NCLEX #351-400
NO.364 On admission to the postpartal unit, the nurse's assessment identifies the client's fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likely an indication of: A. Normal involution B. A full bladder C. An infection pain D. A hemorrhage
Answer: B Explanation: (A) Immediately after expulsion of the placenta, the fundus should be in the midline and remain firm. (B) A boggy displaced uterus in the immediate postpartum period is a sign of urinary distention. Because uterine ligaments are stretched, a full bladder can displace the uterus. (C) Symptoms of infection may include unusual uterine discomfort, temperature elevation, and foul-smelling lochia. The stem of this question does not address any of these factors. (D) While excessive bleeding is associated with a soft, boggy uterus, the stem of this question includes displacement of the uterus, which is more commonly associated with bladder distention.
NO.366 A 35-weeks-pregnant client is undergoing a nonstress test (NST). During the 20-minute examination, the nurse notes three fetal movements accompanied by accelerations of the fetal heart rate, each 15 bpm, lasting 15 seconds. The nurse interprets this test to be: A. Nonreactive B. Reactive C. Positive D. Negative
Answer: B Explanation: (A) In a nonreactive NST, the criteria for reactivity are not met. (B) A reactive NST shows at least two accelerations of FHR with fetal movements, each 15 bpm, lasting 15 seconds or more, over 20 minutes. (C, D) This term is used to interpret a contraction stress test (CST), or oxytocin challenge test, not an NST.
NO.379 A 15-year-old child is admitted to the pediatric unit with a diagnosis of thalassemia. Which of the following would be included in educating the mother and child as part of discharge planning? A. Give oral iron medication every day. B. Have the child's blood pressure monitored every week. C. Know the signs and symptoms of iron overload. D. Keep exercise at a minimum to reduce stress.
Answer: C Explanation: (A) Oral iron supplements are contraindicated in thalassemia. (B) Although heart failure may be an end result of this disease, this action is unnecessary. (C) Iron overload is a potential complication of frequent blood transfusions of children with thalassemia. (D) Children should be encouraged to pursue activities related to their exercise tolerance.
NO.394 When inspecting a cardiovascular client, the nurse notes that he needs to sit upright to breathe. This behavior is most indicative of: A. Pericarditis B. Anxiety C. Congestive heart failure D. Angina v
Answer: C Explanation: (A) Pericarditis can cause dyspnea but primarily causes chest pain. (B) Anxiety can cause dyspnea resulting in SOB, yet it is not typically influenced by degree of head elevation. (C) The inability to oxygenate well without being upright is most indicative of congestive heart failure, due to alveolar drowning. (D) Angina causes primarily chest pain; any SOB associated with angina is not influenced by body position.
NO.382 A 50-year-old depressed client has recently lost his job. He has been reluctant to leave his hospital room. Nursing care would include: A. Forcing the client to attend all unit activities B. Encouraging the client to discuss why he is so sad C. Monitoring elimination patterns D. Providing sensory stimulation
Answer: C Explanation: (A) The client should be encouraged to attend the unit activities. The nurse and client should choose a few activities for the client to attend that will be positive experiences for him. (B) The nurse should encourage the client to discuss his feelings and to begin to deal with the depression. (C) Depressed persons often have little appetite and poor fluid intake. Constipation is common. (D) A calm, consistent level of stimuli is most effective. Sensory deprivation and overstimulation should be avoided.
NO.386 A female client comes for her second prenatal visit. The nurse-midwife tells her, "Your blood tests reveal that you do not show immunity to the German measles." Which notation will the nurse include in her plan of care for the client? "Will need . . . A. Rh-immune globulin at the next visit" B. Rh-immune globulin within 3 days of delivery" C. Rubella vaccine at the next visit" D. Rubella vaccine after delivery on the day of discharge"
Answer: D Explanation: (A) Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune response. (B) Rh immune globulin is given to Rh-negative mothers to prevent the maternal Rh immune response. (C) The rubella vaccine is not given during pregnancy because of its teratogenicity. (D) Nonimmune mothers are vaccinated early in the postpartum period to prevent future infection with the rubella virus.
NO.390 A pregnant client continues to visit the clinic regularly during her pregnancy. During one of her visits while lying supine on the examining table, she tells the RN that she is becoming light- headed. The RN notices that the client has pallor in her face and is perspiring profusely. The first intervention the RN should initiate is to: A. Place the examining table in the Trendelenburg position B. Assess the client to see if she is having vaginal bleeding C. Obtain the client's vital signs immediately D. Help the client to a sitting position
Answer: D Explanation: (A) This position would cause the gravid uterus to bear the increased pressure of the vena cava, which could lead to maternal hypotension, in turn causing the client to continue to have pallor and to feel light-headed. (B) This would not be the first intervention the RN should initiate. TheRN should understand the supine position and its effect on the gravid uterus and vena cava. (C) The RN's first intervention should be one that helps to alleviate the client's symptoms. Obtaining her vital signs will not alleviate her symptoms. (D) This would move the gravid uterus off of the client's vena cava, which would alleviate the maternal hypotension that is the cause of her symptoms.
NO.355 A male client is admitted to the psychiatric unit after experiencing severe depression. He states that he intends to kill himself, but he asks the nurse not to repeat his intentions to other staff members. Which response demonstrates understanding and appropriate action on the part of the nurse? A. "I understand you're depressed, but killing yourself is not a reasonable option." B. "We need to discuss this further, but right now let's complete these forms." C. "Don't do that, you have so much to live for. You have a wonderful wife and children. The client in the next room has no one." D. "This is very serious. I do not want any harm to come to you. I will have to report this to the rest of the staff."
Answer: D Explanation: (A) To the client, suicide may be a reasonable action and the only one he can cope with at this time. (B) This response indicates to the client that his intention to commit suicide is not important to the nurse at this time. (C) The client is so depressed that he is not able to see the positive aspects of his life. At no time should the nurse discuss another client's problems in conversation. (D) This statement tells the client that the nurse recognizes his problem is of a serious nature and will take all steps necessary to help him.
NO.400 The usual treatment for diabetes insipidus is with IM or SC injection of vasopressin tannate in oil. Nursing care related to the client receiving IM vasopressin tannate would include: A. Weigh once a week and report to the physician any weight gain of10 lb. B. Limit fluid intake to 500 mL/day. C. Store the medication in a refrigerator and allow to stand at room temperature for 30 minutes prior to administration. D. Hold the vial under warm water for 10-15 minutes and shake vigorously before drawing medication into the syringe.
Answer: D Explanation: (A) Weight should be obtained daily. (B) Fluid is not restricted but is given according to urine output. (C) The medication does not have to be stored in a refrigerator. (D) Holding the vial under warm water for 10-15 minutes or rolling between your hands and shaking vigorously before drawing medication into the syringe activates the medication in the oil solution.
NO.378 In healthcare settings, nurses must be familiar with primary, secondary, and tertiary levels of care. As a nurse in the community, which of the following interventions might be a primary prevention strategy? A. Crisis intervention with an intoxicated teenager whose mother just committed suicide B. Referring a client who has been on a detoxification unit to a rehabilitation center C. Teaching fifth-grade children the harmful effects of substance abuse D. Counseling a client with post-traumatic stress disorder
Answer: C Explanation: (A) The teenager is already coping ineffectively and requires early detection and treatment, which is secondary prevention. (B) The client must be sent to a rehabilitation unit, which requires tertiary prevention. (C) Reducing the incidence of disease through education supports primary prevention. (D) A client with identified symptoms of post-traumatic stress disorder requires intervention by treatment.
NO.398 In working with a manipulative client, which of the following nursing interventions would be most appropriate? A. Bargaining with the client as a strategy to control the behavior B. Redirecting the client C. Providing a consistent set of guidelines and rules D. Assigning the client to different staff persons each day
Answer: C Explanation: (A) This answer is incorrect. Bargaining is a manipulative act, which the nurse could expect from the client. (B) This answer is incorrect. Confrontation is an effective nursing strategy with manipulative behavior. Redirection is appropriate for the client who is out of touch with reality. (C) This answer is correct. Manipulative clients must abide by consistent rules. (D) This answer is incorrect. Manipulation is kept at a minimum if the same staff person is assigned to the client. Often the client will attempt to play staff persons against each other.
NO.371 A client has a history of alcoholism. He is currently diagnosed with cirrhosis of the liver. The nurse would expect him to be on which type of diet? A. High protein and high calorie B. High calorie and high carbohydrate C. Low-fat 2-g sodium diet D. High protein and high fat
Answer: B Explanation: (A) A high-protein diet is contraindicated in hepatic disease. (B) High carbohydrates provide high- caloric content to prevent tissue catabolism. (C) A low-fat 2-g sodium diet is a cardiac diet; however, a low-fat diet would be beneficial. (D) A high-protein and high-fat diet is contraindicated in hepatic disease.
NO.360 A newborn is admitted to the newborn nursery with tremors, apnea periods, and poor sucking reflex. The nurse should suspect: A. Central nervous system damage B. Hypoglycemia C. Hyperglycemia D. These are normal newborn responses to extrauterine life
Answer: B Explanation: (A) Central nervous system damage presents as seizures, decreased arousal, and absence of newborn reflexes. (B) In a diabetic mother, the infant is exposed to high serum glucose. The fetal pancreas produces large amounts of insulin, which causes hypoglycemia after birth. (C) Hypoglycemia is a common newborn problem. Increased insulin production causes hypoglycemia, not hyperglycemia. (D) These are not normal adaptive behaviors to extrauterine life.
NO.356 Pin care is a part of the care plan for a client who is in skeletal traction. When assessing the site of pin insertion, which one of the following findings would the nurse know as an indicator of normal wound healing? A. Exudate B. Crust C. Edema D. Erythema
Answer: B Explanation: (A) Exudate (moist, active drainage) is a clinical sign of wound infection. (B) Crust (dry, scaly) is part of the normal stages of wound healing and should not be removed from around the pin site. It usually sloughs off after the underlying tissue has healed. (C) Edema (swelling) is a clinical sign of wound infection. (D) Erythema (redness) is a clinical sign of wound infection.
NO.359 Before completing a nursing diagnosis, the nurse must first: A. Write goals and objectives B. Perform an assessment C. Plan interventions D. Perform evaluation
Answer: B Explanation: (A) Goals and objectives are based on a nursing assessment and diagnosis. (B) Assessment is the first step of nursing process. (C) Interventions are nursing actions to meet goals and objectives. (D) Evaluation process follows nursing interventions.
NO.368 An elective saline abortion has been performed on a 3- week primigravida. Following the procedure, the nurse should be alert for which early side effect? A. Water satiety B. Thirst C. Edema D. Diabetes insipidus
Answer: B Explanation: (A) If the client is experiencing water satiety, there is no more desire for water. (B) Absorption of saline into circulation rather than into amniotic sac increases serum sodium and desire for water. (C) Edema can be a late side effect caused by water intoxication. (D) Diabetes insipidus occurs as a result of deficient antidiuretic hormone.
NO.374 When planning care for a 9-year-old client, the nurse uses which of the most effective means of helping siblings cope with their feelings about a brother who is terminally ill? A. Open discussion and understanding B. Play-acting out feelings in different roles C. Storytelling D. Drawing pictures
Answer: B Explanation: (A) When dealing with grief, siblings are usually most comfortable initially with open discussion. (B) Assuming different roles allows children to act out their feelings without fear of reprisals and to gain insight and control. (C) This method may be helpful, but having the child take an active part through role playing is more effective. (D) This technique may be helpful, but being an active participant through role playing is more effective.
NO.377 A client is being admitted to the labor and delivery unit. She has had previous admissions for "false labor." Which clinical manifestation would be most indicative of true labor? A. Increased bloody show B. Progressive dilatation and effacement of the cervix C. Uterine contractions D. Decreased discomfort with ambulation
Answer: B Explanation: (A) Bloody show is considered a sign of imminent labor, which usually begins in 24-48 hours. An increase in bloody show is an indication that the cervix is changing. (B) Contractions of true labor produce progressive cervical effacement and dilatation. (C) Contractions of false labor may mimic those of true labor. However, the contractions of false labor do not produce progressive effacement and dilatation of the cervix. (D) In true labor, the discomfort is not relieved by ambulation; walking may intensify the discomfort.
NO.393 One of the most dramatic and serious complications associated with bacterial meningitis is Waterhouse- Friderichsen syndrome, which is: A. Peripheral circulatory collapse B. Syndrome of inappropriate antiduretic hormone C. Cerebral edema resulting in hydrocephalus D. Auditory nerve damage resulting in permanent hearing loss
Answer: A Explanation: (A) Waterhouse-Friderichsen syndrome is peripheral circulatory collapse, which may result in extensive and diffuse intravascular coagulation and thrombocytopenia resulting in death. (B) Syndrome of inappropriate antidiuretic hormone is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. (C) Cerebral edema resulting in hydrocephalus is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. (D) Auditory nerve damage resulting in permanent hearing loss is a complication of meningitis, but it is not Waterhouse- Friderichsen syndrome.
NO.387 A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority? A. Ineffective airway clearance related to immobility, ineffective cough, and decreased level of consciousness B. Altered cerebral tissue perfusion related to pathophysiological changes that decrease blood flow C. Potential for injury related to impaired mobility and seizures D. Impaired verbal communication related to aphasia
Answer: A Explanation: (A) An effective airway is necessary to prevent hypoxia and subsequent cardiac arrest. (B) Cerebral tissue perfusion is necessary to preserve remaining cerebral tissue, but this goal is secondary to maintenance of an effective airway. (C) While prevention of injury is important, it is secondary to maintaining an effective airway and cerebral tissue perfusion. (D) Impaired verbal communication is not life threatening in the acute phase of recovery. It is the lowest priority of the nursing diagnoses listed.
NO.351 A client has been diagnosed with thrombophlebitis. She asks, "What is the most likely cause of thrombophlebitis during my pregnancy?" The nurse explains: A. Increased levels of the coagulation factors and a decrease in fibrinolysis B. An inadequate production of platelets C. An inadequate intake of folic acid during pregnancy D. An increase in fibrinolysis and a decrease in coagulation factors
Answer: A Explanation: (A) During pregnancy, the potential for thromboses increases owing to the increased levels of coagulation factors and a decrease in the breakdown of fibrin. (B) An inadequate production of platelets would result in thrombocytopenia with resulting signs and symptoms of bleeding such as petechiae, hematuria, or hematemesis. (C) A deficiency of folic acid during pregnancy produces a megaloblastic anemia. It is usually found in combination with iron deficiency. (D) This combination would result in bleeding disorders because more fibrin would be broken down and fewer clotting factors would be available.
NO.399 The nurse is trying to help a mother understand what is happening with her son who has recently been diagnosed with paranoid schizophrenia. At present, he is experiencing hallucinations and delusions of persecution and suffers from poor hygiene. The nurse can best help her understand her son's condition by which of the following statements? A. "Sometimes these symptoms are caused by an overstimulation of a chemical called dopamine in the brain." B. "Has anyone in your family ever had schizophrenia?" C. "If your son has a twin, he probably will eventually develop schizophrenia, too." D. "Some of his symptoms may be a result of his lack of a strong mother-child bonding relationship."
Answer: A Explanation: (A) The most plausible theory to date is that dopamine causes an overstimulation in the brain, which results in the psychotic symptoms. (B) This statement will only create anxiety in the mother, and the genetic theory is only one of the etiological factors. (C) This statement will cause the mother much alarm, and nothing was mentioned about any other child. (D) The motherchild relationship is one of the previous theories examined, but it is not one to be emphasized, thereby causing a lot of anxiety for the mother.
NO.397 A client is pregnant for the fourth time and has had three normal vaginal deliveries. She is in active labor and fully dilated. Suddenly she calls, "Nurse, the baby is coming." As the nurse responds to her call, which one of the following observations should the nurse make first? A. Inspect the perineum. B. Time the contractions. C. Prepare a sterile area for delivery. D. Auscultate for fetal heart rate (FHR).
Answer: A Explanation: (A) The nurse must assess the labor status to determine if birth is imminent. The nurse may note perineal bulging, crowning, or birth of the head to ascertain labor status. (B) Assessing uterine contractions is one intervention to ascertain labor status. Based on the client's cry, it is not the intervention of choice. (C) If delivery of the infant is imminent, preparing a clean or sterile area for delivery is appropriate, but labor status must be established, whether delivery is imminent, by perineal assessment. (D) Assessing FHR is one intervention to ascertain fetal well-being. Based on the client's cry, this is not the intervention of choice.
NO.369 A 29-year-old client is diagnosed with borderline personality disorder. He has aroused the nurse's anger by using a condescending tone of voice with other clients and staff persons. Which of the following statements from the nurse would be most appropriate in acknowledging feelings regarding the client's behavior? A. "I feel angry when I hear that tone of voice." B. "You make me angry when you talk to me that way." C. "Are you trying to get me angry?" D. "Why do you treat me that way?"
Answer: A Explanation: The nurse appropriately states how he or she feels when the client speaks in a condescending manner. (B) This statement indicates that the client has control over the nurse. No one makes another person angry; each individual has a choice. (C) "Why" questions usually put a person on the defensive. In addition, the client cannot "make" the nurse angry. The client does not have that control. (D) Again, a "why" statement places the client on the defensive.
NO.357 Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack? A. Fresh fruit B. A milkshake C. Saltine crackers and peanut butter D. A ham and cheese sandwich
Answer: B Explanation: (A) Albumin, a blood volume expander, increases the circulating blood volume by exerting an osmotic pull on tissue fluids, pulling them into the vascular system. This fluid shift causes an increase in the heart rate and blood pressure. (B) Albumin, a blood volume expander, exerts an osmotic pull on fluids in the interstitial spaces, pulling the fluid back into the circulatory system. This fluid shift causes an increase in the urinary output. (C) Adventitious breath sounds and dyspnea can occur due to circulatory overload if the albumin is infused too rapidly. (D) Chills, fever, itching, and rashes are signs of a hypersensitivity reaction to albumin.
NO.388 A 72-year-old male client had the Foley catheter that was inserted during the transurethral resection of his prostate removed today. He is concerned about the urinary incontinence he is having since removal of the Foley catheter. The nurse explains that: A. He should not be concerned about it because it will resolve quickly B. This is usually temporary C. The nurse will keep him dry, and he should notify the nurse when this happens D. This is related to the bladder spasms and will soon stop
Answer: B Explanation: (A) This problem is temporary, but it may take some time to resolve, especially in an older man. (B) This problem is usually temporary, but it may take some time to resolve. (C) Keeping the client dry will not relieve his anxiety about his incontinence. (D) The bladder spasms are not the cause of the client's incontinence.
NO.381 An IDDM client's condition stabilizes. He begins to receive a daily injection of NPH insulin at 6:30 AM. The nurse can most likely expect a hypoglycemic reaction to occur that same day at: A. 8:30 AM-10:30 AM B. 2:30 PM-4:30 PM C. 7:30 PM-9:30 PM D. 10:30 PM-11:30 PM
Answer: B Explanation: (A) This time describes the time of onset of NPH insulin's action, rather than its peak effect. (B) NPH insulin, an intermediateacting insulin, usually begins to lower serum glucose levels about 2 hours after administration. The action of NPH insulin peaks 8-14 hours after administration. It has a 20-30 hour duration. (C) The time stated is not the time of peak action for NPH insulin administered at 6:30 AM. (D) The time stated is not the time of peak action for NPH insulin administered at 6:30 AM.
NO.376 After 7 hours in restraints and a total of 30-mg haloperidol in divided doses, a client complains of stiffness in his neck and his tongue "pulling to one side." These extrapyramidal symptoms (EPS) will most likely be relieved by the administration of: A. Lorazepam (Ativan) B. Benztropine (Cogentin) C. Thiothixene (Navane) D. Flurazepan (Dalmane)
Answer: B Explanation: (A) Lorazepam is an antianxiety agent that produces muscle relaxation and inhibits cortical and limbic arousal. It has no action in the basal ganglia of the brain. (B) Benztropine acts to reduce EPS by blocking excess CNS cholinergic activity associated with dopamine deficiency in the basal ganglia by displacing acetylcholine at the receptor site. (C) Thiothixene is an antipsychotic known to block dopamine in the limbic system, thereby causing EPS. (D) Flurazepan is a hypnotic that acts in the limbic system, thalamus, and hypothalamus of the CNS to produce sleep. It has no known action in the vasal ganglia.
NO.384 A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client's fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process: A. Decreases the overall time of the labor process B. Prolongs the client's first stage of labor C. Decreases the time of the client's first stage of labor D. Prolongs the client's third stage of labor
Answer: B Explanation: (A) Posterior position causes a larger diameter of the fetal head to enter the pelvis than an anterior position. Pressure on the sacral nerves is increased, and it takes the fetus a longer time to enter the pelvic inlet. (B) This position will prolong the first stage of labor. When the larger diameter of the fetal head enters the pelvis first, it will have a more difficult time accommodating to the pelvis; therefore, it will take a longer time for the fetus to move through the pelvis. (C) It will increase the time of labor because the larger diameter of the fetal head will have a more difficult time accommodating to the pelvic inlet and thus will move through the pelvis slower. (D) In the third stage of labor the placenta is delivered; therefore, the infant has been delivered.
NO.358 After a 10-year-old child with insulin-dependent diabetes mellitus receives her dinner tray, she tells the nurse that she hates broccoli and wants some corn on the cob. The nurse's appropriate response is: A. "No vegetable exchanges are allowed." B. "Corn and other starchy vegetables are considered to be bread exchanges." C. "Yes, you may exchange any vegetable for any other vegetable." D. "Yes, but only one-half ear is allowed."
Answer: B Explanation: (A) Sites for injection need to be rotated, including abdominal sites, to enhance insulin absorption. (B) The pinch technique is the most effective method for obtaining skin tightness to allow easy entrance of the needle to subcutaneous tissues. (C) Massaging the site of injectionfacilitates absorption of the insulin. (D) Changing the needle will break the sterility of the system. It has become acceptable practice to reuse disposable needles and syringes for 3-7 days.
NO.375 A 33-year-old client was brought into the emergency room unconscious, and it is determined that surgery is needed. Informed consent must be obtained from his next of kin. The sequence in which the next of kin would be asked for the consent would be: A. Parent, spouse, adult child, sibling B. Spouse, adult child, parent, sibling C. Spouse, parent, sibling, adult child D. Parent, spouse, sibling, adult child
Answer: B Explanation: (A) Spouse and adult child would be asked before a parent. (B) The order of kin relationship for an adult, as determined from legal intestate succession, is usually spouse, adult child, parent, sibling. (C) Parent and sibling would be asked after adult child. (D) Spouse and adult child would be asked before parent. Sibling would be asked last.
NO.385 On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and exhibiting a coarse hand tremor. Which one of the following nursing actions is essential at this time? A. Administer her next dosage of lithium, and then call the physician. B. Withhold her lithium, and report her symptoms to the physician. C. Place her on NPO to decrease the excretion of lithium from her body, and call the physician. D. Contact the lab and request a lithium level in 30 minutes, and call the physician.
Answer: B Explanation: (A) The client has lithium toxicity, and the nurse must withhold further dosages. (B) Because of her level of toxicity, further lithium could cause coma and death. The nurse needs further orders from the physician to stabilize the client's lithium level. (C) Ensuring adequate intake of sodium chloride will promote excretion of lithium and will assist in managing the client's lithiumtoxicity. (D) A lithium blood level must be drawn immediately to determine the seriousness of the toxicity and to provide the physician with data for medical orders.
NO.367 A client has returned to the unit following a left femoral popliteal bypass graft. Six hours later, his dorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse should: A. Continue to monitor the foot B. Notify the physician immediately C. Reposition and reassess the foot D. Assure the client that his foot is fine
Answer: B Explanation: (A) The client is losing blood supply to his left foot. Continuing to monitor the foot will not help restore the blood supply to the foot. (B) The physician should be notified immediately because the client is losing blood supply to his left foot and is in danger of losing the foot and/or leg. (C) The presenting symptoms are of an emergency nature and require immediate intervention. (D) This action would be giving the client false assurance.
NO.396 Blood work reveals the following lab values for a client who has been diagnosed with anorexia nervosa: hemoglobin 9.6 g/dL, hemocrit 27%, potassium 2.7 mEq/L, sodium 126 mEq/L. The greatest danger to her at this time is: A. Hypoglycemia from low-carbohydrate intake B. Possible cardiac dysrhythmias secondary to hypokalemia C. Dehydration from vomiting D. Anoxia secondary to anemia
Answer: B Explanation: (A) There is no lab data to support hypoglycemia. (B) Hypokalemia, caused by vomiting and decreased dietary intake of potassium, can result in life-threatening dysrhythmias. (C) Evidence of dehydration is not life threatening at this time, although fluid volume deficit does need to be addressed. (D) The client's hemoglobin does not reflect a life threatening value sufficient to render the client anoxic.
NO.361 A client is pregnant with her second child. Her last menstrual period began on January 15. Her expected date of delivery would be: A. October 8 B. October 15 C. October 22 D. October 29
Answer: C Explanation: (A) Incorrect application of Nagele's rule: correctly subtracted 3 months but subtracted 7 days rather than added. (B) Incorrect application of Nagele's rule: correctly subtracted 3 months but did not add 7 days. (C) Correct application of Nagele's rule: correctly subtracted 3 months and added 7 days. (D) Incorrect application of Nagele's rule: correctly subtracted 3 months but added 14 days instead of 7 days.
NO.372 In cleansing the perineal area around the site of catheter insertion, the nurse would: A. Wipe the catheter toward the urinary meatus B. Wipe the catheter away from the urinary meatus C. Apply a small amount of talcum powder after drying the perineal area D. Gently insert the catheter another 12 inch after cleansing to prevent irritation from the balloon
Answer: B Explanation: (A) Wiping toward the urinary meatus would transport microorganisms from the external tubing to the urethra, thereby increasing the risk of bladder infection. (B) Wiping away from the urinary meatus would remove microorganisms from the point of insertion of the catheter, thereby decreasing the risk of bladder infection. (C) Talcum powder should not be applied following catheter care, because powders contribute to moisture retention and infection likelihood. (D) The catheter should never be inserted further into the urethra, because this would serve no useful purpose and would increase the risk of infection.
NO.352 Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client? A. Increased PaCO2 B. Decreased PaO2 C. Increased HCO3 D. Decreased base excess
Answer: C Explanation: (A) Increased CO2 will occur in both acute and chronic respiratory acidosis. (B) Hypoxia does not determine acid-base status. (C) Elevation of HCO3 is a compensatory mechanism in acidosis that occurs almost immediately, but it takes hours to show any effect and days to reach maximum compensation. Renal disease and diuretic therapy may impair the ability of the kidneys to compensate. (D) Base excess is a nonrespiratory contributor to acid-base balance. It would increase to compensate for acidosis.
NO.363 A client is pleased about being pregnant, yet states, "It is really not the best time, but I guess it will be OK." The nurse's assessment of this response is: A. Initial maternal-infant bonding may be poor. B. Client may have a poor relationship with her husband. C. This response is normal in the first trimester. D. This response is abnormal, to be re-evaluated at the next visit.
Answer: C Explanation: (A) Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of "not now" in the first trimester. The statement still leaves room for exploration. (B) There are no data to support this. This statement by the mother still leaves room for exploration. (C) Ambivalenceis normal during the first trimester. Reva Rubin addresses the issue of "not now." This fact should be shared with the mother during further exploration of the comment. (D) It is not abnormal. If it were, another month would also be too long to wait.
NO.389 When a client with pancreatitis is discharged, the nurse needs to teach him how to prevent another occurrence of acute pancreatitis. Which of the following statements would indicate he has an understanding of his disease? A. "I will not eat any raw or uncooked vegetables." B. "I will limit my alcohol to one cocktail per day." C. "I will look into attending Alcoholics Anonymous meetings." D. "I will report any changes in bowel movements to my doctor."
Answer: C Explanation: (A) Raw or uncooked vegetables are all right to eat postdischarge. (B) This client must avoid any alcohol intake. (C) The client displays awareness of the need to avoid alcohol. (D) This action would be pertinent only if fatty stools associated with chronic hepatitis were the problem.
NO.373 A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm, lasting 20 seconds, every time the fetus moves. The nurse explains that: A. The test is inconclusive and should be repeated B. Further testing is needed C. The test is normal and the fetus is reacting appropriately D. The fetus is distressed
Answer: C Explanation: (A) The test results were normal, so there would be no need to repeat to determine results. (B) There are no data to indicate further tests are needed, because the result of the NST was normal. (C) An NST is reported as reactive if there are two to three increases in the fetal heart rate of 15 bpm, lasting at least 15 seconds during a 15-minute period. (D) The NST results were normal, so there was no fetal distress.
NO.353 A client is admitted to the hospital with a diagnosis of aplastic anemia and placed on isolation. The nurse notices a family member entering the room without applying the appropriate apparel. The nurse will approach the family member using the following information as a basis for discussion: A. The risks of exposure of the visitor to infectious organisms is great. B. Hospital regulations mandate that everyone in the facility adhere to appropriate codes. C. The client is at extreme risk of acquiring infections. D. Adherence to the guidelines are the latest Centers for Disease Control and Prevention recommendations on use of protective apparel.
Answer: C Explanation: (A) Although clients with a compromised immune system may acquire infections, the primary emphasis is on protecting the client. (B, D) Most people are aware of the guidelines once they see posted signs, so quoting regulations is not likely to result in consistent adherence to regulations. (C) Clients with aplastic anemia have white cell counts of 2000 or lower, making them more vulnerable to infections from others.
NO.392 Children often experience visual impairments. Refractive errors affect the child's visual activity. The main refractive error seen in children is myopia. The nurse explains to the child's parents that myopia may also be described as: A. Cataracts B. Farsightedness C. Nearsightedness D. Lazy eye
Answer: C Explanation: (A) Cataracts are not considered refractive errors. Cataracts canbe described as opacity of the lens. (B)Hyperopiais the term forfarsightedness. One can see objects at a distance more clearlythan close objects. (C)Myopiais the term for nearsightedness.Objects that are close in distance are more clearly seen. (D) Lazyeye refers to strabismus or misalignment of the eyes.
NO.362 A client returns to the cardiovascular intensive care unit following his coronary artery bypass graft. In planning his care, the most important electrolyte the nurse needs to monitor will be: A. Chloride B. HCO3 C. Potassium D. Sodium
Answer: C Explanation: (A) Chloride, HCO3, and sodium will need to be monitored, but monitoring these electrolytes is not as important as potassium monitoring. (B) Chloride, HCO3, and sodium will need to be monitored, but monitoring these electrolytes is not as important as potassium monitoring. (C) Potassium will need to be closely monitored because of its effects on the heart. Hypokalemia could result in supraventricular tachyarrhythmias. (D) Chloride, HCO3, and sodium will need to be monitored, but monitoring these electrolytes is not as important as potassium monitoring.
NO.370 A 16-year-old diabetic girl has been selected as a cheerleader at her school. She asks the nurse whether she should increase her insulin when she is planning to attend cheerleading practice sessions lasting from 8 to 11 AM. The most appropriate answer would be: A. "You should ask your doctor about this." B. "Yes, increase your insulin by 1 U for each hour of practice because exercise causes the body to need more insulin." C. "No, do not increase your insulin. Exercise will not affect your insulin needs." D. "No, do not increase your insulin, but eating a snack prior to practice exercise will make insulin more effective and move more glucose into the cells."
Answer: D Explanation: (A) A nurse can give this information to a client. (B) Exercise makes insulin more efficient in moving more glucose into the cells. No more insulin is needed. (C) Exercise makes insulin more efficient unless the diabetes is poorly controlled. (D) Exercise makes insulin more efficient in moving more glucose into the cells.
NO.365 A 30-year-old female client is receiving antineoplastic chemotherapy. Which of the following symptoms should especially concern the nurse when caring for her? A. Respiratory rate of 16 breaths/min B. Pulse rate of 80 bpm C. Complaints of muscle aches D. A sore throat
Answer: D Explanation: (A) A respiratory rate of 16 breaths/min is normal and is not a cause for alarm. (B) A pulse rate of 80 bpm is normal and is not a cause for alarm. (C) Complaints of muscle aches are unrelated to her receiving chemotherapy. There may be other causes related to her hospital stay or the disease process. (D) A sore throat is an indication of a possible infection. A client receiving chemotherapy is at risk of neutropenia. An infection in the presence of neutropenia can result in a life-threatening situation.
NO.391 A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy would include: A. Monitoring the chest tubes B. Positioning the client on the right side C. Positioning the client in semi-Fowler position with a pillow under the shoulder and back D. Monitoring the right lung for an increase in rales
Answer: D Explanation: (A) Chest tubes are usually not necessary in a pneumonectomy because there is no lung to re-expand on the operative side. (B) The pneumonectomy client should be positioned on the back or operated side because the sutured bronchial stump may open, allowing fluid to drain into the unoperated side and drown the client. (C) The client should not have a pillow under the shoulder and back because of the subscapular incision. (D) Rales are commonly heard over the base of the remaining lung, but an increase could indicate circulatory overload and therefore should be closely monitored.
NO.354 A 10-month-old infant's mother says that he takes fresh whole milk eagerly, but that when she offered him baby foods at 6 months of age, he pushed them out of his mouth. Because he has gained weight appropriately, she has quit trying to get him to eat other foods. The nurse's response is based on the knowledge that: A. Milk intake should be limited to no more than four 8-oz bottles per day and should be followed by iron-enriched cereal or other solid foods or juices B. Milk is an excellent food and will meet his nutritional needs adequately until he is ready to eat solid foods C. It is acceptable to continue to give him whole milk and to delay giving solid foods as long as he takes a vitamin supplement daily D. He should be started on iron-enriched cereal, meat, vegetables, fruits, and juices prior to bottle feeds. Milk intake should be limited to 1 qt/day
Answer: D Explanation: (A) If the infant is given the bottle first, he will be less likely to be hungry enough to eat the solid foods. (B) Milk is deficient in iron, vitamin C, zinc, and fluoride. It does not provide an adequate diet. (C) The vitamin supplement will help, but the infant needs an iron supplement. (D) Giving the solid food when the infant is hungriest will increase the likelihood that he will eat. The more solid food he takes, the less milk he will desire.
NO.383 Discharge teaching was effective if the parents of a child with atopic dermatitis could state the importance of: A. Maintaining a high-humidified environment B. Furry, soft stuffed animals for play C. Showering 3-4 times a day D. Wrapping hands in soft cotton gloves
Answer: D Explanation: (A) Maintaining a low-humidified environment. (B) Avoiding furry, soft stuffed animals for play, which may increase symptoms of allergy. (C) Avoiding showering, which irritates the dermatitis, and encouraging bathing 4 times a day in colloid bath for temporary relief. (D) Wrapping hands in soft cotton gloves to prevent skin damage during scratching.
NO.380 What is the most effective method to identify early breast cancer lumps? A. Mammograms every 3 years B. Yearly checkups performed by physician C. Ultrasounds every 3 years D. Monthly breast self-examination
Answer: D Explanation: (A) Mammograms are less effective than breast self-examination for the diagnosis of abnormalities in younger women, who have denser breast tissue. They are more effective forwomen older than 40. (B) Up to 15% of early-stage breast cancers are detected by physical examination; however, 95% are detected by women doing breast self-examination. (C) Ultrasound is used primarily to determine the location of cysts and to distinguish cysts from solid masses. (D) Monthly breast self-examination has been shown to be the most effective method for early detection of breast cancer. Approximately 95% of lumps are detected by women themselves.
NO.395 Several months after antibiotic therapy, a child is readmitted to the hospital with an exacerbation of osteomyelitis, which is now in the chronic stage. The mother appears anxious and asks what she could have done to prevent the exacerbation. The nurse's response is based on the knowledge that chronic osteomyelitis: A. Is caused by poor physical conditions or poor nutrition B. Often results from unhygienic conditions or an unclean environment C. Is directly related to sluggish circulation in the affected limb D. May develop from sinuses in the involved bone that retain infectious material
Answer: D Explanation: (A) Poor nutrition and/or poor physical conditions are factors that predispose to the development of osteomyelitis but do not cause it. (B) An unclean or unhygienic environment may predispose to the development of chronic osteomyelitis, but it does not cause an exacerbation of the previous infection. (C) Sluggish circulation through the medullary cavity during acute osteomyelitis may delay healing, but it does not cause the disease to become chronic. (D) Areas of sequestrum may be surrounded by dense bone, become honeycombed with sinuses, and retain infectious organisms for a long time.
