Practice Exam 3

1. A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every two hours. Which of the following outcome criteria would the nurse use? A. Body temperature of 99°F or less B. Toes moved in active range of motion C. Sensation reported when soles of feet are touched D. Capillary refill of < 3 seconds

1. Answer D is correct. It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Body temperature, motion, and sensation would not give information regarding peripheral circulation; therefore, answers A, B, and C are incorrect.

10. The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia? A. BP 146/88 B. Respirations 28 shallow C. Weight gain of 10 pounds in six months D. Pink complexion

10. Answer B is correct. When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath, as indicated in answer B. The client with anemia is often pale in color, has weight loss, and may be hypotensive. Answers A, C, and D are within normal and, therefore, are incorrect.

100. The first action that the nurse should take if she finds the client has an O2 saturation of 68% is: A. Elevate the head. B. Recheck the O2 saturation in 30 minutes. C. Apply oxygen by mask. D. Assess the heart rate.

100. Answer C is correct. Remember the ABCs (airway, breathing, circulation) when answering this question. Before notifying the physician or assessing the pulse, oxygen should be applied to increase the oxygen saturation, so answers A and D are incorrect. The normal oxygen saturation is 92%-100%, making answer B incorrect.

11. The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching? A. "I will drink 500mL of fluid or less each day." B. "I will wear support hose." C. "I will check my blood pressure regularly." D. "I will report ankle edema."

11. Answer A is correct. The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation, so the statement to drink less than 500mL is incorrect. Answers B, C, and D are incorrect because they all contribute to the prevention of complications. Support hose promotes venous return, the electric razor prevents bleeding due to injury, and a diet low in iron is essential to preventing further red cell formation.

12. A 33-year-old male is being evaluated for possible acute leukemia. Which of the following findings is most likely related to the diagnosis of leukemia? A. The client collects stamps as a hobby. B. The client recently lost his job as a postal worker. C. The client had radiation for treatment of Hodgkin's disease as a teenager. D. The client's brother had leukemia as a child.

12. Answer C is correct. Radiation treatment for other types of cancer can contribute to the development of leukemia. Some hobbies and occupations involving chemicals are linked to leukemia, but not the ones in these answers; therefore, answers A and B are incorrect. Answer D is incorrect because the incidence of leukemia is higher in twins, not siblings.

13. Where is the best site for examining for the presence of petechiae in an African American client? A. The abdomen B. The thorax C. The earlobes D. The soles of the feet

13. Answer D is correct. Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petichiae. Answers A, B, and C are incorrect because the skin may be too dark to make an assessment.

14. The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most important? A. "Have you noticed a change in sleeping habits recently?" B. "Have you had a respiratory infection in the last six months?" C. "Have you lost weight recently?" D. "Have you noticed changes in your alertness?"

14. Answer B is correct. The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous six months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations; therefore, answers A, C, and D are incorrect.

15. Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia? A. Oral mucous membrane, altered related to chemotherapy B. Risk for injury related to thrombocytopenia C. Fatigue related to the disease process D. Interrupted family processes related to life-threatening illness of a family member

15. Answer B is correct. The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority than the diagnoses in answers A, C, and D, which are incorrect.

16. A 21-year-old male with Hodgkin's lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client? A. Sexual dysfunction related to radiation therapy B. Anticipatory grieving related to terminal illness C. Tissue integrity related to prolonged bed rest D. Fatigue related to chemotherapy

16. Answer A is correct. Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin's disease, however, has a good prognosis when diagnosed early. Answers B, C, and D are incorrect because they are of lesser priority.

17. A client has autoimmune thrombocytopenic purpura. To determine the client's response to treatment, the nurse would monitor: A. Platelet count B. White blood cell count C. Potassium levels D. Partial prothrombin time (PTT)

17. Answer A is correct. Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer A the correct answer. White cell counts, potassium levels, and PTT are not affected in ATP; thus, answers B, C, and D are incorrect.

18. The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client's platelet count currently is 80,000. It will be most important to teach the client and family about: A. Bleeding precautions B. Prevention of falls C. Oxygen therapy D. Conservation of energy

18. Answer A is correct. The normal platelet count is 120,000-400,000. Bleeding occurs in clients with low platelets. The priority is to prevent and minimize bleeding. Oxygenation in answer C is important, but platelets do not carry oxygen. Answers B and D are of lesser priority and are incorrect in this instance.

19. The client has surgery for removal of a Prolactinoma. Which of the following interventions would be appropriate for this client? A. Place the client in Trendelenburg position for postural drainage. B. Encourage coughing and deep breathing every two hours. C. Elevate the head of the bed 30°. D. Encourage the Valsalva maneuver for bowel movements.

19. Answer C is correct. A prolactinoma is a type of pituitary tumor. Elevating the head of the bed 30° avoids pressure on the sella turcica and helps to prevent headaches. Answers A, B, and D are incorrect because Trendelenburg, Valsalva maneuver, and coughing all increase the intracranial pressure.

2. A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client? A. Side-lying with knees flexed B. Knee-chest C. High Fowler's with knees flexed D. Semi-Fowler's with legs extended on the bed

2. Answer D is correct. Placing the client in semi-Fowler's position provides the best oxygenation for this client. Flexion of the hips and knees, which includes the kneechest position, impedes circulation and is not correct positioning for this client. Therefore, answers A, B, and C are incorrect.

20. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is: A. Measure the urinary output. B. Check the vital signs. C. Encourage increased fluid intake. D. Weigh the client.

20. Answer B is correct. The large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Measuring the urinary output is important, but the stem already says that the client has polyuria, so answer A is incorrect. Encouraging fluid intake will not correct the problem, making answer C incorrect. Answer D is incorrect because weighing the client is not necessary at this time.

21. A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding? A. Place the client in a sitting position. B. Administer acetaminophen (Tylenol). C. Pinch the soft lower part of the nose. D. Apply ice packs to the forehead.

21. Answer C is correct. C is correct because direct pressure to the nose stops the bleeding. Answers A, B, and D are incorrect because they do not stop bleeding.

22. A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative period for the nurse to take is: A. The blood pressure B. The temperature C. The urinary output D. The specific gravity of the urine

22. Answer A is correct. Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed due to the tumor activity. Temperature would be an indicator of infection, decreased output would be a clinical manifestation but would take longer to occur than blood pressure changes, and specific gravity changes occur with other disorders; therefore, answers B, C, and D are incorrect.

23. A client with Addison's disease has been admitted with a history of nausea and vomiting for the past three days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement? A. Glucometer readings as ordered B. Intake/output measurements C. Evaluating the sodium and potassium levels D. Daily weights

23. Answer A is correct. IV glucocorticoids raise the glucose levels and often require coverage with insulin. Answer B is not necessary at this time, sodium and potassium levels would be monitored when the client is receiving mineral corticoids, and daily weights is unnecessary; therefore, answers B, C, and D are incorrect.

24. A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses' next action be? A. Obtain a crash cart. B. Check the calcium level. C. Assess the dressing for drainage. D. Assess the blood pressure for hypertension.

24. Answer B is correct. The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling can be due to low calcium levels. The crash cart would be needed in respiratory distress but would not be the next action to take; thus, answer A is incorrect. Hypertension occurs in thyroid storm and the drainage would occur in hemorrhage, so answers C and D are incorrect.

25. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in four months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority? A. Impaired physical mobility related to decreased endurance B. Hypothermia r/t decreased metabolic rate C. Disturbed thought processes r/t interstitial edema D. Decreased cardiac output r/t bradycardia

25. Answer D is correct. The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices; therefore, answers A, B, and C are incorrect.

26. The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client taking rosuvastatin (Crestor)? A. Report muscle weakness to the physician. B. Allow six months for the drug to take effect. C. Take the medication with fruit juice. D. Report difficulty sleeping.

26. Answer A is correct. The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyolysis. The medication takes effect within one month of beginning therapy, so answer B is incorrect. The medication should be taken with water because fruit juice, particularly grapefruit, can decrease the effectiveness, making answer C incorrect. Liver function studies should be checked before beginning the medication, not after the fact, making answer D incorrect.

27. The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should: A. Utilize an infusion pump. B. Check the blood glucose level. C. Place the client in Trendelenburg position. D. Cover the solution with foil.

27. Answer B is correct. Hyperstat is given IV push for hypertensive crises, but it often causes hyperglycemia. The glucose level will drop rapidly when stopped. Answer A is incorrect because the hyperstat is given by IV push. The client should be placed in dorsal recumbent position, not Trendelenburg position, as stated in answer C. Answer D is incorrect because the medication does not have to be covered with foil.

28. The six-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor? A. Blood pressure of 126/80 B. Blood glucose of 110mg/dL C. Heart rate of 60bpm D. Respiratory rate of 30 per minute

28. Answer C is correct. A heart rate of 60 in the baby should be reported immediately. The dose should be held if the heart rate is below 100bpm. The blood glucose, blood pressure, and respirations are within normal limits; thus, answers A, B, and D are incorrect.

29. The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to: A. Replenish his supply every three months. B. Take one every 15 minutes if pain occurs. C. Leave the medication in the brown bottle. D. Crush the medication and take with water.

29. Answer C is correct. Nitroglycerine should be kept in a brown bottle (or even a special air- and water-tight, solid or plated silver or gold container) because of its instability and tendency to become less potent when exposed to air, light, or water. The supply should be replenished every six months, not three months, and one tablet should be taken every five minutes until pain subsides, so answers A and B are incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed, as stated in answer D.

3. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client? A. Taking hourly blood pressures with mechanical cuff B. Encouraging fluid intake of at least 200mL per hour C. Position in high Fowler's with knee gatch raised D. Administering Tylenol as ordered

3. Answer B is correct. It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Answer A is incorrect because a mechanical cuff places too much pressure on the arm. Answer C is incorrect because raising the knee gatch impedes circulation. Answer D is incorrect because Tylenol is too mild an analgesic for the client in crisis.

30. The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats? A. Macaroni and cheese B. Shrimp with rice C. Turkey breast D. Spaghetti with meat sauce

30. Answer C is correct. Turkey contains the least amount of fats and cholesterol. Liver, eggs, beef, cream sauces, shrimp, cheese, and chocolate should be avoided by the client; thus, answers A, B, and D are incorrect. The client should bake meat rather than frying to avoid adding fat to the meat during cooking.

31. The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the: A. Feet B. Neck C. Hands D. Sacrum

31. Answer B is correct. The jugular veins in the neck should be assessed for distension. The other parts of the body will be edematous in right-sided congestive heart failure, not left-sided; thus, answers A, C, and D are incorrect.

32. The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the: A. Phlebostatic axis B. PMI C. Erb's point D. Tail of Spence

32. Answer A is correct. The phlebostatic axis is located at the fifth intercostals space midaxillary line and is the correct placement of the manometer. The PMI or point of maximal impulse is located at the fifth intercostals space midclavicular line, so answer B is incorrect. Erb's point is the point at which you can hear the valves close simultaneously, making answer C incorrect. The Tail of Spence (the upper outer quadrant of the breast) is the area where most breast cancers are located and has nothing to do with placement of a manometer; thus, answer D is incorrect.

33. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should: A. Question the order. B. Administer the medications. C. Administer separately. D. Contact the pharmacy.

33. Answer B is correct. Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix for hypertension. Answers A, C, and D are incorrect because the order is accurate. There is no need to question the order, administer the medication separately, or contact the pharmacy.

34. The best method of evaluating the amount of peripheral edema is: A. Weighing the client daily B. Measuring the extremity C. Measuring the intake and output D. Checking for pitting

34. Answer B is correct. The best indicator of peripheral edema is measuring the extremity. A paper tape measure should be used rather than one made of plastic or cloth, and the area should be marked with a pen, providing the most objective assessment. Answer A is incorrect because weighing the client will not indicate peripheral edema. Answer C is incorrect because checking the intake and output will not indicate peripheral edema. Answer D is incorrect because checking for pitting edema is less reliable than measuring with a paper tape measure.

35. A client with vaginal cancer is being treated with a radioactive vaginal implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain that: A. Overnight stays by family members is against hospital policy. B. There is no need for him to stay because staffing is adequate. C. His wife will rest much better knowing that he is at home. D. Visitation is limited to 30 minutes when the implant is in place.

35. Answer D is correct. Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium, putting distance between people and the radium source, and using lead to shield against the radium. Teaching the family member these principles is extremely important. Answers A, B, and C are not empathetic and do not address the question; therefore, they are incorrect.

36. The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client? A. Roast beef sandwich, potato chips, pickle spear, iced tea B. Split pea soup, mashed potatoes, pudding, milk C. Tomato soup, cheese toast, Jello, coffee D. Hamburger, baked beans, fruit cup, iced tea

36. Answer B is correct. The client with a facial stroke will have difficulty swallowing and chewing, and the foods in answer B provide the least amount of chewing. The foods in answers A, C, and D would require more chewing and, thus, are incorrect.

37. The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs? A. "I will make sure I eat breakfast within 10 minutes of taking my insulin." B. "I will need to carry candy or some form of sugar with me all the time." C. "I will eat a snack around three o'clock each afternoon." D. "I can save my dessert from supper for a bedtime snack."

37. Answer A is correct. Novalog insulin onsets very quickly, so food should be available within 10-15 minutes of taking the insulin. Answer B does not address a particular type of insulin, so it is incorrect. NPH insulin peaks in 8-12 hours, so a snack should be eaten at the expected peak time. It may not be 3 p.m. as stated in answer C. Answer D is incorrect because there is no need to save the dessert until bedtime.

38. The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first two weeks of life because: A. New parents need time to learn how to hold the baby. B. The umbilical cord needs time to separate. C. Newborn skin is easily traumatized by washing. D. The chance of chilling the baby outweighs the benefits of bathing.

38. Answer B is correct. The umbilical cord needs time to dry and fall off before putting the infant in the tub. Although answers A, C, and D might be important, they are not the primary answer to the question.

39. A client with leukemia is receiving Trimetrexate. After reviewing the client's chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to: A. Treat iron-deficiency anemia caused by chemotherapeutic agents B. Create a synergistic effect that shortens treatment time C. Increase the number of circulating neutrophils D. Reverse drug toxicity and prevent tissue damage

39. Answer D is correct. Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic acid antagonists. Leucovorin is a folic acid derivative. Answers A, B, and C are incorrect because Leucovorin does not treat iron deficiency, increase neutrophils, or have a synergistic effect.

4. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat? A. Steak B. Cottage cheese C. Popsicle D. Lima beans

4. Answer C is correct. Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. The foods in answers A, B, and D do not aid in hydration and are, therefore, incorrect.

40. A four-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive: A. Hib titer B. Mumps vaccine C. Hepatitis B vaccine D. MMR

40. Answer A is correct. The Hemophilus influenza vaccine is given at four months with the polio vaccine. Answers B, C, and D are incorrect because these vaccines are given later in life.

41. The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication: A. 30 minutes before a meal B. With each meal C. In a single dose at bedtime D. 30 minutes after meals

41. Answer A is correct. Proton pump inhibitors should be taken prior to the meal. Answers B, C, and D are incorrect times for giving proton pump inhibitors like Nexium.

42. A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take? A. Call security for assistance and prepare to sedate the client. B. Tell the client to calm down and ask him if he would like to play cards. C. Tell the client that if he continues his behavior he will be punished. D. Leave the client alone until he calms down.

42. Answer A is correct. If the client is a threat to the staff and to other clients the nurse should call for help and prepare to administer a medication such as Haldol to sedate him. Answer B is incorrect because simply telling the client to calm down will not work. Answer C is incorrect because telling the client that if he continues he will be punished is a threat and may further anger him. Answer D is incorrect because if the client is left alone, he might harm himself.

43. When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to: A. Check the client for bladder distention. B. Assess the blood pressure for hypotension. C. Determine whether an oxytocic drug was given. D. Check for the expulsion of small clots.

43. Answer A is correct. If the fundus of the client is displaced to the side, this might indicate a full bladder. The next action by the nurse should be to check for bladder distention and catheterize, if necessary. The answers in B, C, and D are actions that relate to postpartal hemorrhage.

44. A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client's symptoms are consistent with a diagnosis of: A. Pneumonia B. Reaction to antiviral medication C. Tuberculosis D. Superinfection due to low CD4 count

44. Answer C is correct. A low-grade temperature, blood-tinged sputum, fatigue, and night sweats are symptoms consistent with tuberculosis. If the answer in A had said pneumocystis pneumonia, answer A would have been consistent with the symptoms given in the stem, but just saying pneumonia isn't specific enough to diagnose the problem. Answers B and D are not directly related to the stem.

45. The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client's history should be reported to the doctor? A. Diabetes B. Prinzmetal's angina C. Cancer D. Cluster headaches

45. Answer B is correct. If the client has a history of Prinzmetal's angina, he should not be prescribed triptan preparations because they cause vasoconstriction and coronary spasms. There is no contraindication for taking triptan drugs in clients with diabetes, cancer, or cluster headaches, making answers A, C, and D incorrect.

65. The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client: A. Likes to play football B. Drinks carbonated drinks C. Has two sisters D. Is taking acetaminophen for pain

65. Answer A is correct. The client with osteogenesis imperfecta is at risk for pathological fractures and is likely to experience these fractures if he participates in contact sports. Answers B, C, and D are not factors for concern.

46. The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig's sign is charted if the nurse notes: A. Pain on flexion of the hip and knee B. Nuchal rigidity on flexion of the neck C. Pain when the head is turned to the left side D. Dizziness when changing positions

46. Answer A is correct. Kernig's sign is positive if pain occurs on flexion of the hip and knee. The Brudzinski reflex is positive if pain occurs on flexion of the head and neck onto the chest so answer B is incorrect. Answers C and D might be present but are not related to Kernig's sign.

47. The client with Alzheimer's disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting: A. Agnosia B. Apraxia C. Anomia D. Aphasia

47. Answer B is correct. Apraxia is the inability to use objects appropriately. Agnosia is loss of sensory comprehension, anomia is the inability to find words, and aphasia is the inability to speak or understand, so answers A, C, and D are incorrect.

48. The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as: A. Chronic fatigue syndrome B. Normal aging C. Sundowning D. Delusions

48. Answer C is correct. Increased confusion at night is known as "sundowning" syndrome. This increased confusion occurs when the sun begins to set and continues during the night. Answer A is incorrect because fatigue is not necessarily present. Increased confusion at night is not part of normal aging; therefore, answer B is incorrect. A delusion is a firm, fixed belief; therefore, answer D is incorrect.

49. The client with confusion says to the nurse, "I haven't had anything to eat all day long. When are they going to bring breakfast?" The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make? A. "You know you had breakfast 30 minutes ago." B. "I am so sorry that they didn't get you breakfast. I'll report it to the charge nurse." C. "I'll get you some juice and toast. Would you like something else?" D. "You will have to wait a while; lunch will be here in a little while."

49. Answer C is correct. The client who is confused might forget that he ate earlier. Don't argue with the client. Simply get him something to eat that will satisfy him until lunch. Answers A and D are incorrect because the nurse is dismissing the client. Answer B is validating the delusion.

5. A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The nurse's assessment findings include a pulse oximetry of 92. Assuming that all the following interventions are ordered, which should be done first? A. Adjust the room temperature B. Give a bolus of IV fluids C. Start O2 D. Administer meperidine (Demerol) 75mg IV push

5. Answer C is correct. The pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes precedence over pain relief. Answer A is incorrect because although a warm environment reduces pain and minimizes sickling, it would not be a priority. Answer B is incorrect because although hydration is important, it would not require a bolus. Answer D is incorrect because Demerol is acidifying to the blood and increases sickling.

50. The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's disease. Which side effect is most often associated with this drug? A. Urinary incontinence B. Headaches C. Confusion D. Nausea

50. Answer D is correct. Nausea and gastrointestinal upset are very common in clients taking acetylcholinesterase inhibitors such as Exelon. Other side effects include liver toxicity, dizziness, unsteadiness, and clumsiness. The client might already be experiencing urinary incontinence or headaches, but they are not necessarily associated; and the client with Alzheimer's disease is already confused. Therefore, answers A, B, and C are incorrect.

51. A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate? A. Document the finding. B. Report the finding to the doctor. C. Prepare the client for a C-section. D. Continue primary care as prescribed.

51. Answer B is correct. Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions. It is not enough to document the finding, so answer A is incorrect. The physician must make the decision to perform a C-section, making answer C incorrect. It is not enough to continue primary care, so answer D is incorrect.

52. A client with a diagnosis of HPV is at risk for which of the following? A. Hodgkin's lymphoma B. Cervical cancer C. Multiple myeloma D. Ovarian cancer

52. Answer B is correct. The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the other cancers mentioned in answers A, C, and D, so those are incorrect.

53. During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is: A. Syphilis B. Herpes C. Gonorrhea D. Condylomata

53. Answer B is correct. A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer A is incorrect. Condylomata lesions are painless warts, so answer D is incorrect. In answer C, gonorrhea does not present as a lesion, but is exhibited by a yellow discharge.

54. A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is: A. Venereal Disease Research Lab (VDRL) B. Rapid plasma reagin (RPR) C. Fluorescent treponemal antibody (FTA) D. Thayer-Martin culture (TMC)

54. Answer C is correct. Fluorescent treponemal antibody (FTA) is the test for treponema pallidum. VDRL and RPR are screening tests done for syphilis, so answers A and B are incorrect. The Thayer-Martin culture is done for gonorrhea, so answer D is incorrect.

73. A client is admitted to the unit two hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following? A. Hypovolemia B. Laryngeal edema C. Hypernatremia D. Hyperkalemia

73. Answer B is correct. The nurse should be most concerned with laryngeal edema because of the area of burn. The next priority should be answer A, as well as hyponatremia and hypokalemia in C and D, but these answers are not of primary concern so are incorrect.

55. A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome? A. Elevated blood glucose B. Elevated platelet count C. Elevated creatinine clearance D. Elevated hepatic enzymes

55. Answer D is correct. The criteria for HELLP is hemolysis, elevated liver enzymes, and low platelet count. In answer A, an elevated blood glucose level is not associated with HELLP. Platelets are decreased, not elevated, in HELLP syndrome, as stated in answer B. The creatinine levels are elevated in renal disease and are not associated with HELLP syndrome, so answer C is incorrect.

56. The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex? A. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer. B. The nurse loosely suspends the client's arm in an open hand while tapping the back of the client's elbow. C. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer. D. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.

56. Answer A is correct. Answer B elicits the triceps reflex, so it is incorrect. Answer C elicits the patella reflex, making it incorrect. Answer D elicits the radial nerve, so it is incorrect.

57. A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor's order should the nurse question? A. Magnesium sulfate 4gm (25%) IV B. Brethine 10mcg IV C. Stadol 1mg IV push every 4 hours as needed prn for pain D. Ancef 2gm IVPB every 6 hours

57. Answer B is correct. Brethine is used cautiously because it raises the blood glucose levels. Answers A, C, and D are all medications that are commonly used in the diabetic client, so they are incorrect.

58. A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse's assessment of this data is: A. The infant is at low risk for congenital anomalies. B. The infant is at high risk for intrauterine growth retardation. C. The infant is at high risk for respiratory distress syndrome. D. The infant is at high risk for birth trauma.

58. Answer C is correct. When the L/S ratio reaches 2:1, the lungs are considered to be mature. The infant will most likely be small for gestational age and will not be at risk for birth trauma, so answer D is incorrect. The L/S ratio does not indicate congenital anomalies, as stated in answer A, and the infant is not at risk for intrauterine growth retardation, making answer B incorrect.

59. Which observation in the newborn of a diabetic mother would require immediate nursing intervention? A. Crying B. Wakefulness C. Jitteriness D. Yawning

59. Answer C is correct. Jitteriness is a sign of seizure in the neonate. Crying, wakefulness, and yawning are expected in the newborn, so answers A, B, and D are incorrect.

6. The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select? A. Roast beef, gelatin salad, green beans, and peach pie B. Chicken salad sandwich, coleslaw, French fries, ice cream C. Egg salad on wheat bread carrot sticks, lettuce salad, raisin pie D. Pork chop, creamed potatoes, corn, and coconut cake

6. Answer C is correct. Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not; therefore, answers A, B, and D are incorrect.

60. The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is: A. Decreased urinary output B. Hypersomnolence C. Absence of knee jerk reflex D. Decreased respiratory rate

60. Answer B is correct. The client is expected to become sleepy, have hot flashes, and be lethargic. A decreasing urinary output, absence of the knee-jerk reflex, and decreased respirations indicate toxicity, so answers A, C, and D are incorrect.

61. The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would: A. Place her in Trendelenburg position. B. Decrease the rate of IV infusion. C. Administer oxygen per nasal cannula. D. Increase the rate of the IV infusion.

61. Answer D is correct. If the client experiences hypotension after an injection of epidural anesthetic, the nurse should turn her to the left side, apply oxygen by mask, and speed the IV infusion. If the blood pressure does not return to normal, the physician should be contacted. Epinephrine should be kept for emergency administration. Answer A is incorrect because placing the client in Trendelenburg position (head down) will allow the anesthesia to move up above the respiratory center, thereby decreasing the diaphragm's ability to move up and down and ventilate the client. In answer B, the IV rate should be increased, not decreased. In answer C, the oxygen should be applied by mask, not cannula.

62. A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis? A. Alteration in nutrition B. Alteration in bowel elimination C. Alteration in skin integrity D. Ineffective individual coping

62. Answer A is correct. Cancer of the pancreas frequently leads to severe nausea and vomiting and altered glucose levels. The other problems are of lesser concern; thus, answers B, C, and D are incorrect.

63. The nurse is caring for a client with uremic frost. The nurse is aware that uremic frost is often seen in clients with: A. Severe anemia B. Arteriosclerosis C. Liver failure D. Parathyroid disorder

63. Answer C is correct. Uremic frost is most likely related to liver disease. It is not related to anemia, arteriosclerosis, or parathyroid disorders; therefore, A, B, and D are incorrect.

64. The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client's most appropriate priority nursing diagnosis? A. Alteration in cerebral tissue perfusion B. Fluid volume deficit C. Ineffective airway clearance D. Alteration in sensory perception

64. Answer B is correct. The vital signs indicate hypovolemic shock. They do not indicate cerebral tissue perfusion, airway clearance, or sensory perception alterations, so answers A, C, and D are incorrect.

66. The nurse working the organ transplant unit is caring for a client with a white blood cell count of 450. During evening visitation, a visitor brings a basket of fruit. What action should the nurse take? A. Allow the client to keep the fruit. B. Place the fruit next to the bed for easy access by the client. C. Offer to wash the fruit for the client. D. Ask the family members to take the fruit home.

66. Answer D is correct. The client with neutropenia should not have fresh fruit because it should be peeled and/or cooked before eating. Any source of bacteria should be eliminated, if possible. Answers A, B, and C will not help prevent bacterial invasions.

67. The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40. The initial nurse's action should be to: A. Place the client in Trendelenburg position. B. Increase the infusion of normal saline. C. Administer atropine intravenously. D. Move the emergency cart to the bedside.

67. Answer B is correct. The client's BP is low so increasing the IV is priority. Answers A, C, and D are not the first priority; therefore, they are incorrect.

68. The client admitted two days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes? A. Order a chest x-ray. B. Reinsert the tube. C. Cover the insertion site with a Vaseline gauze. D. Call the doctor.

68. Answer C is correct. If the client pulls the chest tube out of the chest, the nurse's first action should be to cover the insertion site with an occlusive dressing. Afterward, the nurse should call the doctor, who will order a chest x-ray and possibly reinsert the tube. Answers A, B, and D are not the first action to be taken.

69. A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan? A. Assess for signs of abnormal bleeding. B. Anticipate an increase in the Coumadin dosage. C. Instruct the client regarding the drug therapy. D. Increase the frequency of neurological assessments.

69. Answer A is correct. The normal Protime is approximately 12-20 seconds. A Protime of 120 seconds indicates an extremely prolonged Protime and can result in a spontaneous bleeding episode. Answers B, C, and D may be needed at a later time but are not the most important actions to take first.

7. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend? A. A family vacation in the Rocky Mountains B. Chaperoning the local boys club on a snow-skiing trip C. Traveling by airplane for business trips D. A bus trip to the Museum of Natural History

7. Answer D is correct. Taking a trip to the museum is the only answer that does not pose a threat. A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided; therefore, answers A, B, and C are incorrect.

70. Which selection would provide the most calcium for the client who is four months pregnant? A. A granola bar B. A bran muffin C. A cup of yogurt D. A glass of fruit juice

70. Answer C is correct. The food with the most calcium is the yogurt. Answers A, B, and D are good choices, but not as good as the yogurt, which has approximately 400mg of calcium.

71. The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates the understanding of magnesium toxicity? A. The nurse performs a vaginal exam every 30 minutes. B. The nurse places a padded tongue blade at the bedside. C. The nurse inserts a Foley catheter. D. The nurse darkens the room.

71. Answer C is correct. The client receiving magnesium sulfate should have a Foley catheter in place, and hourly intake and output should be checked. Answers A, B, and D are incorrect because they do not indicate understanding of MgSO4 toxicity.

72. The best size cathlon for administration of a blood transfusion to a six-year-old is: A. 18 gauge B. 19 gauge C. 22 gauge D. 20 gauge

72. Answer D is correct. D is correct because the best size cathlon to use in a child receiving blood is a 20 gauge. A, B, and C are incorrect because the size is either too large or too small.

74. The client has recently been diagnosed with diabetes. Which of the following indicates understanding of the management of diabetes? A. The client selects a balanced diet from the menu. B. The client can tell the nurse the normal blood glucose level. C. The client asks for brochures on the subject of diabetes. D. The client demonstrates correct insulin injection technique.

74. Answer D is correct. The client with diabetes indicates understanding of his illness by correctly demonstrating the technique for administration. A, B, and C are incorrect because they do not indicate understanding.

75. The client is admitted following cast application for a fractured ulna. Which finding should be reported to the doctor? A. Pain at the site B. Warm fingers C. Pulses rapid D. Paresthesia of the fingers

75. Answer D is correct. At this time, pain beneath the cast is normal. The client's fingers should be warm to the touch, and pulses should be present. Paresthesia is not normal and might indicate compartment syndrome. Therefore, answers A, B, and C are incorrect.

76. The client with AIDS should be taught to: A. Avoid warm climates. B. Refrain from taking herbals. C. Avoid exercising. D. Report any changes in skin color.

76. Answer B is correct. Herbals can prolong bleeding times or interfere with antiviral medications, therefore the client should avoid the use of herbals. A and D are not contraindicated for the client with AIDS. C is incorrect because there is no need to report all changes in skin color.

77. Which action by the healthcare worker indicates a need for further teaching? A. The nursing assistant ambulates the elderly client using a gait belt. B. The nurse wears goggles while performing a venopuncture. C. The nurse washes his hands after changing a dressing. D. The nurse wears gloves to monitor the IV infusion rate.

77. Answer D is correct. It is not necessary to wear gloves to check the IV drip rate. The healthcare workers in answers A, B, and C indicate knowledge by their actions.

78. The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT, the nurse should: A. Apply a tourniquet to the client's arm. B. Administer an anticonvulsant medication. C. Ask the client if he is allergic to shellfish. D. Apply a blood pressure cuff to the arm.

78. Answer D is correct. The client that is having ECT is given a sedative. When the blood pressure cuff is inflated the fingers twitch when he has a grand mal seizure. A, B, and C are incorrect because there is no need for the nurse to take these interventions prior to ECT.

79. The five-year-old is being tested for enterobiasis (pinworms). Which symptom is associated with enterobiasis? A. Rectal itching B. Nausea C. Oral ulcerations D. Scalp itching

79. Answer A is correct. Pinworms cause rectal itching. B, C, and D are incorrect because they are not signs of pinworms.

8. The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which finding reinforces the diagnosis of B12 deficiency? A. Enlarged spleen B. Elevated blood pressure C. Bradycardia D. Beefy tongue

8. Answer D is correct. The tongue of the client with B12 insufficiency is red and beefy. Answers A, B, and C incorrect because enlarged spleen, elevated BP, and bradycardia are not associated with B12 deficiency.

9. The body part that would most likely display jaundice in the darkskinned individual is the: A. Conjunctiva of the eye B. Soles of the feet C. Roof of the mouth D. Shins

9. Answer C is correct. The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. The conjunctiva can have normal deposits of fat, which give a yellowish hue; thus, answer A is incorrect. The soles of the feet can be yellow if they are calloused, making answer B incorrect; the shins would be an area of darker pigment, so answer D is incorrect.

80. The nurse is teaching the mother regarding treatment for pedicalosis capitis. Which instruction should be given regarding the medication? A. Treatment is not recommended for children less than 10 years of age. B. Bed linens should be washed in hot water. C. Medication therapy will continue for one year. D. Intravenous antibiotic therapy will be ordered.

80. Answer B is correct. Bed linen should be washed in hot water. A is incorrect because special shampoos can be used by children under age 10. Answers C and D are incorrect statements; therefore, they are wrong.

81. The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse? A. The client with HIV B. The client with a radium implant for cervical cancer C. The client with RSV (respiratory synctial virus) D. The client with cytomegalovirus

81. Answer A is correct. The pregnant nurse can care for the client with HIV if she uses standard precautions. The clients in answers B, C, and D pose a risk to the pregnant nurse.

82. The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available? A. The client with methicillin resistant-staphylococcus aureas (MRSA) B. The client with diabetes C. The client with pancreatitis D. The client with Addison's disease

82. Answer A is correct. The client with MRSA is placed on contact precautions. The clients in answers B, C, and D pose no risk to themselves or others.

83. The doctor accidentally cuts the bowel during surgery. As a result of this action, the client develops an infection and suffers brain damage. The doctor can be charged with: A. Negligence B. Tort C. Assault D. Malpractice

83. Answer D is correct. The doctor could be charged with malpractice, which is failing to perform, or performing an act that causes harm to the client. Answers A, B, and C are incorrect because they apply to other wrongful acts. Negligence is failing to perform care for the client; a tort is a wrongful act committed on the client or their belongings; and assault is a violent physical or verbal attack.

84. Which assignment should not be performed by the nursing assistant? A. Feeding the client B. Bathing the client C. Obtaining a stool D. Administering a fleet enema

84. Answer D is correct. The nursing assistant should not be assigned to administer a Fleets enema. They can administer a soap suds or tap water enema. The other tasks can be performed by the nursing assistant; therefore, A, B, and C are incorrect.

85. The mother calls the clinic to report that her newborn has a rash on his forehead and face. Which action is most appropriate? A. Tell the mother to wash the face with soap and apply powder. B. Tell her that 30% of newborns have a rash that will go away by one month of life. C. Report the rash to the doctor immediately. D. Ask the mother if anyone else in the family has had a rash in the last six months.

85. Answer B is correct. The mother is most likely describing a newborn rash. About 30% of all newborns have a rash on the face and forehead that dissipates in approximately one month. A, C, and D are incorrect actions.

86. Which nurse should not be assigned to care for the client with a radium implant for vaginal cancer? A. The LPN who is six months postpartum B. The RN who is pregnant C. The RN who is allergic to iodine D. The RN with a three-year-old at home

86. Answer B is correct. The nurse who is pregnant should not be assigned to the client with a radium implant. The other nurses are not at risk when caring for this client, so A, C, and D are incorrect.

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

87. Answer B is correct. The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C. The failure of the nursing assistant to care for the client with hepatitis might result in termination, but is not of interest to the Joint Commission.

88. The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should: A. Call the Board of Nursing. B. File a formal reprimand. C. Terminate the nurse. D. Charge the nurse with a tort.

88. Answer B is correct. The next action after discussing the problem with the nurse is to document the incident by filing a formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but these are not the first actions requested in the stem. A tort is a wrongful act to the client or his belongings and is not indicated in this instance. Therefore, answers A, C, and D are incorrect.

89. The home health nurse is planning for the day's visits. Which client should be seen first? A. The 78-year-old who had a gastrectomy three weeks ago and has a PEG tube B. The five-month-old discharged one week ago with pneumonia who is being treated with amoxicillin liquid suspension C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter

89. Answer D is correct. The client at highest risk for complications is the client with multiple sclerosis who is being treated with cortisone via the central line. The clients in answers A, B, and C are more stable and can be seen later.

90. The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster? A. A client having auditory hallucinations and the client with ulcerative colitis B. The client who is pregnant and the client with a broken arm C. A child who is cyanotic with severe dypsnea and a client with a frontal head injury D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain

90. Answer B is correct. The pregnant client and the client with a broken arm are the best choices for placing in the same room. The clients in answers A, C, and D need to be placed in separate rooms due to the serious natures of their injuries.

91. Before administering eardrops to a toddler, the nurse should recognize that it is essential to consider which of the following? A. The age of the child B. The child's weight C. The developmental level of the child D. The IQ of the child

91. Answer A is correct. Before instilling the eardrops, the nurse should consider the age of the child because the ear should be pulled down and out to best deliver the drops in the ear canal. Answers B, C, and D are not considerations when instilling eardrops in a small child.

92. The nurse is discussing meal planning with the mother of a twoyear-old. Which of the following statements, if made by the mother, would require a need for further instruction? A. "It is okay to give my child white grape juice for breakfast." B. "My child can have a grilled cheese sandwich for lunch." C. "We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch." D. "For a snack, my child can have ice cream."

92. Answer C is correct. Remember the ABCs (airway, breathing, circulation) when answering this question. Answer C is correct because a hotdog is the size and shape of the child's trachea and poses a risk of aspiration. Answers A, B, and D are incorrect because white grape juice, a grilled cheese sandwich, and ice cream do not pose a risk of aspiration for a child.

93. A client with AIDS has a viral load of 200 copies per ml. The nurse should interpret this finding as: A. The client is at risk for opportunistic diseases. B. The client is no longer communicable. C. The client's viral load is extremely low so he is relatively free of circulating virus. D. The client's T-cell count is extremely low.

93. Answer C is correct. A viral load of 200 is extremely low. This indicates that the client has a low risk for opportunistic illnesses. A, B, and D do not indicate understanding.

94. The client has an order for sliding scale insulin at 1900 hours and Lantus insulin at the same hour. The nurse should: A. Administer the two medications together. B. Administer the medications in two injections. C. Draw up the Lantus insulin and then the regular insulin and administer them together. D. Contact the doctor because these medications should not be given to the same client.

94. Answer B is correct. Lantus insulin cannot be mixed with other insulins, but can be taken by the client taking regular insulin. A, C, and D are not correct methods of administering Lantus insulin with regular insulin.

95. A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is: A. Altered nutrition B. Impaired communication C. Risk for injury/aspiration D. Altered urinary elimination

95. Answer C is correct. Always remember your ABCs (airway, breathing, circulation) when selecting an answer. A, B, and D are incorrect because they are not the priority.

96. What would the nurse expect the admitting assessment to reveal in a client with glomerulonephritis? A. Hypertension B. Lassitude C. Fatigue D. Vomiting and diarrhea

96. Answer A is correct. The client with glomerulonephritis will probably have hypertension. B and C are vague answers and are therefore incorrect. D does not directly relate to glomerulonephritis.

97. Which action is contraindicated in the client with epiglottis? A. Ambulation B. Oral airway assessment using a tongue blade C. Placing a blood pressure cuff on the arm D. Checking the deep tendon reflexes.

97. Answer B is correct. A child with epiglottis has the possibility of complete obstruction of the airway. For this reason, the nurse should not evaluate the airway using a tongue blade. A, C, and D are allowed actions and are therefore incorrect.

98. A 25-year-old client with a goiter is admitted to the unit. What would the nurse expect the admitting assessment to reveal? A. Slow pulse B. Anorexia C. Bulging eyes D. Weight gain

98. Answer C is correct. Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss; therefore, answers A, B, and D are incorrect.

99. Which of the following foods, if selected by the mother with a child with celiac, would indicate her understanding of the dietary instructions? A. Whole-wheat toast B. Angel hair pasta C. Reuben on rye D. Rice cereal

99. Answer D is correct. The child with celiac disease should be on a gluten-free diet. Answers A, B, and C all contain gluten, while answer D gives the only choice of foods that does not contain gluten.