NCLEX-PN 3000
Preschooler For a child who's admitted to the emergency department with an acute asthma attack, nursing data collection is most likely to reveal: 1. apneic periods. 2. expiratory wheezing. 3. inspiratory stridor. 4. absent breath sounds.
ANSWER 2 RATIONALES: Expiratory wheezing is common during an acute asthma attack and results from narrowing of the airway caused by edema. Acute asthma rarely causes apneic periods. Inspiratory stridor more commonly accompanies croup. Acute asthma is more likely to cause adventitious breath sounds than absent breath sounds; however, adventitious sounds are an ominous sign because the client is unable to exchange air.
When collecting data on a neonate, the nurse observes a vaguely outlined area of scalp edema. Which term should the nurse use when documenting this observation? 1. Cephalhematoma 2. Petechiae 3. Subdural hematoma 4. Caput succedaneum
ANSWER #4 RATIONALES: Caput succedaneum refers to a vaguely outlined area of scalp edema that crosses the suture line and typically clears within a few days after birth. Cephalhematoma is a swelling of the head that results from subcutaneous bleeding caused by pressure exerted on the soft tissues during delivery; it's characterized by sharply demarcated boundaries that don't cross the suture lines. Petechiae are minute, circumscribed, hemorrhagic areas of the skin. A subdural hematoma is a collection of blood between the dura and the brain.
Endocrine and Metabolic Disorders In a 28-year-old female client who is being successfully treated for Cushing's syndrome, the nurse would expect a decline in: 1. serum glucose level. 2. hair loss. 3. bone mineralization. 4. menstrual flow.
Correct Answer: 1 RATIONALES: Hyperglycemia, which develops from glucocorticoid excess, is a manifestation of Cushing's syndrome. With successful treatment of the disorder, serum glucose levels decline. Hirsutism is common in Cushing's syndrome; therefore, with successful treatment, abnormal hair growth also declines. Osteoporosis occurs in Cushing's syndrome; therefore, with successful treatment, bone mineralization increases. Amenorrhea develops in Cushing's syndrome. With successful treatment, the client experiences a return of menstrual flow, not a decline.
Intrapartum Period For a client who's moving into the active phase of labor, the nurse should include which of the following as the priority of care? 1. Offer support by reviewing the short-pant form of breathing. 2. Administer opioid analgesia. 3. Allow the mother to walk around the unit. 4. Watch for rupture of the membranes.
Correct Answer: 1 RATIONALES: By helping the client use the pant form of breathing, the nurse can help the client manage her contractions and reduce the need for opioids and other forms of pain relief, which can have an effect on fetal outcome. In the active phase, the mother most likely is too uncomfortable to walk around the unit. The nurse will observe for rupture of membranes and may administer opioid analgesia but these actions don't take priority.
School-Age Child A child, age 10, is hospitalized for treatment of acute osteomyelitis. After recognizing swelling and tenderness of the left tibia, the nurse initiates antibiotic therapy as prescribed. The child's left leg is immobilized in a splint. What is an expected outcome for this child? 1. "The client will change position as soon as he feels minimal discomfort." 2. "The client will bear weight on the affected limb." 3. "The client will ambulate with crutches." 4. "The client will participate in age-appropriate activities."
Correct Answer: 1 RATIONALES: To prevent pressure sores, the child must turn and change positions periodically. However, during the acute phase of osteomyelitis, moving the affected leg may cause extreme pain and discomfort. Therefore, the nurse must support and handle the leg gently during turning and repositioning. Weight bearing is contraindicated because it may cause pathologic fractures. Ambulating with crutches is an inappropriate outcome because the child is restricted to bed rest and the affected leg is immobilized to limit the spread of infection. Participation in age-appropriate activities isn't a realistic outcome because an acutely ill child isn't likely to be interested in activities; this outcome would be suitable after the acute disease phase ends.
The Nursing Process A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is a correctly written client outcome for this nursing diagnosis? 1. "Before discharge, the client correctly identifies three potassium-rich food sources." 2. "The client knows the importance of consuming potassium-rich foods daily." 3. "Before discharge, the client knows which food sources are high in potassium." 4. "The client understands all complications of the disease process."
Correct Answer: 1 RATIONALES: A client outcome must be measurable, objective, concise, realistic for the client, and attainable through nursing management. For each client outcome, the nurse should include only one client behavior, should express that behavior in terms of client expectations, and should indicate a time frame. Knowing the importance of consuming potassium-rich foods and knowing which foods are high in potassium aren't measurable. Understanding all complications isn't measurable or specific to the nursing diagnosis listed.
Cardiovascular Disorders The nurse administers basic cardiac life support to a client in cardiac arrest after establishing unresponsiveness. Which action does the nurse perform during basic life support? 1. Assessing the patency of the airway 2. Administering I.V. medications 3. Administering a countershock of 200 joules 4. Breathing for the client after inserting an endotracheal (ET) tube
Correct Answer: 1 RATIONALES: A nurse certified in basic cardiac life support can assess airway patency. I.V. medications given to maintain blood pressure, correct acidosis, or restore a cardiac rhythm are administered by a provider of advanced cardiac life support. Administering a countershock of 200 joules and breathing for the client after inserting an ET tube are measures carried out during advanced life support.
Substance Abuse, Eating Disorders, Impulse Control Disorders A client is admitted for an overdose of amphetamines. When collecting data on this client, the nurse should expect to see: 1. tension and irritability. 2. slow pulse. 3. hypotension. 4. constipation.
Correct Answer: 1 RATIONALES: An amphetamine is a nervous system stimulant that is subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Options 2 and 3 are incorrect because amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea is a common adverse effect, so option 4 is incorrect.
Endocrine and Metabolic Disorders Hyperthyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction would experience: 1. heat intolerance and systolic hypertension. 2. weight gain and heat intolerance. 3. diastolic hypertension and widened pulse pressure. 4. anorexia and hyperexcitability.
Correct Answer: 1 RATIONALES: An increased metabolic rate in a client with hyperthyroidism caused by excess serum thyroxine leads to systolic hypertension and heat intolerance. Weight loss — not gain — occurs because of the increased metabolic rate. Diastolic blood pressure decreases because of decreased peripheral resistance. Heat intolerance and widened pulse pressure can occur, but systolic hypertension and diastolic hypertension don't. Clients with hyperthyroidism experience an increase in appetite — not anorexia.
Gastrointestinal Disorders When collecting data on a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as: 1. a canker sore of the oral soft tissues. 2. an acute stomach infection. 3. acid indigestion. 4. an early sign of peptic ulcer disease
Correct Answer: 1 RATIONALES: Aphthous stomatitis refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks. Aphthous stomatitis isn't an acute stomach infection, acid indigestion, or early sign of peptic ulcer disease.
Antepartum Period During a physical examination, a client who's 32 weeks pregnant becomes pale, dizzy, and light-headed while supine. Which action should the nurse immediately take? 1. Turn the client on her left side. 2. Ask the client to breathe deeply. 3. Listen to fetal heart tones. 4. Measure the client's blood pressure.
Correct Answer: 1 RATIONALES: As the uterus enlarges, pressure on the inferior vena cava increases. This pressure compromises venous return and causes blood pressure to drop, which may lead to syncope and accompanying symptoms when the client is supine. Turning the client on her left side relieves pressure on the vena cava, restoring normal venous return and blood pressure. Deep breathing wouldn't relieve this client's symptoms. Listening to fetal heart tones and measuring the client's blood pressure wouldn't provide relevant information nor would they treat the client's symptoms.
Genitourinary Disorders The nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence? 1. Encouraging intake of at least 2 L of fluid daily 2. Giving the client a glass of soda before bedtime 3. Taking the client to the bathroom twice per day 4. Consulting with a dietitian
Correct Answer: 1 RATIONALES: By encouraging a daily fluid intake of at least 2 L, the nurse helps fill the client's bladder, thereby promoting bladder retraining by stimulating the urge to void. The nurse shouldn't give the client soda before bedtime; soda acts as a diuretic and may make the client incontinent. The nurse should take the client to the bathroom or offer the bedpan at least every 2 hours throughout the day; twice per day is insufficient. Consultation with a dietitian won't address the problem of urinary incontinence.
Basic Physical Assessment A client undergoes a total abdominal hysterectomy. When checking the client 10 hours later, the nurse identifies which finding as an early sign of shock? 1. Restlessness 2. Pale, warm, dry skin 3. Heart rate of 110 beats/minute 4. Urine output of 30 ml/hour
Correct Answer: 1 RATIONALES: Early in shock, hyperactivity of the sympathetic nervous system causes increased epinephrine secretion, which typically makes the client restless, anxious, nervous, and irritable. It also decreases tissue perfusion to the skin, causing pale, cool, clammy skin. An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits.
Intrapartum Period A client who comes to the labor and delivery area tells the nurse she believes her membranes have ruptured. When obtaining her history, what should the nurse ask about first? 1. The time of membrane rupture 2. The frequency of contractions 3. The presence of back pain 4. The presence of bloody show
Correct Answer: 1 RATIONALES: First, the nurse should ask the client when her membranes ruptured because the risk of perinatal infection increases with the time elapsed between membrane rupture and the onset of contractions. After determining the time of membrane rupture, the nurse should ask about the frequency of contractions and find out whether the client has back pain or bloody show.
Intrapartum Period When assessing a client who has just delivered a neonate, the nurse finds that the fundus is boggy and deviated to the right. What should the nurse do? 1. Have the client void. 2. Assess the client's vital signs. 3. Evaluate lochia characteristics. 4. Massage the fundus.
Correct Answer: 1 RATIONALES: Having the client void can determine whether the boggy, deviated fundus results from a full bladder — the most common cause of these fundal findings. Vital sign assessment is unnecessary unless the nurse suspects hemorrhage from delayed involution. Evaluation of the lochia is done to detect possible hemorrhage. If the uterus remains boggy after the client voids, or if hemorrhage is suspected, the nurse should massage the fundus.
Intrapartum Period During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin (Pitocin). When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate? 1. Contractions will be stronger and more uncomfortable and will peak more abruptly. 2. Contractions will be weaker, longer, and more effective. 3. Contractions will be stronger, shorter, and less uncomfortable. 4. Contractions will be stronger and shorter and will peak more slowly.
Correct Answer: 1 RATIONALES: Oxytocin administration causes stronger, more uncomfortable contractions, which peak more abruptly than spontaneous contractions. Oxytocin doesn't affect the duration of contractions.
School-Age Child A child with diabetes insipidus receives desmopressin acetate (DDAVP). When evaluating for therapeutic effectiveness, the nurse would interpret which finding as a positive response to this drug? 1. Decreased urine output 2. Increased urine glucose level 3. Decreased blood pressure 4. Relief of nausea
Correct Answer: 1 RATIONALES: The primary action of DDAVP is to stimulate water reabsorption by the kidneys, thereby decreasing the urine output. DDAVP has no effect on glucose levels, blood pressure, or nausea.
Neurosensory Disorders The nurse is collecting data on a 38-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find? 1. Vision changes 2. Absent deep tendon reflexes 3. Tremors at rest 4. Flaccid muscles
Correct Answer: 1 RATIONALES: Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of multiple sclerosis. Deep tendon reflexes may be increased or hyperactive — not absent. Babinski's sign may be positive. Tremors at rest aren't characteristic of multiple sclerosis; however, intentional tremors, or those occurring with purposeful voluntary movement, are common in clients with multiple sclerosis. Affected muscles are spastic, rather than flaccid
Basic Physical Care The nurse is informed by the secretary that her client will soon be returning from the postanesthesia care unit. What should the nurse do when preparing a surgical bed? 1. Leave the bed in the high position when finished 2. Place two pillows at the head of the bed 3. Place a bath blanket on top of the fitted sheet 4. Tuck the top sheet and blanket under the bottom of the bed
Correct Answer: 1 RATIONALES: When making a surgical bed, the nurse should leave the bed in the high position when finished. After placing the top linens on the bed, the nurse should fanfold these linens to the side opposite from where the client will enter. She can then place one pillow at the head of the bed or on a chair until the client is transferred to the bed. All of these actions promote transfer of the postoperative client from the stretcher to the bed. When making an occupied or unoccupied bed, the nurse should place the pillow at the head of the bed and tuck the top sheet and blanket under the bottom of the bed. The nurse shouldn't place a bath blanket on top of the fitted sheet because doing so promotes skin breakdown.
Cardiovascular Disorders A client is in hemorrhagic shock. What data reflects the effectiveness of fluid replacement therapy? 1. Blood pressure 2. Hemoglobin level 3. Temperature 4. Heart rate
Correct Answer: 1 RATIONALES: With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. The hemoglobin level reflects red blood cell concentration, not overall fluid status. Temperature and heart rate aren't directly related to fluid status.
Intrapartum Period A primigravida experiences spontaneous rupture of the membranes. What should the nurse do? Select all that apply: 1. Perform a nitrazine test to confirm that the membranes are ruptured. 2. Monitor fetal heart rate and pattern. 3. Assess maternal temperature. 4. Tell the client that delivery will most likely occur within the next hour. 5. Prepare the client for delivery.
Correct Answer: 1,2,3 RATIONALES: When membranes rupture, the nurse should immediately check fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. She should also perform a nitrazine test to confirm that the membranes are ruptured. Maternal temperature should be assessed every 1 to 2 hours so infection can be identified early. Membranes may rupture any time during labor. In some cases, 24 hours may pass between rupture and onset of labor, so the nurse doesn't need to prepare for delivery at this time.
Preschooler Which of the following immunizations should the nurse in the pediatrician's office verify the child has had on entering school? Select all that apply: 1. Hepatitis B series 2. Diphtheria-tetanus-acellular pertussis (DTaP) series 3. Haemophilus influenzae type b series 4. Varicella zoster (if the child never had chickenpox) 5. Pneumonia vaccine 6. Inactivated polio series.
Correct Answer: 1,2,3,4,6 RATIONALES: Hepatitis B series, DTaP series, H. influenzae type b series, inactivated polio series, and the varicella zoster vaccine (administered only if the child hasn't had chickenpox) are immunizations that the child should receive before entering first grade. Pneumonia vaccine isn't required or routinely given to children.
Basic Physical Assessment The nurse is collecting data on a client who has a rash on his chest and upper arms. Which questions should the nurse ask in order to obtain more information about the client's rash? Select all that apply: 1. "When did the rash start?" 2. "Are you allergic to any medications, foods, or pollen?" 3. "How old are you?" 4. "What have you been using to treat the rash?" 5. "Have you traveled outside of the country?" 6. "Do you smoke cigarettes or drink alcohol?"
Correct Answer: 1,2,4,5 RATIONALES: Finding out when the rash first appeared helps the physician make a diagnosis and determine at what stage in the disease process the rash is. Obtaining an allergy history is necessary because rashes related to allergies can occur when a client changes medications, eats new foods, or has contact with allergens in the air (such as pollen). How the client has been treating the rash is important because topical ointments and oral medications may make the rash worse. Travel outside of the country exposes the client to foreign foods and environments that can contribute to the onset of a rash. The client's age and smoking or drinking habits have no real value in determining the cause of the rash.
Intrapartum Period Which conditions are contraindications to epidural blocks? Select all that apply: 1. Infection at the injection site 2. Allergy to the anesthetic drug 3. Urinary tract infection 4. Anticoagulant therapy 5. Bleeding disorder
Correct Answer: 1,2,4,5 RATIONALES: Infection at the injection site, allergy to the anesthetic, anticoagulant therapy, and bleeding disorders are all contraindications to epidural blocks. Urinary tract infection isn't a contraindication.
Intrapartum Period The nurse is caring for a client who has been diagnosed with abruptio placenta. What signs and symptoms of abruptio placenta should the nurse expect to find when she is collecting data on this client? Select all that apply: 1. Vaginal bleeding 2. Decreased fundal height 3. Uterine tenderness on palpation 4. Soft abdomen on palpation 5. Hypotonic, small uterus 6. Abnormal fetal heart tones
Correct Answer: 1,3,6 RATIONALES: Painful vaginal bleeding, uterine tenderness on palpation, and abnormal or absent heart tones are signs of abruptio placenta. Fundal height increases during abruptio placenta as a result of blood becoming trapped behind the placenta. The abdomen would feel hard and boardlike on palpation as blood permeates the myometrium and causes uterine irritability. The uterus would also be hypertonic and enlarged.
Basic Physical Care The nurse is completing the intake and output record for a client who was restarted on his regular diet after being on nothing-by-mouth status for laboratory studies. The client has had the following intake and output during the shift: Intake: 4 oz of cranberry juice, 1/2 cup of oatmeal, 2 slices of toast, 8 oz of black decaffeinated coffee, tuna fish sandwich, 1/2 cup of fruit-flavored gelatin, 1 cup of cream of mushroom soup, 6 oz of 1% milk, 16 oz of water Output: 1,300 ml of urine How many milliliters should the nurse document as the client's intake?
Correct Answer: 1380 RATIONALES: There are 30 ml in each ounce and 240 ml in each cup. The fluid intake for this client includes 4 oz (120 ml) of cranberry juice, 8 oz (240 ml) of coffee, 1/2 cup (120 ml) of fruit-flavored gelatin, 1 cup (240 ml) of cream of mushroom soup, 6 oz (180 ml) of milk, and 16 oz (480 ml) of water, for a total of 1,380 ml.
Preschooler The physician diagnoses leukemia in a child, age 4, who complains of being tired and sleeps most of the day. Which nursing diagnosis reflects the nurse's understanding of the pathophysiology behind leukemia? 1. Ineffective airway clearance related to fatigue 2. Activity intolerance related to anemia 3. Imbalanced nutrition: More than body requirements related to lack of activity 4. Ineffective cerebral tissue perfusion related to central nervous system infiltration by leukemic cells
Correct Answer: 2 RATIONALES: A child with leukemia may experience anemia from bone marrow depression, such as from chemotherapy or replacement of normal bone marrow elements by immature white blood cells. Anemia results in fatigue, lack of energy, and activity intolerance. The information given in the question doesn't support the other diagnoses
Preschooler A child is receiving peritoneal dialysis to treat renal failure. To detect early signs of peritonitis, the nurse should stay alert for: 1. redness at the catheter site. 2. abdominal tenderness. 3. abdominal fullness. 4. headache.
Correct Answer: 2 RATIONALES: Abdominal tenderness is an early sign of peritonitis. Redness at the catheter site indicates a skin infection. Abdominal fullness is expected during dialysate infusion. Headache isn't associated with peritonitis.
Genitourinary Disorders A client with chronic renal failure (CRF) is receiving a hemodialysis treatment. After hemodialysis, the nurse knows that the client is most likely to experience: 1. hematuria. 2. weight loss. 3. increased urine output. 4. increased blood pressure.
Correct Answer: 2 RATIONALES: Because CRF causes loss of renal function, the client with this disorder retains fluid. Hemodialysis removes this fluid, causing weight loss. Hematuria is unlikely to follow hemodialysis because the client with CRF usually forms little or no urine. Hemodialysis doesn't increase urine output because it doesn't correct the loss of kidney function, which severely decreases urine production in this disorder. By removing fluids, hemodialysis decreases rather than increases the blood pressure.
Preschooler A child, age 5, is to receive potassium added to the I.V. fluid. Before initiating this therapy, the nurse first should: 1. check the child's apical pulse rate. 2. measure the blood pressure. 3. monitor fluid intake and output. 4. evaluate respiratory rate and depth.
Correct Answer: 3 RATIONALES: Potassium shouldn't be added to the I.V. fluid until the child regains adequate kidney function, as indicated by balanced fluid intake and output and certain diagnostic test results. The other options aren't related to potassium administration.
Preschooler A preschool child presents with a history of vomiting and diarrhea for 2 days. Which data collection finding indicates that the child is in the late stages of shock? 1. Tachycardia 2. Bradycardia 3. Irritability 4. Urine output of 1 to 2 ml/kg/hour
Correct Answer: 2 RATIONALES: Bradycardia is a sign of late shock in a pediatric client. Cardiovascular dysfunction and impairment of cellular function lead to lowered perfusion pressures, increased precapillary arteriolar resistance, and venous capacitance. Decreased cardiac output occurs in late shock if the circulating volume isn't replaced. Tachycardia and irritability occur during the early phase of shock as compensatory mechanisms are implemented to increase cardiac output. Normal urine output for a pediatric client is 1 to 2 ml/kg/hour; volumes less than this would indicate a decrease in renal perfusion and activation of the renin-angiotensin-aldosterone system to decrease water and sodium excretion.
Intrapartum Period Which action should the nurse perform if the client's blood pressure falls during the first or second stage of labor? 1. Position the client supine. 2. Administer oxygen through a face mask at 6 to 10 L/minute. 3. Assess the client's need for pain medication. 4. Assist the client with breathing techniques.
Correct Answer: 2 RATIONALES: If the client develops hypotension during the first or second stage of labor, the nurse should position the client on her left side (not supine) and administer oxygen through a face mask at 6 to 10 L/minute. Pain medication or lying supine may have caused the client's hypotension. The nurse can assist the client with breathing techniques after the hypotension has resolved.
Infant An infant, age 10 months, is brought to the well-baby clinic for a follow-up visit. The mother tells the nurse that she has been having trouble feeding her infant solid foods. To help correct this problem, the nurse should: 1. point out that tongue thrusting is the infant's way of rejecting food. 2. instruct the mother to place the food at the back and toward the side of the infant's mouth. 3. advise the mother to puree foods if the child resists them in solid form. 4. suggest that the mother force-feed the child if necessary.
Correct Answer: 2 RATIONALES: Placing the food at the back and toward the side of the infant's mouth encourages swallowing. Tongue thrusting is a physiologic response to food placed incorrectly in the mouth. Offering pureed foods wouldn't encourage swallowing, which is a learned behavior. Force-feeding may be frustrating for both the mother and child and may cause the child to gag and choke when attempting to reject the undesired food; also, it may lead to a higher-than-normal caloric intake, resulting in obesity.
Substance Abuse, Eating Disorders, Impulse Control Disorders Which psychosocial influence has been causally related to the development of aggressive behavior and conduct disorder? 1. An overbearing mother 2. Rejection by peers 3. A history of schizophrenia in the family 4. Low socioeconomic status
Correct Answer: 2 RATIONALES: Studies indicate that children who are rejected by their peers are more likely to behave aggressively. Aggression and conduct disorder are represented in all socioeconomic groups. Schizophrenia and an overbearing mother haven't been associated with aggression or conduct disorder.
Adolescent At what age should boys be taught how to do a monthly testicular self-examination? 1. 8 years old 2. 12 years old 3. 16 years old 4. When they become sexually active
Correct Answer: 2 RATIONALES: Testicular cancer occurs most frequently between the ages of 15 and 34; therefore, boys should begin doing testicular self-examinations at age 12, which will help them become familiar with the normal contours and consistency of their genital structures.
Infant Which of the following is an early sign of heart failure in an infant with a congenital heart defect? 1. Tachypnea 2. Tachycardia 3. Poor weight gain 4. Pulmonary edema
Correct Answer: 2 RATIONALES: The earliest sign of heart failure in infants is tachycardia (sleeping heart rate greater than 160 beats/minute) as a direct result of sympathetic stimulation. Tachypnea (respiratory rate greater than 60 breaths/minute in infants) occurs in response to decreased lung compliance. Poor weight gain is a result of the increased energy demands to the heart and breathing efforts. Pulmonary edema occurs as the left ventricle fails and blood volume and pressure increase in the left atrium, pulmonary veins, and lungs.
Intrapartum Period When assessing the fetal heart rate tracing, the nurse assesses the fetal heart rate at 170 beats/minute. This rate is considered fetal tachycardia if which of the following occurs? 1. The fetal heart rate remains at greater than 160 beats/minute for 5 minutes. 2. The fetal heart rate remains at greater than 160 beats/minute for 10 minutes. 3. The fetal heart rate remains at greater than 160 beats/minute for more than 20 minutes. 4. The fetal heart rate is at least 170 beats/minute at any time.
Correct Answer: 2 RATIONALES: The normal parameter for the fetal heart rate is 120 to 160 beats/minute. Tachycardia is defined as a fetal heart rate greater than 160 beats/minute for more than 10 minutes. This definition takes into account the difference between tachycardia and acceleration.
Intrapartum Period Which of the following should be the nurse's initial action immediately following the birth of the neonate? 1. Aspirating mucus from the neonate's nose and mouth 2. Drying the neonate to stabilize the neonate's temperature 3. Promoting parental bonding 4. Identifying the neonate
Correct Answer: 2 RATIONALES: The nurse's first action is to dry the neonate and stabilize the neonate's temperature. Aspiration of the neonate's nose and mouth occurs at the time of delivery. Promoting parental bonding and identifying the neonate are appropriate after the neonate has been dried.
The Neonate To minimize the amount of a drug received by an infant through breast-feeding, the nurse should tell the mother to: 1. take the medication immediately before breast-feeding. 2. take the medication immediately after breast-feeding. 3. feed the infant 2 hours after taking the medication. 4. feed the infant 4 hours after taking the medication.
Correct Answer: 2 RATIONALES: To minimize the amount of a drug received by an infant, the nurse should tell the mother to take the medication immediately after breast-feeding. Feeding the infant within 4 hours after taking the medication increases the risk of the drug being present in breast milk.
Preschooler What is a normal systolic blood pressure for a 3-year-old child? 1. 100 mm Hg 2. 86 mm Hg 3. 120 mm Hg 4. 60 mm Hg
Correct Answer: 2 RATIONALES: Using the formula systolic blood pressure = 80 + (age in years × 2), the estimated blood pressure for a 3-year-old child is 80 + (3 × 2) = 86.
Integumentary Disorders Which instructions should be included in the teaching plan of a 19-year-old client with acne vulgaris who's prescribed tretinoin (Retin-A), benzoyl peroxide, and tetracycline (Achromycin)? Select all that apply: 1. Expect your skin to look red and start to peel after treatment. 2. Take tetracycline on an empty stomach. 3. Use tretinoin and benzoyl peroxide together in the morning and at night. 4. Maintain the prescribed treatment because it is more likely to improve acne than a strict diet and fanatic scrubbing with soap and water. 5. Apply tretinoin at least 30 minutes after washing the face and at bedtime. 6. Avoid exposure to sunlight and don't use a sunscreen.
Correct Answer: 2,4 RATIONALES: Because the prescribed regimen includes tretinoin and benzoyl peroxide, the nurse should instruct the client to use one preparation in the morning and the other at night. Tretinoin should be applied 30 minutes after washing the face and at least 1 hour before bedtime. The nurse should instruct the client receiving tretinoin that his skin should look pink and dry after treatment. If the skin appears red or starts to peel, the preparation may have to be weakened or applied less often. The client should be instructed to take tetracycline on an empty stomach. The nurse should also make sure that the client understands that the prescribed treatment is more likely to improve acne than are a strict diet and fanatic scrubbing with soap and water. The nurse should advise the client to avoid exposure to sunlight or to use a sunscreen.
Antepartum Period A client with pregnancy-induced hypertension (PIH) probably exhibits which of the following symptoms? 1. Proteinuria, headaches, and vaginal bleeding 2. Headaches, double vision, and vaginal bleeding 3. Proteinuria, headaches, and double vision 4. Proteinuria, double vision, and uterine contractions
Correct Answer: 3 RATIONALES: A client with PIH complains of headache, double vision, and sudden weight gain. A urine specimen reveals proteinuria. Vaginal bleeding and uterine contractions aren't associated with PIH.
The Nursing Process The nurse assists in developing a list of nursing diagnoses for a client. This list should include: 1. actions to achieve goals. 2. expected outcomes. 3. factors influencing the client's problem. 4. nursing history.
Correct Answer: 3 RATIONALES: A nursing diagnosis is a written statement of the client's actual or potential health problem. It includes a specified diagnostic label, factors that influence the client's problem, and any signs or symptoms that help define the diagnostic label. Actions to achieve goals are nursing interventions. Expected outcomes are measurable behavioral goals that the nurse develops during the evaluation step of the nursing process. The nurse obtains a nursing history during the assessment step of the nursing process.
Integumentary Disorders A client with atopic dermatitis is prescribed a potent topical corticosteroid. To address a potential client problem associated with this treatment, the nurse helps formulate the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement, which "related-to" phrase should be added? 1. Related to potential interactions between the topical corticosteroid and other prescribed drugs 2. Related to vasodilatory effects of the topical corticosteroid 3. Related to percutaneous absorption of the topical corticosteroid 4. Related to topical corticosteroid application to the face, neck, and intertriginous sites
Correct Answer: 3 RATIONALES: A potent topical corticosteroid may increase the client's risk for injury because it may be absorbed percutaneously, causing the same adverse effects as systemic corticosteroids. Topical corticosteroids aren't involved in significant drug interactions. These preparations cause vasoconstriction, not vasodilation. A potent topical corticosteroid rarely is prescribed for use on the face, neck, or intertriginous sites because application on these areas may lead to increased adverse effects.
Basic Physical Assessment When inspecting a client's skin, the nurse finds a vesicle on the client's arm. Which description applies to a vesicle? 1. Flat, nonpalpable, and colored 2. Solid, elevated, and circumscribed 3. Circumscribed, elevated, and filled with serous fluid 4. Elevated, pus-filled, and circumscribed
Correct Answer: 3 RATIONALES: A vesicle is a circumscribed skin elevation filled with serous fluid. A flat, nonpalpable, colored spot is a macule. A solid, elevated, circumscribed lesion is a papule. An elevated, pus-filled, circumscribed lesion is a pustule.
Gastrointestinal Disorders A client who received an inhalation anesthetic during GI surgery experiences severe shivering postoperatively. In addition to providing extra blankets, the nurse should: 1. notify the physician immediately. 2. increase the I.V. fluid infusion rate. 3. provide oxygen as prescribed. 4. monitor fluid intake and output.
Correct Answer: 3 RATIONALES: Hypothermia is a common effect of inhalation anesthetics, and shivering is normal during postoperative recovery. Administering oxygen as prescribed compensates for the increased oxygen demand caused by shivering. Notifying the physician is necessary only if the client has other signs and symptoms, such as respiratory distress or changes in skin color or vital signs. Increasing the I.V. fluid infusion rate could cause fluid overload. The nurse should monitor the fluid intake and output of all postoperative clients, not just those who are shivering or who received an inhalation anesthetic.
Cardiovascular Disorders A client develops atrial fibrillation after an acute myocardial infarction. The physician prescribes digoxin (Lanoxin), 0.125 mg I.M. daily. The nurse clarifies the order with the physician because I.M. administration of digoxin leads to: 1. an increased serum creatinine level. 2. a decreased serum digoxin level. 3. an increased serum creatine kinase (CK) level. 4. a decreased serum CK level.
Correct Answer: 3 RATIONALES: I.M. administration of digoxin isn't recommended because it causes severe pain at the injection site and increases serum CK, which complicates interpretation of enzyme levels. Regardless of the route of administration, digoxin doesn't increase the serum creatinine level. When digoxin is administered, the serum digoxin level will rise, not decrease.
Substance Abuse, Eating Disorders, Impulse Control Disorders The nurse is providing care for a client undergoing opiate withdrawal. Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with: 1. barbiturates. 2. amphetamines. 3. methadone. 4. benzodiazepines.
Correct Answer: 3 RATIONALES: Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesn't have the same deleterious effects as other opiates, such as cocaine, heroin, and morphine. Barbiturates, amphetamines, and benzodiazepines are highly addictive and would require detoxification treatment.
Respiratory Disorders Which of the following is the hallmark of adult respiratory distress syndrome (ARDS)? 1. Copious amounts of mucus 2. Expectoration of foul sputum 3. Progressive hypoxemia despite oxygen therapy 4. Wheezing and shortness of breath
Correct Answer: 3 RATIONALES: Progressive hypoxemia despite oxygen therapy is the hallmark of ARDS. Copious amounts of mucus is characteristic of bronchitis, expectoration of foul sputum indicates bronchiectasis, and wheezing and shortness of breath are symptoms of asthma
Basic Physical Care Which scenario requires the licensed practical nurse (LPN) to notify the registered nurse (RN) immediately? 1. Decrease in a client's blood pressure from 160/90 mm Hg to 140/84 mm Hg 2. Complaint of pain that rates 7 on a 1-to-10 pain-rating scale 3. Apical pulse rate of 90 beats/minute with a radial pulse rate of 70 beats/minute 4. Family inquiry about the client's discharge time
Correct Answer: 3 RATIONALES: The LPN should immediately report an apical pulse rate of 90 beats/minute associated with a radial pulse rate of 70 beats/minute, which indicates a pulse deficit of 20 beats/minute. This finding signifies an irregular heartbeat that might lead to a decrease in cardiac output. Option 1 is a positive finding and doesn't need to be reported immediately. The LPN can assess pain and administer pain medications as prescribed. The LPN can provide the family with an estimated discharge time without consulting the RN.
Substance Abuse, Eating Disorders, Impulse Control Disorders A client who reportedly consumes 1 qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, the physician is most likely to prescribe which drug? 1. Clozapine (Clozaril) 2. Thiothixene (Navane) 3. Lorazepam (Ativan) 4. Lithium carbonate (Eskalith)
Correct Answer: 3 RATIONALES: The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a benzodiazepine. Clozapine and thiothixene are antipsychotic agents, and lithium carbonate is an antimanic agent; these drugs aren't used to manage alcohol withdrawal syndrome.
The Nursing Process Which option serves as a framework for nursing education and clinical practice? 1. Scientific breakthroughs 2. Technological advances 3. Theoretical and conceptual models 4. Medical practices
Correct Answer: 3 RATIONALES: Theoretical and conceptual models of nursing provide the foundation for all nursing knowledge. They also direct nursing practice based on the concepts of health, person, environment, and nursing. Scientific breakthroughs, technological advances, and medical practices may affect nursing but aren't frameworks for nursing education and practice.
Cardiovascular Disorders When assessing a client with left-sided heart failure, the nurse expects to note: 1. ascites. 2. jugular vein distention. 3. air hunger. 4. pitting edema of the legs.
Correct Answer: 3 RATIONALES: With left-sided heart failure, the client typically has air hunger and other signs of pulmonary congestion. Ascites, jugular vein distention, and pitting edema of the legs are signs of right-sided heart failure.
Medication and I.V. Administration The nurse is administering ampicillin (Polycillin) 125 mg I.M. every 6 hours to a 10-kg child with a respiratory tract infection. The drug label reads, "The recommended dose for a client weighing less than 40 kg is 25 mg to 50 mg/kg/day I.M. or I.V. in equally divided doses at 6- to 8-hour intervals." The drug concentration is 125 mg/5 ml. Which nursing interventions are appropriate at this time? Select all that apply: 1. Draw up 10 ml of ampicillin to administer. 2. Administer the medication at 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. 3. Assess the client for allergies to penicillin. 4. Administer the medication because it's within the dosing recommendations. 5. Question the physician about the order because it's more than the recommended dosage. 6. Obtain a sputum culture before administering the medication.
Correct Answer: 3,4,6 RATIONALES: Because ampicillin is a penicillin antibiotic, the client should be assessed for allergy to penicillin before the medication is administered. The dose of ampicillin is within the recommended range for a 10-kg client: 50 mg/kg X 10 kg = 500 mg. A dose of 500 mg divided by 4 (given every 6 hours) = 125 mg, which is within the recommended range. Cultures should be obtained before antibiotics are given. The nurse should draw up 5 ml to administer the correct dose, according to the concentration on the label. The dosing schedule in option 2 is in 4-hour intervals and shouldn't be used because the recommended dosing is in 6- to 8-hour intervals.
Basic Physical Care Which task can the licensed practical nurse (LPN) appropriately delegate to the nursing assistant? 1. Obtaining vital signs on a client who has just returned from undergoing a colonoscopy 2. Feeding a client for the first time after he has experienced a stroke 3. Administering feedings through a nasogastric tube 4. Encouraging a client to drink fluids
Correct Answer: 4 RATIONALES: The LPN can safely delegate the task of encouraging a client to drink fluids. The LPN shouldn't delegate obtaining vital signs on a client who just underwent a colonoscopy because the client might be unstable and may require nursing intervention. Vital signs can be delegated when the client's condition stabilizes. The client newly diagnosed with a stroke must undergo swallowing studies before feeding. After swallowing studies verify that the client is able to eat, licensed personnel should assist the client with eating for the first time. Nursing assistants aren't qualified to administer feedings through a nasogastric tube.
Medication and I.V. Administration Which type of solution, when administered I.V., would cause a shift of fluid from the interstitial space to the intravascular space? 1. Hypotonic 2. Isotonic 3. Sodium chloride 4. Hypertonic
Correct Answer: 4 RATIONALES: A hypertonic solution causes fluids to be absorbed into the intravascular space until equal pressure is established on both sides of the blood vessel. A hypotonic solution causes fluids to move from the intravascular space into the interstitial space. An isotonic solution has no effect on the cell. A sodium chloride solution can be isotonic, hypertonic, or hypotonic, depending on the concentration of sodium.
Psychotic Disorders Important teaching for a client receiving risperidone (Risperdal) would include advising the client to: 1. double the missed dose to maintain a therapeutic level. 2. be sure to take the drug with a meal because the medication is very irritating to the stomach. 3. discontinue the drug if the client reports weight gain. 4. notify the physician if the client notices an increase in bruising.
Correct Answer: 4 RATIONALES: Bruising may indicate blood dyscrasias, so notifying the physician about increased bruising is very important. Don't double the dose. This drug doesn't irritate the stomach, and weight gain isn't a problem.
Foundations of Psychiatric Nursing A nurse immediately tells the truth about a medication error that she made. This nurse is following which ethical principle? 1. Fidelity 2. Beneficence 3. Respect 4. Veracity
Correct Answer: 4 RATIONALES: By telling the truth, the nurse is following the ethical principle known as veracity. Fidelity is the process of following through with promises. Beneficence is the act of doing good for the benefit of others. When the nurse treats people equally and individually, she's practicing the principle known as respect.
Substance Abuse, Eating Disorders, Impulse Control Disorders Which task is most important when developing a plan of care for a client with anorexia nervosa? 1. Assessing laxative use 2. Monitoring electrolyte levels 3. Monitoring intake and output 4. Evaluating exercise activities
Correct Answer: 4 RATIONALES: Evaluating exercise activities is a priority nursing action for clients with anorexia nervosa. Assessing laxative use and monitoring electrolyte levels and intake and output are important in clients with bulimia nervosa because they tend to induce vomiting and abuse laxatives and diuretics. Vomiting and abusing laxatives and diuretics can cause fluid and electrolyte imbalances.
Genitourinary Disorders A client who returned from a cystoscopic examination complains of pain while attempting to void. Which intervention should a nurse suggest to ease the client's pain while attempting to void? 1. Drink plenty of fluids. 2. Pour water over the perineal area. 3. Run water in the bathroom sink. 4. Sit in a warm sitz bath.
Correct Answer: 4 RATIONALES: The best intervention is for the client to sit in a warm sitz bath when trying to void. Warm water relieves pain and increases circulation to the perineal area and relaxes the muscles, which helps start the voiding process. Drinking plenty of fluids will hydrate the kidneys and cause the client to make more urine. Pouring water over the perineal area will stimulate the client to urinate. Running water in the bathroom sink will also stimulate the client to void but does not address the client's pain.
Medication and I.V. Administration A client begins taking haloperidol (Haldol). After a few days, he experiences severe tonic contractures of muscles in the neck, mouth, and tongue. The nurse should recognize this as: 1. psychotic symptoms. 2. parkinsonism. 3. akathisia. 4. dystonia.
Correct Answer: 4 RATIONALES: These symptoms describe dystonia, which commonly occurs after a few days of treatment with haloperidol. The symptoms may be confused with psychotic symptoms and misdiagnosed. Parkinsonism results in muscle rigidity, shuffling gait, stooped posture, flat-faced affect, tremors, and drooling. Signs and symptoms of akathisia are restlessness, pacing, and inability to sit still.
Antepartum Period A pregnant client's last menstrual period began on October 12. The nurse calculates the estimated date of delivery (EDD) as: 1. June 5. 2. June 19. 3. July 5. 4. July 19.
Correct Answer: 4 RATIONALES: Using Nägele's rule, the nurse calculates the client's EDD by adding 7 days to the first day of the last menstrual period (12 + 7 = 19) and subtracting 3 months from the month of the last menstrual period (October - 3 months = July). This results in an EDD of July 19.