Fundamental Skills

100. The nurse is instructing a client regarding the use of ice packs to treat an eye injury. The nurse should tell the client to perform which action? 1. Keep the ice pack on the eye continuously for 24 hours 2. Place a plastic bag filled with crushed ice directly on the eye socket 3. Wrap a plastic bag filled with ice with a pillow case or towel and place it on the eye 4. Lie flat and place an ice bag on the eye using a rotation schedule of 8 hours on and 8 hours off for 4 days

100. Answer: 3 Rationale: If an ice pack is placed directly against the skin or left in place for an extended period, it carries a risk of tissue damage similar to that of a hot water bottle. An ice pack should never be placed directly against the skin but should be covered with a pillowcase or towel. To prevent tissue damage from excessive cold exposure, the ice pack should be removed in most cases after 30 minutes, and after a short time, may be reapplied. Following an eye injury, the client should keep the head elevated to reduce swelling in the area. • Test-Taking Strategy: Note the subject, cold applications. Noting the words "continuously" in option 1 and "directly" in option 2 will assist in eliminating these options. From the remaining options, recall that lying flat will increase swelling in the affected area. • Review: cold applications.

12. The nurse is caring for an 18-month-old child who has been diagnosed with scabies. The health care provider has prescribed Lindane to be applied to the skin to treat the infection. The nurse should take which most appropriate action at this time? 1. Apply the medication to the child's skin. 2. Contact the health care provider for clarification. 3. Assess the parent's knowledge of the use of this medication. 4. Provide instructions to the parents of the child for application of the medication.

12. Answer: 2 Rationale: Lindane should not be administered to children younger than 2 years of age because of the risk of neurotoxicity; therefore, the nurse should contact the health care provider for further clarification. Options 1, 3, and 4 indicate administration of this medication, which is an unsafe action. • Test-Taking Strategy: Note the strategic words "most appropriate." Note the age of the child in the question as it relates to this medication. In addition, note that options 1, 3, and 4 are comparable or alike in that they indicate administration of the medication before seeking clarification. • Review: medications to treat scabies.

13. Which communication strategies should the nurse use when working with a client who has difficulty speaking as a result of weakness? Select all that apply. 1. Encourage the client to speak quickly 2. Ask "yes" and "no" questions when able 3. Have the client use a communication board 4. Repeat what the client said to verify the message 5. Use a pen and paper to communicate client needs 6. Encourage verbal communication to strengthen the client's voice

13. Answer: 2, 3, 4, 5 Rationale: If a client is having difficulty communicating as a result of weakness, the nurse should ask questions requiring a "yes" or "no" response, listen attentively, develop alternative communication methods (letter board, picture board, pen and paper, flash cards), and verify what the client has said by repeating it. • Test-Taking Strategy: Use therapeutic communication techniques to eliminate options 1 and 6. Encouraging the client to speak quickly and frequently is difficult, unsuccessful, and counterproductive. • Review: communication methods.

14. The nurse is assigned to the following four clients for total care during the day shift. Breakfast trays are arriving, and the common practice on the unit is to assist clients to the bedside chair to eat. Which client will require the greatest assistance from the nurse? 1. The client who underwent right hip replacement 2. The client who underwent left knee replacement 3. The client who underwent right ankle replacement 4. The client who underwent repair of a rotator cuff, left shoulder

14. Answer: 1 Rationale: Movement of a hip replacement client requires that an abduction pillow be placed between the legs before moving to a sitting position. If the right leg adducts, the head of the femur will dislocate from the socket, possibly requiring a return to surgery. Even though the clients in options 2, 3, and 4 will likely need the assistance of one person, they do not require maintenance of specific positions or the greatest assistance in order to prevent injury. • Test-Taking Strategy: Note the subject, prioritizing guidelines. Note the words "greatest assistance." Visualizing the surgical procedure for each client and thinking about each client's needs will direct you to the correct option. • Review: surgical positioning guidelines.

15. The nurse is demonstrating adult cardiopulmonary resuscitation (CPR) chest compression techniques to health care team members. Which action performed by a member on return demonstration indicates the need for additional teaching in the performance of CPR? 1. Lets the fingers rest on the chest 2. Straightens the arms and locks the elbows 3. Keeps the shoulders directly over the hands 4. Places the heel of the hand over the lower half of the sternum

15. Answer: 1 Rationale: To maximize the effectiveness of chest compressions, the person administering CPR needs to avoid letting the fingers rest on the chest. This also helps prevent accidental injury to internal organs. The actions listed in the other options are all part of correct CPR chest compression procedures. • Test-Taking Strategy: Note the strategic words "needs additional teaching." These words indicate a negative event query and the need to select the incorrect option as the answer. Visualize each action in the options to direct you to the correct option. • Review: basic life support.

16. The nurse is performing catheter care for a client who has an indwelling urinary catheter. Which action, if performed by the nurse, is indicative of unsafe practice? 1. The nurse performs hand hygiene before and after the procedure. 2. The nurse removes the anchor device to free the catheter tubing before cleaning. 3. The nurse cleans from the area of most contamination to the area of least contamination. 4. The nurse places a waterproof pad under the client and applies clean gloves before the procedure.

16. Answer: 3 Rationale: When performing catheter care on a client with an indwelling urinary catheter, the nurse should perform hand hygiene before and after the procedure to reduce the spread of infection. The nurse should place a waterproof pad under the client and apply clean gloves before the procedure. The anchor device should be removed to free the catheter tubing before cleaning. The nurse should clean from the area of least contamination to the area of most contamination to reduce the spread of infection. • Test-Taking Strategy: Note the subject, an action performed by the nurse that is indicative of unsafe practice. Recall that cleaning from the most contaminated area to the least contaminated can potentially spread infection. • Review: indwelling urinary catheter care.

17. The prescription for a client reads "cleansing enemas until clear." The nurse has administered a total of three enemas, and the output is liquid brown. The nurse notifies the health care provider, understanding that continued administration can result in which outcome? 1. Acid-base imbalances 2. Blood pressure changes 3. Electrolyte disturbances 4. Blood glucose alterations

17. Answer: 3 Rationale: If the nurse has a prescription indicating "enemas until clear," the nurse can administer up to three enemas (or per agency policy). If the output has not become clear after the third enema, the nurse should notify the health care provider because continued administration could result in electrolyte disturbances. Options 1, 2, and 4 are not complications specifically associated with this procedure. • Test-Taking Strategy: Note the subject, of the question, enema administration. Visualizing the procedure and recalling its physiological effects will direct you to the correct option. • Review: enema administration.

18. The nurse understands that which identifies a correct principle of surgical asepsis? 1. A sterile package that becomes wet is unsterile 2. The nurse should hold sterile objects below waist level 3. A 3-inch border around the edges of a sterile field are considered contaminated 4. Prolonged exposure to air will not contaminate a sterile field as long as the client's room windows and doors are kept closed

18. Answer: 1 Rationale: When a sterile object becomes wet, the object becomes contaminated by capillary action from contact with unsterile materials. Any sterile object held below waist level is considered contaminated because it cannot be viewed at all times. A 1-inch border around the edges of a sterile field is considered contaminated. A sterile field becomes contaminated by prolonged exposure to air. • Test-Taking Strategy: Focus on the subject, surgical asepsis. Read and visualize each option. Recalling the principles of asepsis will direct you to the correct option. • Review: surgical asepsis procedures.

19. An older client has been lying in bed for 2 hours. The nurse who is repositioning this client would be most concerned with examining which area( s) of the client" s body? Select all that apply. 1. Heels 2. Sacrum 3. Back of the head 4. Back of the knees 5. Greater trochanter 6. Palms of the hand

19. Answer: 1, 2, 3, 5 Rationale: Areas at risk for skin breakdown due to immobilization are found over bony prominences of the body. The nurse should pay special attention to the heels, sacrum, back of the head, and the greater trochanter. The back of the knees and the palms of the hand are not bony prominence areas and are at a lower risk for skin breakdown due to immobilization. • Test-Taking Strategy: Note the strategic word "most" and visualize the client lying in bed and the location of the bony prominences to assist in answering the question. • Review: areas at risk for developing pressure ulcers.

20. As prescribed, the nurse is applying a dressing to a client's wound that allows wound visualization, is waterproof, and is painless on removal. Which type of dressing material is being used? 1. Hydrogel 2. Cotton gauze 3. Hydrocolloidal 4. Adhesive transparent

20. Answer: 3 Rationale: Hydrocolloidal dressing material provides absorption, protection, and debridement. This type of dressing material is waterproof and painless on removal. Hydrogel dressing material provides absorption, protection, and debridement. It is conducive to use with topical agents, and conforms to uneven wound surfaces but allows only partial wound visualization. It is also waterproof but is not completely painless on removal. Cotton gauze is a continuous dry dressing that provides absorption and protection and may be painful on removal. Adhesive transparent dressing material provides protection for partial-thickness lesions, debridement, and serves as a secondary dressing. This type of dressing provides good visualization of the wound. This type of dressing is waterproof but is not completely painless on removal. • Test-Taking Strategy: Note the subject, a type of dressing material that is waterproof and painless on removal. Note the relationship between the word "waterproof" and the correct option. In addition, recall that this type of dressing material is painless on removal. • Review: types of dressing materials.

21. The clinic nurse is discussing nutrition with a client who is lactose intolerant. The nurse should instruct the client to supplement the dietary source of calcium by eating which food? 1. Dried fruits 2. Hard cheese 3. Creamed spinach 4. Fresh-squeezed orange juice

21. Answer: 1 Rationale: The best source of calcium is dairy products; however, women with lactose intolerance need other sources of calcium. Calcium is present in dark green, leafy vegetables; broccoli; legumes; nuts; and dried fruits. Cheese is a dairy product and cannot be eaten when the client is lactose intolerant. Spinach contains calcium, but it also contains oxalates that decrease calcium availability. Additionally, creamed spinach may not be tolerated by a client with lactose intolerance. Orange juice does not contain significant amounts of calcium unless fortified with calcium. • Test-Taking Strategy: Focus on the subject, and the client's diagnosis. Recalling that a client with lactose intolerance cannot tolerate dairy products will assist in eliminating options 2 and 3. From the remaining options, recalling that orange juice does not contain calcium unless it is fortified with calcium will direct you to the correct option. • Review: calcium-rich foods.

22. The nurse reviews the most current laboratory data for the four clients to whom the nurse is assigned. The nurse should first assess the client with which laboratory result? 1. Potassium 5.0 mEq/ L 2. Hemoglobin 11.8 g/ dL 3. Platelets 40,000 cells/ mm3 4. White blood cell (WBC) count 5000 cells/ mm3

22. Answer: 3 Rationale: A client with platelets at 40,000 cells/ mm3 or below is at risk for spontaneous bleeding. A potassium level of 5.0 mEq/ L is normal. A hemoglobin of 11.8 g/ dL is slightly below normal and is not indicative of an urgent situation. A white blood cell count at 5000 cells/ mm3 is at the lower range of normal. • Test-Taking Strategy: Note the strategic word "first" and focus on the laboratory values in the options. Recalling the normal laboratory values will direct you to the correct option, the only abnormal value. • Review: normal and abnormal laboratory values.

23. The nurse is administering enteral feedings via a nasogastric (NG) tube. The nurse should take which action when caring for this client to maintain client safety? 1. Keep the client in a supine position 2. Change the NG tube with every other feeding 3. Check for tube placement and residual at least every 4 hours 4. Increase the rate of the feeding if the infusion falls behind schedule

23. Answer: 3 Rationale: A complication of an NG tube is aspiration pneumonia caused by regurgitation of formula contents from the stomach into the respiratory tract. This risk can be minimized by checking tube placement and residual and by keeping the head of the bed elevated to 30 degrees at all times. Nasogastric tubes may be left in place from weeks to months depending on the type of tube inserted. The feeding bag itself should be changed daily. Increasing the rate of the feeding can lead to complications and should not be done. • Test-Taking Strategy: Focus on the subject, safe administration of enteral feedings. Eliminate option 1 because a supine position could cause aspiration pneumonia. Eliminate option 2 next because nasogastric tubes may be left in place from weeks to months depending on the type of tube inserted. Choose option 3 over option 4 because it is definitive action that helps protect the client from aspiration. • Review: enteral feedings and nasogastric (NG) tube maintenance.

24. The nurse is caring for a hospitalized child with a diagnosis of measles (rubeola). In preparing to care for the child, which supplies should the nurse bring to the child's room to prevent the transmission of the virus? 1. Gown and gloves 2. Goggles and gloves 3. Mask, gown, and gloves 4. Gown, gloves, and goggles

24. Answer: 3 Rationale: Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Respiratory isolation is required, and a mask, gown, and gloves should be worn by those in contact with the child. Goggles are not specifically indicated for care of the child with rubeola. • Test-Taking Strategy: Focus on the subject, routes of transmission. Recalling that the route of transmission of rubeola is via airborne particles or direct contact with infectious droplets will direct you to the correct option. • Review: transmission methods of rubeola.

25. A client is admitted to a medical unit with nausea and bradycardia. The family is upset and states, "That doctor doesn't know how to take care of my father." The most therapeutic response by the nurse is which statement? 1. "You're right." 2. "Don't worry about this. I'll take care of everything." 3. "You are concerned that your loved one receives the best care." 4. "I think you're wrong. That health care provider has been in practice more than 30 years."

25. Answer: 3 Rationale: The correct option reflects the family's concern, but remains nonjudgmental. Options 1 and 2 create doubt about the health care provider's practice and ability without actually knowing the circumstances. Option 4 dismisses the family's concerns and disempowers the family and is argumentative and nontherapeutic. • Test-Taking Strategy: Use therapeutic communication techniques. Reflection of the client or family's concerns is the most therapeutic response. • Review: therapeutic communication techniques.

28. The nurse prepares to bathe and change the bed linens of a client with methicillin-resistant Staphylococcus aureus in an abdominal wound covered by a dressing. Which protective action should the nurse take during the bathing of this client? 1. Wears gloves 2. Wears a gown and gloves 3. Wears a gown, gloves, and a mask 4. Wears a gown and gloves to change the bed linens and gloves only for the bath

28. Answer: 2 Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items such as from wound drainage, or in caring for a client who is incontinent, or a client who has an ileostomy or a colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn. • Test-Taking Strategy: Think about the method of transmission of infection noting the task that is presented. In this case, it is bathing and changing linens. Eliminate option 3 because the method of transmission is not respiratory in nature. Eliminate options 1 and 4 because they are comparable or alike and neither provides adequate protection based on the method of transmission. • Review: transmission-based precautions.

29. The nurse is providing home care instructions to the client diagnosed with severe acute respiratory syndrome (SARS). Which statement, if made by the client, indicates a need for further instruction? 1. "I may develop a dry cough after a few days." 2. "I should avoid having visitors for some time." 3. "I need to be sure to wash my hands frequently." 4. "It is okay to share eating utensils after a few days."

29. Answer: 4 Rationale: Severe acute respiratory syndrome (SARS) is a respiratory illness caused by the coronavirus and begins with a fever, overall feeling of discomfort, body aches, and mild respiratory symptoms. After 2 to 7 days, the client may develop a dry cough and dyspnea. The client should avoid having visitors until he or she is no longer contagious because this is easily spread through direct contact with infectious material, such as respiratory secretions or objects infected by respiratory droplets. Frequent handwashing will assist in preventing transmission. The client should avoid sharing food, drinks, and eating utensils because of the potential for transmission. • Test-Taking Strategy: Note the strategic words "need for further instruction." This phrase indicates a negative event query and the need to select the incorrect client statement. Recall the route of transmission of this infection in order to direct you to the correct option. • Review: severe acute respiratory syndrome (SARS).

31. The nurse is analyzing laboratory values that were prescribed to determine nutrition status for the older adult client. Which laboratory value( s) would be of concern to the nurse? Select all that apply. 1. Hematocrit 30% 2. Albumin 3.0 g/ dL 3. Calcium 10 mg/ dL 4. Hemoglobin 8 g/ dL 5. Creatinine 0.6 mg/ dL 6. Blood urea nitrogen 20 mg/ dL

31. Answer: 1, 2, 4 Rationale: Expected laboratory values for the older adult may vary slightly when compared to that of the adult client. Laboratory values of concern to the nurse would be the hematocrit, albumin, and hemoglobin levels. For the older adult client, the normal hematocrit range is approximately 38 to 44%; normal albumin level is 3.5 to 5.0 g/ dL; and normal hemoglobin is 12 to 16 g/ dL. Options 3, 5, and 6 are within normal ranges. The normal calcium level ranges from approximately 9 to 11 mg/ dL; creatinine 0.5 to 1.0 mg/ dL; and blood urea nitrogen 10 to 20 mg/ dL. • Test-Taking Strategy: Focus on the subject, and note the words "would be of concern to the nurse" in the question. It is necessary to know the normal laboratory values for the older adult client in order to answer this question correctly. • Review: normal laboratory values for the older adult.

32. The nursing instructor asks a nursing student to identify the type of isolation precautions necessary for the client with active tuberculosis (TB). The student understands the route of transmission if the student states that which type of isolation precaution should be maintained? 1. Contact precautions 2. Airborne precautions 3. Standard precautions 4. Handwashing precautions

32. Answer: 2 Rationale: TB is an infectious disease caused by the bacillus Mycobacterium tuberculosis and is spread primarily by the airborne route. Contact precautions are indicated when an infection is transmitted by direct contact with the client or contaminated items in the client's environment. Standard precautions are to be used with all clients to protect health care workers from contracting and transmitting communicable diseases. Proper handwashing by health care workers assists with prevention of transmission of infection. • Test-Taking Strategy: Note the subject, isolation precautions. Focus on the diagnosis. Recalling that TB is a respiratory disease will direct you to the correct option. • Review: transmission-based precautions.

33. A postoperative client says to the nurse, "Don't touch me. I'll take care of myself!" Which response is therapeutic? 1. "Fine! I won't touch you!" 2. "Let's work together so you can do things for yourself." 3. "I have to change your dressing so I have to touch you." 4. "If that's what you want but I need to report this to the surgeon."

33. Answer: 2 Rationale: The therapeutic response is the one that reflects the client's feelings and empowers the client by offering some self-control over one's own care. Option 1 is an aggressive and nontherapeutic communication technique. Option 3 reflects assault by telling the client that he or she needs to be touched. In option 4, the nurse is demeaning. • Test-Taking Strategy: Use therapeutic communication techniques. Focus on the client's feelings to direct you to the correct option. • Review: therapeutic communication techniques.

34. Ampicillin sodium 250 mg in 50 mL of NS is being administered over a period of 30 minutes. The drop factor is 10 drops per 1 mL. The nurse determines that the infusion is running safely at the prescribed rate if the infusion is delivering how many drops per minute? Fill in the blank. Round to the nearest whole number. Answer: _________ gtts/ min

34. Answer: 17 Rationale: Follow the formula for calculating IV infusion rates. Formula: Total volume in mL x Drop factor/Time in minutes= gtts per min 50mL x 10gtts/30 mins= 16.6 round to 17 gtts per min Test-Taking Strategy: Note the subject, an intravenous flow rate. Follow the intravenous flow rate formula. Use a calculator to verify the answer. Remember to round the answer to the nearest whole number. Review: intravenous flow rate calculations.

35. The nurse provides instructions to the client using an incentive spirometer and tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse incorporates the understanding that which action is the primary benefit? 1. Dilate the major bronchi 2. Increase surfactant production 3. Maintain inflation of the alveoli 4. Enhance ciliary action in the tracheobronchial tree

35. Answer: 3 Rationale: Sustained inhalation for 3 to 5 seconds helps maintain inflation of terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as the incentive spirometer can help prevent atelectasis and pneumonia in clients at risk. An incentive spirometer does not achieve the actions in options 1, 2, or 4. • Test-Taking Strategy: Note the strategic word "primary." Use anatomy and physiology. Recalling that the alveoli are the most distal part of the respiratory tree helps you to choose the correct option as the area to obtain the benefit from maximum sustained inhalation. • Review: incentive spirometry.

36. The nurse understands that which are characteristics of anthrax? Select all that apply. 1. It is caused by the bacillus Yersinia pestis 2. Cutaneous lesions become a black eschar 3. Gastrointestinal anthrax causes bloody diarrhea 4. Flulike symptoms are a sign of pulmonary anthrax 5. Person-to-person transmission of inhalation disease does not occur 6. A person can become infected through skin contact, ingestion, or inhalation of the bacillus

36. Answer: 2, 3, 4, 5, 6 Rationale: Anthrax is an acute infectious disease caused by Bacillus anthracis, a spore-forming, gram-positive bacillus. A human becomes infected through skin contact, ingestion, or inhalation. Person-to-person transmission of inhalation disease does not occur. Cutaneous lesions become a black eschar. Gastrointestinal anthrax causes bloody diarrhea. Flulike symptoms are a sign of pulmonary anthrax. Plague is caused by the bacillus Yersinia pestis. • Test-Taking Strategy: Focus on the subject, characteristics of anthrax. Recall that with anthrax, a person can become infected through skin contact, ingestion, or inhalation of the bacillus but that person-to-person transmission of inhalation disease does not occur. Also remember that anthrax is caused by Bacillus anthracis. • Review: characteristics of anthrax.

37. The nurse is auscultating the apical heart rate of a client who is not taking any prescribed medications and notes that the heart rate is regular. To determine beats per minute, the nurse should measure the apical pulse for how many seconds? 1. 15 seconds 2. 30 seconds 3. 45 seconds 4. 60 seconds

37. Answer: 2 Rationale: When auscultating the apical heart rate, the nurse should first determine whether the heart rate is regular. If it is regular, it is sufficient to auscultate for 30 seconds and then multiply by 2 to determine the number of beats per minute. If the heart rate is irregular or if the client is taking cardiac medications, the apical pulse should be measured for a full 60 seconds. Therefore, options 1, 3, and 4 are incorrect. • Test-Taking Strategy: Focus on the subject, a regular heart rate in a client not taking prescribed medications. Recall that a regular apical pulse rate can be measured for 30 seconds and multiplied by 2 to determine the number of beats per minute. • Review: cardiovascular physical assessment techniques.

38. The health care provider prescribes 1000 mL of 0.9% NS to run over 8 hours. The drop factor is 15 drops per 1 mL. The nurse safely adjusts the flow rate to run at how many drops (gtts) per minute? Fill in the blank. Round to the nearest whole number. Answer: ____________ gtts/ min

38. Answer: 31 Rationale: Follow the formula for calculating IV infusion rates. Formula: Total volume in mL x Drop factor/Time in minutes= gtts per min 1000mL x 15gtts/480 min= 31.25 rounded to 31 gtts per min Test-Taking Strategy: Focus on the subject, an intravenous flow rate. Follow the formula. Be sure to convert 8 hours to minutes and calculate to the nearest whole number. Use a calculator to verify the answer. • Review: intravenous flow rate calculations.

4. The nurse prepares to bathe and change the bed linens of a client with localized herpes zoster. The lesions are open and draining a scant amount of serous fluid. Which precaution should the nurse ensure is followed by all health care workers? 1. Contact 2. Droplet 3. Airborne 4. Standard

4. Answer: 1 Rationale: The client with localized herpes zoster who has lesions that are open and draining should be isolated and placed on contact precautions to prevent the spread of infection to others. This communicable disease is not transmitted through air or droplets, unless it has become disseminated; therefore options 2 and 3 are incorrect. This client requires additional transmission-based precautions; therefore option 4 is insufficient. • Test-Taking Strategy: Note the subject, and that the client in this question has lesions that are open and draining. In addition, recall how this disease is transmitted to direct you to the correct option. • Review: transmission-based precautions.

41. The nurse is caring for a client who is retaining carbon dioxide (CO2) due to respiratory disease. The nurse anticipates that as the client's CO2 level rises, the pH will most likely be which value? 1. 7.30 2. 7.50 3. 7.70 4. 7.88

41. Answer: 1 Rationale: CO2 acts as an acid in the body. Therefore, with a rise in CO2, there is a corresponding fall in pH (" opposite effect"). A pH less than 7.35 indicates an acidic state, and a pH greater than 7.45 indicates an alkaline state. Options 2, 3, and 4 indicate an alkaline state and are therefore incorrect. • Test-Taking Strategy: Note the strategic words "most likely." Focus on the subject, CO2. Recall that there is an inverse relationship between pH and the CO2 in the body. As CO2 rises, pH falls, and as CO2 falls, pH rises. • Review: acid-base principles.

42. The nurse performing a home assessment on an older client would be concerned about which unsafe finding( s)? Select all that apply. 1. Nonskid surfaces on slippers 2. Nonskid backing on small rugs 3. Electrical cords taped to the floor 4. Bath mats on the shower stall floor 5. Electrical appliances and cords near the sink

42. Answer: 3, 5 Rationale: Electrical cords need to be secured against baseboards, not to the floor. Electrical cords taped to the floor can result in tripping. Electrical appliances or cords should not be placed near the sink or any other water source because of the risk of electrocution. Options 1, 2, and 4 are safe measures to prevent falls. • Test-Taking Strategy: Focus on the subject, home assessment for the unsafe situations. Note the word "unsafe." Eliminate options 1 and 2 because of the word "nonskid." From the remaining options, visualize each. Remember electrical cords taped to the floor can result in tripping and electrical appliances and cords near water sources can result in electrocution. • Review: home safety measures.

43. The nurse understands that which procedure( s) are used to detect the presence of dysrhythmias? Select all that apply. 1. Telemetry 2. Holter monitor 3. Pulse oximetry 4. Electrocardiogram 5. Blood pressure monitoring

43. Answer: 1, 2, 4 Rationale: To detect the presence of dysrhythmias telemetry, Holter monitors, or electrocardiograms are used. These devices assist in visualizing the trace of the heart beat to determine the presence of and identify the dysrhythmia. Pulse oximetry is used to determine the oxygen saturation of the blood. Blood pressure monitoring will not assist in detecting dysrhythmias. Test-Taking Strategy: Focus on the subject, detecting dysrhythmias. Recalling that dysrhythmias are abnormal heart beats will assist you in eliminating the incorrect options. • Review: dysrhythmias.

44. The nurse is preparing the client for transfer to the operating room (OR). The nurse should take which action in the care of this client at this time? 1. Ensure that the client has voided 2. Administer all the daily medications 3. Practice postoperative breathing exercises 4. Verify that the client has not eaten for the last 24 hours

44. Answer: 1 Rationale: The nurse should ensure that the client has voided if a Foley catheter is not in place. The nurse does not administer all daily medications just before sending a client to the OR. Rather, the health care provider writes a specific prescription outlining which medications may be given with a sip of water. The client is placed on nothing by mouth status for 8 hours before surgery, not 24. The time of transfer to the OR is not the time to practice breathing exercises. This should have been accomplished earlier. • Test-Taking Strategy: Focus on the subject, actions to take just before transferring a client to the OR. Note the words "at this time." Eliminate option 2 because of the closed-ended word "all" and option 4 because of the words "24 hours." From the remaining options, eliminate option 3 because this is not the appropriate time to practice breathing exercises. • Review: preoperative care.

45. The health care provider prescribes 500 mL of 0.9% NS to run over 6 hours. The drop factor is 10 drops per 1 mL. The nurse safely adjusts the flow rate to run at how many drops per minute? Fill in the blank. Round to the nearest whole number. Answer: _________ gtt/ min

45. Answer: 14 Rationale: Follow the formula for calculating IV infusion rates. Formula: Total volume in mL x Drop factor/Time in minutes= gtts per min 500mL x 10gtts/360 min= 13.8 rounded to 14 gtts per min Test-Taking Strategy: Note the subject, an intravenous flow rate. Follow the formula. Be sure to convert 6 hours to minutes. Use a calculator to verify the answer. Review: intravenous flow rate calculations.

46. The nurse is caring for a client whose religious background is Orthodox Judaism. The nurse is delivering the dinner tray to the client. Which nursing action( s) are most appropriate in order to provide for the dietary needs of this client? Select all that apply. 1. Removing the milk if there is meat on the tray. 2. Determining that any fish being served have scales or fins. 3. Ensuring that if there is pork on the tray, it is thoroughly cooked. 4. Checking to be sure that any meat being served is from an herbivore. 5. Asking the client about any specific dietary preferences that need to be followed.

46. Answer: 1, 2, 4, 5 Rationale: Clients whose religious background is Orthodox Judaism have various dietary preferences, and typically must follow a Kosher diet. Milk and meat cannot be consumed together; therefore it is appropriate to remove milk from the tray if meat is being served. Fish with scales or fins are allowed. Clients are not allowed to eat pork; meats allowed include those who are herbivores, cloven-hoofed animals, and those that are ritually slaughtered. • Test-Taking Strategy: Note the strategic words "most appropriate." Also note the client's religious background and think about their beliefs to assist in answering correctly. • Review: religions and dietary practices.

47. The nurse notes that a 5-year-old child is choking but is awake and alert at this time. As the nurse rushes to aid the child, the nurse plans to place the hands between which landmarks to perform the abdominal thrust maneuver? 1. The umbilicus and the groin 2. The lower abdomen and chest 3. The groin and the xiphoid process 4. The umbilicus and xiphoid process

47. Answer: 4 Rationale: To perform the abdominal thrust maneuver, the rescuer stands behind the victim and places the arms directly under the victim's axillae and around the victim. The thumb side of one fist is placed against the victim's abdomen in the midline slightly above the umbilicus and well below the tip of the xiphoid process. The xiphoid process and ribs are avoided to prevent damage to internal organs. The fist is grasped with the other hand and upward thrusts are delivered. • Test-Taking Strategy: Focus on the subject, proper procedure for relief of choking. Visualize each of the anatomical positions and think about the purpose of the abdominal thrust maneuver. This will direct you to the correct option. • Review: abdominal thrust maneuver.

48. The nurse is analyzing the laboratory report for the client who had a specific gravity determination drawn. The report indicates a value of 1.030. The nurse understands that which condition may potentially be causing this result? 1. Renal disease 2. Diabetes insipidus 3. Decreased renal perfusion 4. Inability of the kidneys to concentrate urine

48. Answer: 3 Rationale: The normal urine specific gravity level is 1.016 to 1.022. An increase in urine specific gravity can occur as a result of decreased renal perfusion, increased antidiuretic hormone, or insufficient fluid intake. A decrease in urine specific gravity can occur as a result of increased fluid intake, diabetes insipidus, renal disease, or the inability of the kidneys to concentrate urine. • Test-Taking Strategy: Focus on the subject, conditions that affect urine specific gravity. Noting that the urine specific gravity level is elevated will assist in eliminating the incorrect options. • Review: normal laboratory values.

49. The nurse is conducting a cardiovascular physical assessment on a client. The nurse is shown palpating which pulse? Refer to the figure. 1. Carotid 2. Brachial 3. Popliteal 4. Temporal

49. Answer: 1 Rationale: The nurse is palpating the carotid pulse, which is located in the lower third of the neck. The brachial pulse is located in the groove between the biceps and triceps tendon at the antecubital fossa. The popliteal pulse is located behind the knee in the popliteal fossa. The temporal pulse is located over the temporal bone on either side of the head. • Test-Taking Strategy: Note the subject, cardiovascular physical assessment. Use anatomy and physiology to answer this question. Recall that the carotid artery is located in the neck, directing you to the correct option. • Review: locations of pulses.

5. The nurse finds an infant unconscious and suspects a foreign-body airway obstruction (FBAO). The nurse plans to relieve the obstruction by performing which action? 1. Attempting ventilation 2. Performing blind finger sweeps 3. Performing a head-tilt chin-lift technique 4. Delivering five back slaps and five chest thrusts

5. Answer: 4 Rationale: In order to relieve FBAO in an unconscious infant, the nurse should deliver five back slaps and five chest thrusts and repeat the sequence sequence as necessary. Attempting ventilation will not relieve an obstruction. The nurse should never perform blind finger sweeps because the object can be pushed further down. The head-tilt chin-lift technique does not relieve the obstruction. • Test-Taking Strategy: Focus on the subject, relief of a FBAO. Note that options 1, 2, and 3 are comparable or alike and do not specifically address the subject of relieving an obstruction. • Review: nursing measures for foreign-body airway obstruction (FBAO).

50. The nurse should institute contact precautions for which disease? 1. Measles 2. Varicella 3. Pulmonary tuberculosis 4. Respiratory syncytial virus

50. Answer: 4 Rationale: Respiratory syncytial virus is transmitted via direct client contact or environmental contact and requires contact precautions (private room or cohort client and the use of gowns and gloves). Options 1, 2, and 3 require airborne precautions because they are transmitted by droplet nuclei smaller than 5 mm. • Test-Taking Strategy: Focus on the subject, contact precautions. Think about the method of transmission for each disease in the options to direct you to the correct option. • Review: transmission-based precautions.

51. The nurse is conducting a respiratory assessment and is determining respirations per minute. The nurse understands that which factor( s) generally affect the character of respirations? Select all that apply. 1. Anxiety 2. Exercise 3. Smoking 4. Acute pain 5. Body position 6. Musculoskeletal disorders

51. Answer: 1, 2, 3, 4, 5 Rationale: Factors that influence the character of respirations include anxiety, exercise, smoking, acute pain, body position, medications, neurological injury, and hemoglobin function. Musculoskeletal disorders do not generally affect the character of respirations. • Test-Taking Strategy: Focus on the subject, respiratory assessment. Visualize the pathophysiologic processes associated with each item in the options to direct you to the correct options. • Review: respiratory assessment and factors that affect respiration.

52. The nurse understands that which are judgmental statement( s)? Select all that apply. 1. "I don't think you need to do that." 2. "I would like to be sure I understood." 3. "Tell me about making that decision." 4. "I'm not sure that's what is best for you." 5. "When did you first notice you felt that way?"

52. Answer: 1, 4 Rationale: The statement "I don't think you need to do that" is a judgmental one because it specifically casts judgment on an action. The statement "I'm not sure that's what is best for you" is providing an opinion and advice and casts judgment on a specific situation. The remaining options identify statements that seek to explore with the client. • Test-Taking Strategy: Use therapeutic communication techniques. Eliminate options 2, 3, and 5 because they are comparable or alike and seek to explore with the client. • Review: therapeutic communication techniques.

53. Which should be included in a change-of-shift report? 1. Describing routine tasks performed 2. Describing basic steps of a procedure 3. Reviewing all biographical information about each client 4. Describing objective measurements or observations about a client's condition

53. Answer: 4 Rationale: A change-of-shift report should include information about the client and a description of the objective measurements or observations about a client's condition. The report should include only essential biographical information about the client, not all biographical data. Routine tasks performed and basic steps of a procedure are an unnecessary component of a change-of-shift report. • Test-Taking Strategy: Eliminate option 3 because of the closed-ended word "all." Next, eliminate options 1 and 2 because they are comparable or alike. Also note that the correct option focuses specifically on the client. • Review: change-of-shift report.

54. The nurse educator is conducting a teaching session on the types of dehydration. The nurse describes one type as water and dissolved electrolytes being lost in equal proportions. Which type of dehydration is being described? 1. Isotonic 2. Hypotonic 3. Hypertonic 4. Intracellular

54. Answer: 1 Rationale: Isotonic dehydration is described as water and dissolved electrolytes being lost in equal proportions. Hypotonic dehydration is when electrolyte loss exceeds water loss. Hypertonic dehydration is when water loss exceeds electrolyte loss. Intracellular is not a type of dehydration. • Test-Taking Strategy: Note the subject, types of dehydration. In addition, note the description in the question. Also noting the words "equal proportions" in the question will assist in directing you to the correct option. • Review: types of dehydration.

55. The nurse notes that the client's mechanical ventilator is set to control mode. The nurse understands that this setting will achieve which action? 1. Allows the lungs to rest 2. Allows for spontaneous respirations 3. Hyperventilates the client to ensure adequate oxygenation 4. Provides some breaths for the client but allows the client to breathe on his/ her own also

55. Answer: 1 Rationale: The control mode setting on a mechanical ventilator is used to allow the lungs to rest. In this setting, all respirations are provided to the client by the ventilator. The assist-control mode allows for spontaneous breathing and will provide breaths from the ventilator if the client's respirations fall below a certain preset amount. Mechanical ventilation is not used for hyperventilation. • Test-Taking Strategy: Note the subject, control mode on a mechanical ventilator. Begin by eliminating options 2 and 4 because they are comparable or alike. Next, note the relationship between the subject and the correct option. • Review: mechanical ventilation.

56. The nurse is planning to teach a client about home modifications to reduce the risk of falls. Which recommendation( s) should be included in the teaching plan? Select all that apply. 1. Remove wall-to-wall carpeting 2. Use nightlights during nighttime 3. Place handrails in bathtubs and showers 4. Check staircase railings for secureness and sturdiness 5. Place scatter rugs on hardwood floors and at the bottom of a staircase

56. Answer: 2, 3, 4 Rationale: Home modifications to reduce the risk for falls include ample lighting especially during the nighttime, placing handrails in the bathtub and shower areas, use of railings on all staircases and checking them for secureness and sturdiness, and removing scatter rugs because of the risk of the rug moving when stepping on it, resulting in a fall. Removal of wall-to-wall carpeting is not necessary. • Test-Taking Strategy: Note the subject, fall prevention. Focus on safety. Think about the effect that each item in the options would have with placing the client at risk for falling. • Review: home safety assessment.

57. The nurse is applying and removing personal protective equipment (PPE) when providing care. Number the actions in the options in order of priority with regard to how the nurse should perform this procedure. (Number 1 is the first action and number 6 is the last action.) ____ Put on mask ____ Put on gown ____ Put on gloves ____ Remove mask ____ Remove gown ____ Remove gloves

57. Answer: 1, 2, 3, 6, 5, 4 Rationale: To reduce the spread of infection and employ proper use of PPE, the nurse should first put on the mask, followed by the gown, and then gloves. Upon leaving the room, the nurse should first remove the gloves, followed by the gown and mask. Hand hygiene before donning PPE and after removing it is another integral part of proper use. • Test-Taking Strategy: Note the strategic word "priority." Focus on the subject, proper use of PPE. Using these principles and visualizing the procedure to reduce the spread of infection will assist in answering this question correctly. • Review: proper use of personal protective equipment.

58. Which meal selections would be most appropriate for the nurse to deliver to a Mormon client? 1. Waffles, bacon, fruit, and coffee 2. Steak and eggs, toast, fruit, and coffee 3. Scrambled eggs, hash browns, fruit, and green tea 4. Sausage and cheese omelet, muffin, and orange juice

58. Answer: 4 Rationale: In the Mormon religion, alcohol, coffee, and tea are not usually consumed. Options 1, 2, and 3 all contain coffee or tea. • Test-Taking Strategy: Note the strategic words "most appropriate" and use knowledge about the Mormon religion to answer the question. Also, eliminate options 1, 2, and 3 because they are comparable or alike and contain a caffeine-containing product. • Review: dietary choices for the Mormon client.

59. The nurse should implement droplet precautions for a client with which communicable disease? 1. Scabies 2. Pertussis 3. Herpes simplex 4. Respiratory syncytial virus

59. Answer: 2 Rationale: Droplet precautions are implemented for disorders that produce respiratory droplets larger than 5 mm. These diseases include diphtheria (pharyngeal), rubella, streptococcal pharyngitis, pneumonia, scarlet fever in infants and young children, pertussis, mumps, or pneumonic plague. Options 1, 3, and 4 are diseases that require contact precautions. • Test-Taking Strategy: Focus on the subject, droplet precautions. Recalling the methods of transmission of the diseases in the options will direct you to the correct option. • Review: transmission-based precautions.

6. The nurse is preparing to assist a client who is able to transfer with two assistants from the bed to the chair. The nurse requests assistance from staff members, but no staff members are able to help at this time. Which action by the nurse is most appropriate at this time? 1. Ask the client's family member to assist with the transfer 2. Assist the client to transfer with the aid of the nurse and a walker 3. Use a mechanical lift to transfer the client from the bed to the chair 4. Inform the client that it is necessary to wait until someone can assist

6. Answer: 3 Rationale: The client who requires two assistants for transfer should never be transferred without the aid of any less than two people, unless mechanical aids are used. The safest action by the nurse at this time is to use a mechanical lift to transfer the client from the bed to the chair. Asking the client's family member to assist is inappropriate and potentially unsafe. Assisting the client to transfer with the aid of the nurse and a walker is also a potentially unsafe action, especially if the client is not instructed in proper use of a walker. Informing the client that it is necessary to wait is not the best of the options presented. • Test-Taking Strategy: Note the strategic words "most appropriate." Keeping in mind client safety and determining which action would ensure safety will direct you to the correct option. • Review: ergonomic principles.

60. The nurse is inspecting the lacrimal apparatus of a client's eye. Due to its anatomical location, the nurse should perform which action? 1. Retract the lower eyelid and ask the client to look up 2. Retract the upper eyelid and ask the client to look up 3. Retract the upper eyelid and ask the client to look down 4. Retract the lower eyelid and ask the client to look down

60. Answer: 3 Rationale: The lacrimal apparatus consists of the lacrimal gland (in the upper lid over the outer canthus) and the secretory ducts that direct tears to the lacrimal sac in the inner canthus. The nurse examines part of this apparatus by retracting the upper eyelid and asking the client to look down. Abnormal findings would include edema and tenderness. • Test-Taking Strategy: Focus on the subject, assessment of the eye. Recalling the anatomical location of the lacrimal apparatus will direct you to the correct option. • Review: eye assessment.

61. The nurse monitoring the laboratory results for a client receiving an antineoplastic medication by the intravenous (IV) route should be prepared to initiate bleeding precautions if which laboratory result is noted? 1. A clotting time of 10 minutes 2. An ammonia level of 20 mcg/ dL 3. A platelet count of 50,000 cells/ mm3 4. A white blood cell (WBC) count of 5000 cells/ mm3

61. Answer: 3 Rationale: Bleeding precautions need to be initiated when the platelet count decreases. The normal platelet count is 150,000 to 450,000 cells/ mm3. When the platelets are less than 50,000 cells/ mm3, any small trauma can lead to episodes of prolonged bleeding. The normal WBC count is 5000 to 10,000 cells/ mm3. When the WBC count drops, neutropenic precautions need to be implemented. The normal clotting time is 8 to 15 minutes. The normal ammonia value is 10 to 80 mcg/ dL. • Test-Taking Strategy: Note the subject, bleeding precautions. Options 1, 2, and 4 identify normal laboratory values. Correlate a low platelet count with the need for bleeding precautions and a low WBC count with the need for neutropenic precautions. • Review: normal laboratory values.

62. A client has been instructed to restrict the diet to low-purine foods. Which foods should the nurse instruct the client to avoid? 1. Dairy products such as ice cream 2. Certain fish such as shrimp or scallops 3. High carbohydrate foods such as potatoes 4. Dark green, leafy vegetables such as spinach

62. Answer: 2 Rationale: High-purine foods include organ meats, roe, sardines, scallops, anchovies, broth, mincemeat, herring, shrimp, mackerel, gravy, and yeast. The food items in the remaining options are acceptable to eat. • Test-Taking Strategy: Focus on the subject, low purine foods to avoid. Use your knowledge about food sources high and low in purine to select the correct option. • Review: low-purine foods.

63. When discussing a health care plan with a female Amish client, the nurse should perform which action( s)? Select all that apply. 1. Speak only to the husband. 2. Avoid using medical terms. 3. Maintain adequate personal space. 4. Use complex scientific terminology. 5. Stand close to the client and speak loudly.

63. Answer: 2, 3 Rationale: When speaking to an Amish client and family, the nurse should maintain adequate personal space (formal personal space). Complex scientific or medical terminology should be avoided when communicating with an Amish client or any client. When discussing health care, most often, the husband and wife will want to discuss the plan together. Standing close and speaking loudly is inappropriate in most conversations. • Test-Taking Strategy: Use therapeutic communication techniques and knowledge regarding the Amish culture to answer the question. This will direct you to the correct options. • Review: the religious and dietary practices of the Amish client.

64. The nurse performing an eye assessment notes that the client can see objects clearly that are far away but cannot see objects clearly that are close-up. The nurse documents this finding as which condition? 1. Myopia 2. Hyperopia 3. Photophobia 4. Accommodation

64. Answer: 2 Rationale: Hyperopia (farsightedness) occurs when the refractive ability of the eye is too weak and images are focused behind the retina. When someone is farsighted, they have difficulty seeing objects close-up. Myopia (nearsightedness) occurs when the refractive ability of the eye is too strong for the eye length and images are bent and fall in front of, not on, the retina. When someone is nearsighted, they have difficulty seeing objects that are far away. Photophobia is an abnormal sensitivity to light. Accommodation is the expected change in pupil size when changing gaze from a near object to a far one, and back again. The pupils dilate when looking at the far object and constrict when looking at the near one. • Test-Taking Strategy: Focus on the subject, assessment of the eye. Note the words "can see objects clearly that are far away but cannot see objects clearly that are close-up." This description will direct you to the correct option. • Review: eye assessment.

65. The health care provider's prescription reads ampicillin 250 mg to be administered orally. The label on the medication vial reads 125 mg/ mL. The nurse should prepare how many milliliters of ampicillin to administer the correct dose of medication? Fill in the blank. Answer: _____________ mL

65. Answer: 2 Rationale: Use the formula for calculating the appropriate medication dosage. Formula: Desire/Available x Volume= mL per dose 240mg/125mg x 1mL= 2mL Test-Taking Strategy: Focus on the subject, a medication calculation. Follow the formula for the calculation of the correct dose. Recheck the answer with a calculator and make sure that the answer makes sense. • Review: calculating a medication dosage.

66. A client is diagnosed with myasthenia gravis and the nurse needs to administer a medication to this client. Number the actions in the options in order of priority with regard to how the nurse should perform the actions. (Number 1 is the first action to be performed and number 6 is the last action.) ____ Assess swallowing ability ____ Elevate the head of the bed ____ Check the medication prescription ____ Administer precisely at prescribed time ____Document administration of the medication ____ Monitor response to medication as the day progresses

66. Answer: 3, 2, 1, 4, 5, 6 Rationale: The nurse would first check the medication prescription. Next the nurse would elevate the head of the bed and assess swallowing ability. The medication is administered precisely at the prescribed time, administration of the dose is documented, and the nurse monitors response throughout the day. • Test-Taking Strategy: Note the strategic word "priority." Visualize the procedure for medication administration and use general medication administration guidelines to determine the correct order of action. • Review: medication administration guidelines.

67. The nurse is preparing to assist in examining a Hispanic child who was brought to the clinic by the mother. During the assessment of the child, the nurse should take which action( s)? Select all that apply. 1. Admiring the child 2. Taking the child's temperature 3. Including the child in the discussion 4. Obtaining an interpreter if necessary 5. Making direct eye contact with the mother 6. Asking the mother questions about the child

67. Answer: 2, 3, 4, 6 Rationale: Hispanic clients may believe in mal ojo (" evil eye"). They believe that an individual becomes ill as a result of excessive admiration by another. Direct eye contact is also avoided as it is a sign of disrespect. The remaining options are appropriate interventions. • Test-Taking Strategy: Note the subject, culturally sensitive care. Use knowledge about the Hispanic culture to answer the question. Remember excessive admiration and direct eye contact is avoided. • Review: care of the Hispanic client.

68. The nurse is performing closed catheter irrigation on an assigned client. Which outcome, if noted by the nurse, indicates the need for follow-up? 1. The urine is noted to be cloudy and dark in color 2. The prescribed rate is flowing into the bladder freely 3. The instillation solution returns into the drainage bag 4. There is no bladder distention noted during the procedure

68. Answer: 1 Rationale: Closed catheter irrigation is used to flush the bladder and to determine the presence of an unexpected finding, such as blood or mucus, in the bladder. An unexpected outcome during or following this procedure includes cloudy or dark urine in color or the presence of a fever. These are signs of possible infection. The prescribed rate flowing into the bladder freely, the return of instillation solution into the drainage bag, and absence of bladder distention during the procedure are normal and expected findings. • Test-Taking Strategy: Focus on the strategic words "need for follow-up." These words indicate a negative event query and the need to select the abnormal finding. Recalling the signs of infection will assist in directing you to the correct option. Review: closed catheter irrigation.

69. The health care provider prescribes atenolol (Tenormin) 0.05 g orally daily. The label on the medication bottle states atenolol (Tenormin) 25-mg tablets. How many tablets will the nurse safely administer to the client? Answer: _____________ tablet( s)

69. Answer: 2 Rationale: Formula: Convert 0.05 g to mg. In the metric system, to convert larger to smaller, multiply by 1000 or move the decimal three places to the right. Therefore 0.05 g = 50 mg. The nurse will administer two tablets. • Test-Taking Strategy: Focus on the subject, a medication calculation. In this medication calculation problem, it is necessary to first convert grams to milligrams. Once you have done the conversion, you will know that two tablets is the correct answer. • Review: calculating a medication dosage.

7. Which client is at greatest risk for fluid volume deficit? 1. The client on diuretic therapy 2. The client on fertility medications 3. The client on corticosteroid therapy 4. The client on antiseizure medications

7. Answer: 1 Rationale: The client on diuretic therapy is at risk for fluid volume deficit due to increased fluid loss through diuresis. Clients on fertility medications, corticosteroid therapy, and antiseizure medications are not at risk for this disorder. • Test-Taking Strategy: Note the subject, fluid volume deficit. Note that options 2, 3, and 4 are comparable or alike because they are unrelated to fluid balance in the body. • Review: fluid volume deficit.

70. The nurse has a prescription to administer the morning medications to a client through a nasogastric (NG) tube that is connected to wall suction. The nurse should implement which action to perform this procedure correctly? 1. Clamp the NG tube for 5 minutes following medication administration 2. Position the client in an upright position before medication administration 3. Flush the NG tube with 5 mL of water following medication administration 4. Adjust the suction to low-intermittent setting after medication administration

70. Answer: 2 Rationale: Prior to medication administration, the nurse should position the client in an upright position. The client should remain in this position for 30 minutes to 1 hour after administration of the medication or per agency policy. If a client has an NG tube connected to suction, the nurse clamps the tube and waits 30 minutes before reconnecting the tube to the suction. This allows adequate time for medication absorption. Flushing the NG tube is indicated after medication administration, but 5 mL is an insufficient amount. Adjusting the suction to low-intermittent setting after medication administration would prevent absorption because this action would suck out the medication. • Test-Taking Strategy: Note the subject, correct procedure for administering a medication through an NG tube. Recall that the tube should be clamped for at least 30 minutes and the tube is usually flushed with 30 to 60 mL of water (per agency policy). Additionally, note that suction will suck out the medication. • Review: medication administration via a nasogastric tube.

71. The nurse educator is conducting a teaching session regarding the risk factors for the development of pressure ulcers. The nurse plans to include which factor( s) in the teaching session? Select all that apply. 1. Immobility 2. Moisture on the skin 3. Skin pressure and shearing 4. Increased sensory perception 5. Urinary and bowel incontinence

71. Answer: 1, 2, 3, 5 Rationale: Risk factors for the development of pressure ulcers include immobility, moisture on the skin, skin pressure, skin shearing, skin friction, decreased sensory perception, and urinary and bowel incontinence. • Test-Taking Strategy: Note the subject, risk factors for pressure ulcers. Recalling that decreased (not increased) sensory perception causes less frequent spontaneous positional changes will assist you in eliminating this option. • Review: risk factors for the development of pressure ulcers.

72. The nurse understands that the dietary preferences of an African-American client may include which food( s)? Select all that apply. 1. Pork 2. Rice 3. Fruits 4. Greens 5. Red meat 6. Fried foods

72. Answer: 1, 2, 4, 6 Rationale: African-American food preferences include pork, rice, greens, and fried foods. Fruits and red meat may be eaten, but they are not preferences in this culture. • Test-Taking Strategy: Note the subject, culturally sensitive care. Knowledge regarding the food practices and preferences related to the African-American culture is needed to answer this question. Remember African-American food preferences include pork, rice, greens, and fried foods. • Review: dietary preferences for the African-American client.

73. The health care provider prescribes amoxicillin (Augmentin) 500 mg orally every 6 hours. The medication is supplied as 200 mg/ 5 mL. How many milliliters will be administered in each dose? Fill in the blank. Answer: __________ mL

73. Answer: 12.5 Rationale: Use the medication dosage formula. Formula: Desire/Available x Volume= mL per dose 500mg/200mg x 5mL= 12.5mL Test-Taking Strategy: Focus on the subject, a medication calculation, and use the medication dosage formula to calculate the amount of mL to be administered. Use a calculator to verify the answer. • Review: calculating a medication dosage.

74. The health care provider's prescription reads cyanocobalamin (vitamin B12) 150 mcg intramuscularly. The medication label reads cyanocobalamin (vitamin B12), 100 mcg per 1 mL. The nurse prepares to safely administer how many milliliters to the client? Fill in the blank. Answer: _________ mL

74. Answer: 1.5 Rationale: Use the formula for calculating the appropriate medication dosage. Formula: Desire/Available x Volume= mL per dose 150mcg/100mcg x 1mL= 1.5mL Test-Taking Strategy: Focus on the subject, a medication calculation. Follow the formula for the calculation of the correct dose. Recheck the answer with a calculator and make sure that the answer makes sense. • Review: calculating a medication dosage.

75. The nurse understands that personal health information can be disclosed in which situation( s)? Select all that apply. 1. Compliance with legal proceedings 2. For research purposes in limited circumstances 3. To a family member or significant other in an emergency 4. To nonessential medical personnel involved in client care 5. To appropriate military if a client is a member of the armed forces

75. Answer: 1, 2, 3, 5 Rationale: Personal health information can be disclosed in a variety of situations, including those identified in the correct options. Disclosure can also be made to a personal representative designated by the client or appointed by law; to a coroner, medical examiner, or funeral director about a deceased person; to an organ procurement organization in limited circumstances; to avert a serious threat to the client's health or safety or that of others; to a governmental agency authorized to oversee the health care system or government programs; to the Department of Health and Human Services for the investigation of compliance with the Health Insurance Portability and Accountability Act or to fulfill another lawful request; to federal officials for lawful intelligence or national security purposes; to protect health authorities for public health purposes; and in accordance with a valid authorization signed by the client. • Test-Taking Strategy: Note the subject, disclosure of personal health information. Note the word "nonessential" in the incorrect option to assist in answering correctly. • Review: release of personal health information.

76. The nurse has developed a close relationship with the family of a client who is dying. Which nursing intervention( s) are most appropriate in dealing with the family? Select all that apply. 1. Encouraging family discussion of feelings 2. Accepting the family's expressions of anger 3. Restricting client visits to scheduled hospital visiting hours 4. Facilitating the use of spiritual practices identified by the family 5. Keeping the family informed of changes in the client's condition 6. Making the decisions for the family during the difficult moments

76. Answer: 1, 2, 4, 5 Rationale: Maintaining effective and open communication among family members affected by death and grief is of utmost importance. The family needs to know that someone will be there who is supportive and nonjudgmental and will keep them informed. Spiritual practices give meaning to life and have an impact on how people react to crisis. Options 3 and 6 are inappropriate and remove autonomy and decision making from the family at a time when they are already experiencing feelings of loss of control. • Test-Taking Strategy: Note the strategic words "most appropriate." Use therapeutic communication techniques. Noting the words "restricting" and "making the decisions" in options 3 and 6, respectively, will assist in eliminating these options. • Review: end-of-life care.

77. The nurse has given postprocedure instructions to a client who underwent a colonoscopy. Evaluation of learning would be evident if the client makes which statement( s)? Select all that apply. 1. "It is all right to drive once I've been home for an hour or so." 2. "My abdominal muscles may be tender because of the procedure." 3. "My diet should be light at first, and then I can progress to a regular diet." 4. "It is normal to feel gassy or bloated for a short while after the procedure." 5. "I should expect to have a moderate amount of blood in my stool for the next few days." 6. "If I develop a fever following the procedure, I should call the health care provider immediately."

77. Answer: 2, 3, 4, 6 Rationale: Driving is avoided for 8 to 12 hours. The client may experience gas or abdominal tenderness for a short while after the procedure because air is often instilled during the colonoscopy for better visualization. The client should resume intake slowly and progress as tolerated. A small amount of blood may be noted, but moderate amounts need to be reported. Development of a fever may be indicative of intestinal perforation. • Test-Taking Strategy: Note the subject, postprocedure instructions following colonoscopy. Read each option carefully. Eliminate option 1 because of the words "an hour or so" and option 5 because of the word "moderate." • Review: colonoscopy.

78. The health care provider prescribes meperidine hydrochloride (Demerol), 20 mg for a client in pain. The medication label states meperidine hydrochloride (Demerol), 50 mg per 1 mL. How many milliliters should the nurse safely prepare to administer to the client? Fill in the blank. Answer: _________ mL

78. Answer: 0.4 Rationale: Use the formula for calculating the appropriate medication dosage. Formula: Desired/Available x Volume= mL per dose 20 mg/50 mg x 1ml= 0.4ml Test-Taking Strategy: Focus on the subject, a medication calculation. Follow the formula for the calculation of the correct dose. Recheck the answer with a calculator and make sure that the answer makes sense. • Review: calculating a medication dosage.

79. A vegetarian client asks the nurse about foods to eat that are high in vitamin A. The nurse should include which item( s) in a list of the foods highest in this vitamin? Select all that apply. 1. Peas 2. Corn 3. Carrots 4. Yellow squash 5. White potatoes

79. Answer: 3, 4 Rationale: Foods that are highest in vitamin A include carrots and green, leafy and yellow vegetables. The other vegetables listed are high in vitamins, but do not necessarily have the highest amount of vitamin A. • Test-Taking Strategy: Focus on the subject, the foods highest in vitamin A. Remember carrots and green, leafy and yellow vegetables are high in this vitamin. • Review: foods high in vitamin A.

8. The nurse should take which action to accurately determine the length of a nasogastric tube for insertion in an adult client? 1. Place the tube at the tip of the nose and measure by extending the tube to the umbilicus 2. Place the tube at the tip of the nose and measure by extending the tube midway between the umbilicus and symphysis pubis 3. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process 4. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum

8. Answer: 3 Rationale: Measuring the length of tube needed is done by placing the tube at the tip of the client's nose and extending the tube to the earlobe and then down to the xiphoid process. The average length for an adult is about 22 to 26 inches. Options 1, 2, and 4 are inaccurate methods of measurement. • Test-Taking Strategy: Note the subject, insertion of a nasogastric tube. Visualize this procedure. Remember the acronym NEX (which stands for nose, earlobe, xiphoid process) to assist in answering questions similar to this one. • Review: nasogastric tube insertion procedures.

80. The client who has undergone open reduction internal fixation (ORIF) has been retaining urine, and the health care provider prescribes straight catheterization. In which best position should the nurse place the client to perform this procedure? 1. Prone 2. High-Fowler's 3. Trendelenburg's 4. Side-lying on the side prescribed by the surgeon (Sims')

80. Answer: 4 Rationale: A client who requires straight catheterization and who has undergone ORIF should be placed in a side-lying position on the operative side (if acceptable to the surgeon). This is the best position because the unaffected extremity can be abducted with a pillow to allow for visualization of the urethral meatus. The high-Fowler's, Trendelenburg's, and dorsal recumbent positions would not allow visualization of the urinary meatus. • Test-Taking Strategy: Note the strategic word "best." Note the subject, catheterization of a client who has undergone ORIF. Visualize each position, and think about its effect following this surgical procedure and how the position may allow visualization of the urinary meatus. • Review: positioning for catheterization for the client who has undergone open reduction internal fixation (ORIF).

81. A hospitalized client will be self-administering tube feedings at home. When the client expresses concern about his ability to perform this procedure, the nurse should best respond by saying which statement? 1. "Does your family know about this concern that you have?" 2. "Is there a family member or friend that is willing to help you?" 3. "Do you want me to prescribe home visits from a nurse for you?" 4. "Let's talk about what makes it difficult for you to perform this procedure."

81. Answer: 4 Rationale: This client has a specific fear about not being able to handle tube feedings at home. An open communication statement such as "let's talk about" often leads to valuable information about the client and his concerns. Options 1 and 2 are nontherapeutic responses because they place the client's issues on hold. Option 3 may not be necessary; additionally, the nurse may need a referral for services. • Test-Taking Strategy: Note the strategic word "best," and use therapeutic communication techniques and focus on the client's feelings. This will direct you to the correct option. • Review: therapeutic communication techniques.

83. The nurse prepares a client with right-sided weakness to get out of bed to a chair. Number the actions in the options in order of priority with regard to how the nurse should perform the actions. (Number 1 is the first action and number 6 is the last action.) ____ Secures the chair position ____ Instructs the client about the procedure ____ Places the chair at an angle on the side of the bed ____ Assists the client to stand and move the left arm to the armrest ____ Instructs the client to keep the body weight forward and then pivot ____ Assists the client in sitting when the back of the legs touch the chair

83. Answer: 3, 1, 2, 4, 5, 6 Rationale: The client should first be informed of the procedure so he or she is aware of the expectation. The chair should be positioned on the client's strong side and secured to maintain client safety during the transfer. After standing, the client should use his or her stronger upper extremity to grab the armrest. Body weight should be pitched slightly forward for balance; the client should pivot and then sit when the legs meet the chair edge. • Test-Taking Strategy: Note the strategic word "priority." Visualize the steps for transfer techniques for clients with right-or left-sided weakness. This will assist in determining the correct order of action. • Review: ergonomic principles.

84. The nurse is preparing to administer a rectal suppository to a client. The nurse explains to the client that which position will prevent immediate expulsion of the suppository? 1. Flat 2. Semi-Fowler's 3. High-Fowler's 4. Upright with the hips at a 90-degree angle

84. Answer: 1 Rationale: After administration of a rectal suppository, the suppository should be retained to promote absorption of the medication. The client should assume a flat or side-lying position for at least 5 minutes after insertion. Semi-Fowler's, high-Fowler's, and upright with the hips at a 90-degree angle will not assist in the retention of the suppository. • Test-Taking Strategy: Focus on the subject, preventing expulsion of a suppository and visualize each of the positions in the options. Note that options 2, 3, and 4 are comparable or alike and indicate upright positions. • Review: medication administration procedures.

85. The nurse is teaching a client with tuberculosis (TB) about dietary elements that should be increased in the diet. The nurse suggests that the client increase intake of which best food combinations? 1. Cereal and milk 2. Eggs and spinach 3. Grains and broccoli 4. Meats and citrus fruits

85. Answer: 4 Rationale: The nurse teaches the client with TB to increase intake of protein, iron, and vitamin C. Foods rich in vitamin C include citrus fruits, berries, melons, pineapple, broccoli, cabbage, green peppers, tomatoes, potatoes, chard, kale, asparagus, and turnip greens. Food sources that are rich in iron and protein include liver and other meats. Less than 10% of iron is absorbed from eggs, and less than 5% is absorbed from grains and most vegetables. • Test-Taking Strategy: Note the strategic word "best" and recall that the diet in tuberculosis should be high in protein, vitamin C, and iron. Knowing which types of foods contain these various nutrients will direct you to the correct option. • Review: recommended diet for tuberculosis.

86. The preoperative client expresses anxiety. Which statement by the nurse is most appropriate at this time? 1. "Let me tell you what this surgery is all about." 2. "It is normal for you to feel nervous before surgery." 3. "What have you been told so far about your surgery, and what part( s) make you nervous?" 4. "Your surgeon will explain the entire surgical procedure to you beforehand, so don't worry."

86. Answer: 3 Rationale: Explanations should begin with the information that the client knows. Options 1 and 2 generalize and avoid the client's feelings. Explaining (or having the surgeon explain) the entire operative procedure can be overwhelming. • Test-Taking Strategy: Note the strategic words "most appropriate" and use therapeutic communication techniques to eliminate options 1 and 2. Eliminate option 4 because of the word "entire." • Review: preoperative care.

87. The nurse notes in a client's medical record a documentation of Snellen chart test results as 20/ 200 vision. The nurse understands that which description is accurate for this client's visual acuity? 1. Normal 2. Legally blind 3. Slightly abnormal 4. Better than normal

87. Answer: 2 Rationale: Legal blindness is defined as 20/ 200 or less with corrected vision (glasses or contact lenses). Options 1, 3, and 4 are incorrect. • Test-Taking Strategy: Focusing on the subject, legal blindness, will direct you to the correct option. • Review: Snellen chart.

88. A client, brought to the emergency department, is dead on arrival (DOA). The family of the client tells the nurse that the client cannot have an autopsy because of religious beliefs. The nurse understands that the client may be a part of which religion( s)? Select all that apply. 1. Muslim 2. Mormon 3. Hinduism 4. Buddhism 5. Eastern Orthodox 6. Orthodox Judaism

88. Answer: 1, 5, 6 Rationale: When caring for a client who is DOA, the nurse must consider end-of-life practices and cultural and religious influences. The Muslim, Eastern Orthodox, and Orthodox Judaism religions may prohibit, discourage, or oppose autopsy. The Mormon, Hindu, and Buddhist religions do not necessarily discourage or oppose the practice. • Test-Taking Strategy: Note the subject, cultural preferences. Think about religious beliefs of various cultures. It is necessary to know which religious groups oppose autopsy in order to answer this question correctly. • Review: cultural awareness and religious practices.

89. The nurse is assisting a client on a low-potassium diet to select food items from the menu. Which food item, lowest in potassium and selected by the client, indicates an understanding of this dietary restriction? 1. Spinach 2. Cantaloupe 3. Lima beans 4. Strawberries

89. Answer: 3 Rationale: Cantaloupe, spinach, and strawberries are high-potassium foods and average 7 mEq per serving. Lima beans average 3 mEq per serving. • Test-Taking Strategy: Focus on the subject, foods low in potassium. Remembering that many fruits and green, leafy vegetables are high in potassium will assist in directing you to the correct option. • Review: high and low potassium foods.

9. The nurse auscultates bowel sounds and suspects an intestinal obstruction in a client with a bowel tumor if which is heard? 1. Resonance 2. Diminished sounds 3. High-pitched sounds 4. Absent bowel sounds in all four quadrants

9. Answer: 3 Rationale: High-pitched tinkling sounds are indicative of an intestinal obstruction. Absent or diminished sounds may be indicative of a paralytic ileus. Resonance is not a finding of auscultation. • Test-Taking Strategy: Eliminate options 2 and 4 first because they are comparable or alike. Next, focus on the subject, the assessment findings in an intestinal obstruction. This will direct you to the correct option. • Review: bowel sounds.

90. The nurse is reviewing a health care provider's prescriptions for an adult client who has been admitted to the hospital following a back injury. Carisoprodol (Soma) is prescribed for the client to relieve the muscle spasms. The health care provider has prescribed 350 mg to be administered every 6 hours. The nurse determines that this dosage would deliver how many milligrams in 24 hours? Fill in the blank. Answer: _________ mg

90. Answer: 1400 Rationale: The normal adult dosage for carisoprodol is 350 mg orally three to four times daily. The health care provider has prescribed carisoprodol every 6 hours, which means four times per day. Therefore 4 × 350 = 1400. • Test-Taking Strategy: Focus on the subject of the question, medication calculation; simple multiplication will yield the correct answer. • Review: calculating a medication dosage.

91. During preparation of a continuous intravenous (IV) infusion, the nurse contaminates the IV tubing. Which is the most appropriate action by the nurse? 1. Complete an incident report 2. Wipe the tubing with alcohol 3. Wipe the tubing with Betadine 4. Discard the contaminated tubing and obtain new IV tubing

91. Answer: 4 Rationale: The nurse should discard the contaminated tubing and obtain new IV tubing because contaminated tubing could cause systemic infection in the client. There is no reason to complete an incident report. Wiping the tubing with alcohol or Betadine is insufficient and would be contraindicated regardless, in that the tubing will be attached directly to the catheter device in the client's vein. • Test-Taking Strategy: Note the strategic words "most appropriate." Use knowledge of basic infection control measures and intravenous therapy concepts to answer this question. This will direct you to the correct option.• Review: intravenous therapy guidelines.

92. A client passes a urinary stone, and laboratory analysis of the stone indicates that it is composed of calcium oxalate. On the basis of this analysis, which direction( s) should the nurse include in the dietary instructions? Select all that apply. 1. Drink tea rather than coffee 2. Increase intake of dairy products 3. Eat and drink citrus fruits and citrus juices 4. Eat plenty of leafy vegetables, but avoid spinach and beets 5. Increase intake of foods such as meat, fish, plums, and cranberries

92. Answer: 3, 4, 5 Rationale: Calcium is found in dairy products and these products need to be avoided. Oxalate is found in dark green foods such as spinach. Other foods that raise urinary oxalate are rhubarb, strawberries, chocolate, wheat bran, nuts, beets, and tea. Citrus products are acceptable as are meats, fish, plums, and cranberries. • Test-Taking Strategy: Note the subject, "calcium oxalate." Remembering the foods that are high in calcium and in oxalate will assist in answering correctly. • Review: foods high in calcium and oxalate.

93. The nurse is caring for an older client who has been prescribed buspirone hydrochloride (BuSpar). Which nursing intervention included in the plan of care should be the priority to ensure safety? 1. Document client reports of drowsiness 2. Maintain the bed in the lowest position 3. Instruct the client in the use of the call light 4. Report client response to medication to the health care provider

93. Answer: 2 Rationale: Buspirone hydrochloride (BuSpar) is classified as a nonbenzodiazepine anxiolytic. The older client is at an increased risk for falls, and safety precautions should be instituted. The priority nursing intervention to address this problem is to maintain the bed in the lowest position. Drowsiness is an expected effect of this medication, and should be documented; however, this is not the priority. Instructing the client in the use of the call light may be appropriate, however, depending on client response to the medication, may not be the most effective means in ensuring client safety. Reporting the client response to the health care provider is indicated, but is not directly related to the subject of ensuring client safety. • Test-Taking Strategy: Note the strategic word "priority." This word indicates that all options may be correct, but you must prioritize the most important and relevant option that will ensure safety. Noting the subject, client safety related to medication effects, will direct you to the correct option. • Review: buspirone hydrochloride (BuSpar).

94. The nurse enters the room of a client whose wastebasket is on fire. The nurse removes the client from the room, closes the door, and activates the fire alarm. After obtaining the fire extinguisher, which action should the nurse perform next in preparing to extinguish the fire? 1. Pull the pin 2. Sweep from side to side 3. Aim toward the base of the fire 4. Squeeze the handle of the extinguisher

94. Answer: 1 Rationale: Fire safety principles include removing the client from the vicinity of a fire, confining the fire (closing the door of the room), activating the fire alarm, and extinguishing the fire. In order to use a fire extinguisher, the nurse should first pull the pin, aim toward the base of the fire, squeeze the handle of the extinguisher, and sweep from side to side. • Test-Taking Strategy: Note the strategic word "next." Use the acronyms RACE (remove, activate, confine, extinguish) and PASS (pull, aim, squeeze, sweep) to answer this question correctly. • Review: fire safety.

96. The nurse is assisting a client to obtain a 24-hour urine specimen to test for creatinine clearance. Which instruction should the nurse provide to the client prior to specimen collection? 1. Drink coffee and tea to assist with urination. 2. Save all specimens, including the initial void. 3. Collect the urine for the entire length of the prescribed time. 4. Keep the specimen at room temperature during the collection period.

96. Answer: 3 Rationale: A 24-hour urine specimen is usually prescribed to test for creatinine clearance. Prior to specimen collection, the client should be instructed to drink plenty of fluids to assist with urination; however, coffee and tea should be avoided. All specimens should be included except for the initial void, which should be discarded. Urine should be collected for the entire length of the prescribed time. The specimen should be kept on ice or refrigerated during the collection period, and it should be sent to the laboratory promptly after the collection time is complete. • Test-Taking Strategy: Note the subject, 24-hour urine specimen for creatinine clearance. Note the relationship of the subject and the correct option. • Review: urine creatinine clearance test.

97. The health care provider prescribes the application of a heating pad to a client's back after discharge. The nurse should include which instruction( s) in the discharge teaching? Select all that apply. 1. Set the heating pad on a low setting 2. Place the heating pad under the back 3. Cover the heating pad with pillow case or towel 4. Check the heating pad periodically for proper electrical function 5. Check the skin integrity regularly for signs that the pad is too warm

97. Answer: 1, 3, 4, 5 Rationale: The heating pad should never be placed under the client, but it should be placed lightly against or on top of the involved area. Burns to the skin can occur when the client lies on the pad. Likewise, a low setting and covering the pad will prevent burning. Skin integrity should be checked frequently to ensure that the heat is not burning the skin, and electrical function is checked for safety purposes. • Test-Taking Strategy: Note the subject, discharge instructions for heat applications. Visualize each option. Think about the possible hazards or risks to the client in selecting the correct options. • Review: heat applications.

98. The nurse receives a telephone laboratory report indicating that a client with diabetes mellitus has a glycosylated hemoglobin A1C level of 7.6%. The nurse plans to provide additional reinforcement of diabetic teaching about which measure? 1. Avoiding infection 2. Caring for the feet 3. Preventing hyperglycemia 4. Rotating insulin injection sites

98. Answer: 3 Rationale: This test measures the amount of glucose that has become permanently bound to the red blood cells (RBCs) from circulating glucose. The normal level for glycosylated hemoglobin A1C is 3.5% to 6.0%. Elevations in blood glucose will cause elevations in the amount of glycosylation, helping to detect otherwise unknown episodes of hyperglycemia. Elevations indicate continued need for teaching related to prevention of hyperglycemic episodes. • Test-Taking Strategy: Focus on the strategic words "additional reinforcement." These words indicate a negative event query and the need to select an incorrect option as the answer. Note the subject, normal laboratory values and diabetic management. Familiarity with this test and its significance is needed to answer this question. Remember elevations in blood glucose will cause elevations in the amount of glycosylation. • Review: glycosylated hemoglobin A1C test.

99. The nurse has a prescription to collect a 24-hour urine specimen from a client. The nurse should perform which action( s) while completing this procedure? Select all that apply. 1. Place the specimen on ice 2. Discard a urine specimen collected at the start time 3. Ask the client to void, save the specimen, and note the start time 4. Ask the client to save a sample voided at the end of the collection time 5. Label the specimen with the client's name and send to the laboratory promptly

99. Answer: 1, 2, 4, 5 Rationale: Since the 24-hour urine test is a timed quantitative determination, the test must be started with an empty bladder. Therefore, the first urine is discarded. Fifteen minutes prior to the end of the collection time, the client should be asked to void, and this specimen is added to the collection. The urine collection should be refrigerated or placed on ice to prevent changes in urine. The specimen should be labeled with the client's name and any other necessary identifying information and sent to the laboratory promptly. • Test-Taking Strategy: Note the subject, technique for collecting a 24-hour urine specimen. Recalling that the test must be started with an empty bladder will assist you to eliminate option 3. • Review: 24-hour urine specimen. specimen.

1. Which safety measure(s) should be included in the plan of care for a client with an internal radiation implant. Select all that apply. 1. Wear a lead shield when in the client's room 2. Place the client in a room with a cohort client 3. Limit the time with the client to 1 hour per shift 4. Wear a dosimeter badge when entering the client's room 5. Save bed linens and any dressings until the implant is removed

1. Answer: 1, 4, 5 Rationale: The nurse should wear a lead shield when in the client's room to protect self from the radiation that may be emitted from the implant. Additionally a dosimeter badge is worn to measure the amount of radiation exposure. Bed linens and dressings removed from the client are saved in case the implant was accidentally dislodged and this event was not discovered until the time when the health care provider attempts to remove it (linens and dressings may need to be checked). The client needs to be placed in a private room. The time that the nurse spends in a room of a client with an internal radiation implant is 30 minutes per 8-hour shift. • Test-Taking Strategy: Focus on the subject, care to the client with an internal radiation implant. Use principles of time, distance, and shielding. Think about the potential exposure to radiation that can occur to assist in answering correctly. • Review: interventions for the client with an internal radiation implant.

10. The nursing instructor is observing a nursing student transfer a client from the bed to the chair. The instructor intervenes if the student is observed performing which action? 1. Keeping the back, neck, pelvis, and feet aligned 2. Flexing the knees and keeping the feet wide apart 3. Encouraging the client to assist as much as possible 4. Positioning self as far away from the client as possible

10. Answer: 4 Rationale: When transferring a client, the person performing the transfer should position self as close to the client or object being transferred as possible. The back, neck, pelvis, and feet of the person should remain aligned. Flexing the knees and keeping the feet wide apart will assist in preventing injury to the back. Encouraging the client to assist as much as possible will reduce strain on the person assisting with the transfer. • Test-Taking Strategy: Focusing on the subject, transferring a client from a bed to a chair. Noting the word "intervenes" indicates the need to select an incorrect action by the student. Recalling that positioning self close to the client or object to be moved is indicated during transfer will direct you to this option. • Review: ergonomic principles.

11. The pulse point to use when assessing a pulse in an infant is located in which area? 1. Radial 2. Carotid 3. Brachial 4. Popliteal

11. Answer: 3 Rationale: When assessing a pulse in an infant (younger than 1 year of age), the pulse should be checked at the brachial artery because the relatively short, fat neck of an infant makes palpation of the carotid artery difficult. Likewise, the pulse would be difficult to palpate at the radial or popliteal site in an infant. • Test-Taking Strategy: Focus on the subject, palpating a pulse in an infant. Use knowledge of infant anatomy and body structure to direct you to the correct option. • Review: assessment of vital signs in an infant.

2. An adolescent client with a surgically wired jaw has a prescription for a full liquid diet. The nurse should implement which action to promote the client's compliance with this diet prescription? 1. Offer chocolate milkshakes between meals 2. Explain to the adolescent the importance of good nutrition 3. Offer commercial nutritional supplements 4 to 6 times per day 4. Ask about food preferences and blenderize these foods into liquids

2. Answer: 4 Rationale: An adolescent may dislike a diet that is only liquids and may be at risk for noncompliance. Thus, it is important to have the client participate in as much decision making in the diet as possible. While blenderized foods may be unappealing under many circumstances, the nutrient value is unchanged. The client will be able to ingest the same foods eaten prior to the jaw fracture. The chocolate milkshakes may increase intake, but decreases the nutrient value. Adolescents may or may not respond to reasoning and explanations. The commercial nutritional supplements may be beneficial, but they are costly and may not be appealing to the client's taste. • Test-Taking Strategy: Focus on the subject, and use theories of growth and development to answer this question. Remember that an adolescent is generally more compliant with a difficult regimen when there is some ability to make choices. • Review: dietary guidelines for the client following jaw surgery.

26. The nurse is reviewing the plan of care for the client who has just undergone bilateral knee replacement. Which intervention, if noted in the plan of care, indicates the need for follow-up? 1. Administer analgesics for pain. 2. Monitor surgical sites for drainage and infection. 3. Begin continuous passive range-of-motion exercises immediately. 4. Avoid total weight-bearing and instruct in the use of assistive devices.

26. Answer: 3 Rationale: For the client who has undergone bilateral knee replacement, continuous passive range-of-motion exercises should begin 24 to 48 hours after surgery or as prescribed by the health care provider. Administration of analgesics for pain, monitoring surgical sites for drainage and infection, and avoiding total weight-bearing and instructing on the use of assistive devices are all appropriate interventions for this client. • Test-Taking Strategy: Note the strategic words "need for follow-up." These words indicate a negative event query and the need to choose an option that is an incorrect intervention. • Review: knee replacement surgery.

27. The nurse witnesses a construction worker fall from a ladder. The nurse rushes to the victim, who is unresponsive and uses which method to open the victim's airway? 1. Head tilt/ chin lift 2. Head tilt/ jaw thrust 3. Jaw thrust maneuver 4. Neutral or sniffing position

27. Answer: 3 Rationale: Whenever a neck injury is suspected, the jaw thrust maneuver should be used to open the airway. The head tilt/ chin lift produces hyperextension of the neck and could cause complications if a neck injury is present. The neutral or sniffing position may be used to open the airway in an infant. There is no such position as head tilt/ jaw thrust. • Test-Taking Strategy: Eliminate option 4 first because this position is used in an infant. Eliminate options 1 and 2 next because they are comparable or alike, knowing that the head should not be tilted. • Review: basic life support.

3. The nurse determines that the client understands the elements of follow-up care after a bone scan if the client states that he or she should perform which action( s)? Select all that apply. 1. Resume the usual diet 2. Ambulate at least three times before the end of the day 3. Drink plenty of water for a day or two following the procedure 4. Report any feelings of nausea or flushing to the health care provider 5. Remain isolated in a room for 24 hours to prevent exposure of the radioisotope materials to others

3. Answer: 1, 3 Rationale: There are no special restrictions after a bone scan. The client can resume the usual diet. There are no specific activity guidelines. The client is encouraged to drink large amounts of water for 24 to 48 hours to flush the radioisotope from the system. Nausea and flushing could accompany dye injection during a procedure, but this procedure uses radioisotopes, not dye. There are no hazards to the client or others from the minimal amount of radioactivity of the isotope. • Test-Taking Strategy: Note the subject, follow-up after a bone scan. Think about the procedure for a bone scan and note that the question relates to care after the procedure. Remember, the client can resume the usual diet and fluids to hasten elimination of the isotope from the client's system. • Review: client instructions after bone scan.

30. The nurse understands that which are examples of a nosocomial infection occurring in a health care facility? Select all that apply. 1. A common cold noted on day one of hospitalization 2. Sepsis that results from contaminated intravenous fluid 3. A urinary tract infection that develops after catheter insertion 4. A streptococci wound infection that develops in a postoperative client 5. The development of Clostridium difficile in an immunocompromised client 6. A respiratory tract infection that develops in a client receiving frequent respiratory treatments and requiring frequent suctioning

30. Answer: 2, 3, 4, 5, 6 Rationale: Nosocomial infections occur in a health care facility and result from the delivery of care. A hospital is a likely setting for acquiring an infection because it harbors a high population of virulent organisms that may be resistant to antibiotics. These infections may be exogenous or endogenous. An exogenous infection arises from microorganisms external to the client that does not exist as normal flora. An endogenous infection occurs when part of the client's flora becomes altered and an overgrowth results. Therefore, options 2, 3, 4, 5, and 6 are examples of nosocomial infections. • Test-Taking Strategy: Focus on the subject, nosocomial infections. Recalling that these types of infections occur in a health care facility and result from the delivery of care will direct you to the correct options. • Review: nosocomial infections.

39. The nurse is caring for a client whose religious background is Seventh Day Adventist (Church of God). Which nursing action( s) are most appropriate in terms of providing for the dietary needs for this client? Select all that apply. 1. Providing snacks between each meal. 2. Providing wine with dinner as requested. 3. Removing coffee from the breakfast tray. 4. Ensuring that there is no pork on the dinner tray. 5. Ensuring that meals are delivered in a timely fashion.

39. Answer: 3, 4, 5 Rationale: Clients whose religious background is Seventh Day Adventist (Church of God) have various dietary preferences, including avoidance of overeating. At least 5 to 6 hours must pass between meals, and in-between meal snacking is avoided. Coffee and alcohol are usually prohibited. Many members are lacto-ovovegetarian; those who do eat meat, however, will avoid pork. The nurse should ensure that meals are delivered in a timely fashion because of the hours that must pass between meals for the client. • Test-Taking Strategy: Note the strategic words "most appropriate." Recalling that overeating is prohibited for clients of this religious background and coffee and alcohol is usually prohibited will assist you in eliminating the incorrect options. • Review: religions and dietary practices.

40. The health care provider prescribes a bolus of 500 mL of 0.9% NS to run over 4 hours. The drop factor is 10 drops per 1 mL. The nurse plans to safely adjust the flow rate at how many drops per minute? Fill in the blank. Round to the nearest whole number. Answer: __________ gtt/ min

40. Answer: 21 Rationale: Follow the formula for calculating IV infusion rates. Formula: Total volume in mL x Drop factor/Time in minutes= gtts per min 500mL x 10gtts/240 min= 20.8 rounded to 21 gtts per min Test-Taking Strategy: Note the subject, an intravenous flow rate. Follow the formula. Be sure to convert 4 hours to minutes. Use a calculator to verify the answer. • Review: intravenous flow rate calculations.

82. The nurse is performing a vision test on a client with the use of a Snellen chart. The nurse asks the client to stand at how many feet away from the chart to perform this test? 1. 10 2. 20 3. 30 4. 40

82. Answer: 2 Rationale: When performing a vision test on a client using a Snellen chart, the nurse should position the client in a well-lit area 20 feet away from the chart with the chart at eye level. The distances identified in options 1, 3, and 4 are incorrect. • Test-Taking Strategy: Note the subject, eye examination using a Snellen chart. Visualize each of the distances identified in the options to direct you to the correct option. • Review: Snellen chart.

95. The nurse is providing instructions to a client about foods that are high in potassium. The nurse should tell the client that which food has the highest potassium content? 1. Milk 2. Apple 3. Spinach 4. Pound cake

95. Answer: 3 Rationale: An apple provides approximately 3 mEq of potassium per serving. Spinach provides approximately 7 mEq of potassium per serving. Milk is high in calcium. Pound cake is not a high-potassium food and may contain fat. • Test-Taking Strategy: Note the strategic word "highest." Focus on the subject, the food highest in potassium. Remember spinach is high in potassium. • Review: high potassium foods.