 minutes after this injection, it confirms a diagnosis of myasthenia gravis. Another medication, neostigmine, also may be used because its effect lasts for 1 to 2 hours, providing a better analysis. For either medication, atropine sulfate should be available as the antidote.

*Question: The nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle crash for signs of increased intracranial pressure (ICP). The nurse assesses the child frequently for which early sign of increased ICP?*

*Answer: Nausea* Rationale: Nausea is an early sign of increased ICP. Late signs of increased ICP include a significant decrease in level of consciousness, Cushing's triad (increased systolic blood pressure and widened pulse pressure, bradycardia, and irregular respirations), and fixed and dilated pupils. Other late signs include decreased motor response to command, decreased sensory response to painful stimuli, posturing, Cheyne-Stokes respirations, and papilledema.

*Question: The clinic nurse reads the results of a tuberculin skin test performed on a 5-year-old child. The results indicate an area of induration measuring 8 mm. Which correct interpretation would the nurse make about these results?*

*Answer: Negative* Rationale: Induration measuring 15 mm or greater is considered a positive result in a child 4 years or older who has no associated risk factors. Because this child's results show an area of induration measuring 8 mm, the finding is negative. The remaining options are incorrect interpretations.

*Question: The client, diagnosed with Lyme disease stage 2, asks the nurse "what is indicative of stage 2?" The nurse explains to the client that which sign or symptom is assessed in stage 2?*

*Answer: Neurological deficits* Rationale: Stage 2 of Lyme disease develops within 1 to 6 months in most untreated individuals. The most serious problems include cardiac conduction defects and neurological disorders, such as Bell's palsy and paralysis. These problems are not usually permanent. Arthralgias and joint enlargements are noted in stage 3. A rash appears in stage 1.

*Question: The nurse is caring for a newborn with respiratory distress syndrome (RDS). Which data obtained by the nurse indicate potential complications associated with this disorder?*

*Answer: No audible breath sounds in left lung; heart sounds louder in right side of chest* Rationale: Pneumothorax is a complication associated with respiratory distress syndrome. Clinical signs of pneumothorax include a sudden rapid deterioration in condition, tachypnea, grunting, pallor, cyanosis, decreased or absent breath sounds in the affected lung, shifting of the cardiac apex away from the affected lung, bradycardia, and hypertension. Options 1, 2, and 3 are normal findings.

*Question: A client was involuntarily admitted to the psychiatric unit because of episodes of extremely violent behavior. The client is demanding to be discharged from the hospital. The licensed practical nurse (LPN) reports the information to the registered nurse (RN), and the RN does not allow the client to leave. The LPN understands that which represents the legal ramifications associated with the RN's behavior?*

*Answer: No charge will be made against the RN because the RN's actions are reasonable.* Rationale: False imprisonment is an act with the intent to confine a person to a specific area. The nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital if the client was voluntarily admitted and if there are no agency or legal policies for detaining the client. On the other hand, if the client has been involuntarily admitted or has agreed to an evaluation before discharge, the nurse's actions are reasonable.

*Question: The nurse is providing care for a client suspected of having appendicitis. Which priority intervention would the nurse anticipate will be prescribed for this client?*

*Answer: No oral intake of liquids or food* Rationale: For a client with suspected or known appendicitis, the nurse should ensure the client remains on nothing by mouth status in anticipation of emergency surgery and also to avoid worsening the inflammation. Options 1, 2, and 3 are not prescribed for the client with suspected appendicitis.

*Question: A client receiving enteral feedings develops abdominal distention and diarrhea shortly after initiation of the feedings. Which is the appropriate intervention for the nurse to implement?*

*Answer: Notify the primary health care provider (PHCP) of the client's signs and symptoms.* Rationale: Clients receiving tube feedings can develop distention and diarrhea due to hyperosmolarity of the formula, malabsorption, or contamination. The nurse should notify the PHCP about the problems of the client not tolerating the tube feeding. Encouraging ambulation may improve peristalsis, but this will not improve toleration of the tube feeding. Administering antidiarrheal medication or stopping the tube feeding should not be done without approval of the PHCP. If the client was made NPO without the tube feeding, the client would be at risk for dehydration.

*Question: The nurse is reviewing the laboratory results of a client with bladder cancer and bone metastasis and notes that the calcium level is 15 mg/dL. The nurse would take which appropriate action?*

*Answer: Notify the primary health care provider.* Rationale: The normal calcium level is 9 to 10.5 mg/dL. Hypercalcemia is a serum calcium level greater than 10.5 mg/dL. It most often occurs in clients who have bone metastasis and is a late manifestation of extensive malignancy. The presence of cancer in the bone causes the bone to release calcium into the bloodstream. Hypercalcemia is an oncological emergency, and the primary health care provider must be notified. High calcium levels can lead to formation of stones in the urinary system and can lead to renal impairment. High calcium levels can affect the heart and neurological systems as well.

*Question: The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. After immediately applying sterile gauze over the chest tube insertion site, which would the nurse do next?*

*Answer: Notify the registered nurse (RN).* Rationale: If the chest drainage system is dislodged from the insertion site, the nurse immediately applies sterile gauze over the site and notifies the RN, who then calls the primary health care provider (PHCP). The nurse should maintain the client in an upright position. A new chest tube system may be attached if the tube requires insertion, but this would not be the next action. Pulse oximetry readings should assist in determining the client's respiratory status, but the priority action should be to notify the RN, who will then call the PHCP.

*Question: A licensed practical nurse (LPN) is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. The LPN would take which best action?*

*Answer: Notify the registered nurse of the finding.* Rationale: The legal role of the LPN is to practice under the supervision of the registered nurse. In this instance, the tuft of hair may be indicative of a spinal anomaly, and the registered nurse should be notified of the finding. It is inappropriate to discuss abnormal findings with the parents because this is the responsibility of the primary health care provider if an anomaly is suspected or diagnosed. The LPN should take the priority intervention of notifying the registered nurse before documenting in the chart.

*Question: The nurse is caring for a client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which action would the nurse take next?*

*Answer: Notify the registered nurse.* Rationale: A client who complains of severe pain may need realignment or may have traction weights prescribed that are too heavy. The nurse realigns the client and, if ineffective, would next notify the registered nurse, who will then contact the primary health care provider. Severe leg pain once traction has been established indicates a problem. Medicating the client would be done after trying to determine and treat the cause. The nurse would never remove the weights from the traction without a specific prescription to do so. Providing pin care is unrelated to the problem as described.

*Question: The nurse is monitoring a newborn infant who was circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action?*

*Answer: Notify the registered nurse.* Rationale: Complications following circumcision include bleeding, failure to urinate, displacement of the Plastibell, and infection (indicated by a fever and purulent or foul-smelling drainage). If signs of infection occur, the registered nurse is notified and will then contact the primary health care provider. The nurse should document the findings, but this is not the priority item. The nurse should change, not reinforce, the dressing. The PHCP will prescribe a culture if it is necessary.

*Question: The nurse is caring for a client following enucleation. On data collection, the nurse notes staining and bleeding on the dressing. The nurse would take which action?*

*Answer: Notify the registered nurse.* Rationale: Postoperative nursing care includes observing the dressing and reporting any staining or bleeding to the surgeon. Options 1, 2, and 4 are inaccurate nursing actions if staining or bleeding is present on the dressing following enucleation. The nurse should notify the registered nurse, who would then notify the primary health care provider immediately.

*Question: The student nurse is changing an abdominal dressing on a client with an open incision and notes the presence of sanguineous drainage. Which nursing action would be appropriate?*

*Answer: Notify the registered nurse.* Rationale: Sanguineous drainage is bright red and indicates active bleeding. If active bleeding is present, the registered nurse should be notified. Covering the wound and reassessing in 1 hour will delay needed intervention. Leaving a wound open to air can lead to infection, and the blood will not be contained.

*Question: The nurse in the ambulatory care unit is caring for a client following cataract extraction. The client suddenly complains of nausea and severe eye pain in the surgical eye. The nurse would take which action?*

*Answer: Notify the registered nurse.* Rationale: Severe pain or pain accompanied by nausea is an indicator of increased intraocular pressure and should be reported to the registered nurse who will notify the primary health care provider immediately. The other options are incorrect nursing actions. Ice is not applied to the surgical site unless prescribed. The client is not positioned on the operative side because of the risk of increasing intraocular edema from swelling. Although pain medication and an antiemetic may be prescribed, the client's symptoms indicate a serious complication requiring primary health care provider notification.

*Question: The nurse is monitoring an infant for signs of increased intracranial pressure (ICP) and notes that the anterior fontanel bulges when the infant is sleeping. Based on this finding, which is the priority nursing action?*

*Answer: Notify the registered nurse.* Rationale: The anterior fontanel is diamond-shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. A larger-than-normal fontanel may be a sign of increased ICP within the skull. Although the anterior fontanel may bulge slightly when the infant cries, bulging at rest may indicate increased ICP. Increasing oral fluids and placing the infant in the side-lying position are inaccurate interventions. Although the nurse should document the finding, the first action is to report the finding to the registered nurse, who will then contact the primary health care provider.

*Question: The nurse is assisting in caring for a victim of a burn injury during the emergent/resuscitative phase. On data collection of the client, the nurse notes that the urine output has decreased and the blood pressure is dropping. The nurse would perform which immediate action?*

*Answer: Notify the registered nurse.* Rationale: The nurse notifies the registered nurse, who will then notify the primary health care provider immediately if the burn client exhibits a decreased urine output or blood pressure or an increased pulse rate. Because of the rapid fluid shifts that occur in burn shock, fluid deficit must be detected early so that distributive shock does not occur. The nurse does not increase an IV rate without a specific prescription to do so. Checking the client in 30 minutes will delay necessary interventions to prevent the development of distributive shock. A warm environment is maintained, but this is not the immediate action.

*Question: The nurse assigned to care for a child with mumps is monitoring the child for the signs and symptoms associated with the common complication of mumps. The nurse monitors for which sign/symptom that is indicative of this common complication?*

*Answer: Nuchal rigidity* Rationale: The most common complication of mumps is aseptic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. A red, swollen testicle may be indicative of orchitis. Although this complication appears to cause most concern among parents, it is not the most common complication. Although mumps is one of the leading causes of unilateral nerve deafness, it does not occur frequently. Muscular pain, parotid pain, or testicular pain may occur, but pain does not indicate a sign of a common complication.

*Question: The nurse has provided instructions to a client in an arm cast about the signs/symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states to report which early symptom of compartment syndrome?*

*Answer: Numbness and tingling in the fingers* Rationale: The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign.

*Question: The nurse is attending an agency orientation regarding the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. What does the nurse determine is a characteristic of this type of nursing model practice?*

*Answer: Nursing personnel are led by an RN leader in providing care to a group of clients.* Rationale: In team nursing, nursing personnel are led by an RN leader to provide care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 4 identifies primary nursing.

*Question: The nurse is providing information to a pregnant woman about food items high in folic acid. Which mid-afternoon snack should be recommended to supply folic acid?*

*Answer: Nuts and green, leafy vegetables* Rationale: Folic acid is needed during pregnancy for healthy cell growth and repair. A pregnant woman should have at least four daily servings of foods rich in folic acid. Nuts and green, leafy vegetables contain folic acid. Milk and yogurt supply calcium. Bananas provide potassium.

*Question: The nurse is caring for a newborn whose mother had an elevated temperature during a prolonged labor. Which intervention would be important to include in the newborn's plan of care?*

*Answer: Observe vital signs and central nervous system status frequently during the first 2 days.* Rationale: Clinical signs of sepsis in the newborn include temperature instability, tachycardia, respiratory changes, and central nervous symptoms such as lethargy or irritability. If sepsis is a risk, the nurse should monitor vital signs and central nervous system status frequently. Promoting early maternal-newborn interaction is always important but is unrelated to this question. Delaying a feeding is not appropriate.

*Question: A mother arrives at the emergency department with her child and a diagnosis of epiglottitis is documented. Which of the primary health care provider's prescription would the nurse question?*

*Answer: Obtain a throat culture.* Rationale: The throat of a child with suspected epiglottitis should not be examined or cultured because any stimulation with a tongue depressor or culture swab could cause laryngospasm and complete airway obstruction. Humidified oxygen and antipyretics are components of the treatment. Axillary rather than oral temperatures should be taken.

*Question: A second-day postpartum client diagnosed with a stable cardiac condition has scant lochia with a foul odor and a temperature of 102.2°F. The primary health care provider suspects infection and writes prescriptions to treat the client. Which prescription written by the primary health care provider would the nurse implement first?*

*Answer: Obtain culture and sensitivity of lochia and urine.* Rationale: Culture and sensitivity results should be obtained before any antibiotic therapy is administered to avoid masking the microorganisms identified in the culture. Administering an antibiotic and increasing fluid intake are standard parts of therapy for this type of infection but are not completed first. Although the client's temperature is monitored, reassessing the temperature in 30 minutes is not the first action; also, the data in the question indicate that the temperature has already been checked.

*Question: A client who experienced ventricular fibrillation has just been defibrillated. Following the defibrillation, which action would the nurse take immediately?*

*Answer: Resume cardiopulmonary resuscitation (CPR).* Rationale: Following defibrillation, the nurse immediately resumes CPR for 2 minutes. Even if a normal rhythm has been restored, the heart pump needs to be reprimed to provide improved cerebral blood flow to improve neurological outcome. Options 1, 2, and 3 are not immediate actions following defibrillation.

*Question: Emergency surgery is scheduled for a client with a bowel obstruction. The licensed practical nurse (LPN) tells the registered nurse (RN) that she is unable to obtain informed consent from the client because the client has received opioid analgesics and is sedated. The LPN understands that which action would be implemented?*

*Answer: Obtaining a telephone consent from a family member and ensuring that the oral consent is witnessed by two persons* Rationale: Every effort must be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. Telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent and document the name of the family member, noting that an oral consent was obtained. In emergencies, the client may be unable to sign and family members may not be available. In this type of a situation, the primary health care provider is legally permitted to perform surgery without consent so the surgery would not be delayed. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives.

*Question: A tricyclic antidepressant is administered to a client daily. The nurse plans to alleviate the common side effects of the medication and includes which in the plan of care?*

*Answer: Offer hard candy or gum periodically.* Rationale: Dry mouth is a common side effect of tricyclic antidepressants. Frequent mouth rinsing with water, sucking on hard candy, and chewing gum will alleviate this common side effect. It is not necessary to monitor the blood pressure every 2 hours. In addition, it is not necessary to check the WBC count daily. Weight gain is a common side effect and frequent snacks will aggravate this problem.

*Question: The nurse working in a long-term care facility is approached by the son of a resident, who wants his 78-year-old father to have a heating pad because "his feet are always cold at night." The nurse would incorporate which concept when formulating a response to the family member?*

*Answer: Older adults often have slower neurological response times and are therefore more at risk for burns.* Rationale: Age-related changes in the older adult make the client more at risk for burns as a result of slower neurological response times. The option describing heating pads being dangerous represents a general statement, but it does not pertain to the individual safety of this client. The option describing resident rights ignores the client's safety and is unrelated to the subject of the question. Quoting facility policy represents a bureaucratic response and does not consider client needs.

*Question: The nurse is reinforcing teaching about fall prevention to family members of an older client who is at risk for falls. The nurse realizes further instruction is necessary if the family states which concept is relevant to maintenance of balance for the older adult?*

*Answer: Older clients cannot think quickly enough to respond to emergencies.* Rationale: It is not true that older clients cannot think quickly enough to respond to emergencies. That statement is a stereotypical generalization. The statements contained in the other options indicate the family understands the concepts of balance in the older adult.

*Question: Insulin glargine is prescribed for a client with diabetes mellitus. The nurse tells the client that which is the best time to take the insulin?*

*Answer: Once daily at the same time each day* Rationale: Insulin glargine is a long-acting recombinant DNA human insulin used to treat type 1 and type 2 diabetes mellitus. It has 24-hour duration of action and is administered once a day at the same time each day.

*Question: The nurse is collecting data on a client with a diagnosis of meningitis and notes that the client is assuming this posture. (Refer to figure.) The nurse contacts the registered nurse and reports that the client is exhibiting which?View Figure*

*Answer: Opisthotonos* Rationale: Opisthotonos is a prolonged arching of the back with the head and heels bent backward. Opisthotonos indicates meningeal irritation. In decorticate rigidity, the upper extremities (arms, wrists, and fingers) are flexed with adduction of the arms. The lower extremities are extended with internal rotation and plantar flexion. Decorticate rigidity indicates a hemispheric lesion of the cerebral cortex. In decerebrate rigidity, the upper extremities are stiffly extended and adducted with internal rotation and pronation of the palms. The lower extremities are extended stiffly with plantar flexion. The teeth are clenched and the back is hyperextended. Decerebrate rigidity indicates a lesion in the brainstem at the midbrain or upper pons. Flaccid quadriplegia is complete loss of muscle tone and paralysis of all four extremities, indicating a completely nonfunctional brainstem.

*Question: The nurse is checking a dark-skinned client for the presence of petechiae. Which body area is best for the nurse to check in this client?*

*Answer: Oral mucosa* Rationale: In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa. Cyanosis is best noted on the palms of the hands and soles of the feet. Jaundice would best be noted in the sclera of the eye.

*Question: The nurse is reinforcing instructions to a client scheduled for conization in 1 week for the treatment of microinvasive cervical cancer. The procedure has been explained by the primary health care provider, and the nurse is reviewing the complications associated with the procedure. The nurse determines that the client needs further teaching if the client states that which is a complication of this procedure?*

*Answer: Ovarian perforation* Rationale: Conization is the removal of a cone-shaped tissue sample from the cervix done to confirm and sometimes treat cervical cancer. This procedure generally is not performed on women who desire to bear children because it can lead to incompetence of the cervix or infertility. Complications of the procedure include hemorrhage, infection, and, less frequently, cervical stenosis.

*Question: The nurse is caring for a postoperative client who is being monitored by pulse oximetry. Which is an expected measurement determined by the pulse oximeter?*

*Answer: Oxygen saturation 95% to 100%; blood pressure 120/80 to 130/80 mm Hg* Rationale: Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2). The pulse oximeter does not replace arterial blood gases, but it is an effective tool to monitor the client for subtle or sudden changes in oxygen saturation. It is not the oxygen liter flow that may be prescribed for a client, the oxygen level from arterial blood gases, or the end tidal carbon dioxide, which is measured on exhalation and is more sensitive to hypoxemia that oxygen saturation.

*Question: A pregnant client asks the nurse about the hormone that stimulates postpartum contractions. The nurse tells the client that which primary hormone stimulates postpartum contractions?*

*Answer: Oxytocin* Rationale: Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding. Prolactin stimulates the secretion of milk, called lactogenesis. Progesterone stimulates the secretions of the endometrial glands and causes the endometrial vessels to become dilated and tortuous in preparation for possible embryo implantation. Testosterone is produced by the adrenal glands in the female and induces the growth of pubic and axillary hair at puberty.

*Question: The nurse is reinforcing home care instructions to the mother of an infant who has just been found to have hemophilia. The nurse would would instruct the mother to do which?*

*Answer: Pad crib rails and table corners.* Rationale: Establishment of an age-appropriate safe environment is of paramount importance for hemophiliac clients. Providing a safe environment for an infant includes padding table corners and crib rails, providing extra "joint" padding on clothes, observing a mobile infant at all times, and keeping items that can be pulled down onto the infant out of reach. Use of a soft toothbrush is an appropriate measure for a child with hemophilia, but is not typically necessary for an infant. Rectal temperature measurements and the use of aspirin are contraindicated in hemophiliac individuals because of the risk of bleeding.

*Question: The nurse is caring for a client following a total abdominal hysterectomy. The nurse anticipates that which postoperative outcome will be the priority in the first 24 hours following surgery?*

*Answer: Pain* Rationale: The client who has had abdominal surgery is most likely to experience pain in the first 24 hours after surgery. The other options identify less important issues during this time frame but could increase in importance later in recovery.

*Question: The nurse is checking for the presence of cyanosis in a dark-skinned client. Which body area would provide the best information?*

*Answer: Palms of the hands* Rationale: In a dark-skinned client, the nurse examines the lips, tongue, nail beds, conjunctivae, and palms and soles at regular intervals for subtle color changes. In a client with cyanosis, the lips and tongue are gray, and the palms, soles, conjunctivae, and nail beds have a bluish tinge.

*Question: The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). Which method would be used to monitor the client for crepitus?*

*Answer: Palpating the skin around the chest and neck for a crackling sensation* Rationale: Air caught under the skin in the subcutaneous tissues is known as crepitus or subcutaneous emphysema. It presents as a "puffed-up" appearance that is caused by the leakage of air into the subcutaneous tissues. It is monitored by palpating, and it feels like bubble wrap when palpated. Auscultation of posterior breath sounds gives data about adequate depth of respirations. Pain upon inspiration can occur with pleurisy (inflammation of the pleurae) or pericarditis. Placing the hands over the rib area is a method of determining equal chest expansion on each side.

*Question: A client is admitted to the hospital because of complaints of vomiting and abdominal pain. During data collection, the client tells the nurse that he is taking entacapone. Based on this finding, the nurse elicits information from the client regarding the presence of which condition?*

*Answer: Parkinson's disease* Rationale: Entacapone is an antiparkinsonian agent used in conjunction with levodopa to improve the quality of life in clients with Parkinson's disease. It is not used to treat cardiovascular disorders.

*Question: A client is tentatively diagnosed with ovarian cancer. The nurse gathers data about which late symptom of this disease?*

*Answer: Pelvic pain, anemia, and ascites* Rationale: Pelvic pain, anemia, and ascites are experienced late in the disease process for ovarian cancer. Vague lower abdominal discomfort and mild digestive complaints are early symptoms. Bowel and bladder functions are also affected early in this type of cancer.

*Question: The nurse has administered a dose of diazepam to a client. The nurse would take which most important action before leaving the client's room?*

*Answer: Per agency policy, put up the side rails on the bed.* Rationale: Diazepam is a sedative-hypnotic with anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client's room to ensure that the client does not injure herself or himself. The most frequent side effects of this medication are dizziness, drowsiness, and lethargy. For this reason, the nurse puts the side rails up on the bed before leaving the room to prevent falls. Options 1, 2, and 3 may be helpful measures that provide a comfortable, restful environment, but option 4 is the one that provides for the client's safety needs.

*Question: The nurse is caring for a client who has a cast applied to the left lower leg. On data collection, the nurse notes the presence of skin irritation from the edges of a cast. Which nursing intervention is appropriate?*

*Answer: Petal the cast edges with adhesive tape.* Rationale: If a client with a cast has skin irritation from the edges of the cast, the appropriate intervention by the nurse would be to petal the edges of the cast with tape to minimize the irritation. Massaging the skin will not eliminate the problem. Placing a small face cloth in the cast around the edges of the cast is not appropriate. It is not necessary to contact the primary health care provider.

*Question: The nurse is caring for a hospitalized child with a diagnosis of rubella (German measles). The nurse reviews the primary health care provider's progress notes and reads that the child has developed Forchheimer sign. Based on this documentation, which would the nurse expect to note in the child?*

*Answer: Petechiae spots located on the palate* Rationale: Forchheimer sign refers to petechiae spots, which are reddish and pinpoint and located on the soft palate. Small blue-white spots noted on the buccal mucosa are known as Koplik's spots seen in rubeola. A fiery red edematous rash on the cheeks, also called "slapped cheeks," is seen in erythema infectiosum. Swelling of the parotid gland is seen in mumps.

*Question: The nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to make which observation while caring for the neonate?*

*Answer: The neonate cries incessantly.* Rationale: A neonate born to a woman who is addicted to drugs is irritable, may cry incessantly, and be difficult to console. The neonate would hyperextend and posture rather than cuddle when being held.

*Question: The nurse is repositioning a client who has returned to the nursing unit following internal fixation of a fractured right hip. How would the nurse plan to position the client?*

*Answer: Pillow to keep the right leg abducted during turning* Rationale: Following internal fixation of a hip fracture, the client is turned to the affected side or the unaffected side, as prescribed by the surgeon. Before moving the client, the nurse places a pillow between the client's legs to keep the affected leg in abduction. The client is then repositioned while proper alignment and abduction are maintained. A trochanter roll is useful in preventing external rotation, but it is used once the client has been repositioned. It is not used while repositioning the client.

*Question: The nurse reviews the activity schedule for the day and determines that which supervised activity is the best option for the manic client?*

*Answer: Ping-pong* Rationale: The best supervised activity that the manic client could participate in is ping-pong. A person who is experiencing mania is overactive, full of energy, lacks concentration, and has poor impulse control. The client needs an activity that will allow him or her to use excess energy but not endanger others during the process. Ping-pong is an activity that will help expend the increased energy this client is experiencing and is a safe activity. Painting, reading, and progressive relaxation are relatively sedate activities that require concentration, a quality that is lacking in the manic state. Such activities may lead to increased frustration and anxiety for the client.

*Question: The nurse is preparing a plan of care for a client in skeletal leg traction with an overbed frame. Which nursing intervention would be included in the plan of care to assist the client with positioning in bed?*

*Answer: Place a trapeze on the bed to provide a means for the client to lift the hips off the bed.* Rationale: The nurse can best assist the client in skeletal traction with positioning in bed by providing a trapeze on the bed for the client's use. Encouraging the client to pull up by pushing with the unaffected leg on the bed mattress may cause skin breakdown on the unaffected heel area. Although a draw sheet is helpful and client movement may be more easily facilitated with four nurses, these actions will not promote the means of positioning by the client.

*Question: The nurse is measuring the fundal height of a client who is at 30 weeks of gestation. In preparing to perform the procedure, the nurse would take which action?*

*Answer: Place the client in a supine position and place a wedge under the right hip.* Rationale: When measuring fundal height, the client lies in a supine position, and the nurse places a wedge under the right hip. This position will assist in preventing supine hypotension. Standing, right lateral, or prone positions are incorrect client positions for measuring fundal height.

*Question: A primary health care provider prescribes "eye patching" for a child with strabismus of the right eye. The nurse reinforces instructions to the mother to use which procedure for eye patching?*

*Answer: Place the patch on the left eye.* Rationale: Eye patching may be used in the treatment of strabismus to strengthen the weak eye. In this treatment, the "good" eye is patched. This encourages the child to use the weaker eye. It is most successful when done during the preschool years. The schedule for patching is individualized and is prescribed by the ophthalmologist.

*Question: The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How would the nurse determine that the restraints are not too constrictive?*

*Answer: Place two fingers under the restraint to determine snugness.* Rationale: Limb restraints are often prescribed to prevent clients from pulling out tubes and injuring themselves. The restraint is prescribed for 24 hours, and the nurse must verify that the restraint is protecting the client from self-injury but is not so constrictive as to impair circulation or harm the skin. Limb restraints are made with padding to protect the client's skin. The nurse determines the tightness of the wrist restraint by placing two fingers under the restraint. Observing the skin and checking the temperature of the skin is not as thorough or accurate as checking the tightness of the restraint manually. Restraints need to be removed at least every 2 hours, but this does not evaluate how tight the restraint is around the wrist.

*Question: The nurse has inserted a nasogastric (NG) tube in a client and is checking for the correct placement of an NG tube. Which is the most reliable data to ensure that the end of the tube is in the stomach?*

*Answer: Placement is verified on x-ray.* Rationale: The end of the NG tube should be in the stomach. An x-ray is the most reliable method of determining correct placement. The radiologist may recommend moving the tube backward or forward for a preferable placement. A low pH such as 4.5 of the fluid aspirated is likely to be from the stomach, but pH is affected by tube feeding formulas and prescribed proton-pump inhibitors. The characteristic bile green is highly suggestive that the tube is in the stomach. Auscultation of the air injection is not recommended as a reliable method to establish correct placement.

*Question: A client with retinal detachment is admitted to the outpatient nursing unit in preparation for a scleral buckling procedure. Which prescription would the nurse anticipate?*

*Answer: Placing an eye patch over the client's affected eye* Rationale: The nurse places an eye patch over the client's affected eye to reduce eye movement. Some clients may need bilateral patching. Depending on the location and size of the retinal break, activity restrictions, including watching television, may be needed immediately. These restrictions are necessary to prevent further tearing or detachment and to promote drainage of any subretinal fluid. The nurse positions the client as prescribed by the primary health care provider.

*Question: The nurse is assisting with care for a pregnant client in labor who will be delivering twins. The nurse prepares to monitor the fetal heart rates by performing which?*

*Answer: Placing external fetal monitors so that each fetal heart rate is monitored separately* Rationale: In a client with a multifetal pregnancy, each fetal heart rate is monitored separately. Options 2, 3, and 4 are incorrect because these actions would not provide information regarding the status of each fetus.

*Question: The nurse would monitor for which laboratory result as indicating an adverse reaction in the client who is receiving chemotherapy?*

*Answer: Platelet count 20,000 mm3* Rationale: A normal platelet count ranges from 150,000 mm3 to 400,000 mm3. A platelet count of 20,000 mm3 places the client at severe risk for bleeding. All of the other values, hemoglobin, BUN, and WBC, are within normal limits.

*Question: The nurse is reviewing the laboratory results of a child scheduled for tonsillectomy. Which laboratory value would be significant to review?*

*Answer: Platelet count* Rationale: Before the surgical procedure, the child is assessed for signs of active infection and for redness and exudate of the throat. Because the tonsillar area is so vascular, postoperative bleeding is a concern. The prothrombin (PT), partial thromboplastin time (PTT), platelet count, hemoglobin and hematocrit (H&H), white blood cell (WBC) count, and urinalysis are performed preoperatively. The platelet count result would identify a potential for bleeding. The BUN and creatinine would not determine the potential for bleeding but rather evaluate renal function.

*Question: The nurse monitors the 3-day postoperative client who underwent abdominal surgery. Vital signs are: temperature: 37.9° C (100.2° F), pulse 104 beats per minute, respirations 22 breaths per minute, blood pressure 128/74 mm Hg. Oxygen saturation is 93% on room air. The client feels tired and has a productive cough. Fine crackles are audible in the bases of the lungs posteriorly. The nurse considers the client has developed which postoperative problem?*

*Answer: Pneumonia* Rationale: Pneumonia is a postoperative condition caused by inflammation and infection in the lungs. Frequently it results from shallow breathing that leads to atelectasis (the alveoli partially collapse and eventually become fluid-filled). This fluid is good medium for bacteria. Pneumonia usually occurs 3 to 7 days postoperatively. Signs and symptoms include fever, productive cough, painful breathing, and an increased respiratory effort and rate. Fine crackles may be audible over the lung area involved. Treatment includes coughing up the purulent sputum, deep breathing, antibiotics, and adequate hydration. Hypoxia is inadequate concentration of oxygen in the blood and usually occurs as an acute process, such as respiratory depression as a result of anesthesia or analgesia, or the pulmonary oxygen saturation is relatively below normal, less than 92%. Atelectasis occurs 1 to 2 days postoperatively, and auscultation reveals diminished breath sound and/or crackles tha

*Question: The nurse is caring for a client with a diagnosis of hypoparathyroidism. The nurse reviews the client's laboratory results and notes that the calcium level is extremely low. The nurse would expect to note which sign/symptom on data collection?*

*Answer: Positive Trousseau's sign* Rationale: Hypoparathyroidism is related to a lack of parathyroid hormone secretion or to a decreased effectiveness of parathyroid hormone on target tissues. The end result of this disorder is hypocalcemia. When serum calcium levels are critically low, the client may exhibit positive Chvostek's and Trousseau's signs, which indicate potential tetany. Options 1, 3, and 4 are not related to the presence of hypocalcemia.

*Question: The nurse is caring for a woman who has delivered a baby after a pregnancy complicated with placenta previa. Which complication is the client most at risk for developing?*

*Answer: Postpartum hemorrhage* Rationale: Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding. The nurse monitors the client frequently for signs of postpartum hemorrhage. Options 1, 2, and 3 are not directly associated with placenta previa.

*Question: A client receiving an anxiolytic medication complains that he feels very "faint" when he tries to get out of bed in the morning. The nurse explains to the client that which side effect is associated with this type of medication?*

*Answer: Postural hypotension* Rationale: Anxiolytic medications can cause postural hypotension. The client needs to be taught to rise to a sitting position and get out of bed slowly because of this adverse effect related to the medication. The other side effects are unrelated to the use of this medication.

*Question: The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of U waves. The nurse checks the client and then reviews the results of the client's recent electrolyte results. The nurse expects to note which electrolyte value?*

*Answer: Potassium 3.0 mEq/L* Rationale: The U wave is a very small wave that may be present following the T wave on a heart monitor strip. It is thought to represent repolarization of the Purkinje fibers. It is present in some clients who have hypokalemia. A serum potassium level below 3.5 mEq/L is indicative of hypokalemia. In hypokalemia, the electrocardiogram (ECG) changes that occur include inverted T waves, ST segment depression, heart block, and prominent U waves. The normal sodium level is 135 to 145 mEq/L. The normal potassium level is 3.5 to 5.0 mEq/L.

*Question: The nurse is reviewing the arterial blood gas results of the client. Blood gas results indicate a pH of 7.30 and a Pco2 of 50 mm Hg, and the nurse has determined that the client is experiencing respiratory acidosis. Which additional laboratory values would the nurse expect to note in this client?*

*Answer: Potassium 5.4 mEq/L* Rationale: Serum potassium levels are often high in acidosis as the body attempts to maintain electroneutrality during buffering. In acidosis, extracellular hydrogen ion content increases, and hydrogen ions then begin to move into intracellular fluid. To keep the intracellular fluid electrically neutral, an equal number of potassium ions must leave the cell, creating a relative hyperkalemia. Sodium, magnesium, and phosphorus would remain within normal range.

*Question: The nurse prepares to administer sodium polystyrene sulfonate to a client with chronic kidney disease for which laboratory abnormality?*

*Answer: Potassium level of 7.2 mEq/L* Rationale: Sodium polystyrene sulfonate is a cation exchange resin used in the treatment of hyperkalemia. The resin either passes through the intestine or is retained in the colon. It releases sodium ions in exchange for primarily potassium ions. The therapeutic effect occurs 2 to 12 hours after oral administration and longer after rectal administration.

*Question: The nurse is preparing to administer furosemide to a client with a diagnosis of heart failure. Which is the most important laboratory test result for the nurse to review before administering this medication?*

*Answer: Potassium level* Rationale: Furosemide is a loop diuretic. The medication causes a decrease in the client's electrolytes, especially potassium, sodium, and chloride. Administering furosemide to a client with a low potassium level could precipitate ventricular dysrhythmias. The options of BUN and creatinine reflect renal function. The cholesterol level is unrelated to the administration of this medication.

*Question: The nurse is caring for a client with kidney failure. The nurse is told that the blood gas results indicate a pH of 7.30 and a HCO3- of 20 mm Hg, and that the client is experiencing metabolic acidosis. The nurse reviews the laboratory results and finds which value to be of concern?*

*Answer: Potassium level, 5.6 mEq/L* Rationale: Signs/symptoms of metabolic acidosis include weakness, malaise, and headache. Hyperkalemia will occur because the cells will draw hydrogen into the cell and in exchange will push potassium out of the cell into the blood. The pH will be lower than 7.35, and the HCO3- ion level will be lower than 22 mEq/L. The remaining options identify normal laboratory values, whereas a potassium level of 5.6 mEq/L indicates hyperkalemia.

*Question: The nurse is assisting in planning a diet for a client with acute kidney injury (AKI). The nurse plans to restrict which dietary component from this client's diet?*

*Answer: Potassium* Rationale: In the client with renal failure, potassium intake must be restricted as much as possible (30 to 50 mEq/day). The primary mechanism of potassium removal during acute kidney injury is dialysis. Options 1, 2, and 4 normally are not restricted in the client with acute kidney injury.

*Question: The nurse preparing a client for surgery reviews the client's medication record. The client is to receive nothing by mouth (NPO) after midnight. Which medication noted on the client's record would the nurse question?*

*Answer: Prednisone* Rationale: Prednisone is a corticosteroid that can cause adrenal atrophy, which reduces the body's ability to withstand stress. Before and during surgery, dosages may be temporarily increased. Cyclobenzaprine is a skeletal muscle relaxant. Alendronate is a bone-resorption inhibitor. Allopurinol is an antigout medication.

*Question: The nurse is administering medications to a 6-year-old child with nephrotic syndrome. To reduce proteinuria, the nurse would expect which medication to be prescribed?*

*Answer: Prednisone* Rationale: With nephrotic syndrome, the child is usually prescribed prednisone initially to reduce proteinuria, which in turn helps to reduce edema. Diuretics may also be used to help with edema related to fluid volume overload. Enalapril is most commonly used to control hypertension. Insulin is usually used to manage blood glucose levels. Cyclophosphamide is an alkylating agent.

*Question: The nurse is caring for a client with sickle cell disease who is in labor. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily accomplish which goal?*

*Answer: Prevent dehydration and hypoxemia.* Rationale: A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during labor. Maintaining adequate IV fluid intake and the administration of oxygen via face mask will help ensure a safe environment for maternal and fetal health during labor. These measures will not stimulate the labor process, avoid the need for a cesarean delivery, or eliminate the need for analgesic administration.

*Question: The nurse is assigned to care for a 2-year-old child who has been admitted to the hospital for surgical correction of cryptorchidism. What is the highest priority in the postoperative plan of care for this child?*

*Answer: Prevent tension on the suture.* Rationale: When a child returns from surgery, the testicle is held in position by an internal suture that passes through the testes and scrotum and is attached to the thigh. It is important not to dislodge this suture. Depending on the type of anesthesia used, option 2 may be appropriate but is not the priority in this surgery. Although adequate hydration is important to maintain, fluids should not be forced. Testing urine for glucose is not related to this type of surgery.

*Question: A term client is being seen for a final prenatal appointment. The clinic nurse is making arrangements for the client to be admitted to the labor and delivery unit for an oxytocin induction. The nurse reviews the client's chart and would contact the primary health care provider regarding which documented finding to verify the oxytocin induction?*

*Answer: Previous classical vertical uterine incision* Rationale: A previous classical vertical uterine incision is associated with a higher incidence of uterine rupture in subsequent pregnancies and may prohibit the use of an oxytocin induction. An L/S ratio of 2:1 indicates fetal lung maturity and is not a contraindication to an oxytocin induction. Gestational diabetes in a term pregnancy could warrant an induction of labor. A hemoglobin of 12 g/dL is considered normal for a pregnant woman and would not interfere with scheduling an induction.

*Question: A child is seen in the clinic, and the primary health care provider documents a diagnosis of primary nocturnal enuresis. The mother asks the nurse about the diagnosis. Which would the nurse relay to the mother about primary nocturnal enuresis?*

*Answer: Primary nocturnal enuresis is common, and most children will outgrow bed-wetting without therapeutic intervention.* Rationale: Primary nocturnal enuresis is bed-wetting and is described as occurring in a child that has never been dry at night for extended periods. It is common in children, most of whom will outgrow bed-wetting without therapeutic intervention. The child is not able to sense a full bladder and does not awaken to void. The child may have delayed maturation of the central nervous system (CNS). It is not caused by a psychiatric problem. Behavioral conditioning with use of alarms has been used for treatment in the older child with nocturnal enuresis. A device that contains a moisture-sensitive alarm is worn on the child's pajamas. As the child starts to void, the alarm goes off, awakening the child. The alarm system may need to be used consistently over 15 weeks for resolution.

*Question: The nurse is reviewing the health record of a child with a diagnosis of celiac disease. Which clinical manifestation would the nurse expect to note documented in the health record?*

*Answer: Profuse watery diarrhea and vomiting* Rationale: Celiac disease causes profuse watery diarrhea and vomiting. Option 1 is a symptom of lactose intolerance. Option 2 is a symptom of Hirschsprung's disease. Option 4 is a symptom of irritable bowel syndrome.

*Question: The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy, and the woman asks the nurse about the purpose of progesterone. According to the nurse, what is the purpose of progesterone?*

*Answer: Progesterone maintains the uterine lining for implantation.* Rationale: Progesterone maintains the uterine lining for implantation and relaxes smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat and is antagonistic to insulin. Human chorionic gonadotropin prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed. Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

*Question: The nurse is assigned to assist in caring for a client who has had surgery and has pneumatic sequential compression devices (SCDs) in place. The client asks about these devices. The nurse instructs the client that SCDs are used for which purpose?*

*Answer: Promoting venous return to the heart* Rationale: Pneumatic sequential compression devices (SCDs) are placed on the client's lower extremities during and after surgery to prevent venous thrombotic embolic complications. The SCDs promote venous return to the heart decreasing the risk of deep venous thrombosis and pulmonary embolism. SCDs are not used to prevent edema or improve oxygenation to the lower extremities. SCDs are not used to treat an existing thrombus.

*Question: After a tonsillectomy, a child is brought to the pediatric unit. The nurse places the child in which appropriate position?*

*Answer: Prone* Rationale: The child should be placed in a prone or side-lying position after tonsillectomy to facilitate drainage. The remaining options identify positions that will not achieve this goal.

*Question: The nurse is assigned to reinforce instructions to a client and the family about the management of home intravenous (IV) infusion therapy. The nurse begins the process by teaching the client and family principles related to what actions first?*

*Answer: Proper hand-washing technique* Rationale: Teaching should begin with an emphasis on proper hand-washing technique. This is essential to prevent infection. The items in options 1, 2, and 4 are components of the instructions, but proper hand-washing technique is addressed first.

*Question: The nurse collecting data from a 35-year-old client determines that the client has gained more than 100 pounds in an 18-month period. The client confided in the nurse that she was sexually molested at the age of 7 and began putting on weight after that time. The client presently weighs 422 pounds. The nurse determines that obesity for this client most likely represents which reason?*

*Answer: Protection from the risk of intimacy* Rationale: Obesity for this client most likely represents protection from the risk of intimacy. Clients who become obese after a trauma as described in the question may be trying to portray themselves as "fat and unattractive." The first two situations are incorrect interpretations. There is not enough data in the question to support option 4.

*Question: A new mother is attempting to breastfeed for the first time. The nurse notices that the client has inverted nipples. What nursing action can the nurse take to assist the client in breastfeeding the newborn?*

*Answer: Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn to grasp.* Rationale: Wearing breast shells and using a breast pump before each feeding will make it easier for the newborn to grasp the nipple. Option 1 is appropriate advice for mothers experiencing inverted nipples. True inverted nipples will retract if the areola is pressed between the thumb and forefinger, making option 2 incorrect. Option 3 will only make the mother cold and has no effect on inverted nipples.

*Question: A client with lung cancer receiving chemotherapy tells the nurse that the food on the meal tray tastes "funny." Which is the appropriate nursing intervention?*

*Answer: Provide oral hygiene care frequently.* Rationale: Chemotherapy may cause distortion of taste. Frequent oral hygiene aids in preserving taste function. Keeping a client NPO increases nutritional risks. Antiemetics are used when nausea and vomiting are a problem. Parenteral nutrition is used when oral intake is not possible.

*Question: A client with depression reports to the nurse that she has not been sleeping or eating adequately. The nurse would plan to do which to assist the client in meeting nutritional needs?*

*Answer: Provide small, frequent meals.* Rationale: The plan that would assist in meeting nutritional needs is providing small, frequent meals to the client. A depressed client may eat small amounts of food rather than large amounts that may be overwhelming to her. If this client becomes overwhelmed, she may respond by withdrawing further. Option 1 may not be effective if the client is not motivated to eat. Option 3 is ineffective for the same reason. Option 4 violates client rights.

*Question: Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The parent of the child asks the nurse why the child needs the medication. The nurse correctly responds that the purpose of this medication is which explanation?*

*Answer: Provides adequate oxygen saturation and maintains cardiac output* Rationale: A child with transposition of the great arteries may receive prostaglandin E1 temporarily to increase blood mixing if systemic and pulmonary mixing are inadequate to maintain adequate cardiac output. Options 1, 2, and 3 are incorrect. In addition, hypercyanotic spells occur in tetralogy of Fallot.

*Question: The nurse is assigned to assist in working with food services in a rural, poor school setting. A goal for the school dietary program is to avoid nutritional deficiencies and enhance the children's nutritional status through healthy dietary practices. In implementing interventions by levels of prevention, which primary prevention intervention should the nurse suggest?*

*Answer: Providing educational programs, literature, and posters to promote awareness of healthy eating* Rationale: Primary prevention interventions are those measures that keep illness, injury, or potential problems from occurring. Options 1, 2, and 3 are secondary prevention measures that seek to detect existing health problems or trends.

*Question: The nurse is caring for a hospitalized child with a history of seizures who is receiving oral phenytoin sodium. Which would be included in the plan of care for this child?*

*Answer: Providing oral hygiene, especially care of the gums* Rationale: Phenytoin sodium causes gum bleeding and hypertrophy; therefore, oral hygiene is important. Soft toothbrushes and gum massage should be instituted to reduce the risk of complications and prevent further trauma. Options 1 and 4 are incorrect because the intake and output, as well as heart rate, are not affected by this medication. Option 3 is incorrect because directions for administration of this medication include administering with food to minimize gastrointestinal upset.

*Question: The nurse is preparing to administer eardrops to an infant. How would the nurse administer the eardrops?*

*Answer: Pull down and back on the ear, and direct the solution toward the wall of the canal.* Rationale: When administering eardrops to an infant, the nurse pulls the ear down and straight back. In the adult or a child older than 3 years, the ear is pulled up and back to straighten the auditory canal. The medication is administered by aiming it at the wall of the canal rather than directly onto the eardrum.

*Question: The nurse is observing a parent and child interacting in the clinic waiting room. The child begins to bounce on the couch. The parent removes the child from the couch stating firmly, "Couches are for sitting, not for jumping." The parent then gives the child a toy to play with on the carpet. The child plays with the toy until called by the nurse. The nurse determines the child is acting within which Kohlberg stage of moral development?*

*Answer: Punishment-obedience stage* Rationale: Kohlberg's theory states that individuals move through the six stages of development in a sequential fashion, but not everyone reaches stages 5 and 6 during his or her development of personal morality. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. It also states that moral development progresses in relation to cognitive development, and a person's ability to make moral judgments develops over a period of time. In stage 1 (ages 2-3 years; punishment-obedience orientation), children cannot reason as mature members of society because they are too young to do so. A child obeys rules to avoid punishment. It is appropriate for a parent to explain limitations, and to provide distractions. In the egocentric stage, an infant has no concept of right or wrong. A child who is in the law-and-order orientation stage obeys laws to maintain social order. In the good boy-nice gir

*Question: When checking a client's skin, the nurse notes the presence of multiple straight and wavy threadlike lines beneath the skin and suspects the presence of scabies. Which precaution would the nurse institute before making contact with the client?*

*Answer: Put on a gown and gloves.* Rationale: The Centers for Disease Control and Prevention recommends the wearing of gowns and gloves for close contact with a person infested with scabies. Masks are not necessary. Transmission via clothing and other inanimate objects is uncommon, but hospital workers have become infected with soiled linen. Scabies is usually transmitted from person to person by direct skin contact. All contacts that the client has had should be treated at the same time.

*Question: A client has a chest tube that is attached to a chest drainage system. The chest tube becomes disconnected. What would the nurse do immediately?*

*Answer: Put open end under sterile water.* Rationale: If the chest tube becomes unattached, do not clamp the tube; place the end of the tubing in a container of sterile water. This creates a "water seal" and can prevent tension pneumothorax.

*Question: The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which measure would the nurse avoid in planning for the client's safety?*

*Answer: Putting a padded tongue blade at the head of the bed* Rationale: Seizure precautions may vary somewhat from agency to agency, but they generally have some commonalities. Usually airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client should have an IV access in place to have a readily accessible route if anticonvulsant medications must be administered. The use of padded tongue blades is no longer best practice, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure will more likely harm the client who bites down during seizure activity. Other risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an advanced airway before seizure activity begins.

*Question: A client in a manic state emerges from her room. She is topless and is making sexual remarks and gestures toward staff and peers. Which is an appropriate nursing action?*

*Answer: Quietly approach the client, escort her to her room, and assist her in getting dressed.* Rationale: A person who is experiencing mania lacks insight and judgment, has poor impulse control, and is highly excitable. The nurse must take control without creating increased stress or anxiety in the client. A quiet, firm approach while distracting the client (walking her to her room and assisting her to get dressed) achieves the goal of having her being dressed appropriately and preserving her psychosocial integrity. "Insisting" that the client go to her room may meet with a great deal of resistance, and confronting the client and offering her a consequence of "time-out" may be meaningless to her, so these actions can be easily eliminated. Asking others to ignore the client's behavior is inappropriate.

*Question: The nurse is assigned to assist in caring for a client with frostbite of the toes. Which would the nurse anticipate to be prescribed for this condition?*

*Answer: Rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs* Rationale: Frostbite is ideally treated with rapid and continual rewarming of the tissue in a warm-water bath for 15 to 20 minutes or until flushing of the skin occurs. Hot or cold water is not used in the treatment of frostbite.

*Question: An adult client had a cerebrospinal fluid (CSF) analysis after lumbar puncture. The nurse interprets which finding as abnormal if present?*

*Answer: Red blood cells* Rationale: The adult with normal cerebrospinal fluid has no red blood cells in the CSF. The client may have small levels of white blood cells (0 to 3/mm3). Protein (15 to 45 mg/dL) and glucose (40 to 80 mg/dL) are normally present in CSF.

*Question: The nurse reviews a client's chart and notes that the primary health care provider has documented a diagnosis of paronychia. Based on this diagnosis, which would the nurse expect to note during data collection?*

*Answer: Red, shiny skin around the nail bed* Rationale: Paronychia or infection around the nail is characterized by red, shiny skin, often associated with painful swelling. These infections frequently result from trauma, picking at the nail, or disorders such as dermatitis. Often these become secondarily infected with bacteria or fungus, which later involves the nail. Options 2, 3, and 4 are incorrect descriptions of this disorder.

*Question: The nurse assists a pregnant client with cardiac disease in identifying resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily to accomplish which tasks?*

*Answer: Reduce excessive maternal stress and fatigue.* Rationale: A variety of factors can cause increased emotional stress during pregnancy, resulting in further cardiac complications. The client with known cardiac disease is at greater risk for such complications. Use of appropriate resources will help the client avoid emotional stress, thus reducing additional cardiac compromise during the last trimester. Helping to prepare for the delivery process, avoiding pathogens and resulting infections and preparing a toddler for maternal separation are not primary purposes for use of resources with the pregnant cardiac client.

*Question: Docetaxel is prescribed for a client with metastatic breast cancer. In addition, dexamethasone is prescribed to be administered before initiation of the docetaxel. What is the rationale for the addition of dexamethasone to the treatment plan that the nurse would explain to the client?*

*Answer: Reduces the severity of fluid retention* Rationale: Docetaxel is an antineoplastic medication. Frequent side effects include alopecia, hypersensitivity reaction, fluid retention, nausea, vomiting, diarrhea, fever, myalgia, and nail changes. Before receiving docetaxel, the client is premedicated with an oral corticosteroid to reduce the severity of fluid retention and prevent a hypersensitivity reaction. Dexamethasone may cause neutropenia, does not prevent thromboembolic disorders, and does not enhance the effects of docetaxel. In addition, dexamethasone is used with caution in the client with thromboembolic disorders.

*Question: A client is found to have rape-trauma syndrome. The nurse plans care for the client, knowing that rape-trauma syndrome is a condition that involves which?*

*Answer: Reexperiencing recollections of the trauma* Rationale: The major trauma of rape or sexual assault involves the victim's emotional reaction to being physically forced to do something against his or her will. The life-threatening nature of the crime and feelings of helplessness, loss of control, and the experiencing of self as an object of the perpetrator's rage combine to produce the victim's overpowering fear and stress. In this syndrome, which has been called "rape-trauma syndrome," the client reexperiences the trauma as evidenced by recurrent recollections of the event.

*Question: A client has died, and the nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action?*

*Answer: Remain with the family member without discussing funeral arrangements.* Rationale: The family member is exhibiting the first stage of grief (denial), and the nurse should remain with the family member. Option 1 is an appropriate intervention for the acceptance or reorganization and restitution stage. Option 2 may be an appropriate intervention for the bargaining stage. Option 3 may be an appropriate intervention for depression.

*Question: A client with obsessive-compulsive disorder (OCD) who continually cleans the bathroom becomes enraged with a roommate for using the bar of bathing soap for cleaning the bathroom. The client begins to yell and slaps the roommate. Which action would the nurse take first?*

*Answer: Remove both clients to a separate, safe location.* Rationale: The first responsibility of the nurse is to provide for the safety of all clients. Only option 3 provides for the needs of both clients identified in the question. The other actions are either contraindicated (option 1), have lesser priority (option 2), or may not be indicated depending on the level of injury to the second client (option 4).

*Question: The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. Which is the most appropriate action?*

*Answer: Remove the IV.* Rationale: Blanching, coolness, and edema of the IV site are signs of infiltration. Because infiltration can be damaging to the surrounding tissue, the most appropriate action is to remove the IV to prevent any further damage. The nurse should not depend solely on the blood return for assurance that the cannula is in the vein because a blood return may be present even if the cannula is only partially in the vein. Warm compresses may be applied to the infiltrated area only after the IV is removed and only if the infiltrated solution is not damaging to the surrounding tissues. Measuring the area of infiltration should only be done after the IV has been removed so that further tissue damage is assessed.

*Question: The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. Based on these findings, the nurse plans to take which initial nursing action?*

*Answer: Remove the IV.* Rationale: Phlebitis at an IV site can be determined by client discomfort at the site, as well as by redness, warmth, and swelling proximal to the catheter. The line should be removed, and a new line should be inserted at a different site. Options 2 and 4 are incorrect. The primary health care provider should be notified if phlebitis occurred, but this is not the initial action.

*Question: The nurse is assisting in caring for a client receiving chemotherapy. On review of the morning laboratory results, the nurse notes that the white blood cell count is extremely low, and the client is immediately placed on neutropenic precautions. The client's breakfast tray arrives, and the nurse inspects the meal and prepares to bring the tray into the client's room. Which action would the nurse take before bringing the meal to the client?*

*Answer: Remove the fresh orange from the breakfast tray.* Rationale: In the immunocompromised client, a low-bacteria diet is implemented. This includes avoiding fresh fruits and vegetables and implementing thorough cooking of all foods. Foods should be thoroughly cooked. Removing the coffee from the tray is not necessary. Disposable utensils are used for clients who are infectious and present a risk of transmitting an infection to others. It is best to encourage the client to eat because nutrition is very important in a client receiving chemotherapy who is immunocompromised.

*Question: The nurse is changing the neck ties on a tracheostomy tube. Which method is appropriate for the nurse to take?*

*Answer: Remove the old ties, clean the site, and then apply the new ties while a second health care team member holds the tracheostomy tube.* Rationale: When changing neck ties that hold the tracheostomy tube in place, the nurse must use a technique that guarantees the tracheostomy tube will not be coughed out while the ties are changed. This is done by having a second caregiver assist by holding the tracheostomy tube in place while the other nurse removes the neck ties, cleanses the area, and applies the new ties. Applying the new neck ties before removing the old neck ties would not allow for cleansing the neck area. The obturator is the handle device with a blind smooth end that is placed inside the outer cannula of a tracheostomy tube and used during the insertion process. It occludes the cannula and would block breathing. Safety does not allow the client to assist with holding the tracheostomy tube during the change of neck ties.

*Question: A male child who had surgery to correct hypospadias is seen in a primary health care provider's office for a well-baby checkup. The nurse provides instructions to the mother, knowing that which long-term complication is associated with hypospadias?*

*Answer: Renal anomalies* Rationale: The nurse should ask the child's parents about the child's kidney function because hypospadias may be associated with renal anomalies. The incorrect options are not associated with a long-term effect of hypospadias.

*Question: Colchicine is prescribed for a client with a diagnosis of gout. The nurse reviews the client's medical history in the health record, knowing that the medication would be contraindicated in which disorder?*

*Answer: Renal failure* Rationale: Colchicine is contraindicated in clients with severe gastrointestinal, renal, hepatic, or cardiac disorders, or those with blood dyscrasias. Clients with impaired renal function may exhibit myopathy and neuropathy manifested as generalized weakness. This medication would be used with caution in clients with impaired hepatic function, older clients, and debilitated clients.

*Question: The nurse caring for a male client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's laboratory results and notes a hematocrit level of 30%. Which action would the nurse take?*

*Answer: Report the abnormally low level.* Rationale: The normal hematocrit level in a male client ranges from 42% to 52%, depending on age. A hematocrit level of 30% is a low level and should be reported to the registered nurse and primary health care provider because it indicates blood loss. This laboratory result is neither elevated nor normal.

*Question: The nurse collecting data on a child suspects physical abuse. The nurse understands that which is a primary and legal nursing responsibility?*

*Answer: Report the case in which the abuse is suspected.* Rationale: The primary legal nursing responsibility when child abuse is suspected is to report the case. All 50 states require health care professionals to report all cases of suspected abuse. Although documentation of findings, assisting the family, and referring the family to appropriate resources and support groups are important, the primary legal responsibility is to report the case.

*Question: The nurse observes that a client received pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed this same occurrence several times. Based on the nurse practice act, the observing nurse would plan to take which action?*

*Answer: Report the information to a nursing supervisor.* Rationale: Nurse practice acts require reporting the suspicion of impaired nurses. The state board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This suspicion needs to be reported to the nursing supervisor, who will then report to the board of nursing. Options 1 and 2 are inappropriate. Option 3 may cause a conflict.

*Question: The nurse notes that a 6-year-old child does not recognize that objects exist when the objects are outside of the visual field. Based on this observation, which action would the nurse take?*

*Answer: Report the observation to the primary health care provider.* Rationale: According to Jean Piaget's theory of cognitive development, it is normal for the infant or toddler not to recognize that objects continue to be in existence even if out of the visual field; however, this is abnormal for a 6-year-old. If a 6-year-old child does not recognize that objects still exist outside the visual field, the child is not progressing normally through the developmental stages. The nurse should report this finding to the primary health care provider. Options 1, 2, and 4 delay necessary follow-up and treatment.

*Question: The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action?*

*Answer: Report to the pediatric unit and identify tasks that can be safely performed.* Rationale: Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally the nurse cannot refuse to float unless a union contract guarantees that the nurse can only work in a specified area or the nurse can prove a lack of knowledge for the performance of assigned tasks. When faced with this situation, the nurse should identify potential areas of harm to the client.

*Question: The nurse reviews the arterial blood gas results of a client and notes that the results indicate a pH of 7.30, Pco2 of 52 mm Hg, and HCO3- of 22 mEq/L. Which interpretation would the nurse correctly make about these results?*

*Answer: Respiratory acidosis* Rationale: Normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Pco2. In this situation, the pH is low and the Pco2 is increased. In an acidotic condition, the pH is decreased. Therefore, the values identified in the question indicate a respiratory acidosis.

*Question: A client who has fallen from a roof and fractured his ribs has arterial blood gas (ABG) results of: pH 7.48, Paco2 32 mm Hg, Pao2 89 mm Hg, and HCO3- 22 mEq/L. How would the nurse interpret the client's blood gas results?*

*Answer: Respiratory alkalosis* Rationale: The client has respiratory alkalosis. Normal ranges for pH are 7.35 to 7.45, for Paco2 35 to 45 mm Hg, and for bicarbonate 22 to 26 mEq/L. With acidosis, the pH would be less than 7.35; with alkalosis, the pH would be greater than 7.45. Carbon dioxide levels would be elevated in respiratory acidosis. Bicarbonate levels would be low if a metabolic acidosis is present.

*Question: The nurse has been providing care for a client with a Sengstaken-Blakemore tube. While the tube is inflated the nurse would monitor for which priority sign/symptom?*

*Answer: Respiratory distress* Rationale: A Sengstaken-Blakemore tube is inserted in a client with a diagnosis of cirrhosis with ruptured esophageal varices when other measures used to treat the varices are unsuccessful or contraindicated for the client. When the balloon on the tube is inflated, the nurse should monitor for respiratory distress, which could indicate the balloon has ruptured.

*Question: A client in labor has been pushing effectively for 1 hour and the presenting part is at a +2 station. The nurse determines which physiological need is primary to the client at this time?*

*Answer: Rest between contractions* Rationale: The birth process expends a great deal of energy. Encouraging rest between contractions conserves maternal energy and facilitates voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which improves fetal tolerance of the stress of labor. No data in the question indicate that a change in position is necessary. Oral food and fluids is incorrect because food and fluids are likely withheld at this time, except for ice chips. Intravenous analgesia is incorrect because this action so close to delivery would likely cause central nervous system depression in the infant.

*Question: The nurse is monitoring a child following a tonsillectomy. Which finding would indicate that the child is bleeding?*

*Answer: Restlessness* Rationale: Frequent swallowing, restlessness, a fast and thready pulse, and vomiting bright red blood are signs of bleeding. An elevated BP is not an indication of bleeding. Complaint of discomfort is an expected finding following a tonsillectomy.

*Question: A child suspected of having sickle cell disease (SCD) is seen in a clinic, and laboratory studies are performed. Which laboratory value is likely to be increased in sickle cell disease?*

*Answer: Reticulocyte count* Rationale: A diagnosis is established on the basis of a complete blood count, examination for sickled red blood cells (RBCs) in the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will show decreased hemoglobin and hematocrit levels and a decreased platelet count, an increased reticulocyte count, and the presence of nucleated red blood cells. Increased reticulocyte counts occur in children with SCD because the life span of their sickled RBCs is shortened.

*Question: The nurse is caring for a client who had an above-the-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage that has fallen off. The nurse would immediately perform which action?*

*Answer: Rewrap the residual limb with an elastic compression bandage.* Rationale: If the client with amputation has a cast or elastic compression bandage that falls off, the nurse must immediately wrap the residual limb with another elastic compression bandage. Otherwise, excessive edema will rapidly form, which could cause a significant delay in rehabilitation.

*Question: A client began taking amantadine approximately 2 weeks ago. Which would the nurse expect to decrease if the medication is having a therapeutic effect?*

*Answer: Rigidity and akinesia* Rationale: Amantadine is an antiparkinson agent that potentiates the action of dopamine in the central nervous system. The expected effect of therapy is a decrease in akinesia and rigidity. Leukopenia, urinary retention, and hypotension are all adverse effects of the medication.

*Question: The nurse is developing a plan of care for a child with autism. The nurse would identify which priority problem for this child?*

*Answer: Risk for injury* Rationale: Risk for injury related to an inability to anticipate danger, a tendency for self-mutilation, and sensory perceptual deficits are the priority concerns. Inability to interact socially, troubling thought processes, and inability to verbally communicate are also appropriate problems for the child with autism, but the priority is the risk for injury.

*Question: The nurse has given instructions to the client with Parkinson's disease about maintaining mobility. The nurse determines that the client understands the directions if the client states that he or she will perform which activity?*

*Answer: Rock back and forth to start movement slowly.* Rationale: The client with Parkinson's disease should exercise in the morning, when energy levels are highest. The client should avoid sitting in soft, deep chairs because getting up from them can be difficult. The client can rock back and forth to initiate movement. The client should buy clothes with Velcro fasteners and slide-locking buckles to allow for easier dressing.

*Question: A nursing student is asked to discuss sudden infant death syndrome (SIDS) at the clinical conference being held at the end of the clinical day. The student plans to include which information in the discussion during the conference?*

*Answer: SIDS usually occurs during sleep and is more common in premature infants.* Rationale: SIDS usually occurs during sleep. It most frequently occurs between the second and fourth months of life. It is more common in boys, low-birth-weight infants, and premature infants.

*Question: The nurse is caring for a client with gout who is taking colchicine. The client has been instructed to restrict the diet to low-purine foods. Which food would the nurse instruct the client to avoid while taking this medication?*

*Answer: Scallops* Rationale: High-purine foods to avoid or limit include organ meats, roe, sardines, scallops, anchovies, broth, mincemeat, herring, shrimp, mackerel, gravy, and yeast. Colchicine is a medication used for clients with gout to inhibit the reabsorption of uric acid by the kidney and promote excretion of uric acid in the urine. Uric acid is produced when purine is catabolized. Clients are instructed to modify their diet and limit excessive purine intake.

*Question: A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which action should the nurse take?*

*Answer: Seek an interpreter from the hospital's interpreter services.* Rationale: The nurse should have a professional hospital-based interpreter translate for the client. English-speaking family members may not appropriately understand what is asked of them and may paraphrase what the client is actually saying. Also, client confidentiality and accurate information may be compromised when a family member or a nonhealth care provider acts as interpreter. Using a Spanish-English dictionary is time-consuming and not the best action; accurate interpretation is best done by a professional hospital-based interpreter.

*Question: The parent of a 3-year-old tells the nurse that the child is constantly rebelling and having temper tantrums. Which instruction would the nurse reinforce to the parent?*

*Answer: Set limits on the child's behavior.* Rationale: According to Erikson, the child focuses on independence between the ages of 1 and 3 years. Gaining independence often means that the child has to rebel against the parents" wishes. Saying things like "no" and "mine" and having temper tantrums are common during this period of development. Being consistent and setting limits on the child's behavior are necessary elements. Punishing the child every time the child says "no" is likely to produce a negative response.

*Question: These are signs and symptoms of glaucoma. Which sign or symptom is found only in narrow-angle glaucoma?*

*Answer: Severe pain in and around eye* Rationale: Narrow-angle, or acute, glaucoma is a medical emergency in which there is severe pain in the eye accompanied by the appearance of colored halos around lights, blurred vision, and pain in and around the eye. Nausea and vomiting may occur. Normal intraocular pressure is 10 to 21 mm Hg.

*Question: A postpartum client asks the nurse when she may resume sexual activity. Which response would the nurse give to the client?*

*Answer: Sexual activity may be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped.* Rationale: It is recommended that the woman refrain from sexual intercourse until the episiotomy has healed and the lochia has stopped. This process usually takes about 3 weeks. Options 1, 2, and 3 are inaccurate.

*Question: The nurse notices a "paranoid stare" during a conversation with the client diagnosed with posttraumatic stress disorder (PTSD). The client then begins to fidget and gets up to pace around the room. Which action by the nurse would be most beneficial?*

*Answer: Share the observation with the client and help the client recognize his or her feelings.* Rationale: The action that would be most beneficial to the client is to share the observation with the client and help the client recognize his or her feelings. This action may help the client recognize and acknowledge his or her feelings. Moving to a quiet room or changing the subject will not help the client recognize behaviors and feelings. Allowing the client to pace provides no assistance and may lead to the client's becoming "out of control."

*Question: The nurse is caring for a client diagnosed with somatic symptom disorder who continuously complains of a severe headache. Which interventions are most appropriate when planning care for this client?*

*Answer: Shift the focus from the client's somatic concerns to feelings and coping skills.* Rationale: The most appropriate intervention when planning care for a client with somatization disorder is to shift the focus from the client's somatic concerns about headaches to feelings and effective coping skills. A somatization disorder is characterized by multiple physical complaints involving numerous body systems. The cause of the complaints is presumed to be psychological.

*Question: A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful?*

*Answer: Showing the client the cast cutter and explaining how it works* Rationale: The action by the nurse that would be the most helpful is to show the cast cutter to the client before it is used and explain that the client may feel heat, vibration, and pressure. Clients may be fearful of having a cast removed because of misconceptions about the cast cutting blade. The cast cutter resembles a small electric saw with a circular blade. The nurse should reassure the client that the blade does not cut like a saw but instead cuts the cast by vibrating side to side.

*Question: The nurse is collecting data from a client with placenta previa during an office visit. The nurse would check which item as first priority?*

*Answer: Signs of fetal distress* Rationale: Although all of the options may be assessed, the safety of the mother-infant dyad is the priority. Fetal distress is a primary concern, although the information gained through the other assessments may ultimately affect the well-being of the fetus.

*Question: The nurse assists in preparing a plan of care for the infant with bladder exstrophy. The nurse identifies which immediate problem as the priority for the infant?*

*Answer: Skin disruption* Rationale: In bladder exstrophy, the bladder is exposed and external to the body. The highest priority is skin disruption related to the exposed bladder mucosa. Although the infant needs to be monitored for elimination patterns and kidney function, this is not the priority concern for this condition. Lack of parental understanding related to the diagnosis and treatment of the condition will need to be addressed, but again, is not the priority. Although infection related to the anatomically located defect can be a problem, it is not the immediate one.

*Question: The nurse asks the registered nurse to call the primary health care provider (PHCP) of a client scheduled for a cardiac catheterization because the client has numerous questions regarding the procedure and has requested to speak to the PHCP. The PHCP is very upset and arrives at the unit to visit the client after prompting by the nurse. The nurse is outside the client's room and hears the PHCP tell the client in a derogatory manner that the nurse "doesn't know anything." The nurse pla

*Answer: Slander* Rationale: Defamation is a false communication or careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group.

*Question: A client is receiving baclofen for muscle spasms caused by a spinal cord injury. The nurse monitors the client, knowing that which is a side effect of this medication?*

*Answer: Slurred speech* Rationale: Slurred speech is a one of the side effects of baclofen. Other side effects include drowsiness, dizziness, weakness, and nausea. Occasional side effects include headache, paresthesia of the hands and feet, constipation or diarrhea, anorexia, hypotension, confusion, and nasal congestion. Paradoxical central nervous system excitement and restlessness can occur, along with slurred speech, tremor, dry mouth, nocturia, and impotence. The other side effects are not related to this medication.

*Question: A client with epilepsy is taking the prescribed dose of phenytoin to control seizures. A phenytoin blood level is drawn, and the results reveal a level of 35 mcg/mL. Which symptom would be expected as a result of this laboratory result?*

*Answer: Slurred speech* Rationale: The therapeutic phenytoin level is 10 to 20 mcg/mL. At a level higher than 20 mcg/mL, involuntary movements of the eyeballs (nystagmus) appear. At a level higher than 30 mcg/mL, ataxia and slurred speech occur.

*Question: A client with acute nonlymphocytic anemia receives treatment with cytarabine. The nurse reinforces medication instructions to the client and tells the client that it is important to report which adverse effect to the primary health care provider?*

*Answer: Sore throat* Rationale: The major adverse effect of cytarabine is bone marrow depression resulting in hematological toxicity. Signs of hematological toxicity include fever, sore throat, signs of local infection, easy bruising, or unusual bleeding from any site. If these signs occur, the primary health care provider (PHCP) is notified. Anorexia, nausea, and a transient headache can occur as side effects of the medication but do not necessarily warrant PHCP notification unless they are persistent.

*Question: The nurse reinforces dietary instructions to a client who will be taking warfarin sodium. The nurse tells the client to avoid which food item?*

*Answer: Spinach* Rationale: Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K often are omitted from the diet. Vitamin K-rich foods include green, leafy vegetables; fish; liver; coffee; and tea.

*Question: The nurse inspects a pressure injury on a client's sacrum and notes that the site has partial-thickness skin loss and the formation of a blister. The nurse would document the pressure injury as which category?*

*Answer: Stage II* Rationale: A stage II pressure injury is characterized by nonintact skin. There is partial-thickness skin loss, and the wound may appear as an abrasion, shallow crater, or a blister. A stage I pressure injury is a reddened area that doesn't blanch but has intact skin. Stages III and IV pressure injuries are full thickness, or full thickness with necrosis or damage to muscle, bone, or supportive tissue, respectively.

*Question: The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS) who has Pneumocystis jiroveci pneumonia. In planning infection control for this client, which would be the appropriate form of isolation to use to prevent the spread of infection to others?*

*Answer: Standard precautions* Rationale: The acquired immunodeficiency syndrome (AIDS) virus is transmitted through anal, vaginal, or oral sexual contact with infected semen or vaginal secretions; contact with infected blood or blood products; from mother to fetus during childbirth; or during breast-feeding. P. jiroveci pneumonia is an opportunistic infection seen in clients with compromised immune function. Standard precautions include blood and body fluid precautions and are used for contact with all clients including those who are HIV-positive. Pneumocystis jiroveci is normally not pathogenic for persons with a healthy immune system, so no extra precautions are necessary for the nurse to follow. Droplet, enteric, and contact precautions are not indicated for the client in the question. If the client would develop another disease, some precautions may be needed.

*Question: The nurse is providing care for a client with with ulcerative colitis who underwent the creation of a transverse colostomy. Which observation requires immediate notification of the surgeon?*

*Answer: Stoma has a purple discoloration* Rationale: Ischemia of the stoma would be associated with a dusky or bluish or purple color. A beefy red and shiny stoma is normal and expected. Skin excoriation needs to be addressed and treated but does not require as immediate attention as purple discoloration of the stoma. Semiformed stool is a normal finding.

*Question: The nurse caring for a client who is receiving oxytocin for the induction of labor notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, which is the nurse's priority action?*

*Answer: Stop the oxytocin infusion.* Rationale: Oxytocin stimulates uterine contractions and is used to induce labor. If uterine hypertonicity or a nonreassuring FHR pattern occurs, the nurse should intervene to reduce uterine activity and increase fetal oxygenation. The oxytocin infusion is stopped. In addition, the client is placed in a side-lying position, and oxygen by face mask at 8 to 10 L/minute is administered. The registered nurse is immediately notified and will then contact the primary health care provider. The nurse should monitor the client's blood pressure and monitor intake and output. However, the nurse should first stop the infusion.

*Question: The nurse is teaching a pregnant client how to perform Kegel exercises. The nurse would tell the client that these exercises are for which purpose?*

*Answer: Strengthen the pelvic floor in preparation for delivery.* Rationale: Kegel exercises will assist in strengthening the pelvic floor. Pelvic tilt exercises will help reduce backaches. Leg elevation will assist in preventing ankle edema. Instructing a client to drink 8 ounces of fluids 6 times a day will help prevent urinary tract infections.

*Question: A child with croup is being discharged from the hospital. The nurse reinforces home care instructions to the mother and advises the mother to bring the child to the emergency department if the child develops which symptom?*

*Answer: Stridor* Rationale: The mother should be instructed to bring the child to the emergency department if the child develops stridor at rest, cyanosis, severe agitation or fatigue, moderate to severe retractions, or is unable to take oral fluids.

*Question: A pregnant client with mitral valve prolapse is receiving anticoagulant therapy during pregnancy. The nurse collects data on the client and expects which prescription?*

*Answer: Subcutaneous administration of heparin sodium 5000 units daily* Rationale: Pregnant women with mitral valve prolapse are frequently given anticoagulant therapy during pregnancy because they are at greater risk for thromboembolic disease during the antepartum, intrapartum, and postpartum periods. Warfarin is contraindicated during pregnancy because it crosses the placental barrier, causing potential fetal malformations and hemorrhagic disorders. Heparin sodium, which does not cross the placental barrier, is safe to use during pregnancy and should be administered by the subcutaneous route. Terbutaline is indicated for preterm labor management only.

*Question: The nurse has just been told by the primary health care provider that a prescription has been written to administer a heparin injection to a client every 12 hours. The nurse anticipates using which technique to administer the medication?*

*Answer: Subcutaneous using the abdomen* Rationale: Heparin, a rapid-acting anticoagulant, is administered by injection as a prophylactic measure to lower the risk of venous thromboembolic complications. The correct technique for administering a heparin injection is subcutaneously using a small gauge needle (25 to 26 gauge) ½ to ⅝ inch needle preferably in the abdomen to decrease the likelihood of bleeding at the injection site. Heparin is not administered intramuscularly, Z track, or with a 20-gauge needle.

*Question: The nurse prepares to administer a measles, mumps, and rubella (MMR) vaccine to a 5-year-old child. How would the nurse plan to administer the vaccine?*

*Answer: Subcutaneously in the outer aspect of the upper arm* Rationale: MMR is administered subcutaneously in the outer aspect of the upper arm. Each child should receive two vaccinations, the first between 12 and 15 months of age and the second between 4 and 6 years or 11 and 12 years.

*Question: The clinic nurse prepares to administer an MMR (measles, mumps, rubella) vaccine to the child. The nurse would administer this vaccine by which method?*

*Answer: Subcutaneously in the outer aspect of the upper arm* Rationale: The MMR vaccine is administered subcutaneously in the outer aspect of the upper arm. The gluteal muscle is most often used for intramuscular injections. The MMR vaccine is not administered by the intramuscular route.

*Question: The nurse is suctioning an unconscious client who has a tracheostomy. The nurse would avoid which action during this procedure?*

*Answer: Suctioning for longer than 30 seconds* Rationale: Suction equipment should be kept at the bedside of an unconscious client, regardless of whether an artificial airway is present. The nurse auscultates breath sounds every 2 to 4 hours, or more frequently if there is a need. The client should be hyperoxygenated before, during, and after suctioning to minimize cerebral hypoxia. The client should not be suctioned for longer than 10 seconds at one time to prevent cerebral hypoxia and an increase in intracranial pressure.

*Question: The nurse provides dietary instructions to a client with Ménière's disease. The nurse tells the client that which food or fluid item is acceptable to consume?*

*Answer: Sugar-free Jell-O* Rationale: The underlying pathological changes of Ménière's disease include overproduction and defective absorption of endolymph. This increases the volume and pressure within the membranous labyrinth until distention results in rupture and mixing of the endolymph and perilymph fluids. Dietary therapy frequently is quite helpful in controlling the symptoms associated with Ménière's disease. The nurse encourages the client to follow a low-salt diet and to avoid caffeine, sugar, monosodium glutamate, and alcohol.

*Question: The nurse is assisting in conducting a group therapy session and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which?*

*Answer: Suggest that the client stop talking and try listening to others.* Rationale: If a client is monopolizing the group, it is important that the nurse be direct and decisive. The appropriate nursing action is to suggest that the client stop talking and try listening to others. Although telling the client not to monopolize the group may be a direct response, suggesting that the client stop talking and attempt to listen is the most therapeutic direct statement. The remaining options are inappropriate.

*Question: The nurse should anticipate that which medication is the most likely to be prescribed prophylactically for a child with spina bifida (myelomeningocele) who has a neurogenic bladder?*

*Answer: Sulfasalazine* Rationale: A neurogenic bladder prevents the bladder from completely emptying because of the decrease in muscle tone. The most likely medication to be prescribed to prevent urinary tract infection would be an antibiotic. A common prescribed medication is sulfasalazine. Prednisone relieves allergic reactions and inflammation rather than preventing infection. Furosemide promotes diuresis and decreases edema caused by heart failure. IVIG assists with antibody production in immunocompromised clients.

*Question: A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is positioned on the delivery room table and the nurse places the client in which position?*

*Answer: Supine with a wedge under the right hip* Rationale: Vena cava and descending aorta compression by the pregnant uterus impede blood return from the lower trunk and extremities. This occurrence leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this should be side-lying with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's positioning places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler's, prone, or Trendelenburg's position with the legs in stirrups is not practical for this type of abdominal surgery.

*Question: The nurse is assigned to assist with caring for a client after cardiac catheterization performed through the left femoral artery. The nurse would plan to maintain bed rest for this client in which position?*

*Answer: Supine with head elevation no greater than 30 degrees* Rationale: After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for the prescribed time period to prevent arterial occlusion or bleeding and hematoma. With a femoral approach, the client's affected extremity is kept straight and the head elevated no more than 30 degrees (some cardiologists prefer a lower head position or the flat position) until hemostasis is adequately achieved. The client may turn from side to side. Bathroom privileges are not allowed during the immediate postcatheterization period. High-Fowler's (90-degree elevation), flat, and side lying on the puncture site are not effective in preventing complications or allowing for client comfort.

*Question: A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse would plan to place the client in which position?*

*Answer: Supine, with the residual limb supported with pillows* Rationale: The residual limb is usually supported on pillows for the first 24 hours following surgery to promote venous return and decrease edema. After the first 24 hours, the residual limb usually is placed flat on the bed to reduce hip contracture. Edema also is controlled by limb-wrapping techniques. In addition, it is important to check the surgeon's prescription(s) regarding positioning following amputation.

*Question: A client is seen in the clinic for a physical examination. Laboratory studies are performed and reveal that the hemoglobin and hematocrit are low, indicating the need for further diagnostic studies and possibly a blood transfusion. The client is a Jehovah's Witness and states he will never have a blood transfusion. Which would be an appropriate action by the clinic nurse?*

*Answer: Support the client's decision not to receive a blood transfusion.* Rationale: Cultural and ethnic background influences an individual's response to health, illness, surgery, and death. Awareness of cultural differences enhances the nurse's knowledge of how a health care experience may be perceived by the client or family. In the Jehovah's Witness religion, the administration of blood and blood products is forbidden. Therefore, the nurse should support the client's decision. The nurse should respect the autonomy of the client and not try to convince the client or the family that a transfusion must be taken. The nurse may explain the laboratory tests, but this should not be done in an effort to convince the client of the need for a blood transfusion.

*Question: A mother arrives at the clinic with her child. The mother tells the nurse that the child has had a fever and a cough for the past 2 days, and this morning the child began to wheeze. Viral pneumonia is diagnosed. Which component of the treatment plan would the nurse anticipate?*

*Answer: Supportive treatment* Rationale: With viral pneumonia, treatment is supportive. More severely ill children may be hospitalized and given oxygen, chest physiotherapy, and IV fluids. Antibiotics are not given. Bacterial pneumonia, however, is treated with antibiotic therapy.

*Question: The nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is available for emergency use?*

*Answer: Surgical tourniquet* Rationale: Monitoring for complications is an important aspect of initial postoperative care. Vital signs and pulse oximetry values are monitored closely until the client's condition stabilizes. The wound and any drains are monitored closely for excessive bleeding because hemorrhage is the primary immediate complication of amputation. Therefore, a surgical tourniquet needs to be readily available in case of acute bleeding. An over-the-bed trapeze increases the client's independence in self-care activities but is not a priority in the immediate postoperative period. An incentive spirometer and dry sterile dressings also should be available, but these are not priority items.

*Question: The nurse instructs the assistive personnel (AP) assigned to care for an older adult client to place an extra blanket in the client's room. The nurse provides this instruction because the older adult is less able to regulate hot and cold body changes as a result of alterations in the activity of which gland?*

*Answer: Sweat glands* Rationale: Functions of the skin include protection, sensory reception, homeostasis, and temperature regulation. The skin helps regulate the body temperature in two ways, by dilation and constriction of blood vessels and by the activity of the sweat glands. As aging progresses, alterations in sweat gland activity make the glands less effective in temperature regulation, so the aging person is less able to regulate hot and cold body changes. The parotid glands are responsible for the drainage of saliva, which plays an important role in digestion. The pineal gland is a major site of melatonin biosynthesis. The thymus gland plays an immunological role throughout life.

*Question: The nurse is reinforcing home care instructions to the mother of a child with hemophilia. Which activity would the nurse suggest that the child can safely participate in with peers?*

*Answer: Swimming* Rationale: Children with hemophilia need to avoid contact sports and need to take precautions, such as wearing elbow and knee pads and helmets, when participating in other sports. The safest activity that will prevent injury is swimming.

*Question: A pregnant client asks the nurse about the type of exercises that are allowable during the pregnancy. The nurse would instruct the client that which is the safest exercise?*

*Answer: Swimming* Rationale: Non-weight-bearing exercises are preferable to weight-bearing exercises. Competitive or high-risk sports such as scuba diving, water skiing, downhill skiing, horseback riding, basketball, volleyball, and gymnastics should be avoided. Non-weight-bearing exercise such as swimming is allowable. Exercises to avoid are shoulder standing and bicycling with the legs in the air because the use of the knee-chest position should be avoided.

*Question: The nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings in the newborn would alert the nurse to the possibility of this syndrome?*

*Answer: Tachypnea and retractions* Rationale: A newborn with respiratory distress syndrome may present with cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible expiratory grunts. Acrocyanosis is the bluish discoloration of the hands and feet, is associated with immature peripheral circulation, and is not uncommon in the first few hours of life. Options 1, 3, and 4 do not indicate clinical signs of respiratory distress syndrome.

*Question: The nurse teaches a child with cystic fibrosis how to perform the "huff" maneuver. Which instructions would the nurse tell the child?*

*Answer: Take a deep breath and then exhale rapidly, whispering the word huff.* Rationale: The "huff" maneuver (forced expiratory technique) is used to mobilize secretions. This technique reduces the likelihood of bronchial collapse. The child is taught to cough with an open glottis by taking a deep breath, then exhaling rapidly, whispering the word huff.

*Question: The nurse is teaching the client with myasthenia gravis about prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by which activity?*

*Answer: Taking medications on time to maintain therapeutic blood levels* Rationale: Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. It is very important to take medications correctly to maintain blood levels that are not too low or too high. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms as are exposure to heat, crowds, erratic sleep habits, and emotional stress.

*Question: A primary health care provider initiates carbidopa/levodopa therapy for a client with Parkinson's disease. A few days after the client starts the medication, the client complains of nausea and vomiting. What would the nurse tell the client regarding how to avoid side effects when taking this combination medication?*

*Answer: Taking the medication with food will help prevent the nausea.* Rationale: If carbidopa/levodopa is causing nausea and vomiting, the nurse would tell the client that taking the medication with food may decrease the nausea. Additionally, the client should be instructed not to take the medication with a high-protein meal because the high protein will affect absorption. Antiemetics from the phenothiazine class should not be used because they block the therapeutic action of dopamine. Options 1, 3, and 4 are incorrect.

*Question: Which would be included in the plan of care for a pregnant teenager to reinforce instructions regarding dental care?*

*Answer: Tell the dental office staff that she is pregnant.* Rationale: It is important to continue dental care during pregnancy. The dental staff needs to know about the pregnancy so that care is taken during examinations and x-ray studies are avoided. Local anesthetics for minor dental work do not have adverse effects on the fetus. Baking soda may irritate the gums, which are more likely to bleed because of the hormonal changes of pregnancy. Tooth loss during pregnancy is not expected.

*Question: A licensed practical nurse is providing care for a child with hydrocephalus who has had a ventriculoperitoneal shunt revision. Which data collection finding would be reported to the registered nurse immediately?*

*Answer: Temperature 100.9°F* Rationale: Fever may be an indication of an infection of the shunt, which is the primary concern in the postoperative period related to a shunt insertion. All of the other vital signs are normal findings for this child.

*Question: The nurse is preparing to assist the primary health care provider to test the extraocular movements in a client and muscle weakness in the eyes. The nurse anticipates that which physical assessment technique will be done?*

*Answer: Testing the six cardinal positions of gaze* Rationale: Testing the six cardinal positions of gaze is done to check for muscle weakness in the eyes. The client is asked to hold the head steady, then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the two eyes. The Ishihara chart is used to detect color blindness. A Snellen eye chart is used to determine visual acuity and cranial nerve II (optic nerve) functioning. Testing the corneal light reflex, shining a penlight in the eyes of a client gazing straight ahead, should demonstrate the corneal reflection in the exact position in each eye and parallel alignment.

*Question: The nurse is reviewing the primary health care provider's prescriptions for a client admitted to the hospital with a diagnosis of an acute attack of Ménière's disease. Which prescription noted on the client's chart should the nurse question?*

*Answer: The administration of a vasoconstrictor* Rationale: Medical interventions during the acute phase of Ménière's disease include using atropine or diazepam to decrease the autonomic nervous system function. Diphenhydramine may be prescribed for its antihistamine effects, and a vasodilator also will be prescribed. The client will remain on bed rest during the acute attack and when allowed to be out of bed, will need assistance with walking, sitting, or standing.

*Question: The emergency department nurse is caring for a child brought to the emergency department following the ingestion of approximately one half bottle of acetylsalicylic acid (aspirin) 10 minutes before arrival. Which would the nurse anticipate as the likely initial treatment?*

*Answer: The administration of activated charcoal* Rationale: Initial treatment of salicylate overdose includes administration of activated charcoal to decrease absorption of the aspirin. Intravenous (IV) fluids and inducing emesis may be prescribed to enhance excretion but would not be the initial treatment. Dialysis is used in extreme cases if the child is unresponsive to therapy. Vitamin K is the antidote for warfarin overdose.

*Question: A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. What would the nurse tell the client to provide greater reassurance?*

*Answer: The cane has a flared tip with concentric rings to provide stability.* Rationale: A cane should have a slightly flared tip, with flexible concentric rings. This tip acts as a shock absorber and provides optimal stability. The other items about canes are incorrect.

*Question: The nurse is monitoring a client with a closed chest tube drainage system and notes fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of this finding, which conclusion would the nurse make?*

*Answer: The chest tube is functioning as expected.* Rationale: The presence of fluctuation of the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if the suction is not working properly, or if the lung has reexpanded. The remaining options are incorrect interpretations of the finding.

*Question: The parents of a 2-year-old arrive at the hospital to visit their child. The child is in the play room and ignores the parents during the visit. The nurse tells the parents that this behavior in a 2-year-old child indicates which characteristic about the child?*

*Answer: The child is exhibiting a normal pattern.* Rationale: The toddler is particularly vulnerable to separation. A toddler often shows anger at being left by ignoring the parent or pretending to be more interested in play than in going home. The parents of hospitalized toddlers are frequently distressed by such behavior. The toddler normally engages in parallel play and plays alongside (but not with) other children. Options 1, 2, and 4 are incorrect.

*Question: The nurse is collecting data regarding the motor development of a 24-month-old child. Based on the age of the child, the nurse expects to note which highest level of developmental milestone?*

*Answer: The child uses a doorknob to open a door.* Rationale: A 24-month-old would be able to use a doorknob to open a door. At age 15 months, the child could build a tower of two blocks. At age 30 months, the child would be able to snap large snaps and put on simple clothes independently.

*Question: A school nurse is preparing a physical education plan for a child with Down syndrome. Before preparing the plan, the nurse obtains which copy of an x-ray report?*

*Answer: The child's cervical spine* Rationale: Children with Down syndrome frequently have instability of the space between the first two cervical vertebrae. They require diagnostic studies (an x-ray of the cervical spine) to determine if this is present before participating in activities that put pressure on the head and neck, which could cause spinal cord compression. Options 1, 2, and 4 are not necessary.

*Question: The nurse is reinforcing home care instructions to the mother of a child with bacterial conjunctivitis. Which instruction would the nurse give the mother?*

*Answer: The child's towels and washcloths should not be used by other members of the household.* Rationale: Bacterial conjunctivitis is highly contagious, and infection control measures should be taught. These include good hand washing and not sharing towels or washcloths with others. The child should be kept home from school until 24 hours after antibiotics are started. Bottles of eye medication should never be shared with others. Crusted material may be wiped from the eye with a cotton ball soaked in warm water, starting at the inner aspect of the eye and moving toward the outer aspect.

*Question: A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if which action is noted?*

*Answer: The client advances the walker with reciprocal motion.* Rationale: The client should use the walker by placing the hands on the handgrips for stability. The client lifts the walker to advance it and leans forward slightly while moving it. The client walks into the walker, supporting the body weight on the hands while moving the weaker leg. A disadvantage of the walker is that it does not allow for reciprocal walking motion. If the client were to try to use reciprocal motion with a walker, the walker would advance forward one side at a time as the client walks; thus the client would not be supporting the weaker leg with the walker during ambulation.

*Question: The nurse is monitoring a client with a diagnosis of depression. Which behavior observed by the nurse indicates that suicide precautions would be instituted for this client?*

*Answer: The client asks to meet with a lawyer to take care of unfinished business.* Rationale: Warning signs of suicide include talking about suicide, preoccupation with death and dying, behavioral changes, giving away special possessions and making arrangements to take care of unfinished business, decreased appetite, difficulty with sleep, and a loss of interest in usual activities. The remaining behaviors deal with anger and "acting-out" behaviors.

*Question: The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse indicates that the client is performing the technique correctly?*

*Answer: The client breathes out slowly through the mouth.* Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. The client should close the mouth and breathe in through the nose. The client then purses the lips and breathes out slowly through the mouth without puffing the cheeks. The client should spend at least twice the amount of time breathing out that it took to breathe in. The client should use the abdominal muscles to assist in squeezing out all of the air. The client also is instructed to use this technique during any physical activity, to inhale before beginning the activity, and to exhale while performing the activity. The client should never hold his or her breath.

*Question: A client's vision is tested with a Snellen chart. The results of the test are documented as 20/60. How would the nurse interpret this result?*

*Answer: The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet.* Rationale: Vision that is 20/20 is normal; that is, the client can read from 20 feet what a person with normal vision can read from 20 feet. A client with a visual acuity of 20/60 can only read at a distance of 20 feet what a person with normal vision can read at 60 feet.

*Question: A resident in a long-term care facility refuses a medication that has been prescribed. The nurse takes appropriate action after considering which fact?*

*Answer: The client cannot be forced to take the medication.* Rationale: Option 1 is a true statement. The client has the right to refuse any medication prescribed unless deemed incompetent in a court of law. Options 2 and 3 are incorrect statements. Option 4 is an opinion not supported by fact.

*Question: The nurse is assisting in planning care for a client with a diagnosis of placenta previa. The nurse identifies which as the priority goal for the client?*

*Answer: The client exhibits no signs of fetal distress.* Rationale: Option 1 clearly identifies a physiological need. Understanding her condition, utilizing support systems and complying with activity limitations may be components of the plan of care, but the physiological integrity and safety of the mother newborn dyad are the priorities.

*Question: During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. Which interpretation would the nurse make of this behavior?*

*Answer: The client is displaying typical behaviors that can occur during termination.* Rationale: In the termination phase of a relationship, it is normal for a client to demonstrate a number of regressive behaviors. Typical behaviors include return of signs/symptoms of anger, withdrawal, and minimizing the relationship. The anger that the client is experiencing is a normal behavior during the termination phase and does not necessarily indicate the need for hospitalization or treatment.

*Question: While a client is holding and talking to her newborn immediately following delivery, she begins to cry. How does the nurse interpret the client's behavior?*

*Answer: The client is experiencing a normal response to birth.* Rationale: The birth of a baby is an emotionally charged moment for new parents. Crying can be a normal expression of emotions surrounding birth. Holding, eye contact, and touch are signs of healthy maternal-newborn attachment. Options 1, 2, and 3 are incorrect interpretations and there are no data to support these options.

*Question: The nurse is assisting in caring for a pregnant client who is receiving intravenous magnesium sulfate for the management of preeclampsia and notes that the client's deep tendon reflexes are absent. On the basis of this data, the nurse reports the finding and makes which determination?*

*Answer: The client is experiencing magnesium toxicity.* Rationale: Magnesium toxicity can occur as a result of magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression; loss of deep tendon reflexes; sudden decrease in fetal heart rate, maternal heart rate, or both; and sudden drop in blood pressure. Hyperreflexia indicates increased cerebral edema. An absence of reflexes indicates magnesium toxicity. The therapeutic serum level of magnesium for a client receiving magnesium sulfate ranges from 4 to 7.5 mEq/L (5 to 8 mg/dL).

*Question: A 45-year-old woman delivered her first baby by cesarean section 5 days ago. The postpartum recovery has been complicated by thrombophlebitis in her left leg. She cries frequently and requests to have her newborn infant stay in the nursery. The nurse recognizes that the mother may have intensified "postpartum blues" because of which situation?*

*Answer: The client is required to stay on bed rest.* Rationale: Clients with thrombophlebitis may be placed on bed rest with elevation of the affected extremity. Bed rest restricts normal newborn care, feeding, and parenting and will require interventions that promote attachment. Options 1, 2, and 4 are unrelated to the subject of the question.

*Question: A client beginning week 30 of gestation comes to the clinic for a routine visit. Which observation by the nurse indicates a need for further teaching?*

*Answer: The client is wearing knee-high hose.* Rationale: Varicose veins often develop in the lower extremities during pregnancy. Any constricting clothing, such as knee-high hose, impedes venous return from the lower legs and thus places the client at higher risk for developing varicosities. Clients should be encouraged to wear support hose (pantyhose). Flat, nonslip shoes with proper arch support are important to help the pregnant woman maintain proper posture and balance and minimize fall risks.

*Question: The nurse reinforces cast application instructions to a client who is going to have a plaster cast applied. The nurse determines that the client needs further teaching if the client makes which statement about the casting?*

*Answer: The client may bear weight on the cast in 30 minutes.* Rationale: The client needs further teaching about plaster casts if the client plans to bear weight on the cast in 30 minutes. A plaster cast can tolerate weight bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast. The procedure for casting involves washing and drying the skin and placing a stockinette material over the area to be casted. A roll of padding is then applied smoothly and evenly. The plaster is rolled onto the padding, and the edges are trimmed or smoothed as needed. A plaster cast gives off heat as it dries.

*Question: The nurse is preparing a pregnant client for a transvaginal ultrasound exam. The nurse should tell the client that which will occur?*

*Answer: The client will feel some pressure when the vaginal probe is moved.* Rationale: Transvaginal ultrasonography, in which a lubricated probe is inserted into the vagina, allows evaluation of the pelvic anatomy. A transvaginal ultrasound exam is well tolerated by most clients because it alleviates the need for a full bladder. The client is placed in a lithotomy position or with her pelvis elevated by towels, cushions, or a folded blanket. The procedure is not physically painful, although the woman may feel pressure as the probe is moved.

*Question: A client in the mental health unit is administered haloperidol. What would the nurse check to determine its effectiveness?*

*Answer: The client's orientation and delusional status* Rationale: To determine medication effectiveness, the nurse would check the client's orientation and delusional status. Haloperidol is used to treat clients exhibiting psychotic features. Vital signs are routine and not specific to this situation. The physical safety of other clients is not a direct assessment of this client. Monitoring nutritional intake is not related to this situation.

*Question: The nurse is preparing to reinforce instructions to a client regarding how to safely use crutches. Before initiating the teaching, the nurse collects data on the client. Which priority data would be included?*

*Answer: The client's vital signs, muscle strength, and previous activity level* Rationale: Priority data related to vital signs, muscle strength, and previous activity level would be included. Vital signs provide a baseline to determine how well the client will tolerate activity. Assessing muscle strength will help determine if the client has enough strength for crutch walking and if muscle-strengthening exercises are necessary. The previous activity level will provide information related to the tolerance of activity. The other data are also important, but physiological needs take precedence over psychosocial needs.

*Question: A child is brought to a clinic after developing a rash on the trunk and on the scalp. The parents report that the child has had a low-grade fever, has not felt like eating, and has been generally tired. The child is diagnosed with chickenpox. Which statement by the nurse is accurate regarding chickenpox?*

*Answer: The communicable period is 1 to 2 days before the onset of the rash to 6 days after the onset and crusting of lesions.* Rationale: The communicable period for chickenpox is 1 to 2 days before the onset of the rash to 6 days after the onset and crusting of lesions. In roseola the communicable period is unknown. Option 2 describes diphtheria. Option 3 describes rubella.

*Question: The nurse is planning to reinforce instructions to the client about proper use of a thoracolumbosacral orthosis (TLSO) after spinal fusion with instrumentation. The nurse plans to include which teaching points in discussion with the client?*

*Answer: The device is applied before getting out of bed in the morning.* Rationale: A back brace or TLSO is individually fitted to the client. The brace is applied in the morning before getting out of bed. The brace should not irritate the skin with proper fitting. The closures should be secure but not overly loose or tight. A layer of clothing is worn between the orthosis and the skin.

*Question: A primary health care provider has prescribed phenobarbital sodium 25 mg orally twice daily for a child with febrile seizures. The child's weight is 7.2 kg. The safe pediatric dosage is 1 to 6 mg/kg/day. What would the nurse determine about the medication dosage?*

*Answer: The dosage is too high.* Rationale: Calculate the dosage parameters using the safe dosage range identified in the question and the child's weight in kilograms. Next determine the total daily dosage. Dosage parameters: 1 mg/kg/day × 7.2 kg = 7.2 mg/day; 6 mg/kg/day × 7.2 kg = 43.2 mg/day. Dosage frequency: 25 mg × 2 doses = 50 mg/day. The dosage is too high.

*Question: Penicillin V 250 mg orally every 8 hours, is prescribed for a child with a respiratory infection. The child's weight is 45 pounds. The safe pediatric dosage is 25 to 50 mg/kg/day. Which statement accurately describes the prescribed dosage for this child?*

*Answer: The dosage is within the safe dosage range.* Rationale: Convert pounds to kilograms by dividing by 2.2 and then determine the dosage frequency. Pounds to kilograms: 45 lb ÷ 2.2 lb/kg = 20.45 kg. Dosage parameters: 25 mg/kg/day × 20.45 kg = 511.25 mg/day; 50 mg/kg/day × 20.45 kg = 1022.5 mg/day Dosage frequency: 250 mg × 3 doses (every 8 hours) = 750 mg/day. The dosage is within the safe dosage range.

*Question: Cloxacillin sodium 100 mg orally every 8 hours is prescribed for a child with an elevated temperature who is suspected of having a respiratory tract infection. The child weighs 17 pounds. The safe pediatric dosage is 50 mg/kg/day. Which statement accurately describes the prescribed dosage for this child?*

*Answer: The dosage is within the safe dosage range.* Rationale: Convert pounds to kilograms by dividing by 2.2.Pounds to kilograms: 17 lb ÷ 2.2 lb/kg = 7.72 kg.Safe dosage parameter: 50 mg/kg/day × 7.72 kg = 386 mg/day.Dosage frequency: 100 mg × 3 doses (every 8 hours) = 300 mg/day.The dosage is within the safe dosage range.

*Question: Diphenhydramine hydrochloride 25 mg orally every 6 hours is prescribed for a child with an allergic reaction. The child weighs 25 kg. The safe pediatric dosage is 5 mg/kg/day. What would the nurse determine about the medication dosage?*

*Answer: The dosage is within the safe range.* Rationale: Calculate the dosage parameters using the safe dosage range identified in the question and the child's weight in kilograms. Next, determine the total daily dosage. Dosage parameters: 5 mg/kg × 25 kg = 125 mg/day. Dosage frequency: 25 mg × 4 doses = 100 mg/day. The dosage is safe.

*Question: The nurse is checking postoperative prescriptions and planning care for a 110-pound child after spinal fusion. Morphine sulfate, 8 mg subcutaneously every 4 hours as needed (PRN) for pain, is prescribed. The pediatric drug reference states that the safe dosage is 0.1 to 0.2 mg/kg/dose every 2 to 4 hours. What would the nurse determine about the medication dosage?*

*Answer: The dosage is within the safe range.* Rationale: Convert pounds to kilograms by dividing by 2.2, because 1 kg = 2.2 pounds. Therefore, 110 lb ÷ 2.2 = 50 kg. Then determine the dosage parameters.Dosage parameters:0.1 mg/kg × 50 kg = 5 mg0.2 mg/kg × 50 kg = 10 mgThe dosage is safe.

*Question: Penicillin G procaine 1 million units intramuscularly has been prescribed for a child with a throat infection. The child's weight is 62 pounds. The safe pediatric dosage for a child that weighs greater than 60 pounds is 600,000 to 1,200,000 units daily. Which would the nurse determine about the medication dosage?*

*Answer: The dosage is within the safe range.* Rationale: The child's weight is 62 pounds, which falls within the safe pediatric dosage range of 600,000 to 1,200,000 units daily. The dosage is safe.

*Question: The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a modified left lateral recumbent position. The nurse explains that this positioning is preferred because of which reason?*

*Answer: The enema will flow into the bowel easily.* Rationale: When administering an enema, the client is placed in a modified left lateral recumbent position so that the enema solution can flow by gravity in the natural direction of the colon. The anatomy of the colon consists of ascending on the right, transverse across, with descending on the left leading to the sigmoid and rectum. If the client lies on the left side, the enema solution will flow easily into the bowel. The hand dominance of the nurse is not a factor. The nurse assists the client to relax the rectal sphincter by asking the client to take a deep breath. The nurse assists the client to retain the enema solution by administering the enema slowly. The nurse should also use teach-back to determine client's understanding about the reason for the enema.

*Question: The nurse is checking lochia discharge on a client in the immediate postpartum period and notes that the lochia is bright red and contains some small clots. Which interpretation would the nurse make about this finding?*

*Answer: The finding is normal.* Rationale: Lochia, the uterine discharge present after birth, initially is bright red and may contain small clots. During the 2 hours after birth, the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time the lochial flow should steadily decrease, and the color of the discharge should change to a pinkish red or reddish brown. Because this is a normal, expected occurrence, the remaining options are incorrect.

*Question: The nurse is reinforcing instructions about the procedure to a client who is to have a gallium scan. The nurse would include which item as part of the instructions?*

*Answer: The gallium will be injected intravenously 2 to 3 hours before the procedure.* Rationale: A gallium scan is similar to a bone scan, but with an injection of gallium isotope instead of technetium-99m (99mTc). Gallium is injected 2 to 3 hours before the procedure, which takes 30 to 60 minutes to perform. The client must lie still during the procedure. There is no special aftercare.

*Question: The nurse reinforces instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which instruction provided by the nurse is accurate?*

*Answer: The harness needs to be removed to check the skin and for bathing.* Rationale: The harness should be worn 23 hours a day and should be removed only to check the skin and for bathing. The hips and buttocks should be supported carefully when the infant is out of the harness. The harness does not need to be removed for diaper changes or feedings.

*Question: The nurse is reviewing the criteria for early discharge of a newborn infant with a new mother. Which data, if noted in the infant, indicate that the criterion for early discharge has not been met?*

*Answer: The infant has evidence of significant jaundice.* Rationale: Criteria for early discharge in the newborn include no evidence of significant jaundice within the first 24 hours after birth. The infant should have urinated and passed at least 1 stool, completed at least 2 successful feedings, and have normal vital signs for at least 12 hours.

*Question: A 2-year-old child is diagnosed with constipation due to encopresis. Which description is a characteristic of this disorder?*

*Answer: The infrequent and difficult passage of dry stools* Rationale: Constipation can affect any child at any time, although its incidence peaks at ages 2 to 3 years. Option 3 describes encopresis, which can develop as a result of constipation and is one of the major concerns regarding constipation. Encopresis generally affects preschool and school-age children. Option 1 is not associated with encopresis. Option 2 describes imperforate anus, which is diagnosed in the neonatal period. Option 4 describes intussusception, which is the most common cause of bowel obstruction in children ages 3 months to 6 years.

*Question: A client who is taking lithium carbonate is scheduled for surgery. The nurse would reinforce what information in the preoperative teaching about this medication?*

*Answer: The medication will be discontinued 1 to 2 days before the surgery and resumed as soon as full oral intake is allowed.* Rationale: The client who is on lithium carbonate must be off the medication for 1 to 2 days before a scheduled surgical procedure and can resume the medication when full oral intake is prescribed after the surgery. The other options regarding when to discontinue lithium carbonate before surgery are incorrect.

*Question: Which action, if noted in the new mother, indicates the need for further data collection by the nurse for signs of postpartum depression?*

*Answer: The mother constantly complains of tiredness and fatigue.* Rationale: Postpartum depression is not the normal depression that many new mothers experience from time to time. The woman experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The woman is also unable to show pleasure or love and may have intense feelings of unworthiness, guilt, and shame. The woman often expresses a sense of loss of self. Generalized fatigue, complaints of ill health, and difficulty in concentrating are also present. The mother would have little interest in food and experience sleep disturbances.

*Question: The nurse is working with a new nurse employee in a hospice agency. The nurse recognizes the new employee needs further assistance in facilitating effective communication between a client and the family if the new nurse employee performs which action?*

*Answer: The new nurse employee makes decisions for the client and family in order to relieve them of unnecessary demands.* Rationale: Making decisions for the client and family removes autonomy and decision-making from the client and family, who are already experiencing feelings of loss of control in that they cannot change the process of dying. This is an ineffective intervention that can further impair communication. Encouraging discussion of feelings is likely to enhance communication and would not require further assistance. Because spiritual practices give meaning to life and have an effect on how people react to crisis, no further assistance is required. The client and family need to know that someone will be supportive and nonjudgmental; this would not require further assistance.

*Question: The nurse is preparing to reinforce instructions to a pregnant client about nutrition. The nurse plans to include which instruction in this client's teaching plan?*

*Answer: The nutritional status of the mother significantly influences fetal growth and development.* Rationale: Poor nutrition during pregnancy can negatively influence fetal growth and development. Although pregnancy poses some nutritional risk for the mother, not all clients are at high risk. Calcium is critical during the third trimester but must be increased from the onset of pregnancy. Intake of dietary iron is usually insufficient for the majority of pregnant women, and iron supplements are prescribed routinely.

*Question: The nurse is employed in a long-term care facility as a charge nurse of the night shift. The nurse determines that as a charge nurse, authority appropriately refers to which explanation?*

*Answer: The official power to approve an action, command an action, or to see that a decision is enforced* Rationale: Authority refers to the official power an individual has to approve an action, to command an action, or to see that a decision is enforced. Options 1, 2, and 3 are not related to the description of a position of authority.

*Question: The nurse is assisting in reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which data would indicate a negative variance?*

*Answer: The presence of dysrhythmias in a client with a myocardial infarction* Rationale: Variances are actual deviations or detours from the critical paths. Variances can be positive or negative, avoidable or unavoidable, and can be caused by a variety of things. Positive variance occurs when the client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs when untoward events prevent a timely discharge. Variance analysis occurs continually in order to anticipate and recognize negative variance early so that appropriate action can be taken.

*Question: The nurse is developing a nutritional plan for an assigned client. Which is the most critical piece of data to collect before formulating the plan?*

*Answer: The presence of food allergies* Rationale: The presence of food allergies is critical to know before developing a nutritional plan. Dietary diary results, food preferences, and medical history provide good information but are not as crucial as the presence of food allergies.

*Question: The nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse notes that the lochia is red and has a foul odor. The nurse determines that this finding indicates which?*

*Answer: The presence of infection* Rationale: Lochia, the discharge present after birth, is red the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor similar to the odor of menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. Encouraging the woman to drink fluids and ambulate are not accurate interpretations related to the assessment finding.

*Question: A child is scheduled for a tonsillectomy. Which would present the highest risk of aspiration during surgery?*

*Answer: The presence of loose teeth* Rationale: In the preoperative period, the child should be observed for the presence of loose teeth to decrease the risk of aspiration during surgery. Options 1 and 3 are incorrect. Bleeding during surgery will be controlled via packing and suction as needed.

*Question: The nurse obtains a prescription to restrain a client using a belt (safety) restraint and instructs the assistive personnel (AP) to apply the restraint. Which observation, if made by the nurse, indicates unsafe application of the restraint?*

*Answer: The restraint straps are safely secured to the side rails.* Rationale: The restraint strap is secured to the bed frame (never to the side rail) to avoid accidental injury in case the side rail is released. The nurse recognizes that tying the strap to the side rail is not correct and unsafe. A half-bow or safety knot should be used when applying a restraint, because it does not tighten when force is applied against it and allows for the quick and easy removal of the restraint in case of an emergency. The belt restraint should be secure, and one to two fingers should easily slide between the restraint and the client's skin. The client should be able to turn from back to side while in the restraint. A purpose of a restraint is to remind the client not to get out of bed alone.

*Question: The nurse is asked to test the visual acuity of a client using a Snellen chart. The nurse prepares to perform the test, knowing that which procedure accurately identifies this visual acuity test?*

*Answer: The right eye is tested, followed by the left eye, and then both eyes are tested.* Rationale: Visual acuity is tested in one eye at a time, and then in both eyes together, with the client comfortably seated. Begin with the right eye while the left eye is covered, and then test the left eye with the right eye covered, followed by testing both eyes together. Visual acuity is measured with or without corrective lenses, with the client standing at a distance of 20 feet from the chart.

*Question: The nurse is caring for a client with cancer receiving chemotherapy who has developed stomatitis. The nurse plans to give mouth care by using oral care agents and devices that meet which additional criterion?*

*Answer: The severity of stomatitis.* Rationale: Interventions used to treat stomatitis are based on the varying degrees and severity of the disorder. The incorrect options do not focus on the individual needs of the client with this complication of cancer chemotherapy.

*Question: The nurse assists in conducting a home safety assessment with a client preparing for discharge. The client tells the nurse that a space heater is used to heat part of the apartment. Which instruction would the nurse provide to the client regarding the use of the space heater?*

*Answer: The space heater needs to be placed at least 3 feet from anything that can burn.* Rationale: Space heaters need to be used appropriately because they present a great risk of fire. A space heater needs to be placed at least 3 feet from anything that can burn. Placing a heater in a hallway does not guarantee that it will be 3 feet from anything that can burn. A low setting does not reduce the risk of fire. A space heater can be used in an apartment if there is ample space and safety precautions are followed.

*Question: The nurse is caring for a client who had a cesarean section to deliver a nonviable fetus as a result of abruptio placentae. The client develops signs of disseminated intravascular coagulopathy (DIC). The spouse asks the nurse what is happening, and the nurse explains the condition. The spouse becomes upset and says to the nurse, "I lost my baby and now my wife! What am I going to do?" Which appropriately describes the situation?*

*Answer: The spouse lacks hope because of the loss of the baby and illness of his wife.* Rationale: A person who lacks hope experiences hopelessness and sees no way out of the situation except for death. There are no data in the question that support the situation of grieving, deficient knowledge, or anxiety.

*Question: The nurse is caring for a client who will be undergoing surgical treatment for Ménière's disease. The nurse plans care based on which expected outcome?*

*Answer: The surgery relieves pressure from accumulation of inner ear fluid in the endolymphatic sac.* Rationale: Surgical treatment for Ménière's disease involves relief from accumulation of inner ear fluid in the endolymphatic sac. Procedures may be directed toward relief of pressure by the bony structures surrounding the sac or toward opening the sac and diverting the flow of endolymph by a shunt to the mastoid bone or to the subarachnoid space. The remaining options are procedures unrelated to Ménière's disease.

*Question: The nurse is providing information to the family of a child about a synthetic cast that has been applied to the child for the treatment of a clubfoot. Which information would the nurse provide to the mother?*

*Answer: The synthetic cast allows for greater mobility than a plaster cast.* Rationale: Synthetic casts dry quickly (in less than 30 minutes) and are lighter than plaster casts. Synthetic casts allow for greater mobility than a plaster cast. However, synthetic casts are not as strong as plaster casts and are more expensive.

*Question: The nurse is assisting in working with disaster relief following a tornado. The nurse's goal with the overall community is to prevent as much injury and death as possible from the uncontrollable event. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are examples of which type of prevention?*

*Answer: The tertiary level of prevention* Rationale: Tertiary prevention involves the reduction of the amount and degree of disability, injury, and damage following a crisis. Primary prevention means keeping the crisis from occurring, and secondary prevention focuses on seeking to detect existing health problems or trends and reducing the intensity and duration of the crisis during the crisis itself. There is no known aggregate care prevention level.

*Question: The client has been on treatment for rheumatoid arthritis for 3 weeks. Which is most important for the nurse to check during the administration of etanercept?*

*Answer: The white blood cell counts and platelet counts* Rationale: When the client is taking etanercept, it is most important for the nurse to check the client's white blood cell count. Infection and pancytopenia are adverse effects of etanercept. Laboratory studies are performed before and during treatment. The appearance of abnormal white blood cell counts and abnormal platelet counts can alert the nurse to a potential life-threatening infection. Injection site itching is a common occurrence following administration of the medication. In early treatment, residual fatigue and joint pain may still be apparent. A metallic taste and loss of appetite are not common signs of side effects of this medication.

*Question: The registered nurse (RN) and a licensed practical nurse (LPN) are discussing total parenteral nutrition (TPN) with a client who is receiving TPN through a peripherally inserted central catheter (PICC). The client asks why the solution is being infused through a central catheter IV. The nurses explain that TPN is preferably infused through a central line for which reason?*

*Answer: There is greater blood flow with a central line IV to dilute the TPN, which is a concentrated solution and needs to be diluted to avoid damage to the blood vessel.* Rationale: TPN is a hypertonic solution because it contains amino acids and increased concentrations of glucose. When it is infused through a central line IV it is diluted with the increased blood flow in a larger central vein. This prevents damage to red blood cells and the endothelial lining of the vein. Infection is a risk with TPN because of the greater concentration of glucose. Infection in a central line can be serious because of the proximity to the heart and the risk for endocarditis. Antibiotics are not infused through the TPN solution, and the risk of hyperglycemia is associated with the constant concentrated glucose infusion, not the type of venous access.

*Question: The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding?*

*Answer: Thick, yellow drainage from the pin sites* Rationale: The nurse should monitor for signs of infection such as inflammation, purulent drainage, and pain at the pin site. However, some degree of inflammation, pain at the pin site, and serous drainage would be expected; the nurse should correlate assessment findings with other clinical findings, such as fever, elevated white blood cell count, and changes in vital signs. Additionally, the nurse should compare any findings to baseline findings to determine if there were any changes.

*Question: The nurse has gathered data regarding an older client. The nurse recognizes that which indicator of fluid imbalance is least likely to be reliable for a client in this age group?*

*Answer: Thirst* Rationale: Thirst in the older adult is subjective and is not always consistent with fluid balance. The appearance of oral mucosa, skin turgor, and the differences between intake and output are more reliable measures of fluid balance in the older adult.

*Question: An elective cesarean delivery is being planned for a pregnant client. The nurse is reviewing the plans for the surgery with the client. A low transverse uterine incision will be used. The client asks the nurse to explain why this approach is being used. The nurse's response is based on which premise?*

*Answer: This incision allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy.* Rationale: A low transverse uterine incision is unlikely to rupture during a subsequent labor and is the only type of uterine incision considered safe for a subsequent VBAC delivery. It cannot be extended laterally because of the location of the major uterine blood vessels in the lower uterine segment. In the presence of a placenta previa, a classic incision into the body of the uterus would be needed to prevent incising into the placental area. A suprapubic skin incision can be made with a lower uterine transverse incision.

*Question: The nurse is reviewing the postoperative prescriptions for a client who has just returned from surgery and notes that the surgeon has prescribed lepirudin. Which is this medication prescribed to prevent?*

*Answer: Thromboembolic complications* Rationale: Lepirudin is an anticoagulant used in clients with heparin-induced thrombocytopenia and associated thromboembolic disease to prevent further thromboembolic complications. In the postoperative client, the initial dose is administered as soon as possible after surgery but not more than 24 hours after surgery.

*Question: Anastrozole is prescribed for a postmenopausal client with breast cancer. The nurse assists in developing a plan of care for the client and suggests monitoring the client closely for which adverse effect of this medication?*

*Answer: Thromboembolism* Rationale: Anastrozole is an aromatase and blocks the formation of estrogen. The most serious adverse effect to anastrozole is thromboembolism. Common reactions include nausea, chest pain, edema, and shortness of breath. A variety of gastrointestinal tract or nervous system effects also may occur. Kidney failure, cardiac dysrhythmias, and hyperkalemia are not associated with the use of this medication.

*Question: Stavudine is prescribed for a client diagnosed with advanced human immunodeficiency virus (HIV). The nurse reinforcing medication instructions to the client would instruct the client about the importance of reporting which sign/symptom to the primary health care provider?*

*Answer: Tingling in the extremities* Rationale: Peripheral neuropathy, characterized by numbness, tingling, or pain in the hands or feet, can occur frequently with this medication and is an adverse effect. Headache, diarrhea (not constipation), and fatigue are side effects of the medication.

*Question: A client is admitted to the hospital with complaints of back spasms. The client states, "I have been taking 2 or 3 aspirin every 4 hours for the past week, and it hasn't helped my back." Aspirin intoxication is suspected. Which complaint would indicate aspirin intoxication?*

*Answer: Tinnitus* Rationale: Tinnitus (ringing in the ears) is the most frequently occurring effect noted with acetylsalicylic acid intoxication. Mild intoxication with acetylsalicylic acid is called salicylism and is commonly experienced when the daily dosage is higher than 4 g. Hyperventilation may occur because salicylate stimulates the respiratory center. Fever may result because salicylate interferes with the metabolic pathways involved with oxygen consumption and heat production. The other complaints are incorrect.

*Question: The nurse is completing a medication reconciliation form for a client. Which is a primary purpose of this process?*

*Answer: To compare a client's medication prescriptions to all of the medications the client is taking at home* Rationale: Medication reconciliation is a process of comparing a client's medication prescriptions to all of the medications the client is taking. It helps avoid medication errors related to omissions, duplications, dosing errors, and drug interactions and is done at every transition of care when new medications are prescribed or rewritten. This process does not directly affect the pharmacy or insurance company. It is not related to teaching clients about their medications, although nurses still must inform clients about what medications they are taking and why they need to take them.

*Question: The nurse is caring for a client who is being treated with antibiotics for mastitis. To reinforce instructions, what does the nurse tell the client?*

*Answer: To complete the entire antibiotic regimen* Rationale: If antibiotics are prescribed, the client must complete the regimen even though symptoms will be reduced in 24 to 48 hours. Options 1, 2, and 3 are inappropriate treatment measures for mastitis. The client should breastfeed, wear a supportive bra, and take analgesics as prescribed.

*Question: The nurse is reviewing the primary health care provider's (PHCP) prescriptions for a client scheduled for a cardiac catheterization and notes that the PHCP has prescribed tirofiban. The nurse understands that this medication has been prescribed for which purpose?*

*Answer: To inhibit thrombus formation* Rationale: Tirofiban is an antiplatelet and antithrombotic medication. It produces rapid inhibition of platelet aggregation by preventing binding of fibrinogen to receptor sites on platelets. This action inhibits thrombus formation. It is used as an adjunct to aspirin and heparin for hospitalized clients at high risk for myocardial infarction or for clients undergoing a cardiac catheterization procedure. The action of tirofiban is not the prevention of infection or dysrhythmias. Bleeding is a side effect of the medication.

*Question: The nurse is working with a new nurse who is assisting an older client and family with discharge planning following hospitalization. The nurse realizes the new nurse correctly understands the needs of older adults if the new nurse helps the group plan for which situation?*

*Answer: To live independently, but close to their children if possible* Rationale: Most older people prefer to maintain their independence while having the resource of children or family nearby to help in times of need. In general terms, the other options are not as favorably received by the older person, but this would also depend on the specific client and the specific situation.

*Question: A primary health care provider prescribes intravenous potassium for a child with hypertonic dehydration. The nurse assigned to assist in caring for the child would check which highest priority item before administration of the potassium?*

*Answer: Urine output* Rationale: The priority assessment would be to check the status of urine output. Potassium should never be administered in the presence of oliguria or anuria. If urine output is less than 1 to 2 mL/kg/hr, it should not be administered. Although options 1, 3, and 4 may be a component of the data collected, they are not specifically related to the administration of this medication.

*Question: Following a surgical procedure, the nurse applies sequential compression devices to both lower extremities and turns the machine on. The nurse implements this intervention for which purpose?*

*Answer: To prevent thrombosis formation in the veins* Rationale: Compression devices, whether sequential, pneumatic, or intermittent, are external devices applied to the lower extremities to compress the calves of the legs and return blood to the heart similar to the way walking promotes venous return. These compression devices are used for clients who are in bed, especially during surgery and postoperatively, to prevent the complication of venous thrombotic embolism. This embolism can become a pulmonary embolism and cause death during the postoperative recovery period. Heart function determines arterial circulation. The compression devices are not significant in preventing muscle cramps or maintaining muscle strength.

*Question: A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs what?*

*Answer: To regain her breathing pattern* Rationale: When the woman enters this phase of labor, her anxiety level tends to increase as she senses the fairly constant intensification of contractions and pain. The client may need help regaining focus and her breathing pattern. General anesthesia is not needed in this situation. The nurse encourages the woman to refrain from pushing until the cervix is completely dilated and the urge to push is present. The client may be terrified of being left alone during this phase of labor.

*Question: Lamivudine is prescribed for a client diagnosed with human immunodeficiency virus (HIV) who is prescribed zidovudine. Which would the nurse reinforce in the medication instructions to the client?*

*Answer: To report vomiting or abdominal pain to the primary health care provider* Rationale: Lamivudine is an antiretroviral agent administered in combination with zidovudine to delay the appearance of zidovudine resistance. Lamivudine is well absorbed orally with or without food. Peripheral neuropathy can occur with its use, and the client is instructed to notify the primary health care provider if burning, numbness, or tingling of the hands, arms, feet, or legs occurs. Pancreatitis, evidenced by nausea, vomiting, and abdominal pain, is also an adverse effect of the medication and requires primary health care provider notification.

*Question: An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action?*

*Answer: Transport the client to the operating department immediately without obtaining an informed consent.* Rationale: Generally there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. Options 1, 2, and 3 are inappropriate.

*Question: A client has been prescribed cyclobenzaprine in the treatment of painful muscle spasms accompanying a herniated intervertebral disk. The nurse would withhold the medication and question the prescription if the client had which concurrent prescriptions to take?*

*Answer: Tranylcypromine* Rationale: The client would not receive cyclobenzaprine if the client has taken monoamine oxidase inhibitors (MAOIs) such as tranylcypromine or phenelzine within the past 14 days. Otherwise, the client could experience hyperpyretic crisis, seizures, or death.

*Question: A client is seen in the urgent care center for complaints of chest pain 2 days ago. Since that time, the client has not been feeling well and fatigues easily. The nurse reviews the results of the laboratory tests. An elevation of which laboratory test indicates a myocardial infarction occurred at the time of chest pain 2 days ago?*

*Answer: Troponin I* Rationale: When a myocardial infarction occurs, the heart muscle is damaged and enzymes (cardiac markers) are released into the bloodstream. Laboratory testing can detect elevations to support the diagnosis. Troponin I levels elevate as early as 3 hours after myocardial injury and may remain elevated for 7 to 10 days. The myoglobin level can rise as early as 2 hours after a myocardial infarction, with a rapid decline in the level seen after 7 hours. The CK level begins to rise within 6 hours of muscle damage, peaks at 18 hours, and returns to normal in 2 to 3 days. However, factors such as skeletal and cardiac muscle damage, as well as central nervous system damage, can lead to the elevation, so the total CK level is not specific enough. BNP is the primary marker for identifying heart failure.

*Question: In providing initial care to the newborn following delivery, what is the nurse's priority action?*

*Answer: Turn the infant's head to the side.* Rationale: The priority is to maintain an open airway. Turning the infant's head to the side will aid the drainage of mucus from the nasopharynx and trachea to facilitate breathing. Options 1, 2, and 4 are appropriate but can be implemented later.

*Question: The nurse prepares to take a blood pressure (BP) on a school-age child. Where would the nurse place the blood pressure cuff to obtain an accurate measurement?*

*Answer: Two-thirds the distance between the antecubital fossa and the shoulder* Rationale: The size of the BP cuff is important. Cuffs that are too small will cause falsely elevated values, and those that are too large will cause inaccurate low values. The cuff should cover two-thirds the distance between the antecubital fossa and the shoulder.

*Question: The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client?*

*Answer: Uric acid level of 8.4 mg/dL* Rationale: Gout is arthritis caused by high uric acid levels. Uric acid levels are measured in clients with suspected gout. Normal uric acid levels are 2.8 to 6.8 mg/dL in females and 3.5 to 7.8 mg/dL in males. Calcium, potassium, and phosphorus levels are not used in diagnosing gout and are normal.

*Question: A client is taking trihexyphenidyl for the treatment of Parkinson's disease. The nurse would monitor for which side effect of this medication?*

*Answer: Urinary retention* Rationale: Trihexyphenidyl is an anticholinergic medication. Because of this, it can cause urinary hesitancy and retention, constipation, dry mouth, and decreased sweating as side effects.

*Question: An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area. The client sustained the burn from a home fire that occurred in the basement. Which data would indicate that the client sustained a respiratory injury as a result of the burn?*

*Answer: Use of accessory muscles for breathing* Rationale: Clinical indicators in a burn client that would indicate respiratory injury include the presence of facial burns, the presence of soot around the mouth or nose, and singed nasal hairs. Signs of respiratory difficulty include changes in respiratory rate and the use of accessory muscles for breathing. Although anxiety may be a sign of hypoxemia, anxiety along with bradycardia, dysrhythmias, and lethargy would most likely indicate a concern related to a respiratory injury. Abnormal breath sounds and abnormal arterial blood gas values would also be noted. Pain is not specifically related to a respiratory injury.

*Question: A nursing student is planning care for a client with paraplegia who is at risk for injury because of spasticity of their leg muscles. The nurse intervenes if the student plans to include which intervention to minimize the risk of injury to the client?*

*Answer: Use of padded restraints to immobilize the limb* Rationale: Range-of-motion exercises are beneficial in stretching muscles, which may diminish spasticity. Removing potentially harmful objects is an important safety measure. Use of muscle relaxants also is indicated if the spasms cause discomfort to the client or pose a risk to the client's safety. Use of limb restraints will not alleviate spasticity and could harm the client.

*Question: The nurse observes an outburst by a client with a history of schizophrenia, during which the client uses extreme foul language. Which appropriate documentation would the nurse make for this occurrence?*

*Answer: Use quotation marks, exact words, and additional objective information about affect and nonverbal behavior.* Rationale: Option 4 provides accurate, legally defensible information regarding the client's behavior. Options 1 and 2 are not objective. Option 3 is incomplete documentation and is not legally defensible.

*Question: The nurse has given medication instructions to a client beginning anticonvulsant therapy with carbamazepine. The nurse determines that the client understands the use of the medication if the client knows to perform which activity?*

*Answer: Use sunscreen when outside.* Rationale: Carbamazepine acts by depressing synaptic transmission in the central nervous system (CNS). Because of this, the client should avoid driving or doing other activities that require mental alertness until the effect on the client is known. The client should use protective clothing and sunscreen to avoid photosensitivity reactions. The medication may cause dry mouth (not excessive salivation), and the client should be instructed to provide good oral hygiene and use sugarless candy or gum as needed. The medication should not be abruptly discontinued because it could cause return of seizures or status epilepticus. Fever and sore throat should be reported to the primary health care provider (PHCP).

*Question: The nurse is assigned to care for a child with a spica cast. Which action would be avoided when caring for the child?*

*Answer: Using pillows to elevate the head and shoulders* Rationale: Pillows should not be used to elevate the head or shoulders of a child in a body cast because the pillows will thrust the child's chest against the cast and cause discomfort and respiratory difficulty. Neurovascular checks are a critical component of care to ensure that the cast is not causing circulatory compromise. The nurse should observe for nonverbal signs of pain and ask the older child if pain is experienced. A ride on a stretcher to the playroom or around the hospital provides changes of position and scenery.

*Question: Oxytocin is administered to a client following the delivery of the placenta. The nurse assisting in caring for the client monitors for which effective response from the medication?*

*Answer: Uterine contractions* Rationale: Oxytocin stimulates uterine contractions and is administered to reduce the incidence of hemorrhage after expulsion of the placenta. It does not directly affect urinary output or milk production. The subsequent contraction of the uterus may cause an increase in the afterbirth pains.

*Question: The nurse is caring for the client diagnosed with a skin infection who is prescribed amoxicillin 500 mg every 8 hours. Which sign/symptom would indicate to the nurse that the client is experiencing a frequent side effect related to the medication?*

*Answer: Vaginal drainage* Rationale: Amoxicillin is a type of penicillin. Frequent side effects include mild gastrointestinal disturbances, headache, and oral or vaginal candidiasis. A less common but more harmful adverse effect that can occur includes superinfection, such as potentially fatal antibiotic-associated colitis, which results from altered bacterial balance. Symptoms include severe abdominal cramps, severe watery diarrhea, and fever.

*Question: Ribavirin is prescribed for the hospitalized child with respiratory syncytial virus (RSV). The nurse prepares to administer this medication via which route?*

*Answer: Via face mask* Rationale: Ribavirin is an antiviral respiratory medication that may be used in hospitalized children with severe RSV and in high-risk children. Administration is via hood, face mask, or oxygen tent. The medication is most effective if administered within the first 3 days of the infection.

*Question: The nurse is reviewing the record of a pregnant client and notes that the primary health care provider has documented the presence of Chadwick's sign. Which clinical finding supports the documentation of Chadwick's sign?*

*Answer: Violet bluish color of vaginal mucosa and cervix* Rationale: The cervix undergoes significant changes following conception. The most obvious changes occur in color and consistency. In response to the increasing levels of estrogen, the cervix becomes congested with blood, resulting in the characteristic bluish tinge that extends to include the vagina and labia. This discoloration, referred to as Chadwick's sign, is one of the earliest signs of pregnancy. Softening of the cervical tip is Goodell's sign. Softening of the uterine isthmus is Hegar's sign. Rebounding of the fetus is known as ballottement.

*Question: A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, the nurse observed the client has a patent airway. Which is the next nursing assessment?*

*Answer: Vital signs* Rationale: After observing the client has a patent airway, the nurse should check the client's vital signs. The vital signs will provide information regarding airway, breathing, and the circulatory status of the client. In addition, this information provides a baseline for further assessments. The abdominal dressing, IV, and urine output are also components of the assessment, and these assessments would follow the assessment of the vital signs.

*Question: A client has been diagnosed with pernicious anemia. In planning care for the client, the nurse anticipates that the client will be treated with which vitamin or mineral?*

*Answer: Vitamin B12* Rationale: Pernicious anemia is caused by a deficiency of the intrinsic factor, which results in the inability to absorb vitamin B12 in the intestine. Treatment consists of weekly at first and then monthly injections of vitamin B12. Thiamine is most often prescribed for the client with alcoholism. Iron is administered for iron deficiency anemia, and folic acid is prescribed for folic acid deficiency.

*Question: A client has a cerebellar lesion. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item?*

*Answer: Walker* Rationale: The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. Adaptive eating utensils may be beneficial when the client has partial paralysis of the hand. A raised toilet seat is useful when the client does not have the mobility or ability to flex the hips. A slider board is used in transferring a client from a bed to stretcher or wheelchair.

*Question: The nurse has reinforced instructions to a postpartum client who is hepatitis B positive on how to safely bottle-feed her newborn to prevent the transmission of the infection. Which action by the client indicates an understanding of this procedure?*

*Answer: Washes and dries her hands before feeding* Rationale: Hepatitis B virus (HBV) is highly contagious by direct contact with blood and body fluids of infected persons. Strict hand washing before contact with the newborn will assist in prevention of the transmission of infection. Option 2 will not affect disease transmission. Options 3 and 4 are appropriate feeding techniques for bottle-feeding but do not minimize disease transmission for hepatitis B.

*Question: The nurse is caring for a 8-month-old infant. The nurse determines the child is at the expected developmental level if the child displays which behavior?*

*Answer: Waves bye-bye* Rationale: Using single-consonant babbling occurs between 6 and 8 months. Between 8 and 9 months the infant begins to understand and obey simple commands such as "wave bye-bye." Using simple words such as "mama" and the use of gestures to communicate begin between 9 and 12 months.

*Question: A client with diplopia has been taught to use an eye patch to promote better vision and prevent injury. The nurse determines that the client understands how to use the patch if the client states that he or she will do which?*

*Answer: Wear the patch continuously, alternating eyes each day.* Rationale: Placing an eye patch over one eye in the client with diplopia removes the second image and restores more normal vision. The patch is worn continuously and is alternated on a daily basis to maintain the strength of the extraocular muscles of the eyes.

*Question: Which precautions would the nurse specifically take during the administration of ribavirin to a child with respiratory syncytial virus (RSV)?*

*Answer: Wearing goggles* Rationale: Some caregivers experience headaches, burning nasal passages and eyes, and crystallization of soft contact lenses as a result of administration of ribavirin. Specific to this medication is the use of goggles. A gown is not necessary. A mask may be worn. Hand washing is to be performed before and after any child contact.

*Question: A client who has just been told that she is pregnant asks a clinic nurse when the fetus's heart will be developed and beating. The nurse tells the client that the fetal heart is beating at what gestational week?*

*Answer: Week 5* Rationale: The fetal heart is beating and has developed four chambers by gestational week 5.

*Question: A pregnant client in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home for progression of the disease process. The home care nurse reinforces teaching the client about the signs that need to be reported to the primary health care provider (PHCP) and tells the client to call the PHCP if which occurs?*

*Answer: Weight increases by more than 1 pound in a week.* Rationale: The nurse should instruct the client to report any increase in blood pressure, protein in the urine, weight gain greater than 1 pound per week, or edema. The client also is taught how to count fetal movements and is instructed that decreased fetal activity (three or fewer movements per hour) may indicate fetal compromise and should be reported.

*Question: The nurse notes that a client in a long-term care facility is receiving a daily dose of furosemide. The nurse writes in the care plan to monitor which parameter on a daily basis?*

*Answer: Weight* Rationale: Daily weight should be monitored because this reflects the fluid status of the client who is receiving a diuretic. Option 2 is a general assessment and does not relate directly to fluid balance. Options 3 and 4 are laboratory measurements that are not prescribed routinely by the nurse and would not be done on a daily basis in a long-term care facility.

*Question: A furiously angry and aggressive client was put in restraints and was told that the restraints would be removed once the client regained control. The nurse appropriately removes the restraints when which action occurs?*

*Answer: When no acts of aggression are observed within 1 hour after release of two extremity restraints* Rationale: The best indicator that the behavior is controlled is after the client is partially released from the restraints and exhibits no signs of aggression. This is also the best indicator of the client's current physical behavior. The other actions are inaccurate indicators.

*Question: An older gentleman is brought to the emergency department by a neighbor who heard him talking and wandering in the street at 3:00 a.m. The nurse would first determine which about the client?*

*Answer: Whether this is a change in his usual level of orientation* Rationale: The nurse should first determine whether this is a change in the client's neurological status. The next item to determine should include when the client last ate. Blood toxicology levels may be needed, but the primary health care provider would prescribe these. Insurance information must be obtained at some point, but it is not the priority from a clinical care viewpoint.

*Question: A hospitalized client is started on phenelzine sulfate for the treatment of depression. At lunchtime, a tray is delivered to the client. Which food item on the tray would the nurse remove?*

*Answer: Yogurt* Rationale: Phenelzine sulfate is a monoamine oxidase inhibitor (MAOI). The client needs to avoid taking in foods that are high in tyramine. These foods could trigger a potentially fatal hypertensive crisis. Foods to avoid include yogurt; aged cheeses; smoked or processed meats; red wines; and fruits such as avocados, raisins, or figs.

*Question: The nurse is caring for a client scheduled for a cesarean delivery. The nurse reviews the client's health record, knowing that which finding needs to be further investigated before delivery?*

*Answer: White blood cell count of 35,000 mm3* Rationale: White blood cell counts in a normal pregnancy begin to rise in the second trimester and peak in the third trimester with a normal range of 11,000 mm3 to 15,000 mm3 up to 18,000 mm3. A count of 35,000 mm3 before delivery is abnormal and may indicate infection, which can complicate the delivery. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL because of hemodilution caused by an increase in plasma volume during pregnancy. A normal fetal heart rate is 110 to 160 beats per minute.

*Question: A client returns to the nursing unit after an above-knee amputation of the right leg. In which position would the nurse place the client?*

*Answer: With the foot of the bed elevated* Rationale: During the first 24 hours after amputation, the nurse elevates the foot of the bed (but not the residual limb itself) to reduce edema. After the first 24 hours, the bed is kept flat to prevent hip flexion contractures. The health care provider's postoperative prescriptions regarding positioning are always followed.

*Question: A primary health care provider (PHCP) writes a prescription for digoxin, 0.25 mg daily. The nurse teaches the client about the medication and tells the client that it is important to do which?*

*Answer: Withhold the medication and call the PHCP if the pulse is less than 60 beats per minute.* Rationale: An important component of taking this medication is monitoring the pulse rate; however, it is not necessary for the client to take both the radial and carotid pulses. It is not necessary for the client to check the blood pressure every morning and evening because the medication does not directly affect blood pressure. It is most important for the client to know the guidelines related to withholding the medication and calling the PHCP. The client should not stop taking a medication.

*Question: The nurse is preparing to administer digoxin to an infant with heart failure (HF). Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats per minute. Based on this finding, which is the appropriate nursing action?*

*Answer: Withhold the medication.* Rationale: Digoxin is effective within a narrow therapeutic range (0.5 to 2 ng/mL). Safety in dosing is achieved by double-checking the dose and counting the apical heart rate for 1 full minute. If the heart rate is less than 100 beats per minute in an infant, the nurse should withhold the dose and notify the registered nurse and primary health care provider. The remaining options are incorrect actions.

*Question: The nurse is caring for a client who is taking metoprolol. The nurse measures the client's blood pressure (BP) and apical pulse immediately before administration. The client's BP is 122/78 mm Hg and the apical pulse is 58 beats per minute. Based on this data, which is the appropriate action?*

*Answer: Withhold the medication.* Rationale: Metoprolol is classified as a beta-adrenergic blocker and is used in the treatment of hypertension, angina, and myocardial infarction. Baseline nursing assessments include measurement of BP and apical pulse immediately before administration. If the systolic BP is below 90 mm Hg and the apical pulse is below 60 beats per minute, the nurse should withhold the medication and document this action. Although the registered nurse should be informed of the client's vital signs, it is not necessary to do so immediately. The medication should not be administered because the data are outside of the prescribed parameters for this medication. The nurse should not administer half of the medication or alter any dosages at any point in time.

*Question: The nurse is reinforcing medication instructions to a client with a diagnosis of human immunodeficiency virus (HIV) who is prescribed saquinavir. Which instruction would the nurse most appropriately provide the client in regard to taking this medication?*

*Answer: Within 2 hours after a full meal* Rationale: Saquinavir is an antiviral medication. It is administered within 2 hours after a full meal. If the medication is taken without food in the stomach, it may result in no antiviral activity.

*Question: A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when he will be able to walk on the cast. How would the nurse correctly respond to this question?*

*Answer: Within 20 to 30 minutes of application* Rationale: A fiberglass cast is made of water-activated polyurethane materials that are dry to the touch within minutes and reach full rigid strength in about 20 minutes. Because of this, the client can bear weight on the cast within 20 to 30 minutes.

*Question: A client is receiving a continuous intravenous (IV) infusion of heparin in the treatment of deep vein thrombosis. The nurse is told that the client's activated partial thromboplastin time (aPTT) level is 65 seconds and that the client's baseline before the initiation of therapy was 30 seconds. The nurse identifies these results as characteristic of which description?*

*Answer: Within the therapeutic range* Rationale: The normal aPTT varies between 20 and 36 seconds depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal. Thus, the client's aPTT is within the therapeutic range, and the dose should remain unchanged.

*Question: The nurse is caring for a hospitalized older client who has pulled out his IV for the second time. The nurse inserts a new IV. Which intervention would the nurse institute next for the client?*

*Answer: Wrap a light roll of gauze to cover the IV site.* Rationale: An older client who pulls out the IV needs the least restrictive method to promote client safety. The most effective means of helping the client keep the IV is to wrap the IV site with gauze. This will not restrict the client's activity but will add a barrier to pulling the IV out and remove the visual stimulation of seeing the IV. Moving the client to a room closer to the nurse's station is unlikely to keep the client from pulling out the IV again. The client has pulled out the IV previously, so education is unlikely to keep the client from removing the IV. The nurse needs to utilize other measures before obtaining a prescription for restraints.

*Question: The nurse is caring for a client who has bipolar disorder with aggressive social behavior. Which activity would be most appropriate initially for this client?*

*Answer: Writing* Rationale: Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities initially for a client who is aggressive. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. Competitive games like chess, ping-pong, and basketball should be avoided because they can stimulate aggression and increase psychomotor activity.