NCLEX REVIEW #1

The nurse cares for the elderly client admitted with a possible fractured right hip. During the initial nursing assessment, which observation of the right leg validates this diagnosis? 1. The leg appears to be shortened and is adducted and externally rotated. 2. Plantar flexion is observed with sciatic pain radiating down the leg. 3. From the hip, the leg appears to be longer and is externally rotated. 4. There is evidence of paresis with decreased sensation and limited mobility.

1) CORRECT — accurate assessments of the position of a fractured hip prior to repair 2) plantar flexion occurs with foot drop 3) leg would not appear to be longer 4) occurs with injury to the lumbar disc area

Prior to sending a client for a cardiac catheterization, it is most important for the nurse to report which information? 1. The client has an allergy to shellfish. 2. The client has diminished palpable peripheral pulses. 3. The client has cool lower extremities bilaterally. 4. The client is anxious about the pending procedure.

1) CORRECT — allergies to iodine and/or seafood must be reported immediately before a cardiac catheterization to avoid anaphylactic shock during the procedure 2) may be normal finding before the test 3) may be normal finding before the test 4) may be normal finding before the test

The client develops a postoperative infection and receives ceftriaxone sodium IV every day. It is most important for the nurse to monitor for which changes? 1. The surface of the tongue. 2. Hemoglobin and hematocrit. 3. Skin surfaces in skin folds. 4. Changes in urine characteristics.

1) CORRECT — cephalosporin, long-term use of ceftriaxone sodium can cause overgrowth of organisms; monitoring of tongue and oral cavity is recommended 2) does not reflect a problem with this medication 3) does not reflect a problem with this medication 4) does not reflect a problem with this medication

The nurse cares for the client with ataxia. Which action is most important? 1. Supervise ambulation. 2. Measure the intake and output accurately. 3. Consult the speech therapist. 4. Elevate the foot of the bed.

1) CORRECT — client's coordination is poor; the only relevant nursing action is to supervise ambulation 2) unnecessary 3) not relevant 4) not relevant

The client is evaluated for infertility, and the health care provider prescribes clomiphene citrate 50 mg daily for 5 days. The client asks the nurse how the medication works. Which response by the nurse is best? 1. Clomiphene citrate induces ovulation by changing hormonal effects on the ovary. 2. Clomiphene citrate changes the uterine lining to be more conducive to implantation. 3. Clomiphene citrate alters the vaginal pH to increase sperm motility. 4. Clomiphene citrate produces multiple pregnancy for those who desire twins.

1) CORRECT — clomiphene citrate induces ovulation by altering estrogen and stimulating follicular growth to produce a mature ovum 2) infertility problem, but clomiphene citrate does not affect it 3) infertility problem, but clomiphene citrate does not affect it 4) not a desired effect

The nurse cares for an older client scheduled for a colon resection this morning. The nurse notes the client had polyethylene glycol-electrolyte solution and a soapsuds enema the previous evening. This morning the client passes a medium amount of soft brown stool. Which conclusion by the nurse is most accurate? 1. The bowel preparation is incomplete. 2. The client ate something after midnight. 3. This is an expected finding before this type of surgery. 4. The client passed the last stool left in the colon.

1) CORRECT — colon should not have remaining soft stool 2) anything eaten after midnight would not appear as stool by the next morning 3) not expected; need to clean gastrointestinal tract for surgery 4) assumption; not substantiated

The nurse prepares a teaching plan regarding colostomy irrigation. The nurse includes which information? 1. The colostomy needs to be irrigated at the same time every day. 2. Irrigate the colostomy after meals to increase peristalsis. 3. Insert the catheter about 10 inches into the stoma. 4. The solution should be very warm to increase dilation and flow.

1) CORRECT — colostomy irrigation should be done at same time each day to assist in establishing a normal pattern of elimination 2) colostomy should be irrigated only once a day 3) catheter should never be inserted more than 4 inches. 4) solution should be at body temperature; increasing the temperature does not make irrigation more efficient

The nurse cares for a client diagnosed with gastric reflux due to a hiatal hernia. The client asks the nurse why food and fluids should be withheld just before going to bed. Which response by the nurse is most appropriate? 1. "You are less likely to awaken during the night with heartburn if the stomach is empty." 2. "Early-morning vomiting will be less of a problem if the stomach is empty." 3. "Drinking or eating before lying down causes decreased respirations due to increased pressure on the lungs." 4. "You may develop fluid overload if fluids are taken just before going to bed."

1) CORRECT — full stomach is more likely to slide (reflux) through the hernia, causing regurgitation and heartburn 2) vomiting is not related to hiatal hernia 3) decreased respirations are not related to hiatal hernia 4) fluid overload is not related to hiatal hernia

The child is in the early stages of nephrotic syndrome. The nurse discusses which dietary change with the parents? 1. Adequate protein, low sodium intake. 2. Low protein, low potassium intake. 3. Low potassium, low calorie intake. 4. Limited protein, high carbohydrate intake.

1) CORRECT — if child can tolerate the protein intake, then this diet is encouraged to speed healing; sodium is usually restricted 2) low protein contraindicated in clients with kidney disease 3) does not address protein need at all 4) may be appropriate only if the child cannot tolerate protein intake

The toddler diagnosed with lead poisoning is admitted to the pediatric unit. The health care provider writes an order to encourage fluids. Which fluid is best for the nurse to offer to the toddler? 1. Milk. 2. Water. 3. Orange juice. 4. Fruit punch.

1) CORRECT — milk contains calcium; calcium binds to lead and inhibits its absorption 2) good for fluid replacement; does not relate to the lead poisoning 3) good for fluid replacement; does not relate to the lead poisoning 4) good for fluid replacement; does not relate to the lead poisoning

At 32 weeks gestation, the client has an order for an ultrasound. The nurse determines that the client understands the procedure if the client makes which statement? 1. The results will inform us of the baby's size. 2. This test will evaluate the baby's lungs. 3. The test will show us if there is any problem in the baby's genes. 4. Early problems with the baby's blood can be identified with this test.

1) CORRECT — ultrasound detects the size, growth patterns, and gestational age 2) determined with lecithin/sphingomyelin (L/S) ratio by an amniocentesis 3) determined with an amniocentesis 4) determined with an amniocentesis

The health care provider inserts a temporary pacemaker in a client following a myocardial infarction. The nurse knows that which outcome is the primary purpose of the pacemaker?? 1. Increases the force of myocardial contraction. 2. Increases the cardiac output. 3. Prevents premature ventricular contractions (PVCs). 4. Prevents systemic overload.

1) action of cardiac glycosides such as digoxin 2) CORRECT — acts to regulate cardiac rhythm 3) action of antiarrhythmics such as quinidine 4) action of diuretics such as furosemide

The nurse knows that cortisol is responsible for which action? 1. Preparing the body for "flight or fight." 2. Regulating the calcium metabolism. 3. Converting proteins and fat into glucose. 4. Enhancing musculoskeletal activity.

1) action of epinephrine 2) action of parathyroid hormone parathormone 3) CORRECT — action of cortisol; is also an anti-inflammatory agent 4) action of norepinephrine

The client in labor is monitored with an internal fetal monitor. The nurse knows which is the most important reason for the fetal monitor? 1. To evaluate the progress of the client's labor. 2. To assess the strength and duration of the client's contractions. 3. To monitor the oxygen status of the fetus during labor. 4. To determine if an oxytocin drip is necessary.

1) clinical assessments provide information about progress of labor (dilation and effacement) 2) not most important reason for monitoring 3) CORRECT — goal is early detection of mild fetal hypoxia 4) fetal well-being is most important reason for fetal monitoring

The nurse cares for the client diagnosed with type 1 diabetes reporting decreased vision. The client asks the nurse what caused the visual changes. The nurse's response is based on which statement? 1. The client's decreased vision is caused by bleeding into the inner ocular chamber of the eye. 2. The client's decreased vision is caused by gradual separation of the retina from the base of the eye. 3. The client's decreased vision is caused by an increase in the size of the vessels in the back of the eye. 4. The client's decreased vision is caused by gradual destruction and degeneration of the retina.

1) complication of postoperative eye surgery or traumatic injury (hyphema) 2) describes a retinal detachment 3) destruction of the vessels, as well as edema, occurs 4) CORRECT — gradual destruction occurs because of deterioration of the retinal vessels

The nurse performs the Rinne test on a client. Which is an accurate statement of how the first part of this test is performed? 1. The stem of a vibrating tuning fork is held against the auditory canal until the client indicates sound can no longer be heard. 2. The stem of a vibrating tuning fork is held against the mastoid bone until the client indicates sound can no longer be heard. 3. The stem of a vibrating tuning fork is held in the middle of the forehead, and the client's hearing is assessed in both ears. 4. The stem of a vibrating tuning fork is positioned 2 inches behind the client's head, and the length of time sound is heard is documented.

1) inaccurate 2) CORRECT — client should hear sound again when tuning fork is moved from mastoid bone to the front of the auditory canal because air conduction is better than bone conduction 3) the Weber test 4) inaccurate

The nurse cares for the client admitted with a diagnosis of a stroke and facial paralysis. Nursing care is planned to prevent which complication? 1. Inability to talk. 2. Loss of the gag reflex. 3. Inability to open the affected eye. 4. Corneal abrasion.

1) may occur, but nursing care cannot prevent it 2) may occur, but nursing care cannot prevent it 3) may occur, but nursing care cannot prevent it 4) CORRECT — client will be unable to close eye voluntarily; when facial nerve (cranial nerve VII) is affected, the lacrimal gland will no longer supply secretions that protect the eye

The nurse knows which mood-altering drug is most often associated with an increased risk for HIV infection related to intravenous drug use? 1. Benzodiazepines. 2. Marijuana. 3. Barbiturates. 4. Narcotics.

1) not commonly used intravenously 2) not commonly used intravenously 3) not commonly used intravenously 4) CORRECT — narcotics are most often used intravenously

A postoperative cataract client is cautioned about not making sudden movements or bending over. The nurse understands that the rationale for this recommendation is to prevent which complication? 1. Impairment of cerebral blood flow and headaches. 2. Increased intracranial pressure. 3. Pressure on the ocular suture line. 4. Displacement of the lens implant.

1) not relevant to this situation 2) not relevant to this situation 3) CORRECT—sudden changes in position, constipation, vomiting, stooping, or bending over increase the intraocular pressure and put pressure on the suture line 4) occurs because of pressure on suture area; not all clients have lens implants; answer choice 3 is a more comprehensive answer

The nurse collects the following data: anger directed by client toward staff in the form of frequent sarcastic or crude comments, increased wringing of hands, and purposeless pacing, particularly after the client has used the telephone. Based on these data, the nurse makes which nursing diagnosis? 1. Impaired social interaction related to conversion reaction. 2. Risk for potential activity intolerance as evidenced by purposeless pacing. 3. Powerlessness in hospital situation. 4. Ineffective individual coping related to recent anger and anxiety.

1) not warranted with the data indicated 2) not warranted with the data indicated 3) not warranted with the data indicated 4) CORRECT — client is displaying evidence of anger and anxiety and an inability to directly deal with concerns, which is ineffective coping

The nurse identifies which finding has the greatest impact on the elderly client's ability to complete activities of daily living (ADLs)? 1. Perseveration. 2. Aphasia. 3. Mnemonic disturbance. 4. Apraxia.

1) speech disturbance, which would have the greatest impact on communication ability 2) speech disturbance, which would have the greatest impact on communication ability 3) speech disturbance, which would have the greatest impact on communication ability 4) CORRECT — apraxia is loss of purposeful movement in the absence of motor or sensory impairment; when it affects an ADL, such as dressing, the client may not be able to put clothes on properly

Several days after the delivery of a stillborn, the parents say, "We wish we could talk with other couples who have gone through this trauma." Which response by the nurse is best? 1. "SIDS will provide you with this opportunity." 2. "SHARE will provide you with this opportunity." 3. "RESOLVE will provide you with this opportunity." 4. "CANDLELIGHTERS will provide you with this opportunity."

1) support group for parents who have had an infant die from sudden infant death syndrome 2) CORRECT — SHARE is a support group for parents who have lost a newborn or have experienced a miscarriage 3) support group for infertile clients 4) support group for families who have lost a child to cancer

The nurse cares for a client receiving docusate 100 mg through a gastric tube. The solution contains 150 mg/15 mL. The nurse should administer how many mLs of the solution to the client? Do not round. Type the mLs in the box.

10ml

The nurse cares for the client receiving D5 0.45% NS 1,000 mL to run from 0900 to 1700. The drip factor on the delivery tubing is 20 gtt/mL. At what rate does the nurse set the IV to drip? Type the correct answer in the blank. Round to the nearest whole number.

42gtt/min

The nurse performs range-of-motion (ROM) exercises for an elderly client recently immobilized. The nurse identifies which statement as correct about range-of-motion? 1. Passive ROM exercises increase muscle strength. 2. A full ROM must be completed for the elderly client. 3. Exercises should be completed to the point of discomfort. 4. ROM assists the elderly to carry out activities of daily living (ADLs).

Strategy: Think about each answer. 1) inaccurate statement 2) full ROM may not be needed or accomplished without discomfort for an elderly client; ROM may be limited 3) should not be done to point of discomfort 4) CORRECT — emphasis should be on ROMs that support ADLs

The 6-month-old is brought to the clinic for a well-baby checkup. During the exam, the nurse expects to observe which assessment findings? Select all that apply. 1. A pincer grasp. 2. Sitting with support. 3. Tripling of the birth weight. 4. Presence of the posterior fontanelle 5. Playing peek-a-boo. 6. Rolling from back to abdomen.

Strategy: Think of behaviors of a 6-month-old child. 1) Present at 9 months of age. 2) CORRECT - Should occur at this age. 3) Should happen at 1 year. 4) Posterior fontanelle closes at 2-3 months of age. 5) CORRECT - Should be present at this time. 6) CORRECT - Should be able to do this.

Which symptoms might alert the nurse to consider an alcohol problem in a client hospitalized for a physical illness? Select all that apply. 1. Tremors. 2. Elevated temperature. 3. Depression. 4. Nocturnal leg cramps. 5. Night sweats. 6. Decreased concentration.

1) CORRECT - Symptom of withdrawal. 2) CORRECT - Symptom of withdrawal. 3) Seen in a depressed client 4) CORRECT - Symptom of withdrawal. 5) Seen in clients with tuberculosis, leukemia, or other infections. 6) Seen in a depressed client.

The home care nurse visits a new parent and a 2-week-old infant. The client asks the nurse which solid foods to give the child first. Which response does the nurse give? 1. Rice cereal is usually the first solid food and is started around 4 to 5 months. 2. Strained fruits are well tolerated as the first solid food, and infants like them. 3. Introduction of solid foods is not important at this time. 4. Solid foods are usually not started until the infant is around 6 months old.

1) CORRECT - infants are less likely to be allergic to rice cereal than to any other solid food; usually started between 4 and 5 months of age; breast-fed infants may be started on solids even later 2) inaccurate 3) does not answer the parent's question 4) usually started between 4 and 5 months of age

The middle-aged client is admitted to an inpatient psychiatric unit. The client reports a family member is trying to steal the client's property. The client is diagnosed with paranoid disorder. The nurse suspects the client is demonstrating which symptom? 1. Delusions of persecution. 2. Command hallucinations. 3. Delusions of reference. 4. Persecution hallucinations.

1) CORRECT — client has delusions of persecution; delusion is a strongly held belief that is not validated by reality; the idea that a family member is trying to steal property is a belief not validated by reality 2) hallucinations are sensory perceptions that take place without external stimuli; most common are auditory, or hearing voices; other types of hallucinations are tactile, visual, gustatory, and olfactory; command hallucinations involve client experiencing auditory hallucinations that are telling him/her to do something; for example, to kill someone 3) delusions of reference are a false belief that public events or people are directly related to the individual 4) are not hallucination

A client comes to the outpatient psychiatric clinic for treatment of a fear of heights. The nurse knows that phobias involve which behaviors? 1. Projection and displacement. 2. Sublimation and internalization. 3. Rationalization and intellectualization. 4. Reaction formation and symbolization.

1) CORRECT — projection (attributing one's thoughts or impulses to another) and displacement (shifting of emotion concerning person or object to another neutral or less dangerous person or object) 2) sublimation (diversion of unacceptable drives into socially acceptable channels) and internalization (incorporation of someone else's opinion as one's own) 3) rationalization (attempt to make behavior appear to be the result of logical thinking) and intellectualization (excessive reasoning or logic used to avoid experiencing disturbing feelings) 4) reaction formation (development of conscious attitudes and behavior patterns into opposite of what one really wants to do) and symbolization (something represents something else); symbolization is involved in phobias

The outpatient clinic nurse cares for an elderly client diagnosed with type 1 diabetes. Because the client is unwilling to perform blood glucose monitoring, the client tests urine for glucose and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which reason? 1. The renal threshold for glucose is elevated in the elderly. 2. Blood glucose monitoring is easier and less costly for clients to perform. 3. Urine testing for glucose provides false-positive readings. 4. Determination of the color on a reagent strip varies from person to person.

1) CORRECT — the level at which glucose starts to appear in the urine increases, leading to false-negative readings; results in elevated glucose levels 2) more expensive procedure 3) provides false-negative readings; may be negative from 0 to 180 mg/dL (0-10 mmol/L) 4) results are expressed as a percentage according to color change

The parents of a child diagnosed with hemophilia ask the nurse to explain the cause of the disease. Which response by the nurse is best? 1. "The father transmits the gene to the son." 2. "Both the mother and the father carry a recessive trait." 3. "The mother transmits the gene to her son." 4. "There is a 50% chance that the mother will pass the trait to each of the daughters."

1) affected male inherits gene from the mother and can transmit it only to the daughters 2) it is not an autosomal recessive trait 3) CORRECT — hemophilia is a sex-linked disorder 4) there is a 50% chance the mother will pass the trait to each of her children

The nurse knows that according to Erikson's stages of psychosocial development, which developmental stage best represent a 50-year-old client? 1. Integrity versus despair and disgust. 2. Generativity versus stagnation. 3. Intimacy versus isolation. 4. Identity versus role diffusion.

1) appropriate for ages 65 and older 2) CORRECT — stage of development is appropriate for 45 to 64 years of age 3) appropriate for the young adult 4) appropriate for the adolescent

The nursing team consists of an RN who has been practicing for 6 months, an LPN/LVN who has been practicing for 15 years, and a nursing assistive personnel who has been caring for clients for 3 years. The RN cares for which client? 1. The client 1 day postop after an internal fixation of a fractured left femur. 2. The client receiving diltiazem and phenytoin. 3. The client ordered to receive two units of packed cells. 4. The client admitted yesterday with exhaustion and a diagnosis of acute bipolar disorder.

1) care can be assigned to the nursing assistive personnel; standard, unchanging procedure 2) medication can be given by the LPN 3) CORRECT — requires the assessment and teaching skills of the RN 4) offer food and fluids; assign to the LPN

The adult client is preparing for a plasma cholesterol screening. Which instruction does the nurse give to the client? 1. Eat a vegetarian diet for 1 week before the test. 2. Limit alcohol intake to two glasses of wine the day before the test. 3. Abstain from dairy products for 48 hours before the test. 4. Only take sips of water for 12 hours before the test.

1) client should eat a normal diet the week before the test 2) alcohol intake will interfere with test results 3) normal diet should be eaten the week before the test 4) CORRECT — only sips of water are permitted for 12 hours before plasma cholesterol screening to achieve accurate results

The nurse cautions the client with hypothyroidism to avoid which implementation? 1. Warm environmental temperatures. 2. Narcotic sedatives. 3. Increased physical exercise. 4. A diet high in fiber

1) client with hypothyroidism cannot tolerate cold temperatures 2) CORRECT — client is very sensitive to narcotics, barbiturates, and anesthetics 3) should not be avoided 4) requires high fiber, high cellulose foods to prevent constipation

The nurse cares for the client with a tracheostomy. Which is the priority nursing diagnosis for this client? 1. Impaired verbal communication related to absence of speaking ability. 2. Ineffective airway clearance related to increased tracheobronchial secretions. 3. Risk for impaired skin integrity related to tracheostomy incision. 4. Acute pain related to tracheostomy.

1) correct diagnosis; however, answer choice 2 is the priority 2) CORRECT — ineffective airway clearance is the top priority for clients with a tracheostomy because loss of the upper airway increases the amount and viscosity of secretions 3) correct diagnosis; however, answer choice 2 is the priority 4) tracheostomy is not usually painful

The nurse supervises an LPN/LVN administering an enema to a client. The nurse determines the LPN/LVN's actions are appropriate if which action is observed? 1. The LPN/LVN places the solution 20 inches above the anus. 2. The LPN/LVN adjusts the temperature of the solution. 3. The LPN/LVN inserts the tube 6 inches. 4. The LPN/LVN positions the client left Sims' position.

1) could cause rapid infusion and possible painful distention of the colon 2) is not feasible during the administrative phase 3) tube should be inserted no more than 4 inches 4) CORRECT — allows solution to flow downward along the natural curve of the sigmoid colon and rectum, which improves retention of solution

The nurse identifies the primary reason for elderly adults to have problems with constipation is because of which process? 1. Elderly adults eat a small volume of food with decreased bulk. 2. Elderly adults engage in less activity and have decreased GI muscle tone. 3. Elderly adults have neurological changes in the gastrointestinal tract. 4. Elderly adults have decreased sensation in the gastrointestinal tract.

1) decreased intake of high-fiber foods due to chewing difficulties is seen but is not a major cause of constipation 2) CORRECT — reduced gastrointestinal motility due to decreased muscle tone, decreased exercise; other factors include prolonged use of laxatives, ignoring urge to defecate, adverse effect of medications, emotional problems, insufficient fluid intake, and excessive dietary fat 3) decreased response to stretch receptors in rectum and anal canal occurs but is not a major cause of constipation 4) decreased response to stretch receptors in rectum and anal canal occurs but is not a major cause of constipation

Which type of foods does the nurse encourage for the client diagnosed with hypoparathyroidism? 1. Foods high in phosphorus. 2. Foods high in calcium. 3. Foods low in sodium. 4. Foods low in potassium.

1) diet should be low in phosphorus; hypoparathyroidism is decreased secretion of parathyroid hormone; indications include tetany, muscular irritability, carpopedal spasms, dysphagia, paresthesia, and laryngeal spasm 2) CORRECT—diet for the client should provide high calcium and low phosphorus because the parathyroid controls calcium balance 3) not regulated by the parathyroid 4) not regulated by the parathyroid

The health care provider writes an order for a stat dose of morphine 4 mg IV for pain. Three hours later the client again reports pain, and the nurse administers a second injection of morphine. Which best describes the nurse's liability? 1. The nurse administered the medication appropriately; there is no liability. 2. There is no order for a second dose of medication; the nurse is liable. 3. The client was not injured; if injury did not occur, then the nurse is not liable. 4. The nurse should have waited at least 4 hours; then there would be no liability.

1) does not address the fact that there was no order for the morphine to be repeated 2) CORRECT — order for a stat dose is for a one time administration; nurse practice act addresses scope of practice; by administering a second dose the nurse was prescribing the medication, something only a healthcare provider with prescriptive ability can do; nurse was practicing medicine, not nursing and was outside of scope of practice 3) negligence addresses harm, not liability 4) there was no time range written in the order; illegal to administer a second dose

The nurse cares for the client diagnosed with a pneumothorax resulting from a motor vehicle accident three days ago. The client has a chest tube connected to a three-chamber water-seal drainage system with 20 cm suction. The nurse determines the lung has re-expanded if which observation is made? 1. There is no drainage in the collection chamber for 3 hours. 2. The fluid in the water-seal chamber does not fluctuate with respirations. 3. There is continuous bubbling in the water-seal chamber. 4. There is gentle bubbling in the suction-control chamber.

1) doesn't indicate re-expansion 2) CORRECT — indicates no more air leaking into pleural space 3) indicates air leak; need to check for location of leak; clamp tubing close to chest and check for bubbling, and then clamp tubing close to container and check for bubbling 4) normal finding

Which is most important for the rehabilitation nurse to assess during a new client's admission? 1. The client's expectations of family members. 2. The client's understanding of available supportive services. 3. The client's personal goals for rehabilitation. 4. The client's past experiences in the hospital.

1) important to assess but is not as crucial for future success as the client's goals 2) important to assess but is not as crucial for future success as the client's goals 3) CORRECT — it is important for the nurse to understand what the client expects from the rehabilitation program for future success 4) important to assess but is not as crucial for future success as the client's goals

The nurse cares for the postoperative client diagnosed with type 2 diabetes controlled with oral antihyperglycemic agents. The client asks why the health care provider ordered subcutaneous insulin injections after surgery. The nurse's response is based on knowing which physiological process? 1. Tissue injury after surgery decreases blood glucose. 2. Anesthesia acts to increase glycogen stores. 3. Being NPO inhibits normal blood glucose control. 4. Surgery often leads to insulin dependency.

1) inaccurate 2) inaccurate 3) CORRECT - temporary control by insulin is needed due to inability to control diabetes mellitus by diet and oral agents, surgically induced metabolic changes, being NPO both before and after surgery, and the infusion of intravenous fluids 4) inaccurate

The client had a kidney transplant yesterday, and the client's adult child has come to visit. The nurse instructs the adult child to take which action? 1. No special actions are necessary. 2. Wear a double mask and gloves. 3. Perform good hand washing. 4. Wear a gown and a mask.

1) inaccurate 2) inaccurate; masks are unnecessary for this client 3) CORRECT — good hand washing is the most effective method of reducing infection; very important with immunosuppressed clients 4) inaccurate; masks are unnecessary for this client

The nurse on a psychiatric unit of the hospital declines the client's request to organize a party on the unit for the client's friends. The client becomes angry and uses abusive language toward the nurse. Which statement indicates the nurse has an understanding of the client's behavior? 1. Allowing the client to use abusive language will undermine the authority of the nurse. 2. Responding in kind to a client who uses abusive language will perpetuate the behavior. 3. Abusive language is one of the behaviors symptomatic of the client's illness. 4. The nurse should model acceptable behavior and language for all clients.

1) inaccurate; doesn't undermine authority of staff 2) shows lack of understanding of cause for client's behavior 3) CORRECT — symptoms will respond to treatment 4) suggests that using acceptable language will change client's behavior; shows lack of understanding of client's behavior

The nurse leads a parenting class for a group of expectant clients. How many extra calories a day does the nurse advise the clients to consume to support breastfeeding? 1. 200. 2. 300. 3. 400. 4. 500.

1) inadequate amount 2) inadequate amount 3) inadequate amount 4) CORRECT — milk production requires an increase of 500 calories per day

The nurse cares for a 3-month-old infant scheduled for a barium swallow in the morning. Prior to the procedure, it is most appropriate for the nurse to take which action? 1. Offer the infant only clear liquids. 2. Make the infant NPO for 3 hours. 3. Feed the infant regular formula. 4. Maintain the infant NPO for 6 hours.

1) inappropriate 2) CORRECT — infant should be NPO 3 hours prior to the procedure 3) inappropriate 4) unnecessary for an infant to be NPO for 6 hours

The health care provider orders mannitol for the client with a closed head injury. Which response does the nurse recognize as desired to this medication? 1. The blood pressure increases to 150/90. 2. Urinary output increases to 175 mL/hour. 3. There is a decrease in the level of activity. 4. There is an absence of fine tremors of the fingers.

1) increase in blood pressure is not desired 2) CORRECT — mannitol is an osmotic diuretic; increases urinary output and decreases intracranial pressure 3) does not indicate desired effect of medication 4) does not indicate desired effect of medication

Which information does the nurse recognize as being the most pertinent to the diagnosis of cholecystitis? 1. Flatulence. 2. Nausea and vomiting. 3. Right upper abdominal pain. 4. Dyspepsia.

1) indicates other gastrointestinal problem 2) indicates other gastrointestinal problem 3) CORRECT — will experience pain in the upper-right abdominal quadrant 4) indicates other gastrointestinal problem

The nurse cares for clients in a drug rehabilitation facility. Which complication of IV drug abuse is the nurse most likely to observe? 1. Jaundice. 2. Rash. 3. Bruising. 4. Cellulitis.

1) jaundice can develop because of hepatitis B and cirrhosis, which may occur in narcotic abusers who use intravenous drugs 2) may occur because of the chemicals that are used in cutting the drugs by the client or the drug dealer 3) may occur because of the chemicals that are used in cutting the drugs by the client or drug dealer 4) CORRECT — most narcotic addicts do not inject sterile purified material with aseptic techniques; cellulitis is a common complication because of skin popping or using an infected drug apparatus

Which action is the best way for the nurse to assess the fluid balance of an elderly client? 1. Assess the client's blood pressure. 2. Check the client's tissue turgor. 3. Determine if the client is thirsty. 4. Maintain an accurate intake and output.

1) may be elevated because of age-related hypertension 2) not accurate because of changes in skin elasticity due to the aging process 3) not reliable indicator; may have diminished sensation of thirst 4) CORRECT—best indicator of fluid status

The health care provider orders naproxen sodium for the elderly client. The nurse assesses the client for which symptoms? 1. Stomatitis and photosensitivity. 2. Bradycardia and dry mouth. 3. Fluid retention and dizziness. 4. Gynecomastia and impotence.

1) not adverse effects seen with this medication; may see headache, nausea 2) not adverse effects seen with this medication; may see epigastric distress and rash 3) CORRECT — NSAID (nonsteroidal anti-inflammatory drug) used as analgesic; adverse effects include headache, dizziness, gastrointestinal distress, pruritus, and rash 4) not adverse effects seen with this medication; may see nephrotoxicity and pruritus

The parent of a child with chickenpox asks the clinic nurse why the child will not come down with chickenpox again if exposed to the virus at school at a later date. Which explanation does the nurse give? 1. Natural passive immunity occurs because the child receives antibodies from outside the body. 2. Artificial active immunity occurs because the child receives specific antigens against the chickenpox virus. 3. Natural active immunity occurs because the child's body actively makes antibodies against the chickenpox virus. 4. Artificial passive immunity occurs because of the inflammatory process of chickenpox.

1) occurs when antibodies are passed from mother to fetus via placenta, colostrum, and breast milk 2) small amounts of specific antigens are used for vaccination; body responds by actively making antibodies 3) CORRECT - antigen enters the body without human assistance; body responds by actively making antibodies 4) involves injection with antibodies that were produced in another person or animal; used to protect person exposed to serious disease

The adolescent is brought to the hospital for treatment of deep partial thickness and full thickness burns sustained in a house fire. An intravenous infusion is started in the client's left forearm. The nurse identifies which reason as the primary purpose for the IV? 1. Provide a route for pain medications. 2. Maintain fluid balance. 3. Prevent gastrointestinal upset. 4. Obtain blood specimens for analysis.

1) route used for pain medication to ensure absorption, but not primary purpose of IV 2) CORRECT — loss of fluid occurs from open burn surfaces; maintaining circulation is life-saving requirement 3) threat of gastrointestinal upset not primary importance; IV's primary purpose to maintain fluid and electrolyte balance 4) peripheral IV not used for this purpose

The 7-year-old child is seen in the clinic with a diagnosis of pituitary dwarfism. Which clinical manifestation is the nurse most likely to observe? 1. Abnormal body proportions. 2. Early sexual maturation. 3. Delicate features. 4. Coarse, dry skin.

1) see small size but normal body proportions 2) usually have delayed sexual maturity 3) CORRECT — appear younger than chronological age 4) usually see fine, smooth skin

The nurse cares for the client receiving a blood transfusion for approximately 30 minutes. Which symptom indicates a severe allergic reaction is occurring? 1. Bounding peripheral pulses. 2. Chills. 3. Respiratory wheezing. 4. Lower back discomfort.

1) seen with circulatory overload; severe anaphylactic reaction may cause hypotension 2) indicative of a hemolytic or febrile transfusion reaction 3) CORRECT — allergic reaction is characterized by wheezing, urticaria (hives), facial flushing, and epiglottal edema 4) indicative of a hemolytic transfusion reaction

Which observation suggests to the nurse the client has developed an Addisonian crisis? 1. Muscular weakness and fatigue. 2. Restlessness and rapid, weak pulse. 3. Dark pigmentation of the skin. 4. Gastrointestinal disturbances and anorexia.

1) signs and symptoms of Addison's disease, but do not indicate a crisis 2) CORRECT — may be signs of shock related to an Addisonian crisis 3) signs and symptoms of Addison's disease, but do not indicate a crisis 4) signs and symptoms of Addison's disease, but do not indicate a crisis

The health care provider orders hydromorphone hydrochloride 15 mg IM for a client. The nurse observes for which adverse effects? 1. Photosensitivity and constipation. 2. Hypotension and respiratory depression. 3. Tardive dyskinesia and diplopia. 4. Dry mouth and tinnitus.

1) these adverse effects are not seen with this medication 2) CORRECT — narcotic analgesic used for moderate to severe pain, monitor vital signs frequently 3) these adverse effects are not seen with this medication 4) these adverse effects are not seen with this medication

In the process of a normal adjustment to a terminal illness, the nurse knows that the client's initial denial and isolation will give way to the second stage. The second stage is characterized by which behavior? 1. Acceptance. 2. Bargaining. 3. Anger. 4. Depression.

1) this is the fifth stage 2) this is the third stage 3) CORRECT— second stage is characterized by anger 4) this is the fourth stage

The nurse cares for the child diagnosed with pediculosis capitis (head lice) who is being treated with permethrin 1% cream rinse. The nurse includes which information when instructing the child's parents? 1. Apply the cream rinse every other day for 1 week. 2. Wash the child's clothing and personal belongings in soap and cool water. 3. Repeat the application of the cream rinse in 7 days if nits are still present. 4. Comb the child's hair weekly with a nit comb.

1) too frequent an application of the rinse 2) wash with detergent in very hot water and dry for 20 minutes in a dryer 3) CORRECT— may be repeated 7 days after first application 4) hair should be combed daily with a nit comb

The nurse administers oral verapamil to a client. Which assessment does the nurse make before administering the medication? 1. The client's electrolytes. 2. The client's urine output. 3. The client's weight. 4. The client's heart rate.

1) unnecessary action 2) unnecessary action 3) unnecessary action 4) CORRECT - verapamil is indicated for the treatment of supraventricular tachycardia, so the client's heart rate should be checked prior to administration

The nurse prepares the older client for an intravenous pyelogram (IVP). The client asks the nurse to explain the reason why the procedure is performed. The nurse's response is based on which explanation? 1. The health care provider is able to directly observe the kidney pelvis. 2. An IVP assesses the glomerular filtration rate. 3. The health care provider is able to examine the urinary tract by x-ray. 4. Medication is injected into the urinary system

1) would involve invasive procedure, such as cystoscopy 2) not primary purpose 3) CORRECT — x-rays of entire urinary tract taken, evaluates kidney function 4) not primary purpose

The nurse cares for the newborn infant diagnosed with fetal alcohol syndrome. The nurse expects to see which characteristics? 1. An infant large for gestational age (LGA), craniofacial abnormalities, and hydrocephalus. 2. An infant with a small head circumference, low birth weight, and undeveloped cheekbones. 3. An infant with a large head circumference, low birth weight, and excessive rooting and sucking behaviors. 4. An infant with a normal head circumference, low birth weight, and respiratory distress syndrome.

Strategy: All answers are assessment. Determine how each assessment relates to fetal alcohol syndrome. 1) usually small for gestational age 2) CORRECT—seen with fetal alcohol syndrome 3) may have feeding difficulties and poor sucking ability 4) head circumference usually small, respiratory distress related to preterm birth, neurologic damage, small trachea, floppy epiglottis

A client with an endotracheal tube requires suctioning. Which statement is an accurate description of how the nurse performs the procedure? 1. Inserts the suction catheter 4 in into the tube. Applies suction for 30 seconds, using a twirling motion as the catheter is withdrawn. 2. Hyperoxygenates the client. Inserts the suction catheter into the tube, and suctions while removing the catheter in a back and forth motion. 3. Explains the procedure to the client. Inserts the catheter gently while applying suction, and withdraws using a twisting motion. 4. Inserts the suction catheter until resistance is met, and then withdraws it slightly. Applies suction intermittently as the catheter is withdrawn.

Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? 1) catheter is inserted until resistance is met; never suction longer than 10-15 seconds 2) use twirling motion when withdrawing catheter 3) suction is never applied when catheter is inserted 4) CORRECT — insert suction catheter until resistance is met without applying suction, withdraw 0.4 to 0.8 inches (1 to 2 cm), and apply intermittent suction with twirling motion

The nurse prepares the adult client diagnosed with intellectual delay for discharge. The health care provider ordered warfarin sodium, 5 mg each day. To maintain client safety, which action does the nurse take first? 1. Instructs the significant other about the medication regimen. 2. Determines the client's comprehension of the medication administration. 3. Prepackages the medication to encourage correct administration. 4. Encourages a return demonstration of medication self-administration.

Strategy: Answers are a mix of assessment and implementation. Does this situation require assessment? Yes. 1) implementation; might be done after assessment of the comprehension level 2) CORRECT — assessment; intellectually delayed client should be carefully evaluated to ensure complete comprehension of the dosage regimen to prevent overdose and underdose 3) implementation; might be done after assessment of the comprehension level 4) implementation; might be done after evaluation of the comprehension level

The nurse cares for a client receiving chlorpromazine. The nurse notes the client is restless, unable to sit still, and reports insomnia and fine tremors of the hands. Which does the nurse identify as the best explanation for these symptoms occurring? 1. An adverse effect of the medication that will disappear as time passes. 2. The reason the client is receiving this medication. 3. Extrapyramidal adverse effects resulting from this medication. 4. An indication the dosage of the medication needs to be increased.

Strategy: Determine how each answer relates to chlorpromazine. 1) untrue statement; dosage may need to be decreased because of adverse effect of medication; antiparkinsonian medication such as benztropine may be ordered 2) not accurate; antipsychotic medication 3) CORRECT - adverse effects include akathisia (motor restlessness), dystonias (protrusion of tongue, abnormal posturing), pseudoparkinsonism (tremors, rigidity), and dyskinesia (stiff neck, difficulty swallowing) 4) dosage may be decreased; antiparkinsonian medication such as benztropine may be ordered

The 18-month-old is admitted to the unit with a diagnosis of laryngotracheobronchitis (LTB). During the initial assessment, the nurse expects to find which early symptoms? 1. Kussmaul respirations and bradycardia. 2. Elevated temperature and slow respiratory rate 3. Expiratory wheezing and substernal retractions. 4. Inspiratory stridor and restlessness.

Strategy: Determine how each answer relates to croup. 1) Kussmaul respirations are associated with diabetic ketoacidosis; hypoxia and anxiety are associated with tachycardia 2) respiratory rate would be increased 3) more often noted with respiratory distress of the newborn 4) CORRECT—this condition is characterized by edema and inflammation of upper airways

The client, gravida 2 para 1, is admitted with hypertension. The client reports her wedding band is tight. The nurse assesses for which indications of mild pre-eclampsia? 1. Blurred vision and proteinuria. 2. Epigastric pain and headache. 3. Facial swelling and proteinuria. 4. Polyuria and hypertonic reflexes

Strategy: Determine how each answer relates to pre-eclampsia. 1) only partially correct; blurred vision appears later, with eclampsia 2) contains signs of eclampsia before a seizure 3) CORRECT — represents two of the three symptoms seen with pre-eclampsia; also includes hypertension 4) oliguria is seen later with eclampsia

Which statement is documented by the nurse to reflect a client's emotional adjustment to being hospitalized in the intensive care unit? 1. "The client is unable to complete activities of daily living without assistance." 2. "The client appears to be depressed and anxious regarding impending surgery." 3. "The client constantly calls for nurses and cries uncontrollably." 4. "The family is unable to visit more often than once a week because they live far away.

Strategy: Good documentation is the objective. 1) does not describe emotional adjustment 2) draws conclusions without supporting data 3) CORRECT — gives an objective description of the client's behavior and affect 4) describes the client's family, not the client

Return messages in which order by priority

Strategy: Identify any normal behaviors. Identify the least stable infant to see first. 1) first: bulging fontanelle may indicate increased intracranial pressure and is most serious 2) second: circumcision should have yellowish exudate at this time, but swelling is not normal and may interfere with urination 3) third: umbilical cord should be dry and hard; draining indicates a possible infection and needs to be assessed 4) last: describes the Moro Reflex and is normal

The nurse is discussing growth and development with the parents of a 4-year-old child. The nurse identifies which type of play as characteristic of this age group? 1. Solitary play. 2. Parallel play. 3. Associative play. 4. Aggressive play.

Strategy: Picture a 4-year-old. 1) describes play for an infant 2) describes play for a toddler 3) CORRECT — this is the play that characterizes 4-year-olds 4) is not play but a behavior

The nurse cares for the prenatal client at 8 weeks gestation with a positive VDRL. When the nurse prepares the teaching plan, it is most important for the nurse to include which information? 1. Advise the client not to take any over-the-counter medications. 2. Instruct the client about the importance of taking all of the medication. 3. Inform the client to refrain from sexual activity. 4. Maintain the confidentiality of sexual partners or contacts.

Strategy: Think "Maslow." 1) physical, should not take over-the-counter medication unless prescribed by a health care provider, but not highest priority 2) CORRECT — physical, vitally important to complete all the medication 3) physical, more important to be treated for disease 4) psychosocial, communicable diseases are reportable; partners or contacts need to be found and notified so they may be treated

The nurse recognizes which symptoms are early signs of lithium toxicity? Select all that apply. 1. Fine motor tremors. 2. Involuntary muscle movements. 3. Seizures. 4. Nausea and vomiting. 5. Orthostatic hypotension. 6. Diarrhea

Strategy: Think of lithium toxicity. 1) CORRECT - A symptom of toxicity. 2) Associated with antipsychotics. 3) Associated with severe lithium toxicity. 4) CORRECT - An early symptom. 5) Associated with antipsychotics. 6) CORRECT - An early symptom.

During the mother's fourth stage of labor, the nurse palpates the client's fundus in which location?

uterus is normally contracted and palpable at the umbilicus