test5

*Question: The nurse enters a client's room to check the client who began receiving a blood transfusion 45 minutes earlier. The client is flushed and dyspneic. The nurse listens to the client's lung sounds and notes the presence of crackles in the lung bases. The nurse determines that this client is most likely experiencing which complication of blood transfusion therapy?*

*Answer: Fluid (circulatory) overload* Rationale: With fluid (circulatory) overload, the client has the presence of crackles in the lungs in addition to dyspnea. Hypovolemic shock (restlessness, increased pulse, decreased blood pressure) is not likely to occur in a client receiving fluids. An allergic reaction, which is one type of blood transfusion reaction, would produce symptoms such as flushing, dyspnea, itching, and a generalized rash. With bacteremia, the client would have a fever, which is not part of the clinical picture presented.

*Question: The nurse is assisting in the care of a client with a left foot that sustained a crush injury. The nurse determines that the client developed third spacing of body fluid based on which observation?*

*Answer: Left foot has 4+ pitting edema.* Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third spacing include tissues where an injury or burn occurred, the pleural and peritoneal cavities, and the pericardial sac. Clients at high risk for third spacing include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal malabsorption, and malnutrition. The left foot that was crushed and is grossly edematous is an example of third spacing of body fluid. The blood pressure represents intravascular fluid status. Normal skin turgor and slight abdominal distention are not examples of third-spacing of fluids.

*Question: A licensed practical nurse (LPN) is assisting in the care of a client receiving a continuous intravenous (IV) infusion of heparin sodium for deep vein thrombosis (DVT). The LPN notes that the result of a newly drawn activated partial thromboplastin time (aPTT) level is 90 seconds. The client's baseline before the initiation of therapy was 30 seconds. The LPN would take which action?*

*Answer: Notify the RN about the value immediately.* Rationale: The normal aPTT varies between 20 and 36 seconds, depending on the type of activator used in testing. When a client receives intravenous heparin, the range of the aPTT is ordered by the primary health care provider but is greater than the normal range. Heparin treatment for DVT often involves a protocol to follow determined by the results of aPTT. If the aPTT is within the desired level, the rate is maintained and an aPTT is not ordered again until the next morning. The LPN should report the findings immediately to the RN, who will take further action to follow up on the elevated value. Checking for pain from the DVT, checking for additional heparin, and delaying reporting the aPTT are not appropriate actions.

*Question: The nurse is conducting a teaching session on basic life support (BLS) for nursing students. Which statement made by a nursing student indicates a need for further teaching?*

*Answer: "I will remember the algorithm airway, breathing, and compressions to guide my actions when providing BLS."* Rationale: The American Heart Association set forth new guidelines for BLS for the primary health care provider. Among these changes is a new emphasis on the algorithm CAB—compressions, airway, breathing—rather than the ABCs—airway, breathing, and circulation. Another new emphasis is on effective compressions and the avoidance of excessive ventilation. In addition, CPR should be performed if the client is not breathing or is gasping. The nursing student should be taught to allow for full chest recoil when performing chest compressions in order for the compressions to be effective.

*Question: The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse would tell the client that which food item is least likely to contain calcium?*

*Answer: Butter* Rationale: Butter comes from milk fat and does not contain significant amounts of calcium. Milk, spinach, and collard greens are calcium-containing foods and should be avoided by the client on a calcium-restricted diet.

*Question: A hospitalized client is a lacto-vegetarian. Which food item would the nurse remove from the meal tray?*

*Answer: Eggs* Rationale: Lacto-vegetarians eat milk, cheese, and dairy foods but avoid meat, fish, poultry, and eggs.

*Question: A client has a prescription to take guaifenesin every 4 hours, as needed. The nurse determines that the client understands the most effective use of this medication if the client makes which statement?*

*Answer: "I will take the tablet with a full glass of water."* Rationale: Guaifenesin is an expectorant. It should be taken with a full glass of water to decrease the viscosity of secretions. Sustained-release preparations should not be broken open, crushed, or chewed. The medication may occasionally cause dizziness, headache, or drowsiness. The client should contact the PHCP if the cough lasts longer than 1 week or is accompanied by fever, rash, sore throat, or persistent headache.

*Question: The nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time?*

*Answer: "Sometimes people hear things or voices others can't hear."* Rationale: It is important for the nurse to reinforce reality with the client. Options 1, 2, and 4 do not reinforce reality but reinforce the hallucination that the voices are real.

*Question: The nurse is assigned to care for a client at risk for alcohol withdrawal. The client's spouse asks the nurse, "When will the first signs of withdrawal appear?" The nurse would give which reply?*

*Answer: "Within a few hours"* Rationale: Early signs of alcohol withdrawal develop within a few hours after cessation or reduction of alcohol and peak after 24 to 48 hours.

*Question: The nurse is caring for a client with glaucoma. Which medication prescribed for the client would the nurse question?*

*Answer: Atropine sulfate* Rationale: Options 1, 2, and 4 are miotic agents used to treat glaucoma. Option 3 is a mydriatic and cycloplegic medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye.

*Question: The nurse is monitoring a newborn who was born to a drug-addicted mother. Which findings would the nurse expect to note during data collection for this newborn? Select all that apply.*

** Rationale: A newborn born to a woman using drugs is irritable and is easily overloaded by sensory stimulation. The newborn may cry incessantly and be difficult to console. The newborn would not be lethargic and would hyperextend and posture rather than cuddle when being held.

*Question: A client with breast cancer has been given a prescription for cyclophosphamide. The nurse determines that the client understands the proper use of the medication if the client makes which statements? Select all that apply.*

** Rationale: A toxic effect of cyclophosphamide is hemorrhagic cystitis. The client should drink large amounts of fluid during the administration of this medication and observe the urine for bleeding. Clients also should observe for hematuria. The medication should be taken on an empty stomach, unless gastrointestinal upset occurs. Hyperkalemia can result from the use of the medication; therefore, the client would not be encouraged to increase potassium intake. The client would not be instructed to alter magnesium intake.

*Question: The nurse is reinforcing instructions to a client with pneumonia about the use of an incentive spirometer in the postoperative period. The nurse would include which information in discussions with the client? Select all that apply.*

** Rationale: An incentive spirometer is a volume- or flow-oriented device used to encourage deep breathing by giving visual feedback to the client during its use. For optimal lung expansion with an incentive spirometer, the client should assume the semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely while the client inhales slowly with a constant flow through the unit. The breath should be held for 2 to 3 seconds before exhaling slowly. The client is taught to use the incentive spirometer for 5 to 10 breaths every hour while awake to prevent post-operative atelectasis and pneumonia.

*Question: The nurse is caring for a client with a neurogenic bowel due to a lower motor neuron spinal cord injury below T12 resulting in flaccid functionality. Besides triggering or facilitating techniques for defecation, what are some of the strategies the nurse needs to address to reestablish defecation patterns? Select all that apply.*

** Rationale: Besides using triggering or facilitating techniques, the strategies the nurse needs to address that would help reestablish defecation patterns include a high-fiber, not low-fiber, diet; increased, not limited, fluids; suppository use; manual disimpaction; and a consistent toileting schedule. The client needs to avoid drinks with caffeine such as coffee, tea and cocoa, and many soft drinks.

*Question: A nursing student is preparing a clinical conference, and the topic of the discussion is caring for the child with cystic fibrosis (CF). The student prepares a handout for the group and lists which on the handout? Select all that apply.*

** Rationale: CF is a chronic multisystem disorder affecting the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait and can affect both males and females.

*Question: The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which would the nurse expect to note in this client? Select all that apply.*

** Rationale: Clinical manifestations of COPD include hypoxemia, hypercapnia, and dyspnea during exertion and at rest, oxygen desaturation with exercise, use of accessory muscles of respiration, and a prolonged expiratory phase of respiration. The client may also exhibit difficulty breathing while talking, and may have to take breaths between every one or two words. Some clients with COPD, especially those with a history of smoking, often have a productive cough particularly when arising in the morning. The chest x-ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.

*Question: Which interventions would be implemented in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply.*

** Rationale: If a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonlatex gloves and latex-safe supplies and would keep a latex-safe supply cart available in the client's area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication bottles with rubber stoppers that require puncture with a needle. It is not necessary to place the client in a private room.

*Question: The client is receiving meperidine hydrochloride for pain. Which signs/symptoms are side and adverse effects of this medication? Select all that apply.*

** Rationale: Meperidine hydrochloride is an opioid analgesic. Side and adverse effects include respiratory depression, drowsiness, hypotension, constipation, urinary retention, nausea, vomiting, and tremors.

*Question: About which laboratory values would the nurse be immediately concerned because they could cause cardiac arrest? Select all that apply.*

** Rationale: Normal laboratory values are calcium, 9.0 to 10.5 mg/dL; sodium, 135 to 145 mEq/L; potassium, 3.5 to 5.0 mEq/L; chloride, 98 to 106 mEq/L; and magnesium 1.8 to 2.6 mg/dL. Decreased calcium and/or increased potassium can lead to cardiac arrest

*Question: A primary health care provider prescribes gabapentin 0.9 g three times by mouth daily. The label on the medication bottle states gabapentin 300-mg tablets. How many tablets will the nurse administer to the client for one dose? Fill in the blank.*

** Rationale: Rationale not found

*Question: A primary health care provider prescribes hydromorphone hydrochloride, 0.5 mg intramuscularly stat, for a client in pain. The medication label states hydromorphone hydrochloride 2 mg/mL. How many milliliters (mL) will the nurse prepare to administer to the client? Fill in the blank. Record the answer to two decimal places.*

** Rationale: Rationale not found

*Question: Sulfisoxazole 1 g orally four times daily is prescribed for an adolescent with a urinary tract infection. The medication label reads, "250-mg tablets." The nurse has determined that the prescribed dose is safe. How many tablets per dose would the nurse administer to the adolescent? Fill in the blank.*

** Rationale: Rationale not found

*Question: The nurse is explaining how sound is conducted from the middle ear to the inner ear in teaching a client who is experiencing hearing loss. What is the order of structures conducting sound waves from the middle ear to the inner ear? Arrange the structures in the order that they should occur. All options must be used.*

** Rationale: Rationale not found

*Question: The nurse is collecting data from a child suspected of having juvenile idiopathic arthritis (JIA). Which findings would the nurse expect to note if JIA were present? Select all that apply.*

** Rationale: Signs and symptoms associated with JIA include intermittent joint pain that lasts longer than 6 weeks and painful, stiff, and swollen joints that are warm to the touch, with limited range of motion. The child will complain of morning stiffness and may protect the affected joint or refuse to walk. Systemic symptoms include malaise, fatigue and lethargy, anorexia, weight loss, and growth problems. A history of a late afternoon fever with temperature spiking up to 105°F will also be part of the signs and symptoms.

*Question: The nurse is caring for a client with Paget's disease who has an elevated serum calcium level of 12.3 mEq/L. The nurse would expect the primary health care provider to prescribe which? Select all that apply.*

** Rationale: The normal serum calcium level is 4.5 to 5.5 mEq/L or 9 to 11 mg/dL. Calcitonin, a thyroid hormone, decreases the plasma calcium level by increasing the incorporation of calcium into the bones, thus keeping it out of the serum. In hypercalcemia, large doses of vitamin D should be avoided. Encourage high fluid intake (3000 to 4000 mL/day). Furosemide (Lasix) may be given to promote the excretion of calcium in the urine. Determine the patient's ability to perform self-care safely and provide help as needed.

*Question: The nurse is applying a topical corticosteroid to a client with eczema. The nurse would apply the medication to which body areas? Select all that apply.*

** Rationale: Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles). The nurse should avoid areas of higher absorption to prevent systemic absorption.

*Question: A client is newly admitted to the hospital with cellulitis of the lower leg. The nurse checks the primary health care provider's prescription sheet expecting which to be prescribed? Select all that apply.*

** Rationale: Warm compresses may be used to decrease the discomfort, erythema, and edema that accompany cellulitis. Definitive treatment also includes antibiotic therapy after appropriate cultures have been done. Other supportive measures also are used to manage symptoms such as fatigue, fever, chills, headache, or myalgia. Heat lamps are not used because of the risk of burns and because moist heat is most useful in treating this disorder.

*Question: Which are appropriate interventions for caring for the client undergoing alcohol withdrawal? Select all that apply.*

** Rationale: When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming himself or herself or others. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would frequently reorient the client to reality and would address hallucinations therapeutically. Adequate nutritional and fluid intake must be maintained.

*Question: The nurse is caring for a pregnant client who was diagnosed with acquired immunodeficiency syndrome (AIDS) and asks the nurse if she will be able to breastfeed the infant after delivery. Which response by the nurse is appropriate?*

*Answer: "Breastfeeding is contraindicated."* Rationale: The woman diagnosed with AIDS will need to know that breastfeeding is contraindicated but that she can provide all other care for her infant. Characteristically, the newborn is asymptomatic at birth, and signs and symptoms usually become obvious during the first year of life. No immunization is available for HIV.

*Question: The nurse is reinforcing home care instructions to the mother of a child diagnosed with pneumonia. Which statement by the mother indicates the need for further teaching?*

*Answer: "I can use a warm mist humidifier to keep the secretions loose."* Rationale: A cool mist humidifier rather than a warm mist should be used for the child with pneumonia. In addition, vaporizers that produce steam pose a danger of burns. Options 1, 2, and 4 are appropriate home care instructions regarding care of the child with pneumonia.

*Question: A client is being discharged after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement?*

*Answer: "I need to avoid getting the cast wet."* Rationale: A plaster cast must remain dry to keep its strength. The cast should be handled using the palms of the hands, not the fingertips, until fully dry. Air should circulate freely around the cast to help it dry; the cast also gives off heat as it dries. The client should never scratch under the cast; a cool hair dryer may be used to eliminate itching.

*Question: The client has just undergone computed tomography (CT) scanning with a contrast medium. Which statement by the client demonstrates an understanding of postprocedure care?*

*Answer: "I should drink extra fluids for the remainder of the day."* Rationale: After CT scanning, the client may resume all usual activities. The client should be encouraged to take in extra fluids to replace those lost with diuresis from the contrast dye. Options 1, 2, and 3 are unnecessary.

*Question: A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia. Which statement by the client indicates a correct understanding of Humulin N insulin and exercise?*

*Answer: "I should not exercise in the late afternoon."* Rationale: A hypoglycemic reaction may occur in response to increased exercise. Clients should avoid exercise during the peak time of insulin. Humulin N insulin peaks between 6 and 14 hours; therefore, late-afternoon exercise would occur during the peak of the medication.

*Question: A client asks the nurse about the causes of acne. The nurse would respond by making which statement to the client?*

*Answer: "The exact cause of acne is not known."* Rationale: The exact cause of acne is unknown. Exacerbations that coincide with the menstrual cycle result from hormonal activity. Oily skin alone is not the cause of acne. Heat, humidity, and excessive perspiration also play a role in exacerbation of acne. There is no evidence that consumption of foods such as chocolate, nuts, or fatty foods affects acne.

*Question: A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to which value?*

*Answer: 15 mg/dL (5.25 mmol/L)* Rationale: The normal blood urea nitrogen level is 6 mg/dL to 20 mg/dL (2.1-7.1 mmol/L). Values of 29 mg/dL mg/dL (10.15 mmol/L) and 35 mg/dL (12.25 mmol/L) reflect continued dehydration. A value of 3 mg/dL (1.05 mmol/L) reflects a lower than normal value, which may occur with fluid volume overload, among other conditions.

*Question: The nurse is reviewing the health care record of a pregnant client at 24 weeks' gestation. The nurse would anticipate that the fundus would be located at which level?*

*Answer: 22 cm to 26 cm* Rationale: At 12 weeks' gestation, the uterus extends out of the maternal pelvis and can be palpated above the symphysis pubis. At 24 weeks, the fundus should be located plus or minus 2 cm of the gestational age.

*Question: The nurse notes that the primary health care provider (PHCP) has documented a diagnosis of presbycusis on the client's chart. Which explanation would the nurse give to the client to explain this condition?*

*Answer: A sensorineural hearing loss that occurs with aging* Rationale: Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. Options 1, 2, and 3 are not accurate descriptions.

*Question: A client with myasthenia gravis becomes increasingly weaker. The primary health care provider injects a dose of edrophonium to determine whether the client is experiencing a myasthenic crisis or a cholinergic crisis. The nurse expects that the client will have which reaction if the client is in cholinergic crisis?*

*Answer: A temporary worsening of the condition* Rationale: Edrophonium is a short-acting acetylcholinesterase inhibitor used to diagnose myasthenia gravis or differentiate between myasthenic and cholinergic crisis. An edrophonium injection makes the client in cholinergic crisis temporarily worse, known as a negative edrophonium test. An improvement of the condition (option 3) indicates myasthenia crisis. The other two options are unrelated to the test.

*Question: A client has a prescription to receive albuterol, two puffs and beclomethasone dipropionate, two puffs by metered-dose inhaler. Which would the nurse plan when administering these medications?*

*Answer: Administering the albuterol before the beclomethasone dipropionate* Rationale: Albuterol is an adrenergic type of bronchodilator. Beclomethasone dipropionate is a glucocorticoid. Bronchodilators are administered before glucocorticoids when both are to be given on the same time schedule. This allows for widening of the air passages by the bronchodilator, which then makes the glucocorticoid more effective.

*Question: A client diagnosed with pemphigus is being seen in the clinic regularly. The nurse would plan care based on which description of this condition?*

*Answer: An autoimmune disease that causes blistering in the epidermis* Rationale: Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. During the initial examination, clients may have crusting areas instead of intact blisters. Option 1 describes eczema, option 3 describes herpes zoster, and option 4 describes psoriasis.

*Question: When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse would plan to take which action in the initial care of the wound?*

*Answer: Apply a sterile dressing soaked with normal saline.* Rationale: Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the exposure of underlying tissues. It usually occurs 6 to 8 days after surgery. The client should be instructed to remain quiet and to avoid coughing or straining. The client should be positioned to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline should be used to cover the wound. The primary health care provider must be notified after this initial dressing has been applied to the wound.

*Question: The nurse is reviewing the record of a client with acute respiratory distress syndrome (ARDS). The nurse determines that which finding documented in the client's record is consistent with the most expected characteristic of this disorder?*

*Answer: Arterial Pao2 of 48* Rationale: The most characteristic sign of ARDS is increasing hypoxemia with a Pao2 of less than 60 mm Hg. This occurs despite increasing levels of oxygen that are administered to the client. The client's earliest sign is an increased respiratory rate. Breathing then becomes labored, and the client may exhibit air hunger, retractions, and peripheral cyanosis.

*Question: The nurse notes that the medical record of a client diagnosed with cirrhosis states that the client has asterixis. To effectively verify this information the nurse would take which action?*

*Answer: Ask the client to extend the arms.* Rationale: Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. It is the most common and reliable sign that hepatic encephalopathy is developing.

*Question: The nurse is getting a client who underwent umbilical hernia repair ready for discharge. The nurse explains to the client that it is important to continue to do which action after discharge?*

*Answer: Avoid coughing.* Rationale: Coughing is avoided to prevent disruption of the sutured tissue, which could occur because of the location of this surgical procedure; however, frequent deep breathing exercises are important. A drain is not placed in this procedure, although the client may be instructed in simple dressing changes. The client should continue to take analgesics as needed and as prescribed. Bed rest is not required following this surgical procedure.

*Question: The nurse is caring for a client after a bronchoscopy and biopsy. Which finding would be reported immediately to the primary health care provider (PHCP)?*

*Answer: Bronchospasm* Rationale: If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.

*Question: A client with Bell's palsy exhibits facial asymmetry and cannot close the eye completely on one side. The client is also drooling and has loss of tearing in one eye. The nurse documents that the client displays symptoms of involvement of which cranial nerve (CN)?*

*Answer: CN VII* Rationale: Bell's palsy is a common problem involving CN VII. In addition to the symptoms identified in the question, the client may exhibit loss of the nasolabial fold, an inability to blink automatically or to swallow secretions, and possible loss of taste on the anterior two thirds of the tongue. Other conditions that can affect CN VII function include fracture of the temporal bone and parotid lacerations or contusions.

*Question: The nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular tachycardia (VT), followed by ventricular fibrillation (VF). The client suddenly loses consciousness. Which intervention would the nurse do first?*

*Answer: Call for help and initiate cardiopulmonary resuscitation (CPR).* Rationale: When ventricular fibrillation occurs, the nurse remains with the client and initiates CPR until a defibrillator is available and attached to the client. Options 1, 2, and 4 are incorrect.

*Question: A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma?*

*Answer: Cardiovascular disease* Rationale: Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma. Smoking, ingestion of caffeine or large amounts of alcohol, illicit drugs, corticosteroids, altered hormone levels, posture, and eye movements may cause varying transient increases in intraocular pressure.

*Question: The nurse is teaching a client about foods in the diet that could minimize the risk of osteoporosis. The nurse would encourage the client to increase intake of which food?*

*Answer: Cheese* Rationale: The major dietary source of calcium is from dairy foods, including milk, yogurt, and a variety of cheeses. Calcium also may be added to certain products, such as orange juice, which are then advertised as being "fortified" with calcium. Calcium supplements are available and recommended for those with typically low calcium intake.

*Question: A client receiving a high cleansing enema complains of pain and cramping. Which corrective action is most appropriate for the nurse to take?*

*Answer: Clamp the tubing for 30 seconds and restart the flow at a slower rate.* Rationale: Enema fluid should be administered slowly. If the client complains of fullness or pain, the flow is stopped for approximately 30 seconds and restarted at a slower rate. This action decreases the likelihood of intestinal spasm and premature ejection of the solution. The level of the solution should not be raised because this will aggravate symptoms. There is no need to discontinue the enema or notify the RN based on the information provided.

*Question: Tamoxifen is prescribed for the client with metastatic breast carcinoma. The nurse understands that which is the primary action of this medication?*

*Answer: Compete with estradiol for binding to estrogen in tissues containing high concentrations of receptors.* Rationale: Tamoxifen is an antineoplastic medication that competes with estradiol for binding to estrogen in tissues containing high concentrations of receptors. Tamoxifen reduces DNA synthesis and estrogen response.

*Question: The client diagnosed with acquired immunodeficiency syndrome (AIDS) has begun therapy with zidovudine. The nurse would monitor which laboratory result during treatment with this medication?*

*Answer: Complete blood count* Rationale: A common side/adverse effect of therapy with zidovudine is leukopenia and anemia. The nurse monitors the complete blood count results for these changes. Options 1, 2, and 3 are unrelated to the use of this medication.

*Question: A child is admitted to the hospital, and a diagnosis of bacterial meningitis is suspected. A lumbar puncture is performed, and the results reveal cloudy cerebrospinal fluid (CSF) with high protein and low glucose levels. The nurse determines that these results are indicative of which finding?*

*Answer: Confirmation of the diagnosis* Rationale: A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include increased pressure, cloudy CSF, and high protein and low glucose levels. Options 1 and 4 are incorrect. Option 2 is an unnecessary measure.

*Question: The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn?*

*Answer: Elevation above the level of the heart* Rationale: Circumferential burns of the extremities may compromise circulation. Elevating injured extremities above the level of the heart and performing active exercise help to reduce dependent edema formation. Options 1, 2, and 3 are incorrect.

*Question: A licensed practical nurse (LPN) is assisting in the care of a client who is having central venous pressure (CVP) measurements taken by the registered nurse (RN). The LPN would assist the RN by placing the bed in which position for the reading?*

*Answer: Flat* Rationale: To obtain a CVP measurement, the head of the bed should be flat in order for the readings to be accurate. The use of the other positions listed would result in false low or false high readings.

*Question: The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom would be an indication of this electrolyte imbalance?*

*Answer: Generalized muscle weakness* Rationale: Generalized muscle weakness is seen in clients with hypercalcemia. Twitching, positive Trousseau's sign, and hyperactive bowel sounds are signs of hypocalcemia.

*Question: An adolescent with diabetes mellitus is attending gym class and suddenly becomes flushed and complains of dizziness and a headache. The gym teacher quickly takes the adolescent to the school nurse's office. The nurse obtains a blood glucose level, and the results indicate a level of 65 mg/dL. Which initial nursing intervention is appropriate?*

*Answer: Give the child 6 oz of a regular cola drink.* Rationale: A blood glucose level below 70 mg/dL indicates hypoglycemia. The child is participating in an activity that requires more energy than that of the normal routine at school. Insulin and food requirements change with situations that require more energy. When signs of hypoglycemia occur, the child needs an immediate source of glucose. Options 2, 3, and 4 do not address the hypoglycemic state immediately and delay required treatment.

*Question: A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. Which would the nurse wear to perform these tasks?*

*Answer: Gown and gloves* Rationale: Gowns and gloves are required if the nurse anticipates contact with body fluids, such as wound drainage, diarrhea, or ileostomy or colostomy drainage. Masks are not required unless droplet or airborne precautions are necessary.

*Question: The client with myasthenia gravis is suspected of having cholinergic crisis. Which sign/symptom indicates this crisis is taking place?*

*Answer: Hypertension* Rationale: Cholinergic crisis occurs as a result of an overdose of medication. Indications of cholinergic crisis include gastrointestinal disturbances, nausea, vomiting, diarrhea, abdominal cramps, increased salivation and tearing, miosis, hypertension, sweating, and increased bronchial secretions.

*Question: A client in renal failure is receiving epoetin alfa. The nurse would monitor the client for which adverse effect of this medication?*

*Answer: Hypertension* Rationale: Epoetin alfa is an erythropoietic growth factor and generally is well tolerated, although hypertension can occur and is the most significant adverse effect. Occasionally, tachycardia also may occur as a side effect and may cause an improved sense of well-being. Fever, depression, and bradycardia are not adverse effects of epoetin alfa.

*Question: The nurse tells a client with leukemia that allopurinol has been added to the medication list. The client is currently receiving busulfan. When the client asks the purpose of the new medication, the nurse responds that allopurinol is intended to prevent which complication?*

*Answer: Hyperuricemia* Rationale: Busulfan is an antineoplastic agent used in the treatment of acute myelocytic leukemia and in the palliative treatment of chronic myelogenous leukemia. This therapy can cause blood dyscrasias, and with massive cell death the release of uric acid resulting in hyperuricemia. The client is then at risk of experiencing uric acid nephropathy, renal stones, and acute kidney injury. Allopurinol, an antigout medication, is used with chemotherapy to prevent or treat this complication of therapy. It also may be used in mouthwash following fluorouracil therapy to prevent stomatitis. Allopurinol is not used to prevent alopecia or diabetes. It is used to treat gouty arthritis, but this is the case with its use with chemotherapy.

*Question: The nurse is initiating cardiopulmonary resuscitation on an adult client. The nurse would place the hands in which position to begin chest compressions?*

*Answer: On the lower half of the sternum* Rationale: Chest compressions are done by placing the hands on the lower half of the sternum. The locations in options 2, 3, and 4 would not provide effective chest compressions.

*Question: The nurse is providing postprocedure instructions to a client returning home after arthroscopy of the shoulder. The nurse would reinforce which client instruction?*

*Answer: Report to the registered nurse the development of fever or redness and heat at the site.* Rationale: Following arthroscopy, signs/symptoms of infection such as fever or inflammation (redness or heat) should be reported to the registered nurse, who will perform an assessment and contact the primary health care provider. The client may resume the usual diet immediately. The arm does not have to be immobilized completely once sensation has returned, but the client usually is encouraged to refrain from strenuous activity for at least a few days.

*Question: The nurse reviews the plan of care for a child with Reye's syndrome. Which priority complication would the nurse plan to monitor?*

*Answer: Signs of increased intracranial pressure* Rationale: Intracranial pressure and encephalopathy are major complications of Reye's syndrome. Protein is not present in the urine. Reye's syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this disease.

*Question: A postoperative client has received a dose of naloxone hydrochloride for respiratory depression shortly after transfer to the nursing unit from the postanesthesia care unit. After administration of the medication, the nurse would check the client for which sign/symptom?*

*Answer: Sudden increase in pain* Rationale: Naloxone hydrochloride is an antidote to opioids and may also be given to the postoperative client to treat respiratory depression. When given to the postoperative client for respiratory depression, it may also reverse the effects of analgesics. Therefore, the nurse must check the client for a sudden increase in the level of pain experienced. Options 1, 2, and 4 are not associated with this medication.

*Question: The nurse is teaching a local women's church group about the risks of cervical cancer. The nurse determines that there is a need for further teaching if a group member states that which is a risk factor?*

*Answer: Intercourse with a circumcised male* Rationale: Risk factors associated with cervical cancer include intercourse with uncircumcised males, early frequent intercourse with multiple sexual partners, multiparity, chronic cervicitis, and history of genital herpes or human papillomavirus infection. Cervical cancer is also higher in African Americans.

*Question: The client brought to the emergency department is experiencing an anaphylactic reaction from eating shellfish. The nurse would implement which immediate action?*

*Answer: Maintaining a patent airway* Rationale: If the client experiences an anaphylactic reaction, the immediate action would be to maintain a patent airway. The client then would receive epinephrine. Corticosteroids may also be prescribed. The client will need to be instructed about obtaining and wearing a Medic-Alert bracelet, but this is not the immediate action.

*Question: The nurse reviews the plan of care for a suicidal client admitted to the hospital. The nurse notes documentation of the client's loss of a spouse, which occurred several years ago. The client progresses well and is approaching discharge. Which is an appropriate goal for this client's care?*

*Answer: The client verbalizes stages of grief and plans to attend a community grief group.* Rationale: The appropriate goal for this client's care is to have the client verbalizes stages of grief and plans to attend a community grief group.

*Question: The nurse is monitoring a client who is taking propranolol. Which data collection finding would indicate a potential serious complication associated with propranolol?*

*Answer: The development of audible expiratory wheezes* Rationale: Audible expiratory wheezes may indicate a serious adverse reaction: bronchospasm. ß-Blockers may induce this reaction particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and should be monitored.

*Question: The nurse is assigned to a client who is psychotic. The client is pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines which action is the immediate priority of care?*

*Answer: Provide safety for both the client and other clients on the unit.* Rationale: In this situation, safety for both the client and other clients is the immediate priority. Option 1 is the only one that addresses the client's and other clients' safety needs. Options 2 and 3 address the client's needs only. Option 4 addresses only the needs of the other clients in the unit.

*Question: Trimethoprim-sulfamethoxazole is prescribed for a client. The nurse would instruct the client to report which symptom if it developed during the course of this medication therapy?*

*Answer: Sore throat* Rationale: Clients taking trimethoprim-sulfamethoxazole should be informed about early signs of blood disorders that can occur from this medication. These include sore throat, fever, and pallor, and the client should be instructed to notify the primary health care provider (PHCP) if these symptoms occur. The other options do not require PHCP notification.

*Question: A postoperative client has received a dose of naloxone for respiratory depression. The nurse anticipates that the client will have which additional effect from the administration of this medication?*

*Answer: Sudden increase in pain* Rationale: Naloxone is an antidote to opioids; it also may be given to the postoperative client to treat respiratory depression. When given to the postoperative client for respiratory depression, it may reverse the effects of analgesics. Therefore, the nurse must anticipate that the client may experience a sudden increase in the level of pain. Options 1, 2, and 3 are incorrect.

*Question: A client is newly diagnosed with hypothyroidism. Levothyroxine is prescribed. The nurse would reinforce to the client which instructions about the medication?*

*Answer: Take on an empty stomach.* Rationale: Levothyroxine should be taken on an empty stomach to enhance absorption. The client also is instructed to take the medication in the morning before breakfast. Therefore, options 1, 2, and 3 are incorrect.

*Question: A client has a new prescription to take guaifenesin every 4 hours as needed. Which medication instructions would the nurse reinforce?*

*Answer: Take the tablet with a full glass of water.* Rationale: Guaifenesin is an expectorant. It should be taken with a full glass of water to decrease viscosity of secretions. Sustained-release preparations should not be broken open, crushed, or chewed. The medication occasionally may cause dizziness, headache, or drowsiness as side effects. The client should contact the primary health care provider if the cough lasts longer than 1 week or is accompanied by fever, rash, sore throat, or persistent headache.

*Question: The nurse is reviewing the record of a client admitted to the mental health unit and notes that the client was admitted by voluntary status. The nurse makes which determination?*

*Answer: The client has the right to demand and obtain release from the hospital.* Rationale: Generally, voluntary admission is sought by the client or the client's family by written application to the facility. Voluntary clients have the right to demand and obtain release from the hospital. The other statements identify the criteria for involuntary or emergency involuntary admission to a mental health care facility.

*Question: The nurse is caring for a client who is taking phenytoin for control of seizures. During data collection, the nurse notes that the client is taking birth control pills. Which information would the nurse provide to the client?*

*Answer: The potential for decreased effectiveness of the birth control pills exists while taking phenytoin.* Rationale: Phenytoin enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth control pills. Options 1, 2, are 4 are not accurate.

*Question: The client has a prescription for metoclopramide four times a day. The nurse determines that which is the most appropriate time to schedule this medication?*

*Answer: Thirty minutes before meals and at bedtime* Rationale: Metoclopramide is a gastrointestinal stimulant. The client should be taught to take this medication 30 minutes before meals and at bedtime. Therefore, the other options are incorrect.

*Question: The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time?*

*Answer: The primary health care provider (PHCP) reviews the x-ray results.* Rationale: There is a significant association between cervical spine injury and head injury. For this reason, the nurse leaves any form of spinal immobilization in place until lateral cervical spine x-rays rule out fracture or other damage and the results have been reviewed by the primary health care provider.

*Question: Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed?*

*Answer: Triglyceride level* Rationale: Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on triglycerides has been evaluated. There is no indication that isotretinoin affects potassium, hemoglobin A1c, or total cholesterol levels.

*Question: The nurse is speaking with a client with a hearing impairment. The nurse refrains from doing which least likely helpful action when communicating with this client?*

*Answer: Using many exaggerated hand gestures while talking* Rationale: When communicating with a hearing-impaired client, the nurse should stand directly in front of the client or in such a way that sound reaches the client's better ear. The nurse should speak slowly and clearly in a normal tone of voice. Competing noises such as radio and TV should be minimized. The nurse can use gestures as long as they are appropriate and used in moderation.

*Question: The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that the client is at risk for which vitamin deficiency?*

*Answer: Vitamin B12* Rationale: Deterioration and atrophy of the lining of the stomach lead to the loss of function of the parietal cells. When the acid secretion decreases, the source of the intrinsic factor is lost, which results in the inability to absorb vitamin B12. This leads to the development of pernicious anemia. Options 1, 2, and 3 are incorrect.

*Question: The nurse is assisting in planning discharge instructions to the mother of a child following orchiopexy, which was performed on an outpatient basis. Which is the priority in the plan of care?*

*Answer: Wound care* Rationale: The most common complications associated with orchiopexy are bleeding and infection. Discharge instruction should include demonstration of proper wound cleansing and dressing and teaching parents to identify signs of infection such as redness, warmth, swelling, or discharge. Testicles will be held in a position to prevent movement, and great care should be taken to prevent contamination of the suture line. Analgesics may be prescribed but are not the priority, considering the options presented. Option 3 is not necessary. Option 4 is not a prescribed treatment measure.

*Question: The nurse is working in a long-term care facility and is observing a new assistive personnel (AP) caring for a client who requires a security device (wrist restraints). The nurse determines that the AP is providing safe care if the nurse observes the AP checking skin integrity by completely removing the client's wrist restraints at which time interval?*

*Answer: Every 2 hours* Rationale: Restraints should be completely removed for a brief period at least every 2 hours, and this action should be documented in the nurse's notes. The color of the extremity should be noted, and the pulse should be assessed. The client should be asked to move the extremity, or range-of-motion exercises should be performed. Agency guidelines regarding the use of restraints should always be followed.

*Question: The nurse is administering a dose of a prescribed diuretic to an assigned client. The nurse would plan to monitor the client for hypokalemia as a side effect of therapy if the client is receiving which medication?*

*Answer: Bumetanide* Rationale: Bumetanide is a loop diuretic that places the client at risk for hypokalemia. The nurse would carefully monitor both the serum potassium levels and the client for signs of hypokalemia as well as encourage intake of high-potassium foods. The other medications listed are potassium-sparing diuretics.

*Question: The licensed practical nurse (LPN) renders aid at an automobile accident where several victims sustained injury. Which actions would the LPN take to offer first aid assistance? Select all that apply.*

** Rationale: If the victim is wearing a Medic-Alert bracelet, bring this to the attention of the ambulance or hospital personnel. The most serious and life-threatening injuries must be treated first; those victims who do not seem to be in immediate danger can be attended to by someone else who is capable of watching them and reporting any change in their condition. Determining the mechanism of injury will give clues about the type of injury sustained and the treatment required. An object that has penetrated a part of the body and is still in place should not be removed. Injured victims should not be moved unless in immediate danger and even then not until injuries have been immobilized.

*Question: A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?*

*Answer: "Can you share with me what you've been told about your surgery?"* Rationale: In assisting clients to deal with anxiety related to medical treatments, it is important that the nurse focus on the client and promote the expression of feelings. An open-ended question will assist the client to express emotions and concerns. Explanations should begin with the information that the client knows. By providing the client with an individualized explanation of care and procedures, the nurse can assist the client in handling fears and providing a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. The nurse should not trivialize the client's expression of anxiety or cut off communication by giving excessive information and focusing on the surgery and not the client.

*Question: A client brought to the emergency department is dead on arrival (DOA). The family of the client tells the primary health care provider that the client had terminal cancer. The emergency department primary health care provider examines the client and asks the nurse to contact the medical examiner regarding an autopsy. The family of the client tells the nurse that they do not want an autopsy performed. Which response to the family is appropriate?*

*Answer: "Your request will be given to the medical examiner when their office is contacted."* Rationale: An autopsy is required by state law in certain circumstances, including the sudden death of a client and a death that occurs under suspicious circumstances. The client may have provided oral or written instructions regarding an autopsy following death. If an autopsy is not required by law, these oral or written requests will be granted. If no oral or written instructions were provided, state law determines who has the authority to consent for an autopsy. Most often, the decision rests with the surviving relative or next of kin.

*Question: A licensed practical nurse (LPN) has received the assignment for the day shift. After making rounds and checking all of the assigned clients, which client will the LPN plan to care for first?*

*Answer: A client with a fever who is diaphoretic and restless* Rationale: The LPN would plan to care for the client who has a fever and is diaphoretic and restless first because this client's needs are the priority. It is best to wait for pain medication to take effect before providing care to the postoperative client. The client who is ambulatory and the client scheduled for physical therapy later in the day do not have priority needs related to care.

*Question: A nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse must assign 4 clients and has a licensed practical nurse (LPN) and 3 assistive personnel (AP) on a nursing team. To which client would the nurse assign the LPN?*

*Answer: A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours* Rationale: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Collecting a 24-hour urine, assisting with frequent ambulation, and giving a bed bath can be done by an AP. The LPN is skilled in wound irrigations and dressing changes, and this client should be assigned to this staff member.

*Question: A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. To aid the client in symptom management, the nurse would most appropriately suggest which diet during the acute phase?*

*Answer: A low-fiber diet* Rationale: A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. This diet is usually prescribed during the acute phase for acute diverticulitis, ulcerative colitis, and irritable bowel syndrome. Once the acute phase has subsided, the primary health care provider usually prescribes a high fiber diet. Neither a low-fat diet, a high-fat diet, nor a high-carbohydrate diet will aid in symptom management in acute diverticulitis.

*Question: The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells. Before leaving the room, the nurse tells the client that it is important to immediately report which sign if it occurs?*

*Answer: Backache* Rationale: The nurse should instruct the client to immediately report signs of a transfusion reaction, which can include a backache among other signs such as chills, itching, or rash. These signs of transfusion reaction would require the nurse to stop the transfusion. Fatigue, headache, and nausea are not specifically related to transfusion reaction; however, if these occur, the nurse should investigate their cause.

*Question: A client who has developed atrial fibrillation that is not responding to medication therapy has begun taking warfarin. The nurse is reinforcing dietary discharge teaching with the client. The nurse would plan to teach the client to avoid which food while taking this medication?*

*Answer: Broccoli* Rationale: Anticoagulant medications work by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K often are omitted from the diet. Vitamin K is found in large amounts in green leafy vegetables such as broccoli, cabbage, turnip greens, and lettuce. The other options listed are foods that are lower in vitamin K.

*Question: The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the medication cart. Which is the appropriate action by the nurse?*

*Answer: Change the IV tubing.* Rationale: The nurse should change the IV tubing because it has become contaminated and could cause systemic infection in the client. Wiping the port with povidone-iodine is insufficient and would be contraindicated regardless because the catheter will be attached directly to an angiocatheter in the client's vein. The needleless device has not been contaminated and does not need replacement or cleansing.

*Question: The nurse is assigned to care for a newly admitted client and is reviewing the primary health care provider's prescriptions. The nurse notes that the primary health care provider has prescribed a medication dose that is twice the amount that the client reports taking before admission. Which nursing action is appropriate?*

*Answer: Consult with the registered nurse (RN).* Rationale: If the nurse determines that a primary health care provider's prescription is unclear or if the nurse has a question about a prescription, the nurse should consult with the RN, who will then contact the primary health care provider before implementing the prescription. Under no circumstances should the nurse carry out the prescription unless the prescription is clarified. Questioning the client regarding the accuracy of the dosage of the medication may seem like a viable option, but this action also may cause the client to become upset. The nurse would not administer the medication, nor would the nurse administer an altered dosage.

*Question: The licensed practical nurse (LPN) is assisting in the care of a client who overdosed on acetylsalicylic acid 24 hours ago. The LPN would report to the registered nurse (RN) which findings associated with an anticipated acid-base disturbance?*

*Answer: Drowsiness, headache, and tachypnea* Rationale: The client who ingests a large amount of aspirin (acetylsalicylic acid) is at risk for developing metabolic acidosis 24 hours later. If metabolic acidosis occurs, the client is likely to exhibit drowsiness, headache, and tachypnea. In the very early hours following aspirin overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism. By 24 hours after overdose, however, the compensatory mechanism fails and the client reverts to metabolic acidosis. The client with metabolic alkalosis (option 4) is likely to experience cardiac irregularities and a compensatory decreased respiratory rate and depth. Options 2 and 3 indicate respiratory acidosis and alkalosis, respectively.

*Question: The nurse admits a client with a diagnosis of dehydration and a positive history of cancer to the nursing unit. The client is extremely weak and has an irregular heart pulse rhythm. There are absent bowel sounds, and the client's last bowel movement was 4 days earlier. The nurse plans to review serum electrolyte levels because the client is at high risk for which electrolyte imbalance?*

*Answer: Hypercalcemia* Rationale: The nurse will review the electrolyte results and consider the client at high risk for hypercalcemia, a calcium level higher than 10.5 mg/dL (2.75 mmol/L). The normal adult serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A client with a history of malignancy is at risk for a high calcium level, especially if bone metastasis has occurred. Muscle weakness and heart irregularities are associated with hypercalcemia. Bowel sounds are often absent and peristalsis is seriously depressed. Hyponatremia, low sodium level, is noted to cause hyperactive bowel sounds and diarrhea. Hypocalcemia, low calcium level, is associated with tremors and hyperactive reflexes. Hypomagnesemia, low magnesium level, has similar neuromuscular effects to hypocalcemia, and often clients have painful muscle contractions.

*Question: The licensed practical nurse (LPN) employed in a long-term care facility is asked to assist in planning implementation of a change in the method of documentation system in the nursing unit. Many problems have occurred as a result of the present documentation system, and the nurse manager determines that a change is required. The LPN understands that which is the initial step in the process of change?*

*Answer: Identify the inefficiency that needs improvement or correction.* Rationale: When beginning the change process, the nurse should identify and define the problem or the inefficiency that needs improvement or correction. This important first step can prevent many future problems because if the problem is not correctly identified, a plan for change may be aimed at the wrong problem. This is followed by goal setting, identifying potential solutions and strategies, and setting goals and priorities. The nurse then plans strategies to implement the change.

*Question: The nurse is caring for a client with an internal radiation implant. The nurse would observe which principles? Select all that apply.*

** Rationale: A client receiving treatment for cancer with an internal radioactive implant is emitting radioactive beams, and others in the environment must take precautions to avoid injury. Pregnant persons are not allowed in the room. Nurses delivering bedside care must wear a lead apron, which will stop the radioactive beams. The time that the nurse spends in the room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The dosimeter badge must be worn when in the client's room. Children younger than 16 years old and pregnant women are not allowed in the client's room. These guidelines protect individuals from radiation exposure.

*Question: The nurse is reinforcing discharge instructions to a client with cancer of the prostate after a suprapubic prostatectomy. The nurse would reinforce which discharge instruction? Select all that apply.*

** Rationale: A suprapubic approach involves a lower abdominal incision to remove the prostate to treat prostate cancer. The nurse will reinforce instructions about the incision activity, medications, and when to contact the urologist. The client should take the prescribed stool softener because constipation will lead to straining and cause pain and tension on the surgical site. The client should avoid lifting more than 20 pounds for 6 weeks to avoid tension on the surgical site. Driving a car and sitting for long periods of time are restricted for at least 3 weeks. A daily fluid intake of 2 L to 2.5 L per day (unless contraindicated) should be maintained to limit clot formation and prevent infection. The incision is not on the scrotum but in the lower abdominal area. Small pieces of tissue or blood clots can be passed during urination for up to 2 weeks after surgery and do not need to be reported.

*Question: The nurse is assisting with conducting a health-promotion program to community members regarding testicular cancer. The nurse determines that further teaching is needed if a community member states that which is a sign/symptom of testicular cancer? Select all that apply.*

** Rationale: Alopecia is not a sign/symptom of testicular cancer. However, it may occur as a result of radiation or chemotherapy. Elevated PSA levels are associated with prostate cancer. Testicular swelling without pain and a feeling of heaviness in the scrotum occur with testicular cancer as a result of the tumor growing. Back pain may indicate metastasis to the retroperitoneal lymph nodes.

*Question: The client is receiving external radiation to the neck for cancer of the larynx. The nurse monitors the client knowing that which are side/adverse effects of the external radiation? Select all that apply.*

** Rationale: External radiation is used to treat cancer in a specific area by emission of ionizing radiation beams that destroy cancer cells and have minimal damage to the surrounding normal cells. The client receiving external radiation experiences both general side/adverse effects such as fatigue, nausea, anorexia and localized side/adverse effects in the specific area receiving radiation. A client who is receiving radiation to the larynx is most likely to experience a sore throat and dry, reddened skin in the throat area. Diarrhea or constipation occur with radiation to the gastrointestinal (GI) tract. Dyspnea may occur with lung involvement.

*Question: The nurse is caring for a client with a diagnosis of pemphigus. The nurse would include which interventions in the plan of care for the client? Select all that apply.*

** Rationale: Pemphigus is a chronic autoimmune condition in which bullae (blisters) develop on the face, back, chest, groin, and umbilicus. The blisters rupture easily, releasing a foul-smelling drainage. Potassium permanganate baths, Domeboro solution, and oatmeal products with oil may be prescribed to soothe the affected areas, reduce odor, and decrease the risk of infection. Treatments may include corticosteroids, other immunosuppressants, and oral or topical antibiotics. Acyclovir is an antiviral medication used to treat chickenpox or shingles. Amphotericin B is an antifungal used to treat fungal infections.

*Question: A hospitalized client is prescribed phenelzine sulfate for the treatment of depression. The nurse reinforces instructions to the client and tells the client to avoid consuming which foods while taking this medication? Select all that apply.*

** Rationale: Phenelzine sulfate is a monoamine oxidase inhibitor. The client should avoid consuming foods that are high in tyramine. Eating these foods could trigger a potentially fatal hypertensive crisis. Some foods to avoid include yogurt, aged cheeses, smoked or processed meats, red wines, and fruits such as avocados, raisins, and figs.

*Question: The licensed practical nurse (LPN) in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The LPN immediately notifies the registered nurse (RN) and expects which interventions to be prescribed? Select all that apply.*

** Rationale: Pulmonary edema is a life-threatening event that can result from severe heart failure. During pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high-Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

*Question: A primary health care provider (PHCP) prescribes potassium chloride (KCl) elixir, 20 mEq orally daily. The medication label states potassium chloride (KCl), 30 mEq/15 mL. How many milliliters should the nurse prepare to administer the dose? Fill in the blank.*

** Rationale: Rationale not found

*Question: The nurse provides skin care instructions to the client who is receiving external radiation therapy. Which statement by the client indicates the need for further teaching? Select all that apply.*

** Rationale: The client needs to be instructed to avoid exposure to the sun because of the risk of burns, resulting in altered tissue integrity. No lotions, ointments, or medications should be applied to the skin unless prescribed by the radiologist.

*Question: The nurse is instructing a client with a diagnosis of systemic lupus erythematosus (SLE) about dietary alterations. The nurse would remind the client to avoid which primary foods? Select all that apply.*

** Rationale: The client with SLE is at risk for cardiovascular disorders, such as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce intake of salt, fat, and cholesterol.

*Question: A nonstress test is prescribed for a pregnant client, and the client asks the nurse about the procedure. Which informative statement would the nurse provide to the client?*

*Answer: "An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly."* Rationale: A nonstress test is a noninvasive test, and an ultrasound transducer that records fetal heart activity is secured over the maternal abdomen where the fetal heart is heard most clearly. A tocodynamometer that detects uterine activity and fetal movement is then secured to the maternal abdomen. Fetal heart activity and movements are recorded. The test is termed "nonstress" because it consists of monitoring only; the fetus is not challenged or stressed by uterine contractions to obtain the necessary data. The nonstress test takes about 30 to 40 minutes.

*Question: A postpartum nurse is reinforcing instructions to a mother regarding how to provide a bath to the newborn. Which statement by the mother indicates the need for further teaching?*

*Answer: "I need to bathe my newborn after a feeding."* Rationale: It is not advisable to bathe a newborn or infant after a feeding because handling may cause regurgitation. Because bathing is thought to be relaxing to the newborn, before feeding may be the best time. Options 2, 3, and 4 are appropriate interventions in bathing a newborn.

*Question: The nurse has reinforced discharge instructions to the mother of an 18-month-old child following surgical repair of hypospadias. Which statement by the mother indicates a need for further teaching?*

*Answer: "I should carry my child by straddling the child on my hip."* Rationale: Parent teaching following hypospadias repair includes restricting the child from activities that put pressure on the surgical site. Straddling the child on the hip will cause pressure on the surgical site. The parents should be instructed to use double diapers to hold the stent in place and should be instructed how to hold the child during the postoperative period. Fluids should be encouraged to maintain hydration. Toilet training should not be an issue during this stressful period.

*Question: The nurse is reinforcing instructions to the client who has just been fitted for a halo vest. Which statement by the client indicates the need for further teaching?*

*Answer: "I will avoid driving at night because the vest limits the ability to turn the head."* Rationale: The client wearing a halo vest should not drive at all because the device impairs head movement and the range of vision. The inability to turn the head without turning the torso would make driving contraindicated. The halo device does alter balance and can pose increased risk of falls for the client. The client should clean the skin daily under the vest to protect the skin from ulceration and should use powder or lotions sparingly or not at all. The client should have food cut into small pieces to facilitate chewing and use straws for drinking because the head immobilization makes eating and drinking harder.

*Question: A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is reinforcing teaching for the client about the medications prescribed, including clarithromycin, esomeprazole, and amoxicillin. Which statement by the client indicates the best understanding of the medication regimen?*

*Answer: "The medications will kill the bacteria and stop the acid production."* Rationale: Triple therapy for Helicobacter pylori infection usually includes two antibacterial drugs and a proton pump inhibitor. Clarithromycin and amoxicillin are antibacterials. Esomeprazole is a proton pump inhibitor. These medications will kill the bacteria and decrease acid production.

*Question: During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse would make which therapeutic response to the client?*

*Answer: "You sound very upset. Are you thinking of hurting yourself?"* Rationale: Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plans. The client should be directly asked if a plan for self-harm exists. Options 1, 2, and 3 are not therapeutic responses.

*Question: The client arrives at the emergency department after a burn injury that occurred in a home basement, and an inhalation injury is suspected. Which would the nurse anticipate as being prescribed for the client?*

*Answer: 100% oxygen via a tight-fitting, nonrebreather face mask* Rationale: If an inhalation injury is suspected, the administration of 100% oxygen via a tight-fitting, nonrebreather face mask is prescribed until the carboxyhemoglobin level falls below 15%. With inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation is also determined. Options 1, 2, and 3 are incorrect.

*Question: The nurse is monitoring the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse prepares to implement bleeding precautions if the child becomes thrombocytopenic and the platelet count is less than which value?*

*Answer: 20,000 mm3* Rationale: If a child is severely thrombocytopenic, with a platelet count of less than 20,000 mm3, precautions need to be taken because of the increased risk of bleeding. The precautions include limiting activity that could result in head injury, using soft toothbrushes or Toothettes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. In addition, suppositories and rectal temperatures are avoided. The normal platelet count ranges from 150,000 to 400,000 mm3.

*Question: The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse would plan to tell the client to place the crutches in which position?*

*Answer: 8 inches to the front and side of the client's toes* Rationale: The classic tripod position is taught to the client before giving instructions on gait. The crutches are placed anywhere from 6 to 10 inches in front and to the side of the client, depending on the client's body size. This provides a wide enough base of support to the client and improves balance.

*Question: A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client would be an appropriate choice as this client's roommate?*

*Answer: A client receiving diagnostic tests* Rationale: The client receiving diagnostic tests is an appropriate roommate. The client with anorexia is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which he or she can focus on the nutritional needs of others or be managed by others, because this may contribute to sublimation and suppression of his or her own hunger.

*Question: The nurse is assisting with creating a plan of care for the client in a crisis state. When developing the plan, the nurse would consider which about a crisis response?*

*Answer: A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.* Rationale: Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one person may not constitute a crisis for another person because each is a unique individual. Being in a crisis state does not mean that the client is suffering from an emotional or mental illness.

*Question: The client asks the nurse about which product should be taken for a headache. The client is taking lansoprazole for long-term management of the diagnosis of Zollinger-Ellison syndrome. The nurse would determine that which medication is the most appropriate choice for this client?*

*Answer: Acetaminophen* Rationale: Zollinger-Ellison syndrome is a hypersecretory condition of the stomach. The client should avoid taking medications that are irritating to the stomach lining. Irritants would include aspirin and nonsteroidal anti-inflammatory drugs (naproxen and ibuprofen). The client should be advised to take acetaminophen for headache.

*Question: The nurse is caring for a client with a burn injury to the lower legs. Silver sulfadiazine is prescribed to be applied to the sites of injury. Which indicates the appropriate method to apply this medication?*

*Answer: Apply to cleansed, debrided wounds as prescribed.* Rationale: This medication is classified as an anti-infective and acts by producing a bactericidal effect, and it commonly is used to treat burns. This medication should be applied to cleansed, debrided wounds as prescribed using sterile gloves and sterile procedure. Burn areas should be kept covered with this medication at all times and should be reapplied to areas removed by client activity. Dressings covering the injury sites also may be prescribed. The medication should be applied only to the affected site, not the surrounding unaffected areas.

*Question: To use an external cardiac defibrillator on a client, which action would be performed to check the cardiac rhythm?*

*Answer: Applying the adhesive patch electrodes to the skin and moving away from the client* Rationale: The nurse or rescuer puts two large adhesive patch electrodes on the client's chest in the usual defibrillator position. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds. The machine then indicates if it is necessary to defibrillate. Although automatic external defibrillation can be done transtelephonically, it is done through the use of patch electrodes (not standard electrocardiographic electrodes) that interact via telephone lines to a base station that controls any actual defibrillation. It is not necessary to hold defibrillator paddles against the client's chest with this device.

*Question: The nurse is assisting in the care of a client with myocardial infarction who should reduce intake of saturated fat and cholesterol. The nurse would help the client comply with diet therapy by selecting which food items from the dietary menu?*

*Answer: Baked haddock, steamed broccoli, herbed rice, sliced strawberries* Rationale: A client trying to lower fat and cholesterol in the diet should decrease the use of fatty cuts of meats such as beef, lamb or pork, organ meats, sausage, hot dogs, bacon, and sardines; avoid vegetables prepared in butter, cream, or other sauces; use low-fat milk products instead of whole milk products and cream; and decrease the amount of commercially prepared baked goods. Option 3 is the only option that identifies low-fat and low-cholesterol foods.

*Question: A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet?*

*Answer: Baked turkey* Rationale: Regular soup (1 cup) contains 900 mg of sodium. Fresh shellfish (1 oz) contains 50 mg of sodium. Poultry (1 oz) contains 25 mg of sodium.

*Question: After a renal biopsy, the client complains of pain at the biopsy site that radiates to the front of the abdomen. Which would this indicate?*

*Answer: Bleeding* Rationale: If pain originates at the biopsy site and begins to radiate to the flank area and around the front of the abdomen, bleeding should be suspected. Hypotension, a decreasing hematocrit, and gross or microscopic hematuria should also indicate bleeding. Signs of infection should not appear immediately after a biopsy. Pain of this nature is not normal. There are no data to support the presence of renal colic.

*Question: A client with a pituitary tumor will undergo transsphenoidal hypophysectomy. The nurse reinforces which information in the preoperative teaching plan for the client?*

*Answer: Blowing the nose following surgery is prohibited.* Rationale: The approach used for this surgery is the oronasal route, specifically where the upper lip meets the gum. The surgeon then uses a route through the sphenoid sinus to get to the pituitary gland. The client is not allowed to blow the nose, sneeze, or cough vigorously because these activities could raise intracranial pressure. The client also is not allowed to brush the teeth to avoid disrupting the surgical site. Alternate methods for performing mouth care are used.

*Question: A client with psoriasis has been prescribed coal tar for use in the treatment of the disorder. In reinforcing instructions to the client about the medication, the nurse incorporates which aspect of this medication?*

*Answer: Can stain the skin and hair* Rationale: Coal tar is used to treat psoriasis and other chronic disorders of the skin. It suppresses DNA synthesis, mitotic activity, and cell proliferation. It frequently can stain the skin and hair, and clients should be taught about this aspect of the medication. It has an unpleasant odor and can cause phototoxicity. It does not carry a risk for systemic effects.

*Question: A client with heart disease is instructed regarding a low-fat diet. The nurse determines that the client understands the diet if the client states to avoid which food item?*

*Answer: Cheese* Rationale: Fruits, vegetables, and skim milk contain minimal amounts of fat. Cheese is high in fat.

*Question: The nurse has reviewed the primary health care provider's prescriptions for a child suspected of a diagnosis of neuroblastoma and is preparing to implement diagnostic procedures that will confirm the diagnosis. The nurse prepares to do which?*

*Answer: Collect a 24-hour urine sample.* Rationale: Neuroblastoma is a solid tumor found only in children. It arises from neural crest cells that develop into the sympathetic nervous system and the adrenal medulla. Typically the tumor infringes on adjacent normal tissue and organs. Neuroblastoma cells may excrete catecholamines and their metabolites. Urine samples will indicate elevated vanillylmandelic acid levels. A bone marrow aspiration will assist in determining marrow involvement. A neurological examination and a chest x-ray may be performed but will not confirm the diagnosis.

*Question: The nurse is teaching a mother how to administer eardrops to an infant. The nurse determines the mother understands instructions if the mother demonstrates pulling the ear in which manner?*

*Answer: Down and back and directing the solution toward the wall of the canal* Rationale: The ear is pulled down and straight back in a child younger than 3 years of age. The infant is turned onto the side with the affected ear uppermost. The nurse pulls down and back on the earlobe with the nondominant hand while resting the wrist of the dominant hand on the infant's head. The medication is directed toward the wall of the canal rather than onto the eardrum. The infant should lie with the affected ear uppermost for 10 to 15 minutes to retain the solution. In an adult or a child older than 3 years, the ear is pulled up and back to straighten the auditory canal.

*Question: The nurse is caring for a client with severe depression. Which activity is appropriate for this client?*

*Answer: Drawing* Rationale: Concentration and memory are poor in a client with severe depression. When a client has a diagnosis of severe depression, the nurse needs to provide activities that require little concentration. Activities that have no right or wrong choices or decisions minimize opportunities for the client to put down himself or herself. The nurse can also process the client's feelings by sitting with the client and talking or encouraging the client to write in a journal.

*Question: A client is receiving bolus feedings via a nasogastric tube. The nurse plans to place the client's head of the bed (HOB) in which optimal position once the feeding is completed?*

*Answer: Elevated 30 to 45 degrees with the client in the right lateral position for 60 minutes* Rationale: Aspiration is a possible complication associated with nasogastric tube feeding. The HOB should be elevated 30 to 45 degrees for 60 minutes following bolus tube feeding to prevent vomiting and aspiration. The right lateral position uses gravity to facilitate gastric emptying, which also will reduce the risk of vomiting. The flat or supine position should be avoided because of the risk of aspiration.

*Question: A client has sustained partial-thickness burns on the posterior thorax and legs. The nurse who is assisting in caring for the client would monitor for which sign/symptom during the first 24 hours after the burn injury?*

*Answer: Elevated hematocrit levels* Rationale: The emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the emergent phase, the hematocrit rises above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% are expected during the first 24 hours after injury but generally return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys, reducing renal perfusion and glomerular filtration. This leads to a decreased urine output. Pulse rates are typically higher than normal; the blood pressure is normal or slightly elevated unless hypovolemia is severe.

*Question: A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription?*

*Answer: Holding the next dose of warfarin* Rationale: The normal PT is 11 seconds to 12.5 seconds (conventional therapy and SI units). The normal INR is 0.81 to 1.2 (conventional therapy and SI units); 2 to 3 for standard warfarin therapy, which is used for the treatment of atrial fibrillation, and 3 to 4.5 for high-dose warfarin therapy, which is used for clients with mechanical heart valves. A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the values of 35 seconds and 3.5 are high, the nurse should anticipate that the client would not receive further doses at this time. Therefore, the prescriptions noted in the remaining options are incorrect.

*Question: A client calls the primary health care provider's office to schedule an appointment because a home pregnancy test was performed and the results were positive. The nurse determines that the home pregnancy test identified the presence of which in the urine?*

*Answer: Human chorionic gonadotropin (hCG)* Rationale: In early pregnancy, hCG is produced by trophoblastic cells that surround the developing embryo. This hormone is responsible for positive pregnancy tests. Options 1, 2, and 3 are incorrect.

*Question: The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse would monitor for which symptoms?*

*Answer: Hypertension, disorientation, hallucinations* Rationale: The symptoms associated with alcohol withdrawal delirium typically are anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations, agitation, fever, and delusions.

*Question: A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right!" Which action would the nurse take?*

*Answer: Identify recent behaviors or accomplishments that demonstrate skill or ability.* Rationale: Feelings of low self-esteem and worthlessness are common symptoms of the depressed client. An effective plan of care is to provide successful experiences for the client that are challenging but will not be met with failure to enhance the client's personal self-esteem. Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of himself or herself. Options 1 and 4 offer false reassurances. Option 2 is not a therapeutic intervention with a depressed client.

*Question: A client diagnosed with diabetes insipidus is beginning medication therapy with lypressin. The nurse realizes the client understands instructions if the client comments the medicine will be taken in which manner?*

*Answer: Intranasally to promote water reabsorption* Rationale: Lypressin is antidiuretic hormone administered by the intranasal route. The usual adult dosage is 1 or 2 sprays into each nostril 4 times daily. It acts on the collecting ducts of the kidneys to increase water reabsorption by increasing their permeability to water.

*Question: An adult female client has a hemoglobin level of 10.8 g/dL (108 g/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history?*

*Answer: Iron deficiency anemia* Rationale: The normal hemoglobin level for an adult female client is 12 g/dL to 16 g/dL (120-160 g/L). Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body's need for more oxygen-carrying capacity.

*Question: The nurse is providing instructions to a client diagnosed with acquired immunodeficiency syndrome (AIDS) experiencing night fever and night sweats. The nurse would advise the client to do which action to best increase comfort while minimizing symptoms?*

*Answer: Keep liquids on the nightstand at home.* Rationale: For clients with AIDS who experience night fever and night sweats, it is useful to keep liquids on the nightstand at home. The client should keep a plastic cover on the pillow and also place a towel over the pillowcase if needed. The client should not decrease fluid intake, and the client should take an antipyretic before going to sleep and before the fever spikes.

*Question: The nurse is assigned to care for a client after a left pneumonectomy. Which position is contraindicated for this client?*

*Answer: Lateral position* Rationale: Complete lateral positioning is contraindicated for a client following pneumonectomy. Because the mediastinum is no longer held in place on both sides by lung tissue, lateral positioning may cause mediastinal shift and compression of the remaining lung. The head of the bed should be elevated.

*Question: The nurse reinforces postoperative liver biopsy instructions to a client. Which would the nurse tell the client?*

*Answer: Lie on the right side for 2 hours.* Rationale: To splint the puncture site, the client is kept on the right side for a minimum of 2 hours. It is not necessary to remain NPO for 24 hours. Permission regarding the consumption of alcohol should be obtained from the PHCP. It is not necessary to save all stools.

*Question: The nurse is reviewing the laboratory results of a child with aplastic anemia and notes that the white blood cell (WBC) count is 2000 mm3, and the platelet count is 150,000 mm3. Which nursing intervention would the nurse incorporate into the plan of care?*

*Answer: Maintain strict isolation precautions.* Rationale: The normal WBC ranges from 5000 to 10,000 mm3, and the normal platelet count ranges from 150,000 to 400,000 mm3. Strict isolation procedures would be required if the WBC count were low to protect the child from infection. Precautionary measures to prevent bleeding should be taken when a child has a low platelet count. These include no injections, no rectal temperatures, use of a soft toothbrush, and abstinence from contact sports or activities that could cause an injury.

*Question: A client in the clinical unit who is allergic to shellfish unknowingly ate a dish brought by a friend that had shellfish as an ingredient. The client quickly develops anaphylaxis. The nurse would focus on which intervention first until additional help arrives?*

*Answer: Maintaining a patent airway* Rationale: The initial priority of the nurse would be to maintain a patent airway. Once additional help arrives, the client would likely receive epinephrine and corticosteroids. The topic of the Medic-Alert bracelet should be deferred until the client is stable.

*Question: The nurse is caring for the client who is at risk for lung cancer because of an extremely long history of heavy cigarette smoking. The nurse tells the client to report which frequent early symptom of lung cancer?*

*Answer: Nonproductive hacking cough* Rationale: Cough is the most frequent early symptom of lung cancer; it begins as nonproductive and hacking and progresses to productive. In the smoker who already has a cough, a change in the character and frequency of the cough usually occurs. Hoarseness and blood-streaked sputum are later signs. Pain is a very late sign and is usually pleuritic in nature.

*Question: The nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. Based on this data, the nurse would make which determination about the client's neurovascular status?*

*Answer: Normal, caused by increased blood flow through the leg* Rationale: An expected outcome of surgery is warmth, redness, and edema in the surgical extremity caused by increased blood flow. Options 1, 3, and 4 are incorrect.

*Question: The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is appropriate?*

*Answer: Notify the registered nurse (RN).* Rationale: A normal fetal heart rate is 110 to 160 beats per minute. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the RN needs to be notified. Options 2, 3, and 4 are not appropriate nursing actions in this situation.

*Question: The nurse is reviewing the record of a client who is hospitalized for treatment of a panic disorder. The nurse notes that the client was admitted by voluntary hospitalization. During the day, the client runs down the hallway and demands release from the hospital. The nurse notes that the client is exhibiting signs/symptoms of anxiety and attempts to assist the client back to the client's hospital room. Which is the next appropriate nursing action at this time?*

*Answer: Notify the registered nurse (RN).* Rationale: The next appropriate nursing action is to notify the RN. Generally, voluntary admission is sought by the client or client's guardian through a written application to the facility. Voluntary clients have the right to demand and obtain release. If the client is a minor, the release may be contingent on the consent of the parents or guardian. The nurse needs to be familiar with the state and facility policies and procedures. Many states require that the client submit a written release notice to the facility staff, who reevaluates the client's condition for possible conversion to involuntary status, according to criteria established by laws. Options 2 and 3 are inappropriate. Option 4 is inaccurate information. The next appropriate nursing action is to notify the RN, who will then contact the primary health care provider.

*Question: The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action?*

*Answer: Observing rigid rules and regulations* Rationale: Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help the clients manage their anxiety. Options 1, 2, and 4 are incorrect.

*Question: The client with a gastric ulcer has a prescription for sucralfate 1 g by mouth four times daily. The nurse would schedule the medication to be administered at which times?*

*Answer: One hour before meals and at bedtime* Rationale: Sucralfate is a gastric protectant. The medication should be scheduled for administration 1 hour before meals and at bedtime. The medication is timed to allow it to form a protective coating over the ulcer before food intake stimulates gastric acid production and mechanical irritation. The other options are incorrect.

*Question: Which data would indicate a potential complication associated with age-related changes in the musculoskeletal system?*

*Answer: Overall sclerotic lesions* Rationale: Sclerotic lesions occur as bone resorption increases and results in replacement of original bone with fibrous material. This condition occurs in Paget's disease, an age-related disorder. Options 1, 3, and 4 identify normal age-related changes in the musculoskeletal system.

*Question: The client is hospitalized for the insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. Which is the immediate nursing action?*

*Answer: Pick up the implant with long-handled forceps and place into a lead container.* Rationale: A lead container and long-handled forceps should be kept in the client's room at all times during internal radiation therapy. Lead is an element that has a high density and high atomic number and is used to shield persons from radiation. If dislodged, the implant must be handled carefully to limit radiation exposure to the client and all persons in the environment. If the implant becomes dislodged, the nurse should pick up the implant with long-handled forceps and place it into the lead container. The radiation safety officer of the institution should be notified. Although the PHCP needs to be notified, this is not the immediate action. The nurse cannot reinsert the implant. A radioactive implant is specifically placed inside the client to kill the cancer while limiting damage to adjacent tissues and organs. Touching the implant with gloves and flushing this down the toilet exposes the

*Question: The nurse notes that a client with type 1 diabetes mellitus has lipodystrophy on both upper thighs. Which further information would the nurse obtain from the client during data collection?*

*Answer: Plan for injection rotation* Rationale: Lipodystrophy (i.e., the hypertrophy of subcutaneous tissue at the injection site) occurs in some diabetic clients when the same injection sites are used for prolonged periods of time. Thus clients are instructed to adhere to a rotating injection site plan to avoid tissue changes. Preparation of the site, aspiration, and the angle of insulin administration do not produce tissue damage.

*Question: The nurse is reinforcing discharge instructions to the parents of a 2-year-old child who had an orchiopexy procedure done to treat cryptorchidism. The nurse would determine the parents understood the discharge instructions if they state which play activity is best for the child after this procedure?*

*Answer: Playing with clay* Rationale: Cryptorchidism occurs when one or both testes fail to descend into the scrotum. Orchiopexy is performed to replace the undescended testicle into the scrotum in the case of cryptorchidism in which the testes is palpable. The parents of a child who underwent an orchiopexy procedure should be taught that the child should avoid jumping activities, especially those that cause pressure on the surgical area, and should also avoid activities that include straddle toys that involve spreading the inner thighs, such as a rocking horse or tricycle. Option 2 is appropriate for this age group with adult supervision and does not put strain on the surgical site.

*Question: A mother is breast-feeding her newborn. The mother complains to the nurse that she is experiencing severe nipple soreness. The nurse would provide which suggestion to the client?*

*Answer: Position the newborn infant with the ear, shoulder, and hip in straight alignment and with the baby's stomach against the mother's.* Rationale: Severe nipple soreness most often occurs as a result of poor positioning, incorrect latch-on, improper suck, or monilial infection. Comfort measures for nipple soreness include positioning the newborn with the ear, shoulder, and hip in straight alignment and with the baby's stomach against the mother's. Options 1, 2, and 3 do not identify measures that will alleviate the nipple soreness.

*Question: A client in the postpartum unit complains of sudden, sharp chest pain. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which would be the initial nursing action?*

*Answer: Prepare to administer oxygen at 8 to 10 L by tight face mask.* Rationale: If pulmonary embolism is suspected, oxygen should be administered at 8 to 10 L by tight face mask. Oxygen is used to decrease hypoxia. The woman also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this action is not the initial nursing action. An IV line also will be required, but this action should follow the administration of the oxygen.

*Question: The nurse is checking the casted extremity of a client. The nurse would check for which sign indicative of infection?*

*Answer: Presence of a "hot spot" on the cast* Rationale: Signs and symptoms of infection under a casted area include odor or purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others. The primary health care provider (PHCP) should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished arterial pulse, and edema.

*Question: The nurse is caring for a child with osteosarcoma following amputation of the left lower limb. The child is continually complaining of aching and cramping in the missing limb. Which action would the nurse take?*

*Answer: Reassure the child that this is a temporary condition.* Rationale: Following amputation, phantom limb pain is a temporary condition that some children may experience. This sensation of burning, aching, or cramping in the missing limb is most distressing to the child. The child needs to be reassured that the condition is normal and only temporary. Requesting a referral for a psychiatric consultation and asking the pediatrician for a prescription for a placebo are inappropriate. Although the sensation of phantom pain is temporary, the prosthesis will not necessarily relieve this sensation.

*Question: A client who suffered a cervical spine injury had Crutchfield tongs applied in the emergency department. The nurse would avoid which action in the care of the client?*

*Answer: Removing the weights when repositioning the client* Rationale: Crutchfield tongs are a method of skeletal traction used with cervical spine injury. All of the principles of assessment and care that apply to the client in traction apply to this client. The nurse should not remove the weights to administer care; removing the weights will disrupt the traction applied. The nurse should ensure that weights hang freely and that the amount of weight matches the current prescription. The nurse should inspect the integrity and position of the ropes and pulleys. The client is placed on a Stryker frame or Roto-Rest bed while the Crutchfield tongs are in use.

*Question: The nurse is told that the arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco2 of 32 mm Hg (32 mm Hg). The nurse determines that these results are indicative of which acid-base disturbance?*

*Answer: Respiratory alkalosis* Rationale: The normal pH is 7.35 to 7.45. If a respiratory condition exists, an opposite relationship will be seen between the pH and the Pco2, as is seen in the correct option. If an alkalotic condition exists, the pH is increased. During an acidotic condition, the pH is decreased so both metabolic acidosis and respiratory acidosis can be eliminated. Metabolic alkalosis can also be eliminated because both pH and HCO3- are increased above normal values with this condition.

*Question: The nurse is assigned to care for a client diagnosed with cytomegalovirus retinitis and acquired immunodeficiency syndrome (AIDS) who is receiving foscarnet. The nurse would monitor the results of which laboratory study while the client is taking this medication?*

*Answer: Serum creatinine level* Rationale: Foscarnet is toxic to the kidneys. Serum creatinine is monitored before therapy, two to three times per week during induction therapy, and at least weekly during maintenance therapy. Foscarnet may also cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus these levels are also measured with the same frequency.

*Question: Alendronate is prescribed for a client with osteoporosis, and the nurse is providing instructions for the administration of the medication. Which instruction would the nurse reinforce?*

*Answer: Take the medication with a full glass of water after rising in the morning.* Rationale: Precautions need to be taken with the administration of alendronate to prevent gastrointestinal side/adverse effects (especially esophageal irritation) and to increase absorption of the medication. The medication needs to be taken with a full glass of water after rising in the morning. The client should not eat or drink anything for 30 minutes following administration and should not lie down after taking the medication.

*Question: The nurse in the pediatric unit is admitting a 2-year-old child. The nurse plans care, considering the child will likely display which behavior during Erikson's psychosocial stage of development corresponding with the age?*

*Answer: The child frequently says "no" when the parents or the nurse asks a question.* Rationale: A 2-year-old child, a toddler, is in the autonomy vs. shame and doubt stage. In this stage, the toddler develops a sense of control over the self and bodily functions and exerts him or herself. Trust vs. mistrust characterizes the stage of infancy, and behavior would be constantly sucking on a pacifier for comfort. Initiative vs. guilt characterizes the preschool age. A preschool child would enjoy finger painting. Industry vs. inferiority characterizes the school-age child who would be able to sort blocks, or other items, according to size and color.

*Question: The client has been taking medication for rheumatoid arthritis for 3 weeks. During the administration of etanercept, it is most important for the nurse to collect which data?*

*Answer: The white blood cell and platelet counts* Rationale: Infection and suppression can occur as a result of etanercept. Laboratory studies are performed before and during treatment. The appearance of abnormal white blood cell and platelet counts can alert the nurse to a potentially life-threatening infection or potential bleeding. Injection site itching and edema are common occurrences following administration. A metallic taste and loss of appetite are not associated with this medication. Fatigue and joint pain occur with rheumatoid arthritis.

*Question: The nurse is performing a safety assessment in the home of a mother with two children. The ages of the children are 1 and 3 years. Which observation noted during the assessment would present the greatest hazard to the children?*

*Answer: Toys with small loose parts in the playroom* Rationale: Toys with small loose parts would be the priority concern. Children at this age are likely to place the small toy parts in their mouths, which could lead to aspiration and choking. The temperature of the water heater is a concern, but it is not the greatest hazard. The mother should be aware of and taught safety measures related to safe water temperatures for bathing the children. A gate placed at the stairs of the second floor is a safety measure. A small dog as a house pet is not necessarily a hazard.

*Question: Disulfiram is prescribed for a client and the nurse is collecting data on the client and is reinforcing instructions regarding the use of this medication. Which is most important for the nurse to determine before administration of this medication?*

*Answer: When the last alcoholic drink was consumed* Rationale: Disulfiram is used as an adjunct treatment for selected clients with chronic alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administered. The most important data are to determine when the last alcoholic drink was consumed. The medication is used with caution in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, nephritis, and hepatic disease. It is contraindicated in severe heart disease, psychosis, or hypersensitivity related to the medication.

*Question: The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which manifestations are specifically associated with withdrawal from opioids?*

*Answer: Yawning, irritability, diaphoresis, cramps, and diarrhea* Rationale: Opioids are central nervous system (CNS) depressants. Withdrawal effects include yawning, insomnia, irritability, rhinorrhea, diaphoresis, cramps, nausea and vomiting, muscle aches, chills, fever, lacrimation, and diarrhea. Withdrawal is treated by methadone tapering or medication detoxification. Option 2 identifies the clinical manifestations associated with withdrawal from opioids. Option 1 describes intoxication from hallucinogens. Option 3 describes withdrawal from alcohol. Option 4 describes withdrawal from cocaine.

*Question: A licensed practical nurse (LPN) is a certified basic life support (BLS) instructor. The LPN is conducting a BLS recertification class and is discussing automated external defibrillation. A member of the class asks the LPN to identify the correct location for the placement of conductive gel pads to treat ventricular fibrillation. The LPN tells the class that the conductive gel pads are placed in which location on the client's chest?*

*Answer: Under the right clavicle and to the left of the precordium* Rationale: In defibrillation, one gel pad is placed on the upper right chest next to the sternum and below the clavicle and the other to the left of the precordium. The electrode paddles are placed over the pads for defibrillation with firm pressure. Options 1, 2, and 3 are incorrect.

*Question: A client with a history of hypertension has been prescribed triamterene. The nurse determines that the client understands the effect of this medication on the diet if the client states to avoid which fruit?*

*Answer: Bananas* Rationale: Triamterene is a potassium-retaining diuretic, and the client should avoid foods high in potassium. Fruits that are naturally higher in potassium include avocados, bananas, fresh oranges and mangoes, nectarines, papayas, and dried prunes and other dried fruits.

*Question: The nurse is reinforcing instructions to a client regarding the use of ice packs to treat an eye injury. The nurse instructs the client to do which action?*

*Answer: Wrap a plastic bag filled with ice with a pillowcase and place it on the eye.* Rationale: If an ice pack is placed directly against the skin or left in place for an extended period, it carries a risk of tissue damage similar to that of a hot water bottle or a heating pad. To prevent tissue damage from excessive cold exposure, the ice pack should be removed in most cases after 30 minutes, and after a short time, it may be reapplied. An ice pack should never be placed directly against the skin but should be covered with a pillowcase or towel. Commercially prepared ice bags are appropriate for use as an ice pack.

*Question: During the monitoring of a client's response to disease-modifying antirheumatic drugs (DMARDs), which findings would the nurse interpret as acceptable responses? Select all that apply.*

** Rationale: Because emotional stress frequently exacerbates the symptoms of rheumatoid arthritis, the absence of symptoms is a positive finding. DMARDs are given to slow progression of joint degeneration. In addition, the improvement in the range of motion after 3 months of therapy with normal blood work is a positive finding. Temperature elevation and inflammation and irritation at the medication injection site could indicate signs of infection.

*Question: A primary health care provider prescribes 1000 mL of 0.9% normal saline (NS) to run over 8 hours. The drop (gtt) factor is 10 drops (gtt) per 1 mL. The nurse adjusts the flow rate to run at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.*

** Rationale: Rationale not found

*Question: The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions would the nurse institute during the care of the client?*

*Answer: Wear a gown and gloves.* Rationale: The Centers for Disease Control and Prevention recommends the wearing of gowns and gloves when in close contact with a person who has MRSA. Masks are not necessary. Transmission via clothing and other inanimate objects is uncommon. MRSA is contagious and is spread to others by direct contact with infected skin or infected articles.

*Question: A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed, the nurse places a sign above the bed stating that the client would remain on bed rest and in which position?*

*Answer: With the head of the bed elevated no more than 15 degrees* Rationale: Following cardiac catheterization, the extremity used for catheter insertion is kept straight for 4 to 6 hours. If the femoral artery was used, strict bed rest is necessary for 4 to 6 hours. The client may turn from side to side. The head of the bed is not elevated more than 15 degrees to prevent kinking of the blood vessel at the groin and possible arterial occlusion. The cardiologist's prescription for positioning is always followed. Some cardiologists may prescribe a supine position.

*Question: An older client has recently been taking cimetidine. The nurse would monitor the client for which most frequent central nervous system side effect of this medication?*

*Answer: Confusion* Rationale: Cimetidine is a histamine 2 (H2)-receptor antagonist. Older clients are especially susceptible to the central nervous system side effects of cimetidine. The most frequent of these is confusion. Less common central nervous system side effects include headache, dizziness, drowsiness, and hallucinations.

*Question: The nurse in the newborn nursery is collecting data on a neonate who was born of a mother addicted to cocaine. Which signs/symptoms would the nurse expect to note in the neonate? Select all that apply.*

** Rationale: Clinical signs/symptoms at birth in neonates exposed to cocaine in utero include tremors, tachycardia, marked irritability, muscular rigidity, hypertension, and exaggerated startle reflex. These infants are difficult to console and exhibit an inability to respond to voices or environmental stimuli. They are often poor feeders and have episodes of diarrhea.

*Question: The nurse is assisting with creating a plan of care for a client with pancytopenia as a result of chemotherapy. The nurse would suggest including which in the plan of care? Select all that apply.*

** Rationale: A client who is experiencing pancytopenia (decrease in all blood cells types: red, white, and platelets) is at high risk for infection because of significantly low immunity. The client should not eat fresh fruits and vegetables because they are at a potential for ingesting bacteria. All foods should be cooked thoroughly. The client should wear a mask when outside of the room to avoid potential infection spread from persons in the hallways. Not all visitors are restricted, but the client is protected from people with known infections. Fluids should be encouraged because dehydration increases the risk for infection. Invasive measures such as an indwelling urinary catheter should be avoided to prevent infection.

*Question: The nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions would the nurse include on the list? Select all that apply.*

** Rationale: A plaster cast takes 24 to 72 hours to dry (synthetic casts dry in 20 minutes). The cast and extremity may be elevated to reduce edema. A wet cast is handled with the palms of the hands until it is dry, and the extremity is turned (unless contraindicated) so that all sides of the wet cast will dry. A cool setting on the hair dryer can be used to dry a plaster cast (heat cannot be used because the cast heats up and burns the skin). The cast needs to be kept clean and dry, and the client is instructed not to stick anything under the cast because of the risk of breaking skin integrity. The client is instructed to monitor the extremity for circulatory impairment such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. The primary health care provider (PHCP) is notified immediately if circulatory impairment occurs.

*Question: The nurse is reinforcing instructions to a client on how to care for a punch biopsy site after the procedure is done. Which would the nurse include in the instructions? Select all that apply.*

** Rationale: After the procedure, the client is given instructions for the care of the biopsy site. Usually the bandage is changed daily. The site may or may not be treated with a topical antibiotic solution or ointment. Biopsy sites for a punch biopsy will not have any sutures. Oxycodone would not be prescribed for pain; acetaminophen or ibuprofen would be adequate to relieve any pain after the procedure.

*Question: The nurse is reviewing the client's record and notes that the primary health care provider (PHCP) has documented that the client has a renal disorder. Which laboratory results would indicate a decrease in renal function? Select all that apply.*

** Rationale: BUN testing is a frequently used laboratory test to determine renal function. The BUN and serum creatinine levels start to rise when the glomerular filtration rate falls below 40% to 60%. A decreased RBC count may be noted if erythropoietic function by the kidney is impaired. An increased WBC is most likely to be noted in renal disease. Thrombocyte cell counts do not indicate decreased renal function.

*Question: A long-term care nurse notes that an older client who is normally alert has become progressively confused and irritable. What diagnostic tests would the nurse anticipate the primary health care provider to prescribe? Select all that apply.*

** Rationale: Confusion may be one of the first signs of cystitis or UTI in older adults. If a patient who is normally alert becomes confused, assess the urine for cloudiness, foul odor, or hematuria (blood in the urine), and check for signs of infection (fever, increased white blood cell [WBC] count).

*Question: A histamine (H2)-receptor antagonist will be prescribed for a client. The nurse understands that which medications are H2-receptor antagonists? Select all that apply.*

** Rationale: H2-receptor antagonists suppress secretion of gastric acid, alleviate symptoms of heartburn, and assist with preventing complications of peptic ulcer disease. These medications also suppress gastric acid secretions and are used in active ulcer disease, erosive esophagitis, and pathological hypersecretory conditions. The other medications listed are proton pump inhibitors.

*Question: The nurse is assisting with developing a plan of care for the client with multiple myeloma. Which nursing intervention would be included to prevent renal failure for this client? Select all that apply.*

** Rationale: In order to prevent renal failure in the client with multiple myeloma, the nurse should encourage fluids and monitor serum calcium and uric acid levels. Hypercalcemia secondary to bone destruction is a priority concern in the client with multiple myeloma. The nurse should encourage fluids in adequate amounts to maintain an output of 1.5 L to 2 L a day. Clients require about 3 L of fluid per day. The fluid is needed not only to dilute the calcium and uric acid, but also to prevent protein from precipitating in the renal tubules. Oral care, encouraging coughing and deep breathing, and monitoring the red blood cell count are important for clients with cancer, but these interventions are not specific to prevention of renal failure.

*Question: The nurse is monitoring a client receiving levothyroxine sodium for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? Select all that apply.*

** Rationale: Insomnia, weight loss, and mild heat intolerance are side effects of levothyroxine sodium. Bradycardia and constipation are not side effects associated with this medication, but rather are associated with hypothyroidism, which is the disorder that this medication is prescribed to treat.

*Question: A postoperative client has been receiving morphine sulfate every 3 to 4 hours for pain. The nurse would be sure to implement which measures to reduce the risk of adverse effects from this medication? Select all that apply.*

** Rationale: Morphine sulfate suppresses the respiratory and cough reflex. The client should be encouraged to cough and deep breathe in order to prevent atelectasis and subsequent pneumonia. Narcotics will also slow down peristalsis and lead to constipation, so the nurse should monitor the number of bowel movements. Encouraging fluids will help liquefy secretions for coughing and prevent constipation. Keeping the client in a supine position is harmful because it could lead to atelectasis. Monitoring the temperature will detect infection but not prevent it.

*Question: The nurse is calculating a client's 24-hour fluid intake. The client consumed coffee (8 oz), water (8 oz), and orange juice (6 oz) for breakfast; soup (4 oz) and iced tea (8 oz) for lunch; and milk (10 oz), tea (8 oz), and water (8 oz) for dinner. The client also consumed 24 oz of water during the day. How many milliliters of fluid did the client consume in the 24-hour period? Fill in the blank.*

** Rationale: Rationale not found

*Question: The prescription of the primary health care provider (PHCP) prescription reads acetaminophen 240 mg orally every 6 hours as needed for relief of pain, for a 5-year-old child. The medication label reads "acetaminophen 160 mg per 5 mL." How many mL per dose would the nurse administer to the child? Fill in the blank.*

** Rationale: Rationale not found

*Question: The primary health care provider (PHCP) has prescribed an antibiotic for a child. The average adult dose is 500 mg. The child has a body surface area (BSA) of 0.63 m2. What is the dose for the child? Fill in the blank.*

** Rationale: Rationale not found

*Question: The primary health care provider (PHCP) has prescribed phenobarbital sodium, 25 mg orally twice daily, for a child with febrile seizures. The medication label reads as follows: "Phenobarbital sodium, 20 mg/5 mL." The nurse has determined that the dose prescribed is a safe dose for the child. How many milliliters per dose would the nurse administer to the child? Fill in the blank.*

** Rationale: Rationale not found

*Question: The nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which statement, if made by one of the parents, indicates an understanding of the use of the harness?*

*Answer: "I can remove the harness to bathe my infant."* Rationale: The harness should be worn 23 hours a day and should be removed only to check the skin and for bathing. The hips and buttocks should be supported carefully when the infant is out of the harness. The harness does not need to be removed for diaper changes or feedings. Option 4 is incorrect.

*Question: The nurse is caring for a client recently diagnosed with Parkinson disease (PD). The nurse is assessing the client and knows that PD is characterized by what cardinal signs/symptoms? Select all that apply.*

** Rationale: The four cardinal signs/symptoms of Parkinson's disease (PD) are tremor, muscle rigidity, bradykinesia or akinesia (slow movement/no movement), and postural instability. In addition to changes in voluntary movement, many clients experience autonomic nervous system symptoms, such as excessive perspiration, not dry skin, and orthostatic hypotension, not hypertension. Orthostatic hypotension is likely related to loss of sympathetic innervation in the heart and blood vessel response. PD is a progressive neurodegenerative disease that is the one of the most common neurologic disorders of older adults.

*Question: An adult client trapped in a burning house suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, the nurse determines the extent of the burn injury to be which percentage?*

*Answer: 22.5%* Rationale: According to the rule of nines, the posterior side of the head equals 4.5%, the upper half of the posterior trunk equals 9%, and the back of both arms equals 9%, totaling 22.5%.

*Question: The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response?*

*Answer: "I cannot discuss any client situation with you."* Rationale: The nurse is required to maintain confidentiality regarding clients and their care. Confidentiality is basic to the therapeutic relationship and is a client's right. Option 3 is correct in a sense, but it is a rather blunt statement. Both options 2 and 4 identify statements that do not maintain client confidentiality.

*Question: Fluoxetine is prescribed, and the nurse reinforces instructions to the client regarding the administration of the medication. Which statement by the client indicates an understanding about the administration of this medication?*

*Answer: "I should take the medication in the morning when I first arise."* Rationale: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI). It is administered in the early morning without consideration to meals. Options 1, 2, and 4 are incorrect.

*Question: The nurse reviews measures to prevent tick bites with a parent of a child with Rocky Mountain spotted fever. Which statement by the parent indicates a need for further teaching?*

*Answer: "I will have my child wear dark colored clothing so the tick will not be attracted to the colors."* Rationale: Protection from tick bites includes wearing light colored clothing to make the ticks more visible if they get on the child. Prevention of Rocky Mountain spotted fever includes measures to take to protect getting tick bites and includes wearing long-sleeved shirts, long pants tucked into socks, and a hat. Checking for ticks on children after they have been exposed to a high-risk area and using insect repellents containing diethyltoluamide and permethrins are also measures to take.

*Question: A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse would tell the client which purpose?*

*Answer: "The medication causes the pupil to constrict and will lower the pressure in the eye."* Rationale: Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork. Options 1, 2, and 4 are incorrect.

*Question: The client is taking phenytoin for seizure control, and a blood sample for a serum drug level is drawn. Which laboratory finding indicates a therapeutic serum drug result?*

*Answer: 15 mcg/mL (59.52 mcmol/L)* Rationale: The therapeutic serum drug level range for phenytoin is 10 to 20 mcg/mL (39.68 to 79.36 mcmol/L). Therefore, options 1, 3, and 4 are incorrect.

*Question: A licensed practical nurse (LPN) is assisting a high school nurse in conducting a session with female adolescents regarding the menstrual cycle. After the session has been completed, the LPN recognizes the adolescents have understood the teaching if the adolescents identify the normal duration of the menstrual cycle is about how many days?*

*Answer: 28 days* Rationale: The normal duration of the menstrual cycle is about 28 days, although it may range from 20 to 45 days. Significant deviations from the 28-day cycle are associated with reduced fertility. The first day of the menstrual period is counted as day 1 of the woman's cycle.

*Question: A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, would be reported before administering the dose of furosemide?*

*Answer: 3.2 mEq/L (3.2 mmol/L)* Rationale: The normal serum potassium level in the adult is 3.5 mEq/L to 5.0 mEq/L (3.5-5.0 mmol/L). The correct option is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. The remaining options are within the normal range.

*Question: The nurse is providing nutritional counseling to a new mother who is breastfeeding her newborn. The nurse instructs the mother to increase her daily caloric intake by which amount?*

*Answer: 500 calories per day* Rationale: If the mother is breastfeeding, her calorie needs increase by approximately 500 calories per day. The mother should also be instructed regarding the need for increased fluids and the need for prenatal vitamins and iron supplements.

*Question: A client received 20 units of NPH insulin subcutaneously at 8:00 a.m. The nurse would check the client for a potential hypoglycemic reaction at which time?*

*Answer: 5:00 p.m.* Rationale: NPH insulin is intermediate-acting insulin. Its onset of action is 60 to 120 minutes, it peaks in 6 to 14 hours, and its duration of action is 16 to 24 hours. Hypoglycemic reactions most likely occur during peak time.

*Question: The nurse is assisting in preparing to care for a child with a brain tumor who will be returning from the recovery room following debulking of the tumor. Which item would the nurse place at the bedside in preparation for the child's return from surgery?*

*Answer: A cooling blanket* Rationale: Special attention is paid to the child's temperature postoperatively, which may be elevated because of hypothalamus or brainstem involvement during surgery. A cooling blanket should either be in place on the bed or readily available if the child becomes hyperthermic. Suctioning is avoided because it can cause increased intracranial pressure. Protective isolation is unnecessary, and there is no need for skeletal traction equipment.

*Question: The nurse is assisting in admitting a child who arrived from the emergency department after treatment for acetaminophen overdose. The nurse reviews the child's record and expects to note that the child received which for the acetaminophen overdose?*

*Answer: Acetylcysteine* Rationale: Acetylcysteine is the antidote for acetaminophen overdose. It is administered orally with juice or cola or via nasogastric tube. Epogen (epoetin alfa) induces erythropoiesis and is used in the treatment of anemia. Protamine sulfate is the antidote for heparin. EDTA (calcium disodium edetate) is used in the treatment of lead poisoning.

*Question: Which individual is least at risk for the development of Kaposi's sarcoma?*

*Answer: An individual working in an environment where exposure to asbestos exists* Rationale: Kaposi's sarcoma is a vascular malignancy that presents as a skin disorder and is a common acquired immunodeficiency syndrome indicator. It is seen frequently in men with a history of same-sex partners. Although the cause of Kaposi's sarcoma is not known, it is considered to be the result of an alteration or failure in the immune system. The renal transplant client and the client receiving antineoplastic medications are at risk for immunosuppression. Exposure to asbestos is not related to the development of Kaposi's sarcoma.

*Question: The nurse is caring for a client after a mastectomy. Which finding would indicate that the client is experiencing a complication that may become a chronic problem related to the surgery?*

*Answer: Arm edema on the operative side* Rationale: Clients who undergo mastectomy for breast cancer, especially those with axillary node resection, may develop chronic lymphedema or excessive swelling in the arm and hand. Lymphedema is a complication that may develop immediately after mastectomy, months, or even years after surgery. Slight edema may occur in the immediate postoperative period, but should decrease especially if the client rests with the arm supported on a pillow. Women should avoid injury to the arm on the affected side and not allow venipunctures or blood pressures to be taken in that arm. Pain and numbness near the incision and drainage from the surgical site are expected occurrences after mastectomy and are not indicative of a complication.

*Question: Saquinavir is prescribed for a client who is diagnosed with human immunodeficiency virus (HIV) seropositive. The nurse would reinforce medication instructions about which health care measure to the client?*

*Answer: Avoid sun exposure.* Rationale: Saquinavir is an antiretroviral (protease inhibitor) used with other antiretroviral medications to manage HIV infection. Saquinavir is administered with meals and is best absorbed if the client consumes high-calorie, high-fat meals. Saquinavir can cause photosensitivity, and the nurse should instruct the client to avoid sun exposure.

*Question: The nursing student is asked to identify the characteristics of bulimia nervosa. Which characteristic, if identified by the student, indicates a need for further teaching about the disorder?*

*Answer: Body weight well below ideal range* Rationale: Clients with bulimia nervosa may not initially appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. During further inspection, the client demonstrates enlargement of the parotid glands with dental erosion and caries if he or she has been inducing vomiting. Electrolyte imbalances are present.

*Question: The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL (3.25 mmol/L). Which prescribed medication would the nurse plan to assist in administering to the client?*

*Answer: Calcitonin* Rationale: The normal serum calcium level is 9 to 10.5 mg/dL (2.2.5-2.75 mmol/L). This client is experiencing hypercalcemia. Calcium gluconate and calcium chloride are medications used for the treatment of tetany, which occurs as a result of acute hypocalcemia. In hypercalcemia, large doses of vitamin D need to be avoided. Calcitonin, a thyroid hormone, decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration.

*Question: A client has begun taking phenelzine. At the initiation of therapy, the nurse teaches the client that which items are allowed in the diet?*

*Answer: Carrots, sweet potatoes, and squash* Rationale: Carrots, sweet potatoes, and squash are allowed in the client's diet. Phenelzine is a monoamine oxidase inhibitor (MAOI). The client should avoid foods high in tyramine because they could trigger a potentially fatal hypertensive crisis. Foods to avoid include aged cheeses; smoked or processed meats; red wines; and avocados, raisins, or figs. Vegetables are generally acceptable, with the exception of broad bean pods.

*Question: The nurse is monitoring an older client suspected of having a urinary tract infection (UTI) for signs of infection. Which sign/symptom is likely to present first?*

*Answer: Confusion* Rationale: In an older client, the only symptom of a UTI may be something as vague as increasing mental confusion or frequent unexplained falls. Frequency and urgency may commonly occur in an older client, and fever can be associated with a variety of conditions.

*Question: A long-term care nurse is caring for an older client taking cimetidine. The nurse would observe this client frequently for which most common central nervous system (CNS) side effect of this medication?*

*Answer: Confusion* Rationale: Older clients are especially susceptible to CNS side effects of cimetidine, of which confusion is most common. Less common ones are headache, dizziness, drowsiness, and hallucinations.

*Question: A client with chronic glaucoma is being started on medication therapy with acetazolamide. The nurse reinforces instructions to the client that which symptom can occur early but subsides or disappears with continued treatment?*

*Answer: Diuresis* Rationale: Diuresis is an early side effect of acetazolamide that usually subsides with continued treatment. This is because the medication is also a weak diuretic, although it is no longer prescribed for that purpose. Fatigue, headache, and loss of libido are common side effects of therapy, but these may not subside spontaneously.

*Question: The nurse prepares to administer a prescribed dose of scopolamine. The nurse would monitor for which side effect of this medication?*

*Answer: Dry mouth* Rationale: Scopolamine is an anticholinergic medication that causes the frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. The other options describe the opposite effects of cholinergic-blocking agents and therefore are incorrect.

*Question: A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which finding?*

*Answer: Evidence of the client's altered and distorted body image* Rationale: Altered or distorted body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and present with regressed behavior, the client's coping pattern relates to the basic issue of distorted body image. The client's behavior is not normal.

*Question: The police arrive at the emergency department with a client who has seriously lacerated both wrists. Which is the initial nursing action?*

*Answer: Examine and treat the wound sites.* Rationale: The initial nursing action is to examine and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions may follow after the client has been treated medically.

*Question: A client with a diagnosis of acute pancreatitis is experiencing severe pain. After noting an absence of an analgesic prescription on the primary health care provider prescription sheet, the nurse would suggest contacting the primary health care provider to request a prescription for which medication?*

*Answer: Hydromorphone* Rationale: Hydromorphone rather than morphine is the medication of choice because morphine can cause spasms in the sphincter of Oddi. Acetylsalicylic acid and acetaminophen with codeine are inappropriate medications because they are not potent enough and because they require the oral route. The client with acute pancreatitis should take nothing by mouth (NPO).

*Question: A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates the occurrence of a systemic effect?*

*Answer: Hyperventilation* Rationale: Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the medication will probably be discontinued for 1 to 2 days. Options 3 and 4 describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury.

*Question: The nurse is told during shift report that a client is having occasional ventricular dysrhythmias. The nurse reviews the client's laboratory results, recalling that which electrolyte imbalance could be responsible for this development?*

*Answer: Hypokalemia* Rationale: The nurse assesses the client's serum laboratory results for hypokalemia. The client may experience ventricular dysrhythmias in the presence of hypokalemia because this electrolyte imbalance increases the electrical instability of the heart. The electrolyte imbalances mentioned in the other options do not have this effect.

*Question: A client arrives in the emergency department with an eye injury resulting from metal fragments that hit the eye while the client was drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action would the nurse take first?*

*Answer: Irrigate the eye with sterile saline.* Rationale: Surface foreign bodies often are removed simply by irrigating the eye with sterile normal saline. The nurse would not use clamps because this risks causing further injury to the eye. Placing an eye patch would not provide relief for the problem. Visual acuity tests are not the priority at this time and might not be feasible because the client most likely has excessive blinking and tearing as well.

*Question: A client sustains a chemical eye injury from a splash of battery acid. The nurse would prepare the client for which immediate measure?*

*Answer: Irrigating the eye with sterile normal saline* Rationale: Emergency care after a chemical burn to the eye includes irrigating the eye immediately with sterile normal saline or ocular irrigating solution. The irrigation should be maintained for at least 10 minutes. After this emergency treatment, visual acuity is assessed. Options 2 and 3 are not immediate measures.

*Question: The nurse observes that a client with diabetic ketoacidosis is experiencing abnormally deep, regular, rapid respirations. How would the nurse correctly document this observation in the medical record?*

*Answer: Kussmaul's respirations* Rationale: Abnormally deep, regular, and rapid respirations observed in the client with diabetic ketoacidosis are documented as Kussmaul's respirations. During apnea, respirations cease for several seconds. During bradypnea, respirations are regular but abnormally slow. Cheyne-Stokes respirations gradually become more shallow and are followed by periods of apnea (no breathing), with repetition of the pattern.

*Question: A client with hiatal hernia chronically experiences heartburn after meals. Which would the nurse teach the client to avoid?*

*Answer: Lying recumbent after meals* Rationale: Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm, where the esophagus usually is positioned. The client generally experiences pain caused by reflux resulting from ingestion of irritating foods, lying flat following meals or at night, and consuming large or fatty meals. Relief is obtained by eating small, frequent, and bland meals; histamine antagonists and antacids; and elevation of the thorax after meals and during sleep.

*Question: The camp nurse prepares to instruct a group of children about Lyme disease. Which information would the nurse include in the instructions?*

*Answer: Lyme disease is caused by a tick carried by deer.* Rationale: Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. Persons bitten by Ixodes ticks can be infected with the spirochete Borrelia burgdorferi. Lyme disease cannot be transmitted from one person to another. Toxoplasmosis is caused by the ingestion of cysts from contaminated cat feces. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings.

*Question: An adult client has increased fluid in the middle ear that is causing vertigo. The nurse checks this client for which associated signs and symptoms of this condition?*

*Answer: Nausea and vomiting* Rationale: Vertigo commonly affects the gastrointestinal system by causing nausea and vomiting. Vertigo can be the result of fluid in the middle ear or may be due to a disorder of the inner ear. This disorder would not cause headache, flushing, tinnitus, or difficulty in swallowing. Fluid in the ear may or may not be uncomfortable for the client, depending on individual circumstances. The client may have a slight, temporary difficulty in hearing if there is fluid in the middle ear.

*Question: The nurse is caring for a client who is receiving an intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. During an inspection of the site, the nurse notes redness and swelling. The nurse would take which appropriate action?*

*Answer: Notify the registered nurse immediately.* Rationale: When antineoplastic medications are administered via IV, great care must be taken to prevent extravasation, the condition in which the medication escapes into the tissues surrounding the injection site, because pain, tissue damage, and necrosis can result. The nurse monitors for signs of extravasation, such as redness or swelling at the insertion site. If extravasation occurs, the RN needs to be notified at once, and the infusion will be stopped. The nurse will contact the primary health care provider. Depending on the specific medication, actions are taken to counteract the negative effects. The medication may be aspirated out, ice or warmth applied, and the area infiltrated with a neutralizing agent specific to the medication.

*Question: A client undergoing chemotherapy with intravenous vincristine sulfate has been given information about the treatment. The nurse determines that the client has adequate understanding if the client identifies which sign or symptom as a potential adverse/side effect of the medication?*

*Answer: Numbness in the feet* Rationale: Vincristine is a mitosis inhibitor chemotherapeutic medication that has the adverse effect of damaging the peripheral nerves. This results in numbness in the extremities. Chest pain, weight gain, and bloody urine are not signs/symptoms associated with its use.

*Question: An intoxicated client is brought to the emergency department by local police. The client is told that the primary health care provider (PHCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the PHCP immediately. The nurse assisting to care for the client would take which appropriate nursing intervention?*

*Answer: Offer to take the client to an examination room until he or she can be treated.* Rationale: Safety of the client, other clients, and staff is of prime concern. Option 3 is in effect an isolation technique that allows for separation from others and provides for a less stimulating environment where the client can maintain dignity. When dealing with an impaired individual, trying to talk may be out of the question. Waiting to intervene could cause the client to become even more agitated and a threat to others. Option 4 would only further aggravate an already agitated individual.

*Question: The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase, an antineoplastic agent. The nurse consults with the registered nurse regarding the administration of the medication if which is documented in the client's history?*

*Answer: Pancreatitis* Rationale: Asparaginase is a antineoplastic enzyme that is contraindicated if hypersensitivity exists in the case of pancreatitis, or if the client has a history of pancreatitis. The medication impairs pancreatic function, and pancreatic function tests should be performed before therapy begins and when a week or more has elapsed between the administration of doses. The client needs to be monitored for signs of pancreatitis, which include nausea, vomiting, and abdominal pain. The medication may be used for clients with a history of diabetes mellitus, myocardial infarction, or chronic obstructive pulmonary disease.

*Question: The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure injury in the sacral area. What would the nurse expect to find when checking the client's sacral area?*

*Answer: Partial-thickness skin loss of the epidermis* Rationale: With a stage 2 pressure injury, the skin is not intact. There is partial-thickness skin loss of the epidermis or dermis. The ulcer is superficial, and it may look like an abrasion, blister, or shallow crater. The skin is intact with a stage 1 pressure injury. A deep, crater-like appearance occurs during stage 3, and tunneling develops during stage 4.

*Question: A primary health care provider is about to remove a chest tube from a client. Once the dressing is removed and the sutures have been cut, the nurse assisting the primary health care provider asks the client to do which action?*

*Answer: Perform the Valsalva maneuver.* Rationale: When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is then quickly withdrawn, and an airtight dressing is taped in place. The pleura seals itself off and the wound heals in less than a week. Therefore, options 1, 2, and 3 are incorrect.

*Question: The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. Which action should the nurse take?*

*Answer: Place the infant in a knee-chest position.* Rationale: If a hypercyanotic episode occurs, the infant is placed in a knee-chest position. The nurse would contact the registered nurse, who would then contact the primary health care provider. The knee-chest position is thought to increase pulmonary blood flow by increasing systemic vascular resistance. This position also improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to obtain this position and relieve chronic hypoxia.

*Question: A client who is recovering from a brain attack (stroke) has residual dysphagia and is prescribed nectar-thickened liquids. The licensed practical nurse has instructed the assistive personnel (AP) in feeding technique. The nurse would intervene if the AP attempts to perform which activity?*

*Answer: Placing food on the affected side of the mouth* Rationale: The client with dysphagia may be started on a diet once the gag and swallow reflexes have returned and a consultation with the speech therapist and dietician is done and a prescription for the diet modifications is completed. Liquids should be thickened to the consistency of oatmeal to avoid aspiration. Food is placed on the unaffected side of the mouth. The client is assisted with meals as needed and is given ample time to chew and swallow.

*Question: The client is prescribed tacrolimus to prevent organ rejection. The nurse would expect to administer the dose with which medication that is also normally prescribed?*

*Answer: Prednisone* Rationale: Tacrolimus is used for the prevention of organ rejection in clients receiving an organ transplant. Concurrent use of glucocorticoids is recommended during administration of this medication. Prednisone is a glucocorticoid. Fluconazole is an antifungal agent. Carbamazepine is an anticonvulsant. Erythromycin is an antibiotic.

*Question: A client diagnosed as human immunodeficiency virus (HIV) seropositive is prescribed stavudine. Which measure would the nurse assess most closely while the client is taking this medication?*

*Answer: Presence of paresthesias* Rationale: Stavudine is an antiretroviral (protease inhibitor) used in the management of HIV infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy; the nurse should monitor closely the client's gait and ask the client about paresthesias. Appetite, level of consciousness, and gastrointestinal function are not associated with this medication.

*Question: A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to reinforce teaching the client about the need for which measure?*

*Answer: Preventing and recognizing hyperglycemia* Rationale: The normal reference range for the glycosylated hemoglobin A1c (HgbA1c) is 4.0% to 6.0%. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. Therefore, an HgbA1c of 9% is elevated. Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes.

*Question: The nurse is collecting data regarding a client after a thyroidectomy and notes the development of a hoarse and weak voice. Which nursing action is appropriate?*

*Answer: Reassure the client that this is usually a temporary condition.* Rationale: Weakness and hoarseness of the voice can occur as a result of trauma to the laryngeal nerve. If this develops, the client should be reassured that the problem will subside in a few days. Unnecessary talking should be discouraged. It is not necessary to notify the registered nurse immediately. These signs do not indicate bleeding or the need to administer calcium gluconate.

*Question: The client has begun prescribed lansoprazole. The nurse would primarily monitor for which intended effect of this medication?*

*Answer: Relief of nighttime heartburn* Rationale: Lansoprazole is a proton pump inhibitor that suppresses gastric acid secretion. It is not used as an antiemetic (option 4). It is not used to directly treat abdominal pain or intestinal gas.

*Question: The nurse notes that a hospitalized client has experienced a positive reaction to the tuberculin skin test. Which action by the nurse is priority?*

*Answer: Report the findings.* Rationale: The nurse who interprets a tuberculin skin test as positive notifies the PHCP immediately. The PHCP would prescribe a chest x-ray to determine whether the client has clinically active tuberculosis or old healed lesions. A sputum culture would be done to confirm the diagnosis of active tuberculosis. The client is placed on tuberculosis precautions prophylactically until a final diagnosis is made. The findings are documented in the client's record, but this action is not the highest priority. Calling the employee health service would be of no benefit to the client.

*Question: The nurse is assisting in developing a plan of care for a child who will be returning from the operating room following a tonsillectomy. The nurse plans to place the child in which position on return from the operating room?*

*Answer: Side-lying* Rationale: The child should be placed in a prone or side-lying position following tonsillectomy to facilitate drainage. Options 1, 3, and 4 will not facilitate drainage.

*Question: The nurse is reviewing the primary health care provider's (PHCP'S) prescriptions written for a client admitted with acute pancreatitis. Which PHCP prescription would the nurse verify if noted in the client's chart?*

*Answer: Supine and flat client positioning* Rationale: The pain associated with acute pancreatitis is aggravated when the client lies in a supine and flat position. Therefore, the nurse would verify this prescription. Options 1, 2, and 4 are appropriate interventions for the client with acute pancreatitis.

*Question: The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which indicates this occurrence?*

*Answer: Sweating and pallor* Rationale: Early manifestations occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

*Question: A postoperative client has regained bowel sounds and is ready to start a clear liquid diet. The nurse is told that the primary health care provider has written a prescription to remove the nasogastric (NG) tube. The nurse assists in the procedure and would ask the client to do which during tube removal?*

*Answer: Take a breath and hold it until the tube is out.* Rationale: When the nurse removes an NG tube, the client is instructed to take a breath and hold it until the tube is out. This will close the epiglottis and prevent aspiration of any secretions. The nurse removes the tube with one very smooth continuous pull. The client is not asked to inhale or exhale to avoid aspirating any fluid left at the tip of the tube. It is unnecessary to perform the Valsalva maneuver.

*Question: A client who returned to the nursing unit 8 hours ago after hypophysectomy has clear drainage saturating the nasal dressing. The nurse would take which action?*

*Answer: Test the drainage for glucose.* Rationale: Following hypophysectomy the client should be monitored for rhinorrhea (clear nasal drainage), which could indicate a cerebrospinal fluid (CSF) leak. If this occurs, the drainage should be collected and tested for the presence of CSF by testing it for glucose. CSF tests positive for glucose, whereas true nasal secretions would not. It is not necessary to test drainage that is clear for occult blood. The head of the bed should not be lowered to prevent a rise in intracranial pressure. Continuing to observe the drainage without taking action could put the client at risk for developing a serious complication.

*Question: An ultrasound of the gallbladder is scheduled for the client with a suspected diagnosis of cholecystitis. Which would the nurse explain to the client about this test?*

*Answer: The test requires the client to lie still for short intervals.* Rationale: Ultrasound of the gallbladder is a noninvasive procedure and is frequently used for emergency diagnosis of acute cholecystitis. The client may need to lie still during the procedure for short intervals of time while visualization of the gallbladder is done. The client may or may not need to be NPO (per PHCP preference), but may be instructed to avoid carbonated beverages for 48 hours before the test to help decrease intestinal gas. It is a painless test and does not require the administration of oral tablets as preparation.

*Question: A nurse is about to give a daily dose of digoxin and notes that a serum digoxin level drawn earlier in the day measured 2.7 ng/mL. The nurse would take which actions? Select all that apply.*

** Rationale: The normal therapeutic range for digoxin is 0.5 to 2 ng/mL. A value of 2.7 ng/mL exceeds the therapeutic range and could be toxic to the client. The nurse should gather data about signs of digoxin toxicity (nausea/vomiting, seeing yellow rings) and then notify the registered nurse who will then contact the primary health care provider. The dose of digoxin should not be administered or recorded as normal. Foods high in potassium should not be administered without knowing the serum potassium level.

*Question: A licensed practical nurse (LPN) is asked to prepare an intravenous (IV) infusion of 1000 mL 5% dextrose in lactated Ringer's at 80 mL/hr to be administered to an assigned client. The LPN time-tapes the bag with a start time of 09:00. After making hourly marks on the time-tape, the LPN notes that which time would mark the completion time for the bag?*

*Answer: 21:30* Rationale: At a rate of 80 mL per hour, the 1000-mL bag will be finished infusing in 12½ hours. This brings the end time to 21:30, using military time.

*Question: A client with hypertension has been prescribed a low-sodium diet. The nurse reinforcing instructions about foods that are allowed would include which foods in a list provided to the client? Select all that apply.*

** Rationale: Foods that are lower in sodium are fruits and vegetables, such as fresh tomato and summer squash, because they do not contain physiological saline. Highly processed or refined foods, such as prepared soups and cereal, are higher in sodium unless they are noted specifically to be "low sodium." Saltwater fish and shellfish (shrimp) are high in sodium.

*Question: The nurse is preparing to clean up a blood spill on the client's bedside table. The spill occurred when a blood tube containing the client's blood specimen broke. The nurse avoids doing which action when cleaning up the blood spill?*

*Answer: Blotting up the spill with a face cloth or cloth towel* Rationale: The nurse should blot the spill with an absorbent, disposable material such as paper towels or terry wipes, not a face cloth or cloth towel. Blood spill kits should be used. Gloves are worn for the procedure, and tongs are used to pick up any broken glass. The area is disinfected with a dilute bleach solution or other agency-required solution.

*Question: A client is determined to be in respiratory alkalosis by blood gas analysis. The nurse would monitor this client for signs of which electrolyte disorder that could accompany the acid-base imbalance?*

*Answer: Hypokalemia* Rationale: Signs and symptoms of respiratory alkalosis include tachypnea, hyperpnea, weakness, paresthesias, tetany, dizziness, convulsions, coma, hypokalemia, and hypocalcemia. Remember that potassium, which is intracellular, and hydrogen ions exchange places to compensate and achieve an equilibrium with acid-base imbalances. The clinical picture does not include hypercalcemia, hypernatremia, or hypochloremia.

*Question: An adult client has had serum electrolytes drawn. The nurse receiving the results by telephone from the laboratory would be most concerned with which result?*

*Answer: Potassium 5.4 mEq/L* Rationale: The normal serum electrolyte ranges for adults are sodium, 135 to 145 mEq/L; potassium, 3.5 to 5.0 mEq/L; chloride, 98 to 107 mEq/L; and bicarbonate (venous), 22 to 29 mEq/L. The only abnormal value identified above is the serum potassium, which would be the one of most concern to the nurse.

*Question: The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at risk for fluid volume deficit?*

*Answer: The client with an ileostomy* Rationale: Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and ileostomy. A client with cirrhosis, heart failure, or decreased kidney function is at risk for fluid volume excess.

*Question: A primary health care provider prescribes 1000 mL of 0.9% NaCl to be infused over a period of 10 hours. The drop (gtt) factor is 20 drops (gtts) per mL. The nurse adjusts the flow rate at how many drops per minute? Fill in the blank.*

** Rationale: Rationale not found

*Question: A primary health care provider prescribes a bolus of 500 mL of 0.9% NaCl to run over 4 hours. The drop (gtt) factor is 10 drops (gtts) per 1 mL. The nurse plans to adjust the flow rate at how many gtt per minute? Fill in the blank. Record your answer to the nearest whole number.*

** Rationale: Rationale not found

*Question: A primary health care provider prescribes an intramuscular (IM) dose of 250,000 units of penicillin G benzathine. The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine 300,000 units/mL. How much medication will the nurse prepare to administer the correct dose? Fill in the blank. Record your answer to 1 decimal place.*

** Rationale: Rationale not found

*Question: The mother of a toddler with mumps asks the nurse what she needs to watch for in her child with this disease. The nurse bases the response on the understanding that mumps is which type of communicable disease?*

*Answer: Respiratory disease caused by a virus involving the parotid gland* Rationale: Mumps is caused by a paramyxovirus that causes swelling from the parotid gland, causing jaw and ear pain. It is transmitted via direct contact or droplets spread from an infected person, salive from infected saliva, and possibly by contact with urine. Airborne and contact precautions are indicated during the period of communicability. Options 1, 2, and 3 are incorrect.

*Question: A primary health care provider prescribes 3000 mL of 5% dextrose in water (D5W) to run over a 24-hour period. The drop (gtt) factor is 15 drops (gtts) per 1 mL. The nurse adjusts the flow rate to run at how many gtts per minute? Fill in the blank. Record your answer to the nearest whole number.*

** Rationale: Rationale not found

*Question: A primary health care provider prescribes digoxin, 0.125 mg by mouth (PO) daily, for a client with heart failure. The medication label states 0.125 mg per tablet. How many tablet(s) will the nurse administer to the client? Fill in the blank.*

** Rationale: Rationale not found

*Question: A nursing instructor asks a nursing student to define a critical path. Which statement made by the student indicates a need for further teaching regarding critical paths?*

*Answer: "They are nursing care plans and use the steps of the nursing process."* Rationale: Critical paths are not specifically nursing care plans; however, they can take the place of a nursing care plan and actually map out the desired clinical progress of a client during acute care admission. Options 1, 3, and 4 appropriately describe the use of a critical path.

*Question: The nurse is assisting to admit a client with a diagnosis of acute Guillain-Barré syndrome. The nurse knows that if the disease progresses to a severe level, the client will be at risk for which acid-base imbalance?*

*Answer: Respiratory acidosis* Rationale: Guillain-Barré is a neuromuscular disorder in which the client may experience weakening or paralysis of the muscles used for respiration. This could cause the client to retain carbon dioxide, which leads to respiratory acidosis resulting from progressive respiratory insufficiency as the paralysis ensues.

*Question: A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 15:00. The nurse, making rounds at 15:45, finds that the client is complaining of a pounding headache, is dyspneic with chills, is apprehensive, and has an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse would take which action?*

*Answer: Shut off the infusion.* Rationale: The client's symptoms are compatible with speed shock. This may be verified by noting that 600 mL has infused in the course of 45 minutes. The first action of the nurse from the options presented is to shut off the infusion. The nurse may elevate the head of the bed to aid the client's breathing. Placing the client in Trendelenburg's position is not an appropriate action. The registered nurse is notified immediately, who then contacts the primary health care provider. The angiocatheter does not need to be removed. It may be needed to treat this complication.

*Question: Ampicillin sodium 250 mg in 50 mL of 0.9% NaCl is being administered over a period of 30 minutes. The drop (gtt) factor is 10 drops (gtts) per mL. The nurse is asked to check the flow rate of the infusion. The nurse determines that the infusion is running at the prescribed rate if the infusion is delivering how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.*

** Rationale: Rationale not found

*Question: The nurse employed in the pediatric unit working on the 11:00 pm to 7:00 am shift finds an infant unresponsive and without respiration or a pulse. The nurse plans to deliver chest compressions at which rate?*

*Answer: 100 times per minute* Rationale: In an infant, the rate of chest compressions is at least 100 per minute. Options 1 and 2 are rates too slow to sustain oxygenation. Option 4 is a rate too fast to allow effective chest compressions.

*Question: The nurse is reinforcing instructions to a client with renal calculi about how to change the urine pH to be more acidic. The nurse determines that the client needs further teaching if the client states which type of drink is acceptable?*

*Answer: Orange juice* Rationale: Orange juice should be avoided because it will make the urine more alkaline. Changing the urine pH can prevent or reduce the incidence of renal calculi. Ascorbic acid or dietary modifications (e.g., cranberry juice, prunes, or lemon juice) can be used to acidify urine.

*Question: The nurse in the hospital is assisting in developing a plan of care for an older client to prevent a fall. Which actions would be least likely to prevent a fall? Select all that apply.*

** Rationale: All clients in the hospital are assessed for risk for falls. The nurse needs to provide interventions that decrease the likelihood of a client fall and potential injury. To prevent falls, a nightlight or bathroom or hall light should be kept on to prevent "sundowning" and an increase in disorientation with approaching darkness. The client with a high fall risk should be closer to the nurse's station so there is active supervision. Hourly rounding, placing the bed in low position, having the call light available to the client, and having upper side rails up are appropriate actions to prevent falls.

*Question: The nurse is assigned to care for a child who is in skeletal traction. The nurse needs to avoid which action when caring for the child?*

*Answer: Placing the bed linens on the traction ropes* Rationale: Bed linens should not be placed on the traction ropes because of the risk of disrupting the traction apparatus. Options 1, 2, and 4 are appropriate measures when caring for a child who is in skeletal traction.

*Question: The nurse is instructing a group of assistive personnel (AP) in the principles of body mechanics. The nurse determines that an AP is using the principles appropriately if the nurse observes the AP doing which action?*

*Answer: Positioning a box that is to be lifted between the knees* Rationale: The nurse should keep the client or object to be moved as close to the body as possible. If moving an object, the nurse should position the object between the knees when moving it from a low surface. The nurse should turn the feet, not the back, if a change in direction is required when carrying an object or client. When turning a client, the nurse should keep his or her back straight and take small steps. The nurse needs to get assistance from a mechanical device and/or another health care worker as appropriate for clients requiring total care.

*Question: The nurse is instructing a pregnant client in her first trimester about nutrition. The nurse would correct which misunderstanding on the part of the client about nutrition during pregnancy?*

*Answer: Pregnancy greatly increases the risk of malnourishment for the mother.* Rationale: Although pregnancy poses some nutritional risk for the mother, the client is not at risk for becoming malnourished. Intake of dietary iron is usually insufficient for the majority of pregnant women, and iron supplements routinely are encouraged. Calcium is critical during the third trimester but must be increased from the onset of pregnancy. Good nutrition during pregnancy significantly and positively influences fetal growth and development.

*Question: An older mental health client diagnosed with chronic neuropathic pain is starting therapy with a tricyclic antidepressant called imipramine hydrochloride. The client is complaining of constipation. The nurse knows that which signs/symptoms are other adverse effects of this medication? Select all that apply.*

** Rationale: Adverse effects of tricyclic antidepressants besides constipation include urinary retention (which can lead to infection), dry mouth, drowsiness, and acute confusion. Clients must be instructed to notify their primary health care provider to report these changes, but they do not stop these medications abruptly.

*Question: The nurse is assisting with caring for a client with cancer who is receiving cisplatin. Which adverse effects are associated with this medication? Select all that apply.*

** Rationale: Cisplatin is an alkylating medication. Alkylating medications are cell cycle phase nonspecific and affect the synthesis of DNA by causing its cross-linking to inhibit cell reproduction. Cisplatin may cause ototoxicity, tinnitus, hypokalemia, hypocalcemia, hypomagnesemia, and nephrotoxicity. Amifostine may be administered before cisplatin to reduce the potential for renal toxicity.

*Question: The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy. The woman asks the nurse about the purposes of estrogen. Which responses would the nurse make to the client? Select all that apply.*

** Rationale: Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle. Human chorionic gonadotropin prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat; it is antagonistic to insulin.

*Question: The nurse is monitoring the status of the postoperative client after abdominal surgery earlier in the day. Which signs or symptoms noted by the nurse would indicate an evolving complication associated with hypovolemia? Select all that apply.*

** Rationale: Hypovolemia is decreased circulating blood volume. In a postoperative client, this often is associated with inadequate fluid replacement or hemorrhage. Increasing restlessness is a sign that requires continuous and close monitoring because it could forecast a complication such as shock. A low and dropping BP with an increased pulse rate could be early compensation for a decrease in circulating blood volume. The WBC count is normal at 5000 to 10,000 mm3 (5 to 10 × 109/L). Hearing hypoactive bowel sounds in all four quadrants is a normal occurrence, as is a capillary refill of 3 seconds in all extremities.

*Question: The nurse is reinforcing sun exposure precautions to a group of older clients. Which would the nurse include in the instructions? Select all that apply.*

** Rationale: It is best to avoid exposure to the sun during the daytime when its rays are most hazardous. Sunscreen is applied liberally 15 to 30 minutes before sun exposure. A sun protection factor (SPF) of at least 30, as well as ultraviolet A (UVA) and ultraviolet B (UVB) protection, should always be used. One can become sunburned on a cloudy or overcast day, so sunscreen is needed. Light, loosely woven clothing will not give adequate protection from the sun's rays.

*Question: Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions would the nurse include when administering this medication? Select all that apply.*

** Rationale: Ketoconazole is an antifungal medication. It is administered with food (not on an empty stomach), and antacids are avoided for 2 hours after taking the medication to ensure absorption. The medication is hepatotoxic, and the nurse monitors liver function studies. The client is instructed to avoid exposure to the sun because the medication increases photosensitivity. The client is also instructed to avoid alcohol. There is no reason for the client to restrict fluid intake. In fact, this could be harmful to the client.

*Question: The nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's syndrome. Which statement by the student indicates an accurate understanding of this disorder?*

*Answer: "Cushing's syndrome is characterized by an oversecretion of glucocorticoid hormones."* Rationale: Cushing's syndrome is characterized by an oversecretion of glucocorticoid hormones. Addison's disease is characterized by the failure of the adrenal cortex to produce and secrete adrenocortical hormones. Options 1 and 4 are inaccurate regarding Cushing's syndrome.

*Question: An older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member indicates that he or she has learned positive coping skills?*

*Answer: "I feel better able to care for my father now that I know where to obtain assistance."* Rationale: Elder abuse sometimes occurs with family members who are being expected to care for their aging parents. This can cause family members to become overextended, frustrated, or financially depleted. Knowing where in the community to turn for assistance with caring for aging family members can bring much-needed relief. Taking advantage of these alternatives is a positive alternative coping strategy, which many families use.

*Question: The nurse reinforces instructions to the mother of a child diagnosed with pediculosis (head lice). Permethrin has been prescribed. Which statement by the mother regarding the use of the medication indicates a need for further teaching?*

*Answer: "I need to shampoo my child's hair, apply the medication, leave it on for 10 minutes, and then rinse it out."* Rationale: Permethrin is an over-the-counter antilice product that kills both lice and eggs with one application and has residual activity for 10 days. It is applied to the hair after shampooing and left for 10 minutes before rinsing out. The hair should not be shampooed for 24 hours after the rinsing treatment.

*Question: The nurse is reinforcing instructions to the mother following delivery regarding care of the episiotomy site to prevent infection. Which statement by the mother indicates a need for further teaching?*

*Answer: "I will change the perineum pads three times a day."* Rationale: Warm sitz baths and cleansing with warm water are helpful for relieving pain, and these measures will promote cleanliness in the perineum area to prevent infection. The mother also should be instructed to wipe the perineum from front to back after voiding and defecation to decrease the risk for contamination with microorganisms from the anus to the vagina. Warm water should be used to rinse the perineum after elimination. The mother also should be instructed that the perineal pad should be changed after each elimination and may be changed in between.

*Question: A client who is diagnosed with pedophilia and recently has been paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters all over the neighborhood with my photograph and details of my crime." Which is an appropriate response by the nurse?*

*Answer: "You understand that people fear for their children, but you're feeling unfairly treated?"* Rationale: Focusing and verbalizing the implied concern is the therapeutic response because it assists the client to clarify thinking and to reexamine what the client is really saying. Option 3 is the only option that reflects the use of this therapeutic communication technique. Option 1 is insensitive and anxiety-provoking. Option 2 gives advice and does not facilitate the client's expression of feelings. Option 4 does not facilitate the client's expression of feelings.

*Question: A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure!' I get so angry when they carry on like this! After all, I'm the one who's dying." Which therapeutic response would the nurse make to the client?*

*Answer: "You're feeling angry that your family continues to hope for you to be 'cured?'"* Rationale: Reflection is the therapeutic communication technique that redirects the client's feelings back to validate what the client is saying. In option 2, the nurse attempts to use focusing, but the attempt to discuss central issues is premature. In option 4, the nurse makes a judgment and is nontherapeutic in the one-on-one relationship. In option 1, the nurse is attempting to assess the client's ability to openly discuss feelings with family members. Although this may be appropriate, the timing is somewhat premature and closes off facilitation of the client's feelings.

*Question: The nurse is reinforcing instructions to a 16-year-old male adolescent regarding dietary patterns. The nurse instructs the adolescent about the recommended amount of daily calories. How many calories a day does the nurse recommend as the approximate daily caloric allowance for a male adolescent?*

*Answer: 2200* Rationale: The recommended amount of daily calories for a male adolescent between the ages of 15 and 18 years is 2200. Options of 1200 or 1800 calories would not provide a sufficient number of calories for this adolescent, and the option of 3000 calories is an incorrect number of calories.

*Question: A 6-year-old is hospitalized with a fracture of the femur and is placed in traction. In meeting the psychosocial needs of the child, the nurse most appropriately selects which play activity for the child?*

*Answer: A board game* Rationale: The school-age child becomes organized, with more direction in play activities. School-age children's interests include collections, drawing, construction, dolls, pets, guessing games, board games, riddles, hobbies, competitive games, and listening to the radio or television. The other options are most appropriate for a toddler.

*Question: A sulfonamide is prescribed for a client with a urinary tract infection. During review of the client's record, the nurse notes that the client is taking warfarin sodium daily. Which prescription would the nurse anticipate for this client?*

*Answer: A decrease in the warfarin sodium dosage* Rationale: Sulfonamides can potentiate the effects of warfarin sodium, phenytoin, and orally administered hypoglycemics such as tolbutamide. When an oral anticoagulant is combined with a sulfonamide, a decrease in the anticoagulant dosage may be needed.

*Question: A client reports to the health care clinic to obtain testing regarding human immunodeficiency virus (HIV) status after being exposed to an individual who is HIV positive. The test results are reported as negative and the client tells the nurse that he feels so much better knowing that he has not contracted HIV. The nurse would explain the test results to the client, including which information?*

*Answer: A negative HIV test is not considered accurate during the first 6 months after exposure.* Rationale: A test done for HIV should be repeated. There might be a lag period after the infection occurs and before antibodies appear in the blood. Therefore, a negative HIV test is not considered accurate during the first 6 months after exposure.

*Question: A postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dL (16.2 mmol/L) and a serum creatinine level of 2.2 mg/dL (193.6 mcmol/L) has a total 2-hour urine output of 25 mL. The nurse understands that the client is at risk for which condition?*

*Answer: Acute kidney injury* Rationale: The client who undergoes cardiac surgery is at risk for acute kidney injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Kidney injury is signaled by a decreased urine output and increased blood urea nitrogen (BUN) and creatinine levels. The client may need medications to increase renal perfusion and could need peritoneal dialysis or hemodialysis.

*Question: An adolescent is seen in the emergency department following an athletic injury, and it is suspected that the child sprained an ankle. X-rays are taken, and a fracture has been ruled out. The nurse reinforces instructions to the adolescent regarding home care for treatment of the sprain and provides the adolescent with which information?*

*Answer: Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 hours.* Rationale: To treat a sprain, the injured area should be wrapped immediately to support the joint and control the swelling. Ice is applied to reduce the swelling and should be applied for no longer than 30 minutes every 4 to 6 hours for the first 24 to 48 hours. The joint should be immobilized and elevated, but strict bed rest for a period of 7 days is not required. A dependent position will cause swelling in the affected area.

*Question: A client receiving a tricyclic antidepressant arrives at the mental health clinic. Which observation indicates that the client is correctly following the medication plan?*

*Answer: Arrives at the clinic neat and appropriate in appearance* Rationale: Depressed individuals will sleep for long periods, are not able to go to work, and feel as if they cannot "do anything." Once they have had some therapeutic effect from their medication, they will report resolution of many of these complaints, as well as demonstrate an improvement in their appearance.

*Question: A licensed practical nurse (LPN) is caring for a client with a diagnosis of schizophrenia. The LPN observes behaviors indicative of paranoia and reports these observations to the registered nurse (RN). The LPN assists the RN in developing a plan of care for the client and suggests inclusion of which intervention in the plan of care?*

*Answer: Avoid joking or laughing in the presence of the client.* Rationale: A client with paranoia is distrustful and suspicious of others. Joking, laughing, or whispering in front of the client would increase these feelings in the client. The other interventions are not appropriate or helpful for the client with paranoia.

*Question: The nurse is caring for a postrenal transplantation client with prescription for cyclosporine. If the nurse notes an increase in one of the client's vital signs and the client is complaining of a headache, which vital sign is most likely increased?*

*Answer: Blood pressure* Rationale: Hypertension can occur in a client taking cyclosporine, and because this client is also complaining of a headache, the blood pressure is the vital sign to be monitored most closely. Other adverse effects include infection, nephrotoxicity, and hirsutism. Options 1, 2, and 4 are unrelated to the use of this medication.

*Question: The nurse is monitoring a child who is receiving calcium disodium edetate for the treatment of lead poisoning. The nurse reviews the laboratory results of the child during treatment with this medication and is particularly concerned with monitoring which laboratory test result?*

*Answer: Blood urea nitrogen* Rationale: Kidney function tests should be monitored because calcium disodium edetate is nephrotoxic. The calcium level also should be monitored because calcium disodium edetate enhances the excretion of calcium. Options 1, 3, and 4 are not the primary concerns during treatment with calcium disodium edetate.

*Question: The nurse is assisting with caring for a client who has a placenta previa. The nurse understands that a cervical examination would not be performed on the client primarily because it could have which consequence?*

*Answer: Cause hemorrhage* Rationale: Because the placenta is implanted low in the uterus, cervical examination could cause the disruption of the placenta and initiate profound hemorrhage. The other options are also correct, but the hemorrhage is of the greatest concern in this case.

*Question: A licensed practical nurse (LPN) is administering medications to a client who has difficulty swallowing. A time-released film-coated medication is prescribed and the client is unable to swallow the pill. Which action by the LPN is most appropriate?*

*Answer: Consult with the registered nurse (RN) about contacting the primary health care provider (PHCP) regarding a medication change.* Rationale: Time-released medications are film-coated and designed to dissolve later in the gastrointestinal tract. The contents are not made to be dissolved in the mouth or esophagus and should not be crushed or broken open. The LPN should consult with the RN because if the client has extreme difficulty swallowing, the PHCP should be notified. Offering large volumes of water and a capsule to a client with impaired swallowing could result in aspiration.

*Question: The client has been given a prescription for trimethoprim. The nurse would determine the client understands how to use the medication properly if the client states an intention to perform which action?*

*Answer: Drink extra fluids while taking the medication.* Rationale: Trimethoprim is a sulfonamide used to treat urinary tract infections. Each dose of trimethoprim should be taken with a full glass of water, and the client should maintain a high fluid intake. The client should not be instructed to discontinue the medication. Some forms of sulfonamides cause the urine to turn dark brown or red. This is an expected effect, and the client does not need to notify the primary health care provider.

*Question: The nurse is monitoring a client receiving baclofen for side effects related to the medication. Which would indicate that the client is experiencing a side effect?*

*Answer: Drowsiness* Rationale: Baclofen is a central nervous system (CNS) depressant and frequently causes drowsiness, dizziness, weakness, and fatigue. It can also cause nausea, constipation, and urinary retention. Clients should be warned about the possible reactions. Options 1, 2, and 4 are not side effects.

*Question: Before administering an intermittent tube feeding through a nasogastric tube, the nurse checks for gastric residual volume. Which is the best rationale for checking gastric residual volume before administering the tube feeding?*

*Answer: Evaluate absorption of the last feeding.* Rationale: All the stomach contents are aspirated and measured before administering a tube feeding. This procedure measures the gastric residual volume. The gastric residual volume is checked to confirm whether undigested formula from a previous feeding remains and thereby evaluates the absorption of the last feeding. It is important to check the gastric residual before administration of a tube feeding. A full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration. If residual feeding is obtained, the PHCP's prescription and agency policy are checked to determine the course of action (hold or reduce the volume of the intermittent tube feeding).

*Question: The nurse is planning to administer hydrochlorothiazide to a client. Which are concerns related to the administration of this medication?*

*Answer: Hypokalemia, hyperglycemia, sulfa allergy* Rationale: Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia.

*Question: A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by which condition?*

*Answer: Impaired tissue perfusion* Rationale: Most pain associated with fractures can be minimized with rest, elevation, application of a cold compress, and administration of analgesics. Pain that is not relieved from these measures should be reported to the RN and PHCP because it may be the result of impaired tissue perfusion, tissue breakdown, or necrosis. Because this is a new closed fracture and cast, infection would not have had time to set in.

*Question: The nurse is assisting in the care of a client with Parkinson's disease who is receiving carbidopa/levodopa. The nurse plans to monitor the client for which adverse effect, which could appear with elevated serum levels of this medication?*

*Answer: Impaired voluntary movements* Rationale: Dyskinesia and impaired voluntary movement may occur with high carbidopa/levodopa doses. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia (the temporary muscle weakness that lasts 1 minute to 1 hour, also known as "on-off phenomenon") are frequent side effects of the medication. The signs and symptoms listed in the other options are incorrect.

*Question: A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions, and the nurse determines that the client is experiencing Braxton Hicks contractions. Which nursing action would the nurse take?*

*Answer: Instruct the client that these are common and may occur throughout the pregnancy.* Rationale: Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, contacting the primary health care provider, maintaining bed rest for the remainder of the pregnancy, and admitting the client to the labor and delivery unit are unnecessary and inaccurate.

*Question: The nurse is caring for an older client who is terminally ill. Which signs indicate to the nurse that death may be imminent?*

*Answer: Irregular, noisy breathing and cold, clammy skin* Rationale: The clinical signs of impending or approaching death include inability to swallow; pitting edema; decreased gastrointestinal and urinary tract activity; bowel and bladder incontinence; loss of motion, sensation, and reflexes; cold or clammy skin; cyanosis; lowered blood pressure; noisy or irregular respiration; and Cheyne-Stokes respirations.

*Question: The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position because it will aggravate breathing?*

*Answer: Lying on his or her back in low-Fowler's position* Rationale: The client should use the positions outlined in options 1, 2, and 3. These positions allow for maximal chest expansion and decreased use of accessory muscles of respiration. The client should not lie on his or her back because it reduces movement of a large area of the client's chest wall. Sitting is better than standing whenever possible. If no chair is available, then leaning against a wall while standing allows accessory muscles to be used for breathing rather than posture control.

*Question: A child is diagnosed with chicken pox. The nurse collects data regarding the child. Which finding is characteristic of chicken pox?*

*Answer: Macular rash on the trunk and scalp* Rationale: A macular rash that first appears on the trunk and scalp and then moves to the face and the extremities is a characteristic of chicken pox. Pseudomembrane formation in the throat is characteristic of diphtheria. A maculopapular or petechial rash primarily on the extremities is characteristic of Rocky Mountain spotted fever. Small red spots with a bluish-white center and red base are known as Koplik spots and are characteristic of measles.

*Question: The nurse is reviewing the immunization schedule for a child with human immunodeficiency virus (HIV) infection with the mother. Which would be a component of the instructions that the nurse reinforces to the mother?*

*Answer: No live virus vaccines should be administered to the child.* Rationale: The mother should be instructed that the child with HIV should keep immunizations up to date. No live virus vaccines should be administered because the child with HIV is immunocompromised. The immunization schedule would not be altered in any other way, and it is important for the mother to understand the immunization schedule clearly.

*Question: A client taking buspirone for 1 month returns to the clinic for a follow-up visit. Which would indicate medication effectiveness?*

*Answer: No rapid heartbeats or anxiety* Rationale: Buspirone hydrochloride is not recommended for the treatment of drug or alcohol withdrawal, paranoid thought disorders, or schizophrenia (thought broadcasting or delusions). Buspirone hydrochloride is most often indicated for the treatment of anxiety and aggression.

*Question: The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that their food is being poisoned. Which communication technique would the nurse plan to use to encourage the client to eat?*

*Answer: Open-ended questions and silence* Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Options 3 and 4 do not encourage the client to express feelings. The nurse should not offer opinions and should not state the reasons, but should encourage the client to identify the reasons for their behavior. Option 2 is not a client-centered intervention.

*Question: The nursing student is creating a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which intervention in the plan that is not specific to this disorder?*

*Answer: Observe for excessive exercise.* Rationale: Excessive exercise is a characteristic of anorexia nervosa, not bulimia nervosa. Frequent vomiting, in addition to laxative and diuretic abuse, may lead to dehydration and electrolyte imbalance. Monitoring for both dehydration and electrolyte imbalance is an important nursing action. Option 3 is the only option that is not associated with care of the client with bulimia.

*Question: The client with small cell lung cancer is being treated with etoposide and the nurse is assisting with caring for the client during administration. The client gets up to use the bathroom and is dizzy and very weak. The nurse understands these symptoms are likely as a result of which side/adverse effect that is specifically associated with this medication?*

*Answer: Orthostatic hypotension* Rationale: A side effect specific to etoposide is orthostatic hypotension. The client's blood pressure is monitored during the infusion. Hair loss occurs with nearly all antineoplastic medications. Chest pain and pulmonary fibrosis are unrelated to this medication.

*Question: A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse monitors this client for which signs/symptoms of this disorder?*

*Answer: Pallor, diminished pulse, and pain in the left hand* Rationale: Arterial steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and diminished pulse distal to the fistula and complains of pain distal to the fistula, which is caused by tissue ischemia. Warmth, redness, and pain should more likely characterize a problem with infection. Options 2 and 3 are not characteristics of steal syndrome.

*Question: A client taking buspirone hydrochloride for 1 month is scheduled for a follow-up appointment. The nurse gathers data from the client and interprets that the medication is effective if the client reports an absence of which sign/symptom?*

*Answer: Palpitations and anxiety* Rationale: The nurse interprets that the medication is effective if the client reports an absence of palpitations and anxiety. Buspirone hydrochloride is indicated most often for the treatment of anxiety and aggression. It is not recommended for the treatment of thought disorders such as delusions, schizophrenia including paranoid thoughts, or drug or alcohol withdrawal signs/symptoms.

*Question: A 9-year-old child is diagnosed with chlamydial conjunctivitis. The nurse consults with the registered nurse and pediatrician regarding necessary follow-up because this infection can be associated with which finding?*

*Answer: Possible sexual abuse* Rationale: A diagnosis of chlamydial conjunctivitis in a child who is not sexually active should signal the pediatrician to assess the child for possible sexual abuse. Allergy and infection can cause conjunctivitis, but the infecting organism would not be chlamydial. Although the infection can be transmitted, it is not directly associated with cleanliness in the home. Chlamydial conjunctivitis also may be suspected in a sexually active adolescent with chronic infection that is unresponsive to other treatment.

*Question: The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional sign/symptom would the nurse expect to note in this client if hyponatremia is present?*

*Answer: Postural blood pressure changes* Rationale: Postural blood pressure changes occur in the client with hyponatremia. Intense thirst and dry mucous membranes are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid, thready pulse is noted.

*Question: A client has just returned from intrathoracic surgery where a chest tube was placed. The nurse notes a small amount of serosanguineous drainage on the chest tube's dressing. Which action would the nurse take?*

*Answer: Reinforce the dressing.* Rationale: Chest tube dressings may be reinforced but are not changed unless prescribed by the surgeon. Dressings are kept dry and occlusive. A small amount of serosanguineous drainage right after surgery can be expected, so the surgeon would not be notified. Just documenting the findings does not ensure a dry dressing.

*Question: The client who frequently uses nonsteroidal antiinflammatory drugs (NSAIDs) has been taking misoprostol. The nurse determines that this medication is having the intended therapeutic effect if which is noted?*

*Answer: Relief of epigastric pain* Rationale: The client who frequently uses nonsteroidal antiinflammatory drugs (NSAIDs) is prone to gastric mucosal injury. Misoprostol is a gastric protectant and is given specifically to prevent this occurrence. Diarrhea can be a side effect of the medication, but it is not an intended effect. Options 3 and 4 are incorrect.

*Question: A client taking lithium carbonate reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is checked as a part of the routine follow-up, and the level is 3.0 mEq/L (3.0 mmol/L). The nurse knows that this is which level?*

*Answer: Toxic* Rationale: The therapeutic serum level of lithium is 0.8 to 1.2 mEq/L (0.8 to 1.2 mmol/L). A level of 3 mEq/L indicates toxicity.

*Question: A client who will undergo thyroidectomy at a later date has been started on medication therapy with potassium iodide. As the licensed practical nurse (LPN) prepares to administer a scheduled dose, the client states that there is a burning sensation and a brassy taste in the mouth. Which action would the LPN take?*

*Answer: Withhold the medication and notify the RN.* Rationale: Long-term ingestion of potassium iodide can produce iodism. Symptoms include a brassy taste, burning sensations in the mouth, soreness of gums and teeth, frontal headache, nasal congestion, salivation, and skin lesions. If these occur, the nurse should withhold the medication and notify the RN, who will then contact the primary health care provider.

*Question: The nurse employed in the ambulatory care department hears a client in the waiting room call out, "Help, fire!" The nurse rushes to the waiting room and finds the wastebasket on fire. Which is the immediate action of the nurse?*

*Answer: Remove the clients from the waiting room.* Rationale: The order of priority in the event of a fire is to rescue the clients in immediate danger. The next step is to activate the fire alarm. The fire is then confined by closing all doors, and last, the fire is extinguished.

*Question: The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse would expect which characteristics of this type of lesion to be documented in the client's record? Select all that apply.*

** Rationale: Basal cell carcinoma appears as a pearly papule with a central crater and a rolled, waxy border. A melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue color. Squamous cell carcinoma is a firm nodular lesion that is topped with a crust or a central area of ulceration. Actinic keratosis, which is a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale.

*Question: A client enters the emergency department confused, twitching, and having seizures. Upon assessment, flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor are noted. The serum sodium level is 172 mEq/L (172 mmol/L). Which interventions would the primary health care provider (PHCP) likely prescribe? Select all that apply.*

** Rationale: Hypernatremia is described as having a serum sodium level that exceeds 145 mEq/L (145 mmol/L). Signs and symptoms would include dry mucous membranes, loss of skin turgor, thirst, flushed skin, elevated temperature, oliguria, muscle twitching, fatigue, confusion, and seizures. Interventions include monitoring fluid balance, monitoring vital signs, reducing dietary intake of sodium, monitoring electrolyte levels, and increasing oral intake of water. Sodium replacement therapy would not be prescribed for a client with hypernatremia.

*Question: The nurse is caring for a client recently diagnosed with secondary gout. Secondary gout involves hyperuricemia (excessive uric acid in the blood) caused by another disease or factor. Which diseases or factors make clients more at risk for acquiring this condition? Select all that apply.*

** Rationale: Hyperuricemia and gout are often seen in older clients with cardiovascular health problems, obese people, and postmenopausal women. Secondary gout affects people of all ages. Disorders such as multiple myeloma and certain carcinomas result in increased production of uric acid because of a greater turnover of cellular nucleic acids. Treatment involves management of the underlying disorder. The incidence of gout is increasing as the baby boomer generation reaches 65 years of age. The risk of acquiring secondary gout is not related to clients with liver disease or those people from poor economic communities.

*Question: Which clients would the nurse determine is at risk for development of metabolic alkalosis? Select all that apply.*

** Rationale: Metabolic alkalosis is caused by any condition that creates the acid-base imbalance through either an increase in bases or a deficit of acids, such as the client who has been vomiting for 2 days and the client receiving furosemide daily. Recall that clients with emphysema and hyperventilation are at risk for a respiratory acid-base disturbance. Chronic kidney disease and aspirin overdose will result in metabolic acidosis.

*Question: The nurse is reviewing the laboratory results of a client who is receiving chemotherapy and notes that the platelet count is 10,000 mm3 (10 × 109/L). On the basis of this laboratory value, the nurse would perform which interventions? Select all that apply.*

** Rationale: Platelets or thrombocytes are necessary for a client to clot. A high risk of hemorrhage exists when the platelet count drops below 20,000 mm3 (20 × 109/L). Fatal central nervous system hemorrhage or massive GI hemorrhage can occur when the platelet count is less than 10,000 mm3 (10 × 109/L). The client may be treated with medications or platelet or blood transfusions to improve the platelet count. The nurse should monitor the client's stools for blood, both obvious and occult. The client should be very gentle if blowing the nose and not cause any pressure to build up in the head. The client also needs to avoid starting bleeding from epistaxis (nosebleed). The client should not bend over at the waist because this action would increase the pressure within the head and increase the risk for an intracerebral bleed. Clients with decreased immunity, which is not stated in the question, should avoid ill persons. The client should not floss the teeth and only use a soft toothb

*Question: The client is diagnosed with pleurisy. The nurse would expect to see which signs and symptoms? Select all that apply.*

** Rationale: Pleurisy is inflammation of the pleura. The most characteristic symptom of pleurisy is abrupt and severe pain. The pain almost always occurs on one side of the chest. Pleurisy pain is sharp, knife-like, and abrupt in onset and is most evident during inspiration. This causes shallow breathing. A pleural friction rub may be heard.

*Question: The nurse is assisting in the care of a client diagnosed with acquired immunodeficiency syndrome (AIDS) who requires an injection. The nurse would include which actions to safely administer the medication? Select all that apply.*

** Rationale: Standard precautions must be used while caring for all clients, including those who are diagnosed with AIDS. The nurse must wear gloves while administering the injection. The correct procedure for needle disposal is to dispose of uncapped needles and sharps in a hard-wall, puncture-resistant container (sharps) immediately after use. Gowns and goggles are not normally necessary to administer an injection unless the client has other problems requiring the nurse to take additional precautions. The client should not dispose of the needle. An enteral form may not be available, and this action is unnecessary because the injection can be safely administered.

*Question: The nurse is providing care for a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response?*

*Answer: "I cannot promise to keep a secret."* Rationale: The nurse should never promise to keep a secret. Secrets are appropriate in a social relationship but not in a therapeutic one. The nurse needs to be honest with the client and tell the client that a promise cannot be made to keep the secret.

*Question: The nurse reviews the home care instructions with a parent of a 3-year-old with pertussis. Which statement by the parent indicates a need for further teaching?*

*Answer: "I understand this whooping cough is viral and I have to let it run its course."* Rationale: Pertussis is caused by the bacteria Bordetella pertussis and treatment requires antimicrobial therapy. Symptoms of pertussis consist of a respiratory infection followed by increased severity of cough with a loud whooping on inspiration. The child may experience respiratory distress, and the parents should be instructed on reducing environmental factors that cause coughing spasms, such as dust, smoke, and sudden changes in temperature.

*Question: A client with dermatitis has been prescribed a topical corticosteroid for use on the affected areas, and the nurse has reinforced instructions about the use of this medication. Which statement by the client indicates a need for further teaching?*

*Answer: "I will apply a bandage over the site after applying the medication."* Rationale: An occlusive dressing (such as a bandage or plastic wrap) should not be used to cover the skin following the application of the topical corticosteroid, unless specifically prescribed by the health care provider. The other options are accurate statements about the use of this medication.

*Question: A licensed practical nurse (LPN) is assigned to assist in caring for a hospitalized child who is receiving a continuous infusion of intravenous (IV) potassium for the treatment of dehydration. The LPN monitors the child closely and notifies the registered nurse if which finding is noted?*

*Answer: A decrease in urine output to 0.5 mL/kg/hr* Rationale: The priority assessment is to monitor the status of urine output. Potassium should never be administered in the presence of oliguria or anuria. If urine output is less than 1 to 2 mL/kg/hr, potassium should not be administered. A slight elevation in temperature would be expected in a child with dehydration. A weight increase of 0.5 kg is relatively insignificant. A BP that is unchanged is a positive indicator unless the baseline was abnormal. However, there is no information in the question to support such data.

*Question: A client is taking lansoprazole for the chronic management of Zollinger-Ellison syndrome. If prescribed, which medication would be appropriate for the client if needed for a headache?*

*Answer: Acetaminophen* Rationale: Zollinger-Ellison syndrome is a hypersecretory condition of the stomach. The client should avoid taking medications that are irritating to the stomach lining. Irritants would include aspirin and nonsteroidal antiinflammatory drugs (NSAIDs) such as naprosen and ibuprofen. Acetaminophen would likely be prescribed for headache for this client because it would not be irritating to the stomach.

*Question: A nursing student is asked to administer a tepid bath to a child with a fever. The student should avoid which action when performing this procedure?*

*Answer: Applies alcohol-soaked cloths over the child's body* Rationale: Alcohol should never be used for bathing the child with a fever because it can cause rapid cooling, peripheral vasoconstriction, and chilling, thus elevating the temperature further. Washcloths can be used to squeeze water over the child's body. Towels are used to dry the child. Toys, especially water toys, can be used to provide distraction during the bath. Lightweight clothing should be placed on the child after the child is dried.

*Question: A 4-year-old child is hospitalized for severe gastroenteritis. The child is crying and clinging to the mother. The mother becomes very upset and is afraid to leave the child. Which nursing intervention would be most appropriate to alleviate the child's fears and the mother's anxiety?*

*Answer: Ask the mother if she would like to stay overnight with the child.* Rationale: Although a 4-year-old may already be spending some time away from his or her parents at a day care center or preschool, illness adds a stressor that makes separation more difficult. The only option that addresses the mother's anxiety and alleviates the fears of the child is option 2. Options 1, 3, and 4 do not address the fears and anxieties of the mother and child.

*Question: A client recently began medication therapy with propranolol. The nurse would be most concerned after noting the presence of which effect in this client?*

*Answer: Audible expiratory wheezes* Rationale: Propranolol is a beta blocker. Audible expiratory wheezes could indicate bronchospasm, a serious adverse reaction. Beta blockers that are not cardioselective may induce this reaction, particularly in clients with chronic obstructive pulmonary disease or asthma. A normal decrease in blood pressure and heart rate is expected. Insomnia is a frequent mild side effect and should continue to be monitored.

*Question: A nurse caring for a 2-month-old febrile infant is asked to collect a urine specimen for a culture and sensitivity. The nurse collects the specimen by performing which action?*

*Answer: Catheterizing the infant using the smallest available straight catheter* Rationale: In young infants less than 3 months of age who are febrile, urine specimens should be collected by bladder catheterization with a straight catheter. A urine collection bag would not get a sterile specimen and may take too long. For some types of urine testing, such as specific gravity, ketones, glucose, and protein, the nurse can aspirate urine directly from the cotton balls in the diaper. But would not be appropriate for a culture and sensitivity urine specimen. It is not reasonable to try to identify the time of the next voiding to attempt to collect the specimen.

*Question: The nurse is reviewing the primary health care provider's prescriptions for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that acetylsalicylic acid is prescribed for the child. Which nursing action is appropriate?*

*Answer: Consult with the registered nurse to verify the prescription.* Rationale: Anti-inflammatory agents, including acetylsalicylic acid, may be prescribed for the child with rheumatic fever. Acetylsalicylic acid should not be given to a child who has chickenpox or other viral infections. The nurse would not administer acetaminophen without specific primary health care provider prescriptions. Options 2 and 3 are not appropriate actions.

*Question: A client who has sustained an eye injury has been prescribed corticosteroid eye drops. The nurse would most carefully monitor for side effects of this medication if the client has which health problem listed on the medical record?*

*Answer: Diabetes mellitus* Rationale: The client with diabetes mellitus is especially at risk for side effects when taking this medication, which is a corticosteroid. The client may experience elevations in blood glucose, which should be monitored routinely. The other options are incorrect and unrelated to the use of corticosteroids.

*Question: A male client has a tentative diagnosis of urethritis. The nurse would assess the client for which manifestation of the disorder?*

*Answer: Dysuria and penile discharge* Rationale: Urethritis in the male client often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear to mucopurulent discharge. Because this disorder often coexists with gonorrhea, diagnostic tests are done for both and include culture and rapid assays. Hematuria is not associated with urethritis. Proteinuria is associated with kidney dysfunction.

*Question: The nurse is assisting in conducting a group therapy session. A client who has shared with the group at a previous session that she isolates herself when she feels depressed, suddenly gets up to leave. Which nursing action is appropriate?*

*Answer: Encourage the client to stay and ask the client what she is feeling.* Rationale: The appropriate nursing action is to encourage the client to stay and ask the client what she is feeling. If a client attempts to leave a group session, ask the client what is going on and what he or she is feeling. It is important for the nurse to try to connect the behavior with a feeling. The door would not be locked. If the client still leaves the session, it is important for the nurse to follow up with the client after the group session and find out more about the client's thoughts and feelings. Locking the door so the client cannot leave is inappropriate and is a violation of the client's rights.

*Question: Amikacin is prescribed for a client with a diagnosed bacterial infection. The nurse instructs the client to contact the primary health care provider (PHCP) immediately if which occurs?*

*Answer: Hearing loss* Rationale: Amikacin is an aminoglycoside. Adverse effects of aminoglycosides include ototoxicity (hearing problems), confusion, disorientation, gastrointestinal irritation, palpitations, blood pressure changes, nephrotoxicity, and hypersensitivity. The nurse instructs the client to report hearing loss to the PHCP immediately. Lethargy and muscle aches are not associated with the use of this medication. It is not necessary to contact the PHCP immediately if nausea occurs. If nausea persists or results in vomiting, the PHCP should be notified.

*Question: It has been determined that a client with hepatitis has contracted the infection from contaminated food. Which type of hepatitis is this client most likely experiencing?*

*Answer: Hepatitis A* Rationale: HAV is transmitted by the fecal-oral route via contaminated food or infected food handlers. HBV, HCV, and HDV are most commonly transmitted via infected blood or body fluids.

*Question: The nurse has been assigned to a client with a hearing impairment. To enhance nurse-client communication, the nurse would plan to communicate with the client by speaking in which manner?*

*Answer: In a normal tone while facing the client* Rationale: To facilitate communication with a client who is hearing impaired, the nurse should speak in a normal tone and not shout. The nurse should speak clearly and directly to the client while facing the client. If the client does not seem to understand what is said, different words should be used to express the message. It may be helpful for the nurse to move closer to the client and toward the better ear to facilitate communication, but it is not helpful to talk directly into the impaired ear.

*Question: A client with newly diagnosed Cushing's syndrome expresses concern about personal appearance, specifically about the "buffalo hump" that has developed at the base of the neck. When counseling the client about this symptom, the nurse would incorporate which knowledge?*

*Answer: It may slowly improve with treatment of the disorder.* Rationale: The client with Cushing's syndrome should be reassured that most physical changes resolve over time with treatment. The other options are incorrect.

*Question: The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid. The nurse determines that which client complaint may be associated with the use of this medication?*

*Answer: Itching* Rationale: Azelaic acid is a topical medication used to treat mild to moderate acne. Adverse effects include burning, itching, stinging, redness of the skin, and hypopigmentation of the skin in clients with a dark complexion. The effects noted in the other options are not specifically associated with this medication.

*Question: The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse would monitor the status of breath sounds in that area by placing the stethoscope in which location?*

*Answer: Just under the left clavicle* Rationale: The apex of the lung is the rounded, uppermost part of the lung. To check breath sounds in a client with a left apical pneumothorax, the nurse would place the stethoscope just under the left clavicle. The other options are incorrect.

*Question: The nurse is assisting in admitting a client who experienced seizure activity in the emergency department. The nurse avoids which action when managing this client's environment?*

*Answer: Keeping the bed position raised to the nurse's waist level* Rationale: Seizure precautions may vary somewhat from agency to agency, but they generally have some commonalities. Usually an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an IV access in place to have a readily accessible route if IV anticonvulsant medications must be administered.

*Question: A client who has just been diagnosed with glaucoma has been given a prescription for a miotic medication. When reinforcing instructions to the client about medication effects, the nurse plans to tell the client that the medication works in which manner?*

*Answer: Lowers intraocular pressure and enhances blood flow to the retina* Rationale: Miotics are used to lower the intraocular pressure, which then increases blood flow to the retina. This in turn decreases retinal damage and loss of vision. Miotics cause a contraction or constriction of the ciliary muscle and widen the trabecular meshwork. The other options are incorrect.

*Question: The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder?*

*Answer: Metabolic acidosis* Rationale: Intestinal secretions high in bicarbonate may be lost through enteric drainage tubes, an ileostomy, or diarrhea. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis. The remaining options are unlikely to occur in a client with severe diarrhea.

*Question: A client who is receiving antineoplastic medication by the intravenous (IV) route complains of pain at the insertion site of the IV. The nurse inspects the site and finds the area is swollen and reddened. The nurse further observes that the solution is no longer infusing. The nurse immediately takes which priority nursing action?*

*Answer: Notifies the registered nurse (RN)* Rationale: When antineoplastic medications are administered by IV, the nurse vigilantly monitors the infusion to prevent extravasation of the medication. If medication escapes into surrounding tissues, pain, tissue damage, and necrosis can result. The nurse monitors for signs of extravasation such as redness or swelling at the insertion site or a decreased or stopped infusion rate. If extravasation occurs, the nurse should immediately notify the RN, who will then discontinue the infusion, leaving the needle or catheter in place, and call the primary health care provider.

*Question: A child is diagnosed with infectious mononucleosis. The nurse reinforces home care instructions to the parents about the care of the child. Which instruction would the nurse provide to the parents?*

*Answer: Notify the pediatrician if the child develops abdominal or left shoulder pain.* Rationale: The parents need to be instructed to notify the pediatrician if abdominal pain (especially in the left upper quadrant) or left shoulder pain occurs, because this may indicate splenic rupture. Children with enlarged spleens are also instructed to avoid contact sports until the splenomegaly resolves. Bed rest is not necessary, and children usually self-limit their activity. Respiratory precautions are not required, although transmission can occur via direct intimate contact or contact with infected blood. Fever is treated with acetaminophen.

*Question: A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's poor nutritional intake. Which nursing intervention related to poor nutrition would be the initial choice?*

*Answer: Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.* Rationale: Change in appetite is one of the major symptoms of depression. Offering the client several small, frequent meals and the nurse's presence at that time to support, encourage, or perhaps even feed the client is the most appropriate intervention. A client with depression experiences poor concentration and will not understand the importance of an adequate nutritional intake. Weighing the client does not address how to increase nutritional intake. Reporting the nutritional problems to the psychiatrist is correct to some degree, but it does not address how one might increase food intake.

*Question: The nurse is assisting with planning the care of a client with a diagnosis of immunodeficiency. The nurse would incorporate which intervention as a priority in the plan of care?*

*Answer: Protecting the client from infection* Rationale: The client with immunodeficiency has inadequate or absent immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. Options 2, 3, and 4 may be components of care but are not the priority.

*Question: The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which situation?*

*Answer: Psychomotor retardation and side effects of medication* Rationale: In this situation, urinary retention is most likely caused by medications. Option 4 is the only option that addresses both constipation and urinary retention. Constipation can be related to inadequate food intake, lack of exercise, and poor diet.

*Question: The nurse is obtaining the report for a group of assigned clients. The nurse plans to monitor the serum potassium levels in which clients at risk for hyperkalemia? Select all that apply.*

** Rationale: Hyperkalemia is likely to occur in clients who experience cellular shifting of potassium (from intracellular to extracellular) from early massive cell destruction such as in trauma or burns. Clients with altered kidney function, such as those with AKI, are at risk because the normally functioning kidney excretes potassium. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis. Clients with Cushing's syndrome or ulcerative colitis or those using laxatives excessively are at risk for hypokalemia.

*Question: The nurse is assisting in the care of a client for whom an arterial blood gas (ABG) must be drawn. The nurse notes that the person who draws the blood sample from the radial artery performs an Allen's test first. The nurse recognizes that this is being done to determine the adequacy of which circulations? Select all that apply.*

** Rationale: Allen's test is done to test the adequacy of the radial and ulnar circulation before drawing an ABG. This is necessary to ensure that the client has adequate circulation to the hand in case the radial artery becomes occluded. The radial artery is also tested to determine that it is patent and capable of hand perfusion. Failure to assess collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture.

*Question: A primary health care provider writes a prescription to apply a heating pad to a client's back. The nurse implements the prescription and avoids which action?*

*Answer: Placing the heating pad under the client* Rationale: The heating pad should never be placed under the client, but it should be placed lightly against or on top of the involved area. Burns to the skin can occur when the client lies on the pad. Using a low setting with a heating pad, observing skin condition frequently, and monitoring heating pad function are appropriate measures for the use of a heating pad.

*Question: A client with liver cancer who is receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter, especially meats. The nurse would instruct the client to eat which foods instead of meat? Select all that apply.*

** Rationale: Chemotherapy may cause distortion of taste. Frequently, beef and pork are reported to taste bitter or metallic. The nurse can promote client nutrition by assisting the client in choosing alternative sources of protein in the diet. Yogurt and custard are protein sources that may be more palatable. Potatoes, cantaloupe, and potato chips are not good sources of protein.

*Question: A client is receiving standard oral anticoagulant therapy with warfarin. The result of a newly drawn international normalized ratio is 3.8 seconds. The client needs to have an invasive procedure done on the next day. Which medication will likely be ordered to reverse the anticoagulant effect?*

*Answer: Phytonadione* Rationale: A client who is prescribed warfarin will need to have the medication reversed if an invasive procedure is planned. Vitamin K1 or phytonadione is administered to reverse warfarin. Naloxone reverses narcotics. Protamine reverses heparin. Calcium chloride will not reverse warfarin.

*Question: A client with methicillin-resistant Staphylococcus aureus (MRSA) needs to be placed on contact precautions, and the licensed practical nurse (LPN) in charge asks a newly licensed LPN to initiate contact precautions. Which action by the new LPN would indicate the need to review the procedure for contact precautions?*

*Answer: Wears a gown when caring for the client and removes the gown immediately after leaving the client's room* Rationale: Contact precautions are used to decrease the likelihood of spreading infection from direct and indirect contact with the client. The nurse wears gown and gloves while caring for the client. The gown worn by the nurse must be removed before he or she leaves the client's room. Goggles are worn to protect the mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, and excretions. In addition, contact precautions require the use of gloves and a gown if direct client contact is anticipated. The client should be placed in a private room, or if a private room is not available, the client is placed in a semiprivate room with another client who has active infection with the same microorganism but has no other infection.

*Question: A client is resuming a diet after partial gastrectomy. To minimize complications, the nurse would instruct the client to avoid which behavior?*

*Answer: Drinking liquids with meals* Rationale: The client who has had a hemigastrectomy is at risk for dumping syndrome. This client should be placed on a diet that is high in protein, moderate in fat, and high in calories. The client should avoid drinking liquids with meals. Frequent small meals are encouraged, and the client should avoid concentrated sweets.

*Question: Which fluids are identified as insensible fluid losses? Select all that apply.*

** Rationale: Insensible fluid losses are those that cannot be perceived by the senses or measured because they occur through the skin, such as sweat, and the lungs, such as sputum. They occur on a daily basis without the client's awareness. Sensible losses are those that are perceivable and measurable and include wound drainage, including output from wound drains such as a Jackson-Pratt drain; gastrointestinal tract losses, such as output from a nasogastric tube; and urine output.

*Question: The mother of a child with Marfan syndrome asks the nurse what can be done at home to help her child. Which are the best responses by the nurse? Select all that apply.*

** Rationale: Parents of the child with Marfan syndrome should be instructed to monitor for vision problems and get regular eye examinations, avoid participation in contact sports, but it is not necessary to stay indoors. Monitor the curvature of the spine as the child grows, anticipate that antibiotics should be taken before any dental procedure to prevent endocarditis, cardiac medications to decrease stress on the aorta, and surgical replacement of the aortic root and valve may be necessary. Making regular pediatric appointments is important for monitoring the child.

*Question: The nurse is monitoring a client who has been newly diagnosed with diabetes mellitus for signs of complications. Which statement made by the client would indicate hyperglycemia and thus warrant primary health care provider (PHCP) notification?*

*Answer: "I am urinating a lot."* Rationale: The classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Options 2, 3, and 4 are not signs of hyperglycemia.

*Question: A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to offer to the client?*

*Answer: Fat-free beef broth* Rationale: A clear liquid diet consists of foods that are relatively transparent. Soft custard and orange juice would be included in a full liquid diet because they are opaque, not clear. Clam chowder is opaque and also includes pieces of clams, thus eliminating it from a full liquid diet.

*Question: The nurse is caring for a client with epididymitis. Which treatment modalities would be implemented? Select all that apply.*

** Rationale: Common interventions used in the treatment of epididymitis include bed rest, elevation of the scrotum, ice packs, sitz baths, analgesics, and antibiotics. A heating pad should not be used because direct application of heat could increase blood flow to the area and increase the swelling.

*Question: Which intervention would be contraindicated in the postprocedure care of the client following a bone biopsy of the left arm?*

*Answer: Place the left arm in a dependent position for 24 hours.* Rationale: The biopsy site would be elevated for 24 hours to reduce edema, not placed in a dependent position. Other aspects of care include monitoring the site for swelling, bleeding, and hematoma formation; monitoring vital signs; and administering analgesics for site discomfort.

*Question: A postoperative client requests medication for flatulence (gas pains). Which medication from the PRN list would the nurse administer to this client?*

*Answer: Simethicone* Rationale: Simethicone is an antiflatulent used in the relief of pain caused by excessive gas in the gastrointestinal tract. Ondansetron is used to treat postoperative nausea and vomiting. Acetaminophen is a nonopioid analgesic. Magnesium hydroxide is an antacid and laxative.

*Question: The nurse is caring for an infant who has been diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests and would expect to note which finding?*

*Answer: An elevated thyroid-stimulating hormone (TSH) level* Rationale: Diagnostic findings in primary hypothyroidism include a low T4 level and a high TSH level. Options 1, 3, and 4 are not diagnostic findings in this condition.

*Question: Heparin sodium is prescribed for the client. Which laboratory result indicates that the heparin is prescribed at a therapeutic level?*

*Answer: Activated partial thromboplastin time (aPTT) of 55 seconds* Rationale: The aPTT will assess the therapeutic effect of heparin sodium. The normal aPTT is 30 to 40 sec. To maintain a therapeutic level, the aPTT should be 1.5 to 2.5 times the normal value. The PT and INR will assess for the therapeutic effect of warfarin sodium. A decreased thrombocyte count can cause bleeding.

*Question: The client has been taking omeprazole for 4 weeks. The nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom?*

*Answer: Heartburn* Rationale: Omeprazole is a proton pump inhibitor classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often called "heartburn" by clients. Omeprazole is not used to treat the conditions identified in options 1, 3, and 4.

*Question: The client has an as-needed prescription for ondansetron. For which condition would the nurse administer this medication?*

*Answer: Nausea and vomiting* Rationale: Ondansetron is an antiemetic used to treat postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy. The other options are incorrect.

*Question: The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching?*

*Answer: "I need to avoid sun exposure before 10:00 am and after 4:00 pm."* Rationale: The client should be instructed to avoid sun exposure between the hours of approximately 10:00 am and 4:00 pm. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any possible cancerous or precancerous lesions.

*Question: A licensed practical nurse (LPN) is assisting in gathering data on a client who is scheduled for a cesarean delivery. Which findings indicate a need to contact the registered nurse (RN)? Select all that apply.*

** Rationale: A blood pressure reading of 144/94 is elevated for pregnancy. The client may need to be evaluated for preeclampsia or gestational hypertension. A normal fetal heart rate is 110 to 160 beats per minute. A count of 180 beats per minute could indicate fetal distress and needs to be reported. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL because of the hemodilution caused by an increase in plasma volume during pregnancy. The total blood volume increases 30% to 50% by the end of the second trimester. Maternal pulse rate during pregnancy increases 10 to 15 beats per minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in a normal pregnancy begin to rise in the second trimester and peak in the third trimester with a normal range of 11,000 to 18,000 mm3. During the immediate postpartum period the count may range from 25,000 to 30,000 cells/mm3 as a result of increased leukoc

*Question: The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster?*

*Answer: An assistive personnel who has never had chickenpox* Rationale: Herpes zoster is caused by a reactivation of the varicella zoster virus, which is the causative virus of chickenpox. Individuals who have not been exposed to the varicella zoster virus are susceptible to chickenpox. Options 1, 2, and 3 are not associated with the herpes zoster virus.

*Question: When reinforcing dietary instructions to a client with irritable bowel syndrome whose primary symptom is alternating constipation and diarrhea, which foods would the nurse tell the client are best to include in the diet for this disorder? Select all that apply.*

** Rationale: A high-fiber, high-residue diet is used for constipation, irritable bowel syndrome when the primary symptom is alternating constipation and diarrhea, and asymptomatic diverticular disease. High-fiber foods include fruits and vegetables and whole-grain products. Gas-forming foods such as beans, cabbage, and Brussels sprouts should be limited.

*Question: The nurse reinforces medication instructions to a client with peptic ulcer disease. Which statement by the client indicates the best understanding of the medication therapy?*

*Answer: "The nizatidine will cause me to produce less stomach acid."* Rationale: Nizatidine, a histamine H2-receptor blocker, is frequently used in the management of peptic ulcer disease. Histamine H2-receptor blockers decrease the secretion of gastric acid (HCL). Antacids are used as adjunct therapy and neutralize acid in the stomach. Omeprazole is a proton pump inhibitor. Sucralfate promotes healing by covering the ulcer, thus protecting it from erosion caused by gastric acids.

*Question: The nurse is preparing to administer eardrops to an adult client. The nurse administers the eardrops by which technique?*

*Answer: Pulling the pinna up and back* Rationale: For an adult, the nurse tilts the client's head slightly away and pulls the pinna up and back. Asking the client to stand and lean to one side is inappropriate and unsafe.

*Question: The nurse is monitoring a client following cardioversion. Which observations would be of highest priority to the nurse?*

*Answer: Status of airway* Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway is the priority.

*Question: The nurse is preparing the client for transfer to the operating room (OR) because of an emergency situation. The nurse would take which actions in the care of the client? Select all that apply.*

** Rationale: A client who is going to surgery on an emergent basis needs to be readied efficiently. The nurse should ensure that the client has voided if a Foley catheter is not in place. The nurse should determine when the client last ate or drank to assist the anesthesiologist in determining the type of anesthesia for the surgery. The nurse assists the client with notifying persons who are the client's support system. These interventions are documented in the client's medical record. The nurse does not administer all daily medications just before sending a client to the OR. The time of transfer to the OR is not the time to practice breathing exercises.

*Question: A hospitalized client with heart disease who is taking digoxin has a digoxin level prescribed. The level is elevated above normal. Based on this finding the nurse plans to notify the registered nurse and primary health care provider (PHCP) and anticipates which additional interventions will be prescribed? Select all that apply.*

** Rationale: Digoxin is a cardiac glycoside that is used as a second-line medication to treat heart failure. It affects the electrical and mechanical actions of the heart and can reach toxic levels easily. An elevated digoxin level is digoxin toxicity. Digoxin toxicity with cardiac dysrhythmias is enhanced by hypokalemia so the electrolytes, especially potassium, should be monitored. Digoxin is excreted through the kidneys so renal function should be determined by the BUN and creatinine levels. The client should be placed on a cardiac monitor so the client can be assessed for dysrhythmias. A repeat digoxin level is not needed because digoxin has a long half-life and the result would not be noticeably different so soon. An additional dose should not be given due to the elevated digoxin level.

*Question: An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this clie

** Rationale: Rationale not found

*Question: The nurse is asked to regulate the flow rate of an intravenous (IV) solution being administered to a client. The IV bag contains 50 mL of solution, and the solution is to be administered over 30 minutes. The administration set has a drop factor of 10 drops (gtts)/mL. The nurse would regulate the roller clamp on the infusion set to deliver how many drops per minute? Fill in the blank. Round answer to the nearest whole number.*

** Rationale: Rationale not found

*Question: The nurse is caring for a newly admitted client with pneumonia. The primary health care provider has prescribed a sputum specimen for culture and sensitivity. The nurse would perform the actions concerning the sputum collection in which priority order? Arrange the actions in the order that they should be performed. All options must be used.*

** Rationale: Rationale not found

*Question: The nurse is preparing to administer 35 mg of a prescribed intramuscular (IM) dose of medication to a client. The medication label reads 50 mg/mL. How many milliliters would the nurse administer to the client? Fill in the blank.*

** Rationale: Rationale not found

*Question: The nurse is reinforcing instructions to a client receiving external radiation therapy. The nurse determines that the client needs further teaching if the client states an intention to take which action? Select all that apply.*

** Rationale: The client should avoid pressure on the radiated area and wear loose-fitting clothing to prevent a disruption in the skin integrity. A client receiving external radiation is not radioactive and does not need to avoid other persons, including young people. A diet high in protein assists in the healing process. Avoiding sunlight and washing the skin with gentle soap and patting dry will assist with preventing skin disruption.

*Question: The health education nurse provides instructions to a group of clients regarding measures that will assist with preventing skin cancer. Which instructions would the nurse provide? Select all that apply.*

** Rationale: The client should be instructed to avoid sun exposure between the hours of brightest sunlight: 10 a.m. to 4 p.m. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any cancerous or precancerous lesions. Sunscreen should be reapplied every 2 to 3 hours and after swimming or sweating; otherwise, the duration of protection is reduced.

*Question: The nurse has admitted a client to the clinical nursing unit following a right mastectomy. Which interventions would be included in the plan of care? Select all that apply.*

** Rationale: The client, who has undergone a mastectomy (removal of the breast) procedure, is at risk for developing lymphedema due to disruption of the lymph circulation. The client's operative arm should be positioned so that it is elevated on one or two pillows and does not exceed shoulder elevation. This will facilitate the flow of fluids through the lymph and venous routes and prevent lymphedema (accumulation of lymph in soft tissue). Placing a sign stating no venipunctures or BPs in the operative arm will inform all health care workers of the precautions needed to prevent infection or blockage of lymph channels in the arm. Checking the radial pulse in the right arm will not block lymph circulation. The left arm needs no precautions because the lymph circulation is intact on that arm. The client may bend the fingers, and not bending them will likely promote edema.

*Question: The nurse in the newborn nursery is assisting in monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings, if noted in the newborn, would alert the nurse to the possibility of this syndrome? Select all that apply.*

** Rationale: The neonate with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible expiratory grunts. Bradycardia is not an associated finding with RDS. Acrocyanosis is the bluish discoloration of the hands and feet and is not uncommon in the first few hours of life.

*Question: During data collection, which behavior would the nurse expect a client diagnosed with agoraphobia to describe?*

*Answer: A fear of leaving the house* Rationale: Agoraphobia is a fear of open spaces (i.e., leaving the house); panic attacks may occur when doing so. Option 2 describes a fear of closed spaces (claustrophobia). Option 3 describes a fear of public speaking (social phobia). Option 4 describes an obsessive-compulsive behavior.

*Question: The nurse on the mental health unit is caring for a client with a history of alcoholism. Aversion conditioning has been chosen as the treatment for this client because other less drastic measures have failed to produce the desired effects. Which are some paradigms or clear examples of aversion conditioning? Select all that apply.*

** Rationale: When working with a client diagnosed with anorexia nervosa, the nurse must limit the amount of rigorous exercise that the client performs while providing for appropriate types and amount of exercise. Clients with anorexia nervosa frequently are preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake, which causes further deterioration of the physical state. The other nursing actions are inappropriate.

*Question: The nurse is caring for a child with heart failure and provides instructions to the mother regarding the procedure for administration of the prescribed digoxin. Which statement by the mother indicates a need for further teaching?*

*Answer: "I can mix the medication with food."* Rationale: Medication should not be mixed with food because this method of administration would not ensure that the child received the prescribed dose. The parents need to be instructed that if the child vomits after the digoxin is administered, they are not to repeat the dose. In addition, the parents should be instructed that if a dose is missed and it is not identified until 4 or more hours later, the dose should not be administered. If more than one dose is missed, the cardiologist needs to be notified.

*Question: The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made?*

*Answer: "I will drive only during the daytime."* Rationale: The client should not drive because the device impairs the range of vision. The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest or the device to protect the skin from ulceration and should use powder or lotions sparingly or not at all. The wool liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed.

*Question: The nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic?*

*Answer: "You must be feeling all alone at this point."* Rationale: The client is experiencing loss and is feeling hopeless. The therapeutic response by the nurse is the one that attempts to translate words into feelings. In option 1, the nurse uses sarcasm, which gives advice and is nontherapeutic as a nursing response. In option 2, the nurse is voicing doubt, which is often used when a client verbalizes delusional ideas. In option 3, the nurse is disagreeing with the client, which implies that the nurse has passed judgment on the client's ideas or opinions.

*Question: A client admitted with depression states to the nurse, "My life has been such a failure; nothing I do turns out right." Which response by the nurse would be therapeutic?*

*Answer: "You seem very discouraged. Can you think of anything recently that went as you planned?"* Rationale: Depressed clients frequently exhibit feelings of low self-esteem and worthlessness. An effective plan of care would be designed to provide client experiences that are challenging but successful in order to enhance the client's self-esteem. Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of self. The other responses are inappropriate and are communication blocks.

*Question: The nurse is having a conversation with a depressed client in an inpatient psychiatric unit. The client says to the nurse, "Things would be so much better for everyone if I just wasn't around." Which response by the nurse would be appropriate at this time?*

*Answer: "You sound very unhappy. Are you thinking of harming yourself?"* Rationale: The appropriate response by the nurse at this time is "You sound very unhappy. Are you thinking of harming yourself?" The best method is to ask the client directly about whether a specific plan has been formed. Clients who are depressed may be at higher risk for suicide. When clients make statements such as the one in the question, it is critical for the nurse specifically to assess suicidal ideation and plan. The other responses do not directly focus on the client's statement.

*Question: A client with diabetes mellitus has a blood sample drawn for the determination of a fasting blood glucose level. When reviewing the client's results, the nurse determines that which requires a call to the primary health care provider for intervention?*

*Answer: 240 mg/dL (13.7 mmol/L)* Rationale: The normal fasting blood glucose level is 70 mg/dL to 100 mg/dL (4-6 mmol/L) in the adult client. Values above the normal range should be evaluated to determine whether further intervention is needed. The most critical value is 240 mg/dL (13.7 mmol/L).

*Question: A client is taking Humulin NPH insulin daily every morning. The nurse reinforces instructions to the client and would tell the client that which is the most likely time for a hypoglycemic reaction to occur?*

*Answer: 6 to 14 hours after administration* Rationale: Humulin NPH is an intermediate-acting insulin. The onset of action is 1 to 2 hours, it peaks in 6 to 14 hours, and its duration of action is 16 to 24 hours. Hypoglycemic reactions most likely occur during peak time.

*Question: An adult client with hepatic encephalopathy has a serum ammonia level of 120 mcg/dL (72 mcmol/L) and receives treatment with lactulose syrup. The nurse determines that the client has the best response if the level changes to which after medication administration?*

*Answer: 70 mcg/dL (42 mcmol/L)* Rationale: The normal serum ammonia level is 10 to 80 mcg/dL (6 to 47 mcmol/L). In the client with hepatic encephalopathy, the serum level is not likely to drop below normal. The most optimal yet realistic change from the options provided would be to 70 mcg/dL (42 mcmol/L), which falls in the normal range. A level of 100 mcg/dL (60 mcmol/L) represents an insufficient effect of the medication. Lactulose is administered for its hyperosmotic laxative effect, thus removing ammonia from the colon. The client should also be monitored for hypokalemia resulting from the severe purging lactulose causes.

*Question: The nurse documents the following assessment findings at 1 minute following birth: heart rate, 122 beats/minute; good, lusty cry; well flexed; cries appropriately; and the body is pink with blue extremities. What would the nurse document as this newborn's 1-minute Apgar score?*

*Answer: 9* Rationale: All of the assessment findings are normal and will receive a score of 2 points each with the exception of having blue extremities (acrocyanosis). This is a 1 point deduction resulting in a score of 9.

*Question: The nurse is monitoring a client receiving glipizide. Which outcome indicates an ineffective response from the medication?*

*Answer: A glycosylated hemoglobin level of 12%* Rationale: Glipizide is an oral hypoglycemic agent administered to decrease the serum glucose level and the signs and symptoms of hyperglycemia. Therefore, a decrease in both polyuria and polyphagia would indicate a therapeutic response. Laboratory values are also used to monitor a client's response to treatment. A fasting blood glucose level of 100 mg/dL (5.7 mmol/L) is within normal limits. However, glycosylated hemoglobin of 12% indicates poor glycemic control.

*Question: A client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin 0.4 mg sublingually. Five minutes later, the client is still experiencing chest pain. If the blood pressure is still stable, the nurse would take which action next?*

*Answer: Administer another nitroglycerin tablet.* Rationale: In the hospitalized client, nitroglycerin tablets usually are prescribed 1 every 5 minutes as needed (PRN) for chest pain up to a total dose of 3 tablets. The nurse in this question should administer the second tablet. The client with known angina pectoris should have low-flow oxygen at a rate of 1 to 3 L/minute via nasal cannula if pain is not relieved. A 12-lead ECG would be done if prescribed by standing protocol or by individual primary health care provider prescription.

*Question: The nurse is assisting in the care of a client who is being evaluated for possible myasthenia gravis. The primary health care provider gives a test dose of edrophonium. The nurse recalls that the client would have which reaction if the client has this disease?*

*Answer: An increase in muscle strength within 1 to 3 minutes* Rationale: Edrophonium is a short-acting acetylcholinesterase inhibitor used to diagnose myasthenia gravis. An increase in muscle strength should be seen in 1 to 3 minutes following the test dose if the client does have the disease. If no response occurs, another dose is given over the next 2 minutes, and muscle strength again is tested. If no increase in muscle strength occurs with this higher dose, the muscle weakness is not caused by myasthenia gravis. Clients who receive injections of this medication commonly demonstrate a drop in blood pressure, feel faint and dizzy, and are flushed.

*Question: The nurse is preparing a client scheduled for an intravenous pyelogram (IVP). The nurse would take which important action before the test?*

*Answer: Ask about allergies to iodine or shellfish.* Rationale: Some IVP dye is iodine based. It can cause allergic reactions manifested by itching, hives, rash, a tight feeling in the throat, shortness of breath, and bronchospasm. Assessing for allergies is the priority. The dye is injected intravenously. The client may or may not receive premedication. Fluids are restricted before the procedure. The client is generally on nothing-by-mouth (NPO) status after midnight, and intravenous fluid rates may be slowed to allow better concentration of the dye in the kidneys.

*Question: A client is diagnosed with hyphema after experiencing a traumatic blow to the eye. The nurse explains to the client that which activity limitation needs to be implemented following this type of injury?*

*Answer: Bed rest with the head in semi-Fowler's position* Rationale: A hyphema is the presence of blood in the anterior chamber of the eye. It is caused by an event that ruptures blood vessels in the eye, such as a penetrating injury, or indirectly from a blow to the forehead. The client is treated with bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea. Therefore, options 1, 2, and 3 are incorrect.

*Question: The nurse is assigned to care for a child admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The nurse prepares the child for which diagnostic test that will confirm the diagnosis?*

*Answer: Blood cultures* Rationale: When endocarditis is suspected, a definitive diagnosis is achieved through blood cultures. A negative blood culture does not rule out the existence of endocarditis; it just indicates a lesser likelihood of its existence. A chest x-ray, echocardiogram, and transesophageal echocardiography are performed to aid in the diagnosis of endocarditis.

*Question: Cyclosporine is prescribed for a client following an allogenic kidney transplant. The nurse would reinforce which instructions to the client regarding this medication?*

*Answer: Blood levels of the medication will need to be measured periodically.* Rationale: Cyclosporine is an immunosuppressant. To avoid toxicity from high drug levels and to avoid organ rejection from low drug levels, blood levels of cyclosporine should be measured periodically. In the organ transplant client, an immunosuppressant will need to be taken for life. Oral administration is the route of choice; intravenous administration is reserved for clients who cannot take the medication orally. The most serious adverse effects are nephrotoxicity and infection.

*Question: A licensed practical nurse (LPN) is assisting in the care of a client in preterm labor who is being started on intravenous magnesium sulfate to stop the contractions. The LPN checks to see that which is available on the unit as an antidote to magnesium sulfate?*

*Answer: Calcium gluconate* Rationale: The antidote for magnesium sulfate is calcium gluconate. This medication should be available if the client experiences magnesium toxicity. The other options are not antidotes for magnesium sulfate.

*Question: The client diagnosed with acquired immunodeficiency syndrome has been prescribed zidovudine. The nurse reviewing the primary health care provider's prescription, should expect to note that which laboratory test has been prescribed?*

*Answer: Complete blood count (CBC)* Rationale: Zidovudine is a nucleoside-nucleotide reverse transcriptase. An adverse effect of this medication therapy is granulocytopenia and anemia. The nurse carefully monitors the CBC results for these changes. With early human immunodeficiency virus infection or in the client who is asymptomatic, CBC levels are monitored monthly for 3 months, then every 3 months thereafter. In clients with advanced disease, these levels are monitored every 2 weeks for the first 2 months, and then once a month if the medication is tolerated well. Options 1, 2, and 3 are not specifically associated with this medication.

*Question: The nurse has just been given a prescription to administer albuterol to a client. The nurse evaluates the effectiveness of the medication by checking which parameters before and during therapy?*

*Answer: Dyspnea and lung sounds* Rationale: Albuterol is an adrenergic bronchodilator. The nurse monitors respiratory pattern, lung sounds, pulse, and blood pressure before and during therapy. The color, character, and amount of sputum also are noted. The medication is not given to affect the parameters listed in any of the other options.

*Question: The nurse is preparing to care for a woman in the immediate postpartum period who has just delivered a healthy newborn. The nurse plans to take the woman's vital signs at which time intervals?*

*Answer: Every 15 minutes for the first hour and then every 30 minutes for the next 2 hours* Rationale: During the immediate postpartum period, vital signs are taken every 15 minutes in the first hour after birth, every 30 minutes for the next 2 hours, and every hour for the next 2 to 6 hours. Vital signs are monitored thereafter every 4 hours for 24 hours and every 8 to 12 hours for the remainder of the hospital stay.

*Question: A client has been brought to the emergency department after attempting to commit suicide by hanging. The nurse would take which nursing action first?*

*Answer: Examine the neck area and assess the airway.* Rationale: The nurse should first assess the airway and prepare to treat injuries to the neck area. Failure to do so could be life threatening. Other interventions may follow after the client has received medical intervention for physical injuries.

*Question: A client experiencing a severe major depressive episode is unable to address activities of daily living. Which is the appropriate nursing intervention?*

*Answer: Feed, bathe, and dress the client as needed until the client can perform these activities independently.* Rationale: The client with depression may not have the energy or interest to complete activities of daily living. Often, severely depressed clients are unable to perform even the simplest activities of daily living. The nurse assumes this role and completes these tasks with the client. Options 2 and 3 are incorrect because the client lacks the energy and motivation to perform these tasks independently. Option 4 will increase the client's feelings of poor self-esteem and unworthiness.

*Question: A client with chronic kidney disease is receiving epoetin alfa. Which laboratory result would indicate a therapeutic effect of the medication?*

*Answer: Hematocrit of 33% (0.33)* Rationale: Epoetin alfa is synthetic erythropoietin, which the kidneys produce to stimulate red blood cell production in the bone marrow. It is used to treat anemia associated with chronic kidney disease. The normal hematocrit level is Male: 42% to 52% (0.42 to 0.52); Female: 37% to 47% (0.37 to 0.47). Therapeutic effect is seen when the hematocrit reaches between 30% and 33% (0.30 and 0.33). The normal platelet count is 150,000 to 400,000 mm3 (150 to 400 × 109/L). The normal blood urea nitrogen level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). The normal white blood cell count is 5000 to 10,000 mm3 (5 to 10 × 109/L). Platelet production, white blood cell production, and blood urea nitrogen do not respond to erythropoietin.

*Question: The nurse discusses the risk factors associated with gastric cancer as part of a health promotion program. The nurse determines that there is a need for further teaching if a member attending the program states that which factor is a risk?*

*Answer: High meat and carbohydrate consumption* Rationale: Gastric cancer usually begins in the mucosal cells of the stomach. High meat and carbohydrate consumption plays a role in the development of cancer of the pancreas, not gastric cancer. Options 1, 2, and 4 identify risk factors related to gastric cancer. The risk also is increased for males 50 years of age and older and clients with a history of precancerous lesions or chronic gastritis.

*Question: A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription?*

*Answer: Holding the next dose of warfarin* Rationale: Rationale not found

*Question: Carbidopa-levodopa is prescribed for a client with Parkinson's disease, and the nurse monitors the client for adverse effects of the medication. Which sign/symptom indicates the client is experiencing an adverse effect?*

*Answer: Impaired voluntary movements* Rationale: Dyskinesia and impaired voluntary movement may occur with high levodopa dosages. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia (the temporary muscle weakness that lasts 1 minute to 1 hour, also known as the "on-off phenomenon") are frequent side effects of the medication.

*Question: A licensed practical nurse (LPN) is reviewing laboratory results for a client taking dantrolene sodium. The LPN would suggest that the registered nurse notify the primary health care provider if which finding is noted on the laboratory report sheet?*

*Answer: Lactate dehydrogenase (LDH) 600 units/L* Rationale: Dantrolene sodium is a skeletal muscle relaxant. Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce the risk of liver damage, tests of liver function would be performed before treatment and throughout the treatment interval. It is administered in the lowest effective dosage for the shortest time necessary. The LDH level reported is high. The other laboratory results are considered normal.

*Question: The nurse is assisting a client who is new to a low-potassium diet to select food items from the menu. Which food item is lowest in potassium and would be recommended to the client on this dietary restriction?*

*Answer: Lima beans* Rationale: Cantaloupe, spinach, and strawberries are high-potassium foods. Lima beans contain potassium but in lower amounts than options 1, 3, and 4.

*Question: The nurse is reinforcing discharge instructions to a client receiving sulfadiazine. Which would be included in the list of instructions?*

*Answer: Maintain a high fluid intake.* Rationale: Each dose of sulfadiazine should be administered with a full glass of water, and the client should maintain a high fluid intake. The medication is more soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Some forms of sulfadiazine cause urine to turn dark brown or red. This does not indicate the need to notify the PHCP.

*Question: The nurse is reinforcing discharge instructions to a client receiving sulfisoxazole. Which would be included in the plan of care for instructions?*

*Answer: Maintain a high fluid intake.* Rationale: Each dose of sulfisoxazole should be administered with a full glass of water, and the client should maintain a high fluid intake. The medication is more soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Some forms of sulfisoxazole cause the urine to turn dark brown or red. This does not indicate the need to notify the primary health care provider.

*Question: The nurse is caring for a child following surgical removal of a brain tumor. The nurse is monitoring the child and notes that the pulse rate has increased and the blood pressure has dropped significantly. Bloody drainage also is noted on the posterior dressing. Which is the best nursing action?*

*Answer: Notify the registered nurse (RN).* Rationale: In the event of bleeding and suspected shock, the primary health care provider is notified immediately. The nurse would contact the RN, who would then contact the primary health care provider. The child is never placed in Trendelenburg's position because it increases intracranial pressure (ICP) and the risk of bleeding. Rechecking the vital signs in 1 hour will delay necessary treatment. The nurse would document the findings, but the initial action would be to notify the RN to avoid any delays in treating this life-threatening situation.

*Question: When performing a postpartum assessment on a client, the licensed practical nurse (LPN) notes clots in the lochia. The LPN examines the clots and notes that they are larger than 1 cm. Which nursing action is appropriate?*

*Answer: Notify the registered nurse (RN).* Rationale: Normally a few small clots may occur in the first 1 to 2 days after birth from pooling of the blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of such clots, such as uterine atony or retained placental fragments, must be determined and treated to prevent further blood loss. Although the findings should be documented, the most appropriate action is to notify the RN. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be an appropriate action in this situation.

*Question: The nurse assisting in the care of a newborn has a standing prescription to administer the hepatitis B vaccine to the infant. The nurse would plan to perform which action when carrying out this prescription?*

*Answer: Obtain written parental consent.* Rationale: The nurse must obtain informed consent from the parents before administering the hepatitis B vaccine to the newborn. The vastus lateralis muscle is used because the dorsogluteal muscle is underdeveloped in the newborn and is dangerously close to the sciatic nerve. In addition, the dorsogluteal site is no longer an acceptable injection location even for adults. A 25-gauge, ½-inch needle is used. The nurse pinches up the skin to inject the medication.

*Question: The nurse is assisting with planning the care of a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention would the nurse include in the plan of care?*

*Answer: One-to-one suicide precautions* Rationale: One-to-one suicide precautions are required for the client who has attempted suicide. Options 2 and 3 are not appropriate, considering the situation. Option 4 may be an appropriate nursing intervention, but the priority is stated in option 1. The best option is constant supervision so that the nurse may intervene as needed if the client attempts to cause harm to him or herself.

*Question: The nursing instructor asks the nursing student to plan and conduct a clinical conference on phenylketonuria (PKU). The student researches the topic and plans to include which information in the conference?*

*Answer: PKU results in central nervous system (CNS) damage.* Rationale: PKU is an autosomal recessive disorder. Treatment includes dietary restriction of phenylalanine intake (not sodium). PKU is a genetic disorder that results in CNS damage from toxic levels of phenylalanine in the blood. All 50 states require routine screening of all newborn infants for PKU.

*Question: A child is diagnosed with scarlet fever. The nurse collects data regarding the child. Which is characteristic of scarlet fever?*

*Answer: Pastia's sign* Rationale: Pastia's sign is a rash seen among children with scarlet fever that will blanch with pressure, except in areas of deep creases and in the folds of joints. The tongue is initially coated with a white furry covering with red projecting papillae (white strawberry tongue). By the fourth to fifth day, the white strawberry tongue sloughs off and leaves a red, swollen tongue (strawberry tongue). The pharynx is edematous and beefy red in color. Option 2 is associated with poliomyelitis. Options 3 and 4 are characteristics of diphtheria.

*Question: A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse would take which action after seeing the laboratory results?*

*Answer: Place the normal report in the client's medical record.* Rationale: A normal platelet count ranges from 150,000 mm3 to 400,000 mm3 (150-400 × 109/L). The nurse should place the report containing the normal laboratory value in the client's medical record. A platelet count of 300,000 mm3 (300 × 109/L) is not an elevated count. The count also is not low; therefore, bleeding precautions are not needed.

*Question: The nurse is observing a nursing student listening to the breath sounds of a client. The nurse intervenes if the student performs which incorrect procedure?*

*Answer: Places the stethoscope on the client's gown* Rationale: To listen to breath sounds, the stethoscope always is placed directly on the client's skin, and not over a gown or clothing. The nurse asks the client to sit up and breathe slowly and deeply through the mouth. Breath sounds are auscultated using the diaphragm of the stethoscope, which is warmed before use.

*Question: A client with diabetes mellitus visits a healthcare clinic. The client's diabetes mellitus previously had been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180 mg/dL to 200 mg/dL (10.2 mmol/L to 11.4 mmol/L). Which medication, added to the client's regimen, may have contributed to the hyperglycemia?*

*Answer: Prednisone* Rationale: Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements. Option 1, a ß-blocker and option 3, a monoamine oxidase inhibitor, have their own intrinsic hypoglycemic activity. Option 4 decreases urinary excretion of sulfonylurea agents, causing increased levels of the oral agents, which can lead to hypoglycemia.

*Question: The nurse is assisting in developing a plan of care for a 10-year-old child diagnosed with acute glomerulonephritis. Following review of the plan of care, the nurse determines that which intervention is the priority for the child?*

*Answer: Promoting bed rest* Rationale: Bed rest is required during the acute phase, and activity is gradually increased as the condition improves. Providing for quiet play according to the developmental stage of the child is important. Fluids should not be forced or restricted. Visitors should be limited to allow for adequate rest.

*Question: The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action would the nurse take?*

*Answer: Raise the head of the bed and remove the noxious stimulus.* Rationale: Key nursing actions are to sit the client up in bed, remove the noxious stimulus, and bring the blood pressure under control with antihypertensive medication per protocol. The nurse can also clearly label the client's chart identifying the risk for autonomic dysreflexia. Client and family should be taught to recognize, and later manage, the signs and symptoms of this syndrome.

*Question: A client with acute glomerulonephritis is admitted to the nursing unit. The nurse would plan to do which action immediately upon admission?*

*Answer: Remove the water pitcher from the bedside.* Rationale: The client with acute glomerulonephritis commonly experiences fluid volume excess and fatigue. Interventions include fluid restriction and ongoing monitoring of weight, intake, and output. It is unnecessary to monitor the temperature as frequently as every 2 hours. The client is placed on bed rest or at least encouraged to rest because increased activity levels are correlated directly with proteinuria and hematuria. The diet is high in calories but low in protein.

*Question: A client presents to the urgent care center with complaints of abdominal pain. Suddenly the client vomits bright red blood. The nurse would take which immediate action?*

*Answer: Take the client's vital signs.* Rationale: The nurse should take the client's vital signs first to determine if the client is hypovolemic or in shock from blood loss; this also provides a baseline blood pressure and pulse by which to gauge the effectiveness of treatment. Signs and symptoms of shock include low blood pressure; rapid, weak pulse; increased thirst; cold, clammy skin; and restlessness. The registered nurse also is notified. Although an NG tube may be inserted, this is not the immediate action. A complete history would be obtained and an abdominal assessment would be done once the client is stable.

*Question: A client diagnosed with peptic ulcer disease has a new prescription for propantheline. Which client teaching instructions would the nurse most reinforce?*

*Answer: Take the medication 30 minutes before meals.* Rationale: Propantheline is classified as an antimuscarinic, anticholinergic medication that decreases gastrointestinal secretions. It should be administered 30 minutes before meals. Therefore, the other options are incorrect.

*Question: Ibuprofen is prescribed for a client. Which instruction would the nurse give the client about taking this medication?*

*Answer: Take with 8 ounces of milk.* Rationale: Ibuprofen is a nonsteroidal antiinflammatory drug (NSAID). NSAIDs should be given with milk or food to prevent gastrointestinal irritation. Options 2, 3, and 4 are incorrect.

*Question: The nurse is caring for a newborn diagnosed with Down syndrome. The parents are asking questions about the disorder. The nurse would provide which information when discussing Down syndrome?*

*Answer: The condition is congenital and results in moderate to severe retardation and has been linked to an extra chromosome 21 (group G).* Rationale: Down syndrome is a form of mental retardation. It is a congenital condition that results in moderate to severe mental retardation. The syndrome has been linked to an extra group G chromosome, chromosome 21 (trisomy 21). Options 1, 2, and 3 are incorrect descriptions.

*Question: Morphine sulfate, 2.5 mg, is prescribed for a child. The safe pediatric dose is 0.05 mg/kg/dose to 0.1 mg/kg/dose. The child weighs 50 kg. Which statement accurately describes the prescribed dosage for this child?*

*Answer: The dose is within the safe dosage range.* Rationale: Use the formula for calculating a safe dosage range.

*Question: A client has been newly diagnosed with glaucoma. As part of the discharge instructions, the nurse would plan to reinforce which information?*

*Answer: The need for lifelong medication therapy* Rationale: The client with glaucoma experiences increased intraocular pressure. The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client must be instructed that lifelong medication therapy is needed to maintain intraocular pressure within the normal limits of 10 to 20 mm Hg. The other options are not necessary in this condition.

*Question: The nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse would tell the client to select which food item that is high in riboflavin?*

*Answer: Milk* Rationale: Food sources of riboflavin include milk, lean meats, fish, and grains. Tomatoes and citrus fruits are high in vitamin C. Green leafy vegetables are high in folic acid.

*Question: The nurse is providing directions to a client about how to test a stool for occult blood. The nurse cautions that which could cause a false-negative result?*

*Answer: Ascorbic acid* Rationale: Ascorbic acid can interfere with results of occult blood testing, yielding false-negative results. Colchicine and iodine can cause false-positive results. Acetylsalicylic acid would either have no effect or cause a positive result by inducing bleeding from the gastrointestinal tract.

*Question: The nurse is caring for a child who sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). The nurse plans to monitor for an early sign of increased ICP by checking for which sign?*

*Answer: Changes in level of consciousness* Rationale: An altered level of consciousness is an early sign of increased ICP. Late signs of increased ICP include tachycardia leading to bradycardia, apnea, systolic hypertension, widening pulse pressure, and posturing.

*Question: The nurse in a primary health care provider's office has scheduled a client with a possible allergen-causing dermatitis to be seen in 1 week for a patch test. The nurse explains the procedure for the patch test and includes which in the explanation? Select all that apply.*

** Rationale: A patch test is done to identify an allergen-causing dermatitis. The patch test is similar to the scratch test except the allergen is simply placed on the surface of the skin and covered with an airtight dressing (patch). For both of these tests, a negative reaction occurs when there is no erythema, swelling, or complaint of itching. Patch tests are sometimes evaluated at a later time rather than the next day. A scratch test (also called a prick or puncture test) involves dropping extracts of allergens into scratches made on the skin. Intradermal injection of allergens is used to detect allergies to insect venom or penicillin.

*Question: The client is admitted to the hospital with a diagnosis of suspected Hodgkin's disease. Which signs and symptoms of the client are associated with Hodgkin's disease? Select all that apply.*

** Rationale: Hodgkin's disease (lymphoma) is a chronic, progressive neoplastic disorder of the lymphoid tissue that is characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Other signs and symptoms include fatigue, weakness, weight loss, and night sweats. Weight gain and joint pain are not associated with Hodgkin's disease.

*Question: The nurse is caring for a recently admitted client with painful muscle spasms due to a traumatic injury. Besides drug therapy, what are some of the physical measures the nurse expects will be prescribed for this client? Select all that apply.*

** Rationale: Muscle spasm is defined as involuntary contraction of a muscle or muscle group. Some physical measures employed to treat muscle spasms related to a traumatic injury include immobilization of the affected muscle; application of cold, not hot, compresses; whirlpool baths; and physical therapy. Limiting fluids can increase the incidence of muscle spasms. Muscle relaxants are a form of drug therapy.

*Question: The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to consult with the registered nurse if the client is also taking which medications? Select all that apply.*

** Rationale: NSAIDs can amplify the effects of anticoagulants, such as warfarin, therefore these medications should not be taken together. Hypoglycemia may result for the client taking ibuprofen if the client is concurrently taking an oral hypoglycemic agent such as glimepiride; these medications should not be combined. A high risk of toxicity exists if the client is taking ibuprofen concurrently with a calcium-channel blocker such as amlodipine; therefore this combination should be avoided. There is no known interaction between ibuprofen and simvastatin or hydrochlorothiazide.

*Question: The client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking nevirapine. The nurse would monitor for which side/adverse effects of the medication? Select all that apply.*

** Rationale: Nevirapine is a nonnucleoside reverse transcriptase inhibitor that is used to treat HIV infection. It is used in combination with other antiretroviral medications to treat HIV. Adverse effects include rash, Stevens-Johnson syndrome, hepatitis, and increased transaminase levels. Hyperglycemia, peripheral neuropathy, and reduced bone density are not side/adverse effects of this medication.

*Question: A client is receiving digoxin daily. The nurse suspects digoxin toxicity after noting which signs and symptoms? Select all that apply.*

** Rationale: Signs and symptoms of digoxin toxicity include gastrointestinal signs, bradycardia, visual disturbances, and hypokalemia. A therapeutic serum digoxin level ranges from 0.8 to 2.0 ng/mL (1.02 to 2.56 nmol/L). The serum potassium level should be between 3.5 mEq/L (3.5 mmol/L) and 5.0 mEq/L (5.0 mmol/L). The apical pulse must be greater than or equal to 60 beats per minute.

*Question: A CD4+ count has been prescribed for a child with human immunodeficiency virus (HIV) infection. The mother asks the nurse about the purpose of the test and why the test needs to be done if it is already known that the child has HIV. The nurse would reinforce which information to the mother? Select all that apply.*

** Rationale: The CD4+ count is the measurement of a specific subset of T lymphocytes used to monitor clients who are HIV positive. CD4+ counts are used to assess a young child's immune status, risk for disease progression, and need for pneumonia prophylaxis after 1 year of age. These counts are measured at ages 1 and 3 months, every 3 months until the age of 2 years, and at least every 6 months thereafter. More frequent monitoring of CD4+ counts is indicated when pneumonia prophylaxis and antiretroviral therapy are administered. The CD4+ is not used by itself to specifically diagnose the HIV-positive client.

*Question: A client diagnosed with schizophrenia is experiencing an acute dystonic reaction. Which interventions would the licensed practical nurse (LPN) initiate? Select all that apply.*

** Rationale: The LPN would monitor the client's airway, notify the RN, remain with the client to provide support, and administer a prescribed antiparkinsonian medication to relieve the dystonia. An acute dystonic reaction is an often painful, sustained contraction of muscles, usually of the head and neck, which typically occurs from 2 to 5 days after the introduction of antipsychotic medications. Placing a client in seclusion and administering an antipsychotic medication are incorrect.

*Question: The nurse is preparing to administer an enema to an adult client. Which interventions would the nurse plan to perform for this procedure? Select all that apply.*

** Rationale: The administration of an enema is a clean procedure, and standard precautions must be used. The nurse applies disposable gloves when administering an enema to prevent the transfer of microorganisms. To administer an enema, the nurse places the client in the left Sims' position because the enema solution will flow downward by gravity along the natural curve of the sigmoid colon and rectum, improving retention of the enema solution. The tube is lubricated for easy insertion and is inserted approximately 3 to 4 inches in an adult. If the client complains of cramping or discomfort during the procedure, the nurse clamps the tubing until the discomfort subsides. The container containing the enema solution is hung about 12 to 18 inches above the client's anus. A flow of solution that is too forceful can damage the bowel. The temperature of the solution should be between 100°F (37.8°C) and 105°F (40.5°C). Solution that is too hot will burn the client, and solution that is to

*Question: Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results would the nurse report? Select all that apply.*

** Rationale: The normal values include the following: platelets 150,000 mm3 to 400,000 mm3 (150-400 × 109/L); sodium 135 mEq/L to 145 mEq/L (135-145 mmol/L); potassium, 3.5 mEq/L to 5.0 mEq/L (3.5-5.0 mmol/L); segmented neutrophils 60% to 70% (0.60-0.70); serum creatinine, 0.6 mg/dL to 1.3 mg/dL (53-115 mcmol/L); and white blood cells 5000 mm3 to 10,000 mm3 (5.0-10.0 × 109/L). The platelet level noted is low; the sodium level noted is high; the potassium level noted is normal; the segmented neutrophil level noted is low; the serum creatinine level noted is normal; and the white blood cell level is low.

*Question: The nurse is caring for a client who will have insertion of an internal cervical radiation implant. Which interventions would the nurse review with the client to prepare her for this procedure? Select all that apply.*

** Rationale: When a client has an internal cervical radioactive implant, precautions are planned to protect those around the client and to keep the implant in place and not harm the client. The client will be placed on bed rest and will have an indwelling urinary catheter in place, and caregivers will wear lead shields for protection. Clients are not normally administered stool softeners because of the risk of loose stools, which could potentially lead to dislodgement of the implant. Clients are log rolled so as not to move the implant. ROM exercises are not done.

*Question: The nurse is reinforcing discharge teaching to a client who has Cushing's syndrome. Which statement by the client indicates that the instructions related to dietary management were understood?*

*Answer: "I can eat foods that contain potassium."* Rationale: A diet that is low in calories, carbohydrates, and sodium but ample in protein and potassium content is encouraged for a client with Cushing's syndrome. Such a diet promotes weight loss, the reduction of edema and hypertension, the control of hypokalemia, and the rebuilding of wasted tissue.

*Question: The nurse, a Cub Scout leader, is preparing a group of Cub Scouts for an overnight camping trip and instructs them about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further teaching?*

*Answer: "I should not use insect repellent because it will attract the ticks."* Rationale: In the prevention of Lyme disease, individuals need to be instructed to use an insect repellent on the skin and clothes when in an area where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. If possible, one should avoid heavily wooded areas or areas with thick underbrush. Socks can be pulled up and over the pant legs to prevent ticks from entering under clothing.

*Question: The nurse is reinforcing discharge instructions to the mother of a child who needs eye drops in the left eye. Which statement by the mother indicates a need for further teaching?*

*Answer: "I will give the medication directly on the eyeball."* Rationale: Drop the correct number of drops into the conjunctival sac, never directly on the eyeball. When instilling eye drops have the client look upward over your head. Applying gentle pressure to the inner canthus prevents the medication from being absorbed in the vascular mucosa of the nose and producing systemic effects. Therefore, options 2, 3, and 4 are correct.

*Question: The nurse has just supervised a client who has newly diagnosed diabetes mellitus self-inject NPH insulin at 7:30 am. The nurse reviews the time frames for peak insulin action with the client, telling the client to be especially watchful for a hypoglycemic reaction during which time frame?*

*Answer: 1:30 pm and 7:30 pm* Rationale: NPH is an intermediate-acting insulin. It begins to work in 1 to 2 hours (onset), peaks in 6 to 12 hours, and lasts for 18 to 24 hours (duration). Hypoglycemic reactions most likely occur during peak time, which in this case is option 2.

*Question: The nurse is caring for a client with emphysema receiving oxygen. The nurse would consult with the registered nurse if the oxygen flow rate exceeded how many L/min of oxygen?*

*Answer: 2 L/min* Rationale: Between 1 L/min and 3 L/min of oxygen by nasal cannula may be required to raise the PaO2 level to 60 mm Hg to 80 mm Hg. However, oxygen is used cautiously in the client with emphysema and should not exceed 2 L/min unless specifically prescribed. Because of the long-standing hypercapnia that occurs in this disorder, the respiratory drive is triggered by low oxygen levels rather than by increased carbon dioxide levels, which is the case in a normal respiratory system.

*Question: The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would suggest to the registered nurse the need for implementing neutropenic precautions if the client's white blood cell count was which value?*

*Answer: 2000 mm3 (2.0 × 109/L)* Rationale: The normal white blood cell count ranges from 5000 mm3 to 10,000 mm3 (5-10 × 109/L). The client who has a decrease in the number of circulating white blood cells is immunosuppressed. The nurse implements neutropenic precautions when the client's values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. The remaining options are normal values.

*Question: A 4-year-old child is admitted to the hospital with suspected acute lymphocytic leukemia (ALL). The nurse would prepare for which diagnostic study that can confirm this diagnosis?*

*Answer: A bone marrow biopsy* Rationale: The confirmatory test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspirate and biopsy. The WBC count may be high or low in leukemia. A lumbar puncture may be done to look for blast cells in the spinal fluid that are indicative of central nervous system disease. An altered platelet count occurs as a result of chemotherapy.

*Question: The nurse must choose a roommate for a client who is in a state of starvation due to anorexia nervosa. The nurse would avoid choosing which client as a roommate for the client with anorexia nervosa?*

*Answer: A client with pneumonia* Rationale: The client who has been starving has a compromised immune system. Having a roommate with pneumonia would put the client at risk for infection. The other clients are acceptable because their health problems do not compromise the immune system of the client with starvation.

*Question: The nurse is assigned to care for a child with a compound (open) fracture of the arm that occurred as a result of a fall. The nurse plans care knowing that this type of fracture involves which specific characteristic?*

*Answer: A greater risk of infection than a simple fracture* Rationale: In a compound (open) fracture, a wound in the skin leads to the broken bone, and there is an added danger of infection. Option 1 describes a transverse fracture. Option 3 describes a closed or simple fracture. Option 4 describes a greenstick fracture.

*Question: The nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection?*

*Answer: A man who is an inspector for the U.S. Postal Service* Rationale: People at high risk for acquiring tuberculosis include children younger than 5 years of age; homeless individuals or those from a lower socioeconomic group, minority groups, or immigrant group; individuals in constant, frequent contact with an untreated or undiagnosed individual; individuals living in crowded areas such as long-term care facilities, prisons, and mental health facilities; older clients; malnourished individuals, those with an infection, or an immune dysfunction or human immunodeficiency virus infection, or individuals who are immunosuppressed as a result of medication therapy; and individuals who abuse alcohol or are IV drug users.

*Question: The nurse is preparing for the administration of ribavirin to a child with respiratory syncytial virus. Which supplies will the nurse obtain for the administration of this medication?*

*Answer: A pair of goggles* Rationale: Some caregivers experience headaches, burning nasal passages and eyes, and crystallization of soft contact lenses as a result of administration of ribavirin. Specific to this medication is the use of goggles. A mask may be worn. Hand washing is to be performed before and after any child contact. A gown is not necessary. The medication is administered via hood, face mask, or oxygen tent, not by the IM or IV route.

*Question: A client is experiencing an acute exacerbation of bursitis. The nurse encourages the client to avoid which least likely helpful measure until the current episode is resolved?*

*Answer: Active intermittent range of motion* Rationale: The least likely helpful measure for the client with acute exacerbation of bursitis is active intermittent range of motion. Local measures that help relieve bursitis (inflammation of a bursa) include joint rest, elevation, and the application of heat. Exercise is not helpful during the acute stage. In addition, nonsteroidal anti-inflammatory agents, analgesics, and short-term systemic corticosteroids may be prescribed.

*Question: Dantrolene sodium is prescribed for a client experiencing flexor spasms, and the client asks the nurse about the action of the medication. The nurse responds knowing that which is the therapeutic action of this medication?*

*Answer: Acts directly on the skeletal muscle to relieve spasticity* Rationale: Dantrolene acts directly on skeletal muscle to relieve muscle spasticity. The primary action is the suppression of calcium release from the sarcoplasmic reticulum. This in turn decreases the ability of the skeletal muscle to contract. Options 1, 3, and 4 are not actions of the medication.

*Question: The nurse is concerned that a client may experience systemic effects from a beta-blocker ophthalmic solution. The nurse realizes the client is able to self-administer the medication if the client instills the drops in which manner?*

*Answer: Applies digital pressure to the lacrimal sac for 1 to 2 minutes after instillation* Rationale: The nurse needs to teach the client methods of administering beta-blocker eye solutions that will prevent systemic absorption. Applying pressure on the lacrimal sac or nasolacrimal duct prevents systemic absorption of the medication. The other options are incorrect.

*Question: A client with Ménière's disease is experiencing severe vertigo. The nurse reinforces instructions to the client to do which to assist with controlling the vertigo?*

*Answer: Avoid sudden head movements.* Rationale: The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Watching television can increase the vertigo.

*Question: The nurse is caring for a client diagnosed with systemic lupus erythematosus (SLE). The nurse assesses a rash on the client's face. What is the name of the major skin manifestation of discoid lupus erythematosus (DLE) and SLE?*

*Answer: Butterfly rash* Rationale: The two main classifications of lupus are discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE). The major skin manifestation of DLE and SLE is a dry, scaly, raised rash on the face called the butterfly rash. This rash may also appear on other sun-exposed areas. The rash is initially nonscarring and may increase in a lupus flare and disappear when the disease is in remission. A harmless rash, pityriasis rosea usually begins as a single scaly, pink patch with a raised border. Days to weeks later, it starts to itch and spread. The rash may look like Christmas trees spread across your body. Doctors don't know for sure what causes it, but they don't think it's contagious. It often goes away in 6 to 8 weeks without treatment. Pityriasis rosea most often shows up between the ages of 10 and 35. There are no known rashes called spider or lilac bush.

*Question: The client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication?*

*Answer: Calcium level* Rationale: Tamoxifen may increase calcium, cholesterol, and triglyceride levels. Before the initiation of therapy, a complete blood count, platelet count, and serum calcium levels should be assessed. These blood levels, along with cholesterol and triglyceride levels, should be monitored periodically during therapy. The nurse should assess for hypercalcemia while the client is taking this medication. Signs of hypercalcemia include increased urine volume, excessive thirst, nausea, vomiting, constipation, hypotonicity of muscles, and deep bone and flank pain. Tamoxifen does not increase glucose or potassium levels, or increase the prothrombin time.

*Question: The client with a cervical spine injury has Crutchfield tongs applied in the emergency department. The nurse would perform which essential action when caring for this client?*

*Answer: Comparing the amount of prescribed weights with the amount in use* Rationale: Crutchfield tongs are applied after drilling holes in the client's skull under local anesthesia. Weights are attached to the tongs, which exert pulling pressure on the longitudinal axis of the cervical spine. The nurse ensures that weights hang freely and that the amount of weight matches the current prescription. The client with Crutchfield tongs is placed on a Stryker frame or Roto-Rest bed. The nurse does not remove the weights to administer care or change the level of tension or traction based on client comfort level.

*Question: A client who recently began medication therapy with levodopa for Parkinson's disease complains of nausea. The nurse reminds the client to do which action to manage this problem?*

*Answer: Eat a snack before taking the medication.* Rationale: Levodopa is a dopaminergic medication used to treat Parkinson's disease. The nurse should remind the client that a snack should be eaten before taking the medication to prevent the nausea. The interventions in options 1, 3, and 4 will not manage the client's problem.

*Question: The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which activity?*

*Answer: Exhaling during repositioning* Rationale: Activities that increase intrathoracic and intraabdominal pressures cause indirect elevation of the ICP. Some of these activities include isometric exercises, Valsalva maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.

*Question: The client is diagnosed with stage I of Lyme disease. The nurse would check the client for which characteristic of this stage?*

*Answer: Flu-like symptoms* Rationale: The hallmark of stage I is the development of a skin rash within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a bull's-eye appearance. The lesion enlarges up to 50 cm to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons develop flu-like symptoms that last 7 to 10 days; these symptoms may reoccur later. Arthralgia and joint enlargements are most likely to occur in stage III. Neurological deficits occur in stage II.

*Question: The nurse is caring for a client after a Billroth II (gastrojejunostomy) procedure. During review of the postoperative prescriptions, which would the nurse clarify?*

*Answer: Irrigating the nasogastric (NG) tube* Rationale: In a Billroth II resection, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the NG tube is critical for preventing the retention of gastric secretions. The nurse, however, should never irrigate or reposition the NG tube after gastric surgery unless specifically prescribed by the surgeon. In this situation, the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative interventions.

*Question: A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased. The nurse explains that this can be harmful because it could cause which difficulty?*

*Answer: It could decrease the client's oxygen-based respiratory drive.* Rationale: Normally, respiratory rate varies with the amount of carbon dioxide present in the blood. In clients with COPD this natural center becomes ineffective after exposure to high carbon dioxide levels for prolonged periods. Instead, the level of oxygen provides the respiratory stimulus. The client with COPD usually cannot increase oxygen levels independently because it could deplete the respiratory drive and lead to respiratory failure. Physician prescriptions are always followed.

*Question: The nurse is assigned to care for a client diagnosed with systemic lupus erythematosus (SLE). The nurse would plan care considering which factor regarding this diagnosis?*

*Answer: It is an inflammatory disease of collagen contained in connective tissue.* Rationale: SLE is an inflammatory disease of collagen contained in connective tissue. Options 1, 2, and 3 are not associated with this disease.

*Question: The nurse is caring for a client prescribed an oral hypoglycemic agent who has just been diagnosed with a urinary tract infection. The primary health care provider plans to treat the infection with sulfamethoxazole. The nurse would expect that because of medication interactions, the primary health care provider will adjust which prescription?*

*Answer: Lower dose of the oral hypoglycemic* Rationale: Sulfonamide antibiotics such as sulfamethoxazole can intensify the effects of warfarin, phenytoin, and oral hypoglycemics. Many oral hypoglycemic agents are classified as sulfonylureas. When combined with sulfonamides, these medications may require a reduction in dosage. Therefore, a higher dose of the oral hypoglycemic, a lower dose of the sulfamethoxazole, and a higher dose of the sulfamethoxazole are incorrect.

*Question: The primary health care provider has prescribed a bacteriostatic agent effective against both gram-positive and gram-negative organisms for application to a burn wound. The nurse determines that which medication has been prescribed?*

*Answer: Mafenide acetate* Rationale: Mafenide acetate is a bacteriostatic agent effective against both gram-positive and gram-negative organisms. Silver nitrate has antimicrobial action. Silver sulfadiazine interferes with DNA synthesis by binding to bacterial cell membrane. Polymyxin B-bacitracin has wide-spectrum antibiotic action.

*Question: The nurse is providing instructions to a client who will be self-administering eye drops. To minimize the systemic effects that eye drops can produce, the client is instructed to perform which action?*

*Answer: Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling the drops.* Rationale: Applying pressure on the nasolacrimal duct prevents systemic absorption of the medication. Options 1, 2, and 3 will not prevent systemic absorption.

*Question: The day nurses in a psychiatric unit are receiving report from the night shift. During report, a client approaches the nurses' station, becomes very loud and angry, and demands to be seen by the primary health care provider immediately. Which nursing intervention is appropriate?*

*Answer: Offer to assist the client to an examination room until the primary health care provider is notified.* Rationale: Safety of the client, other clients, and staff is of prime concern when dealing with a client who may be angry and demanding. Offering to assist the client to an examination room until the primary health care provider is notified is in effect an isolation technique that allows for separation from others and provides a less stimulating environment where the client can maintain dignity. The other nursing interventions place the client on hold and will only cause the behavior to escalate.

*Question: A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel, and a hyphema has been diagnosed. Which position would the nurse prepare to position the client?*

*Answer: On bed rest in a semi-Fowler's position* Rationale: A hyphema is the presence of blood in the anterior chamber. It is produced when a force is sufficient to break the integrity of the blood vessels in the eye. It can be caused by direct injury, such as a penetrating injury from a BB pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea.

*Question: The client has a prescription for sucralfate 1 g by mouth 4 times daily. The nurse would best schedule the administration of the medication at which time?*

*Answer: One hour before meals and at bedtime* Rationale: Sucralfate is a medication that should be scheduled for administration 1 hour before meals and at bedtime. The medication is scheduled so that it has time to form a protective coating over the ulcer before food intake stimulates chemical and mechanical irritation. Therefore, the other options are incorrect.

*Question: The nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further teaching if the nurse observes the client doing which activity?*

*Answer: Performing active range of motion (ROM) to the right ankle and knee* Rationale: Exercise is indicated within therapeutic limits for the client in skeletal traction to maintain muscle strength and ROM. The client may pull up on the trapeze, perform active ROM with uninvolved joints, and do isometric muscle-setting exercises (e.g., quadriceps- and gluteal-setting exercises). The client may also flex and extend his or her feet. Performing active ROM to the affected leg can be harmful.

*Question: A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which problem?*

*Answer: Peripheral neuritis* Rationale: A common adverse effect of isoniazid is peripheral neuritis. This is manifested by numbness, tingling, and paresthesias in the extremities. This adverse effect can be minimized by pyridoxine intake. Options 1, 3, and 4 are incorrect.

*Question: A client who has been taking isoniazid for 1½ months complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which adverse effect?*

*Answer: Peripheral neuritis* Rationale: An adverse effect of isoniazid is peripheral neuritis. This is manifested by numbness, tingling, and paresthesia in the extremities. This adverse effect can be minimized with pyridoxine (vitamin B6) intake.

*Question: A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse would plan for which intervention?*

*Answer: Petaling the cast edges with adhesive tape* Rationale: The edges of the cast can be petaled with tape to minimize skin irritation. If a client has a cast applied and returns home, the client can be taught to do the same. Massaging and applying lotion will not alleviate the skin irritation from the cast edges. Filing the edges will cause cast material to fall into the cast and could lead to skin irritation under the cast.

*Question: The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states to report which occurrence immediately?*

*Answer: Problems with visual acuity* Rationale: Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when a client is driving a motor vehicle. The client is taught to report this symptom immediately. The client is also taught to take the medication with food if GI upset occurs. Impaired hearing results from antitubercular therapy with streptomycin. Red-orange discoloration of secretions occurs with rifampin.

*Question: A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. Which is a life-threatening complication that could be occurring?*

*Answer: Pulmonary embolism* Rationale: Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom which is sudden in onset and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension.

*Question: The client with a diagnosis of urinary tract infection is beginning medication therapy with nitrofurantoin. The nurse should realize the need for further teaching if the client states it is acceptable to eat which food?*

*Answer: Rhubarb* Rationale: When a client is taking nitrofurantoin, the urine pH must be maintained in an acid range. The client should consume an acid-ash diet. Rhubarb will reduce the acidity of the urine and should be avoided by the client taking this medication.

*Question: Isosorbide mononitrate is prescribed for a client with angina pectoris. The client tells the nurse that the medication is causing a chronic headache. Which action would the nurse suggest to the client?*

*Answer: Take the medication with food.* Rationale: Isosorbide mononitrate is an antianginal medication. Headache is a frequent side effect of isosorbide mononitrate and usually disappears during continued therapy. If a headache occurs during therapy, the client should be instructed to take the medication with food or meals. It is not necessary to contact the PHCP unless the headaches persist with therapy. It is not appropriate to instruct the client to discontinue therapy or adjust the dosages.

*Question: The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless, and his color is becoming dusky. Based on this data, which interpretation would the nurse make?*

*Answer: The burn has probably caused laryngeal edema, which has occluded the airway.* Rationale: The client exhibits several warning signs of an inhalation injury: a history of a flame burn to the face, hoarseness, cough, carbonaceous sputum, singed facial hair, facial edema, and color change. Additionally, one of the cardinal signs of hypoxia is restlessness.

*Question: A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse would make which interpretation about the client's behavior?*

*Answer: The client is at increased risk for suicide.* Rationale: The behaviors identified in the question may be manifested by the client who is contemplating suicide. In clients who are depressed, anger may be self-directed in the form of suicide. Many of these symptoms are those of the depressed client; however, with this client, these behaviors have increased. Hospitalization may actually lessen these symptoms in the depressed client because a feeling of hope or relief may occur once treatment begins. Dealing with pertinent issues may be traumatic, but this is not the best interpretation of the behavior. Time off the unit for this client could put the client at risk for injury.

*Question: A client being discharged from the hospital to home with a diagnosis of tuberculosis is worried about the possibility of infecting family members and others. Which information would reassure the client that contaminating family members and others is not likely?*

*Answer: The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.* Rationale: Family members or others who have been in close contact with a client diagnosed with tuberculosis are placed on prophylactic therapy with isoniazid for 6 to 12 months. The client is usually not contagious after taking medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or drug-resistant tuberculosis.

*Question: The nurse is assisting a primary health care provider (PHCP) during an examination of an infant with hip dysplasia. The PHCP performs the Ortolani maneuver. Which data would the nurse expect to note during the examination?*

*Answer: The dislocated femoral head pops back into the acetabulum* Rationale: With the Ortolani maneuver, the examiner reduces the dislocated femoral head back into the acetabulum. A positive Ortolani maneuver is a palpable clunk as the femoral head moves over the acetabular ring. Options 1 and 2 are data collection techniques for the identification of the clinical manifestations of hip dysplasia, but they do not describe the Ortolani maneuver. When performing the Barlow maneuver, the examiner pushes the unstable femoral head out of the acetabulum.

*Question: The nurse would use which best method to open the airway of a victim who has a suspected neck injury?*

*Answer: Jaw thrust maneuver* Rationale: Whenever a neck injury is suspected, it is best to use the jaw thrust maneuver during basic life support (BLS) to open the airway. If this is not possible then the head tilt-chin lift is acceptable. The neutral or sniffing position is used to open the airway in an infant. There is no such position as head tilt-jaw thrust.

*Question: A client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client and determines which symptoms correlate with this client's fluid imbalance? Select all that apply.*

** Rationale: A client with dehydration has a fluid volume deficit, which can be reflected by flat neck veins, a slightly tachycardic pulse rate (104 beats per minute), and weakly palpable peripheral pulses. Other findings are increased respirations, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. The lung crackles are consistent with consolidation in the lungs occurring with pneumonia and the borderline elevated BP may relate to pain associated with breathing.

*Question: A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The licensed practical nurse (LPN) inspects the site and determines that the client has developed phlebitis. The LPN would plan to avoid which action in the care of this client?*

*Answer: Prepare to start a new line in a proximal portion of the same vein.* Rationale: As directed, the LPN should discontinue the IV at the phlebitic site and apply warm, moist compresses to the area to speed resolution of the inflammation. Because phlebitis has occurred, the LPN also notifies the RN, who will contact the primary health care provider about the IV complication. The LPN should prepare for restarting the IV in a vein other than the one that has developed phlebitis.

*Question: A client with diabetes mellitus has a blood glucose level of 596 mg/dL on admission. The nurse anticipates that this client is at risk for which type of acid-base imbalance?*

*Answer: Metabolic acidosis* Rationale: Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises while the cells of the body use all available glucose and then break down glycogen and fat for fuel, which leads to the formation of ketones. The by-products of fat metabolism are acidotic, leading to the complication called diabetic ketoacidosis.

*Question: The nurse is collecting data on a 12-month-old child with iron deficiency anemia. Which finding would the nurse expect to note in this child?*

*Answer: Tachycardia* Rationale: Signs and symptoms of iron deficiency anemia will vary with the degree of anemia but usually include extreme pallor with porcelain-like skin, tachycardia, lethargy, and irritability.

*Question: A primary health care provider has written a prescription for ranitidine 300 mg once daily on the client's discharge medication list. The nurse determines to instruct the client to take the medication at which time?*

*Answer: At bedtime* Rationale: A single daily dose of ranitidine should be taken at bedtime. This allows for prolonged effect and the greatest protection of gastric mucosa. Therefore, the other options are incorrect.

*Question: The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times?*

*Answer: At least 30 minutes before exposure to the sun* Rationale: Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating.

*Question: The nurse is assigned to care for a client with a diagnosis of detached retina. Which findings would indicate that bleeding has occurred as a result of retinal detachment? Select all that apply.*

** Rationale: Complaints of a sudden burst of black spots or floaters indicate that bleeding has occurred as a result of the detachment. Vision may also be cloudy. Options 1, 3, 4 and 6 are not specifically associated with bleeding as a result of detached retina.

*Question: The nurse would implement which actions in the care of a child who is having a seizure? Select all that apply.*

** Rationale: During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side will prevent aspiration because saliva will drain out of the corner of the child's mouth. The child is not restrained because this could cause injury to the child. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure.

*Question: The home care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client, prescribed repaglinide and metformin, asks the nurse to explain these medications. The nurse would reinforce which instructions to the client? Select all that apply.*

** Rationale: Repaglinide is a rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion that should be taken before meals and that should be withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide, and the client should always be prepared by carrying a simple sugar with her or him at all times. Metformin is an oral hypoglycemic given in combination with repaglinide and works by decreasing hepatic glucose production. A common side effect of metformin is diarrhea. Muscle pain may occur as an adverse effect from metformin, but it also might signify a more serious condition that warrants PHCP notification, not the use of acetaminophen.

*Question: The nurse is assisting in preparing a plan of care for a child who is being admitted to the pediatric unit with a diagnosis of seizures. Which components would be included in the plan of care? Select all that apply.*

** Rationale: Restraints are not to be applied to a child with a seizure because they could cause injury to the child. The side rails of the bed are padded with blankets, and the bed is maintained in a low position to provide safety if the child has a seizure. The child's head and the rest of the body are protected from injury if a seizure occurs. Positioning the child on his or her side will prevent aspiration as the saliva drains out of the child's mouth during the seizure. Neither a padded tongue blade nor any other object is placed in the child's mouth once a seizure has started.

*Question: The client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. Besides treatment of the lung cancer, the nurse anticipates that which interventions may be prescribed to treat the SIADH? Select all that apply.*

** Rationale: Syndrome of inappropriate ADH (SIADH) is a condition in which excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. SIADH is a potential complication associated with cancer, especially small cell lung cancer. SIADH is managed by treating the condition and its cause. The SIADH induces low sodium blood levels and results in altered neurological states, including confusion and unresponsiveness. Treatment of SIADH includes fluid restriction, increased sodium intake, and a medication with a mechanism of action that is antagonistic to ADH, such as demeclocycline. Sodium blood levels and neurological status are monitored closely and safety interventions must be instituted. The client should not be treated with an increase in fluid intake or a decrease in the sodium intake.

*Question: A client has just had an application of a nonplaster cast. What are some of the synthetic materials used for nonplaster casts? Select all that apply.*

** Rationale: Synthetic materials for casts are much more common and include fiberglass and polyester-cotton knit. These materials are lighter than plaster and require minimal drying time. Some primary health care providers may use synthetic casts for upper extremities and plaster-of-Paris casts for lower extremities because plaster casts can bear more weight for a longer time. However, newer synthetic materials are stronger than earlier ones. Synthetic casts can be bivalved as needed. Rayon is the oldest manufactured fiber produced and is used in a variety of textile applications including shirts and skirts. Nylon is also a synthetic fiber that was produced to replace silk. Neoprene is a synthetic rubber used frequently for weather resistance, padding, gasket seals, and insulation purposes as well as a fabric for a scuba diving suit. Rayon, nylon and neoprene are not materials used for nonplaster casts.

*Question: The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed? Select all that apply.*

** Rationale: The client with acute pancreatitis is normally placed on a nothing-by-mouth (NPO) status to rest the pancreas and suppress GI secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medication will be prescribed. Some clients experience lessened pain by assuming positions that flex the trunk and draw the knees up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may also help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded, abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress GI secretions.

*Question: A client who was recently paroled as a sex offender is in therapy for pedophilia. The client says, "I've served my sentence and I'm still in therapy, so why does this group have posters of me all over the neighborhood? It has my picture on it and tells all about me." Which would be a therapeutic response by the nurse?*

*Answer: "Are you saying that you understand people are afraid for their children but that you feel you are being unfairly treated?"* Rationale: The therapeutic response by the nurse is, "Are you saying that you understand people are afraid for their children but that you feel you are being unfairly treated?" Focusing and verbalizing the implied are therapeutic communication techniques because they assist the client in clarifying his or her thinking and relooking at what he or she is really saying. The correct response is the only one that reflects the use of this therapeutic communication technique. The remaining responses do not focus on the client's statement and are blocks to communication.

*Question: The client with Cushing's syndrome had bilateral adrenalectomies and is now on corticosteroid therapy. The client also has a history of seizures. The nurse giving discharge instructions concerning corticosteroid therapy realizes there is a need for further teaching when the client makes which statement?*

*Answer: "I know my doctor can now decrease my dosage of phenytoin."* Rationale: Corticosteroid therapy should never be stopped abruptly but tapered off. It should be taken in the morning with food. A Medic Alert bracelet needs to be worn because of the many medication interactions. This therapy will decrease the effect of phenytoin, so the dosage will likely be increased.

*Question: The nurse is reviewing instructions to a parent of a 6-year-old on how to prevent influenza. Which statement by the parent indicates a need for further teaching?*

*Answer: "I will not let my child play with other children who have the flu unless they are taking acetaminophen."* Rationale: Children who have influenza should be kept home and away from other children until they are fever-free without the use of antipyretics. Influenza may be prevented with the annual vaccine, by avoiding other children who are sick, and with frequent hand washing.

*Question: The nurse reinforces discharge instructions to a postoperative client who is taking warfarin sodium. Which statement made by the client reflects the need for further teaching?*

*Answer: "I will take enteric-coated aspirin for my headaches because it is coated."* Rationale: Aspirin-containing products should be avoided while taking this medication. Alcohol consumption should be avoided by a client taking warfarin sodium. Taking prescribed medication at the same time each day increases client compliance. The Medic-Alert bracelet provides health care personnel with emergency information.

*Question: The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response by the student indicates an understanding of this physiological process?*

*Answer: "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high."* Rationale: Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high, thus inhibiting the release of follicle-stimulating hormone and luteinizing hormone, which are necessary for ovulation. Options 2, 3, and 4 are incorrect.

*Question: The mother of a 2-year-old child asks the nurse if it is all right to give the child a bottle at naptime. Which response by the nurse is appropriate?*

*Answer: "You may give the child a bottle if necessary, but if you do, it should contain water."* Rationale: A child should never be allowed to fall asleep with a bottle because of the risk of bottle-mouth caries. If the bottle is allowed in bed, it should contain only water. The other options are inappropriate responses to the mother.

*Question: The nurse is caring for a client diagnosed with esophageal varices who is going to have a Sengstaken-Blakemore tube inserted. The nurse brings which priority item to the bedside so that it is available at all times?*

*Answer: A pair of scissors* Rationale: When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the client's bedside at all times. The client must be observed for sudden respiratory distress that occurs if the gastric balloon ruptures moving the entire tube upward. If this occurs, all balloon lumens are cut and the tube is removed. An obturator and a Kelly clamp would be kept at the bedside of a client with a tracheostomy. An irrigation set may be kept at the bedside, but it is not the priority item.

*Question: A client arrives at the emergency department and has experienced frostbite to the right hand. What would the nurse expect to find when inspecting the client's hand?*

*Answer: A white color of the skin that is insensitive to touch* Rationale: The findings related to frostbite include a white or blue skin color and skin that is hard, cold, and insensitive to touch. As thawing occurs, so does flushing of the skin, the development of blisters or blebs, or tissue edema. Gangrene can develop in 9 to 15 days.

*Question: The nurse is assisting with preparing a teaching plan for the client with diabetes mellitus regarding proper foot care. Which instruction would be included in the plan of care?*

*Answer: Apply a moisturizing lotion to dry feet, but not between the toes.* Rationale: The client should use a moisturizing lotion on his or her feet but should avoid applying the lotion between the toes. The client should also be instructed not to soak the feet and to avoid hot water to prevent burns. The client may cut the toenails straight across and even with the toe itself but he or she should consult a podiatrist if the toenails are thick or hard to cut or if his or her vision is poor. The client should be instructed to wash the feet daily with a mild soap.

*Question: A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse would take which immediate action?*

*Answer: Apply ice to the affected eye.* Rationale: Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client should receive a thorough eye examination to rule out the presence of other eye injuries. Eye irrigation is not indicated in a contusion. Options 3 and 4 will delay immediate treatment. After the application of ice, the PHCP would be notified.

*Question: The nurse is preparing a poster for a health fair about prevention and early detection of skin cancer. The nurse would include on the poster instructions to avoid which activities?*

*Answer: Being in the sun for prolonged periods during the daytime hours to ensure absorption of vitamin D* Rationale: The client should be instructed to avoid sun exposure during the daytime hours when the sun is strongest. Sunscreen, a hat, opaque clothing, and sunglasses should be worn when spending time outdoors. The client should examine the body monthly for the appearance of any possible cancerous or precancerous lesions.

*Question: A client is admitted to the surgical nursing unit following transurethral resection of the prostate (TURP) for benign prostatic hypertrophy. The client has a bladder irrigation infusing, and output is light cherry colored. The blood pressure is 134/82 mm Hg, the pulse is 84 beats per minute, and the client is afebrile with a respiratory rate of 18 breaths per minute. The licensed practical nurse (LPN) assisting in caring for the client collects assessment data 1 hour after admission t

*Answer: Blood pressure of 102/50 mm Hg, pulse 110 beats per minute* Rationale: Frank bleeding, which is either arterial or venous, may occur during the first day after surgery. A rapid pulse with a low blood pressure is a potential sign of blood loss. The LPN would notify the RN who would then contact the primary health care provider. Bladder spasms are expected to occur following surgery and are treated with medication. Some hematuria is usual for several days after surgery and is managed initially by increasing the flow rate of the bladder irrigation. A urinary output of 200 mL greater than intake is adequate.

*Question: A client has been started on long-term therapy with rifampin. Which information about this medication would the nurse provide to the client?*

*Answer: Causes red-orange discoloration of sweat, tears, urine, and feces* Rationale: Rifampin should be taken exactly as directed. Doses should not be doubled or skipped. The client should not stop therapy until directed to do so by a primary health care provider (PHCP). The medication should be administered on an empty stomach unless it causes GI upset, and then it may be taken with food. Antacids, if prescribed, should be taken at least 1 hour before the medication. Rifampin causes red-orange discoloration of body secretions and will permanently stain soft contact lenses.

*Question: A female client has a prescription for a clean-catch urine culture. After providing a sterile specimen cup to the client, the nurse would give which instruction so that the specimen is collected properly?*

*Answer: Cleanse the labia using cleansing towels, begin to void into the toilet, and then collect the specimen.* Rationale: The client should cleanse the labia, begin to void, and then "catch" the sample midstream. Proper cleansing and voiding techniques are necessary so that the specimen does not become contaminated from external sources. The use of toilet paper (option 3) contaminates the specimen because of improper cleansing. The method described in option 2 is not midstream.

*Question: The nurse is caring for the client with a head injury secondary to a motor vehicle crash. The nurse observes the client's status regularly, monitoring closely for which change in vital signs that could indicate increased intracranial pressure?*

*Answer: Decreasing pulse, decreasing respirations, increasing BP* Rationale: A change in vital signs may be a late indication of increased intracranial pressure (ICP). Trends include increasing BP and decreasing pulse and respiratory rate. Irregularities of respiratory rhythm may also arise.

*Question: A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to assist the registered nurse with which action?*

*Answer: Drawing a sample for prothrombin time (PT) and international normalized ratio (INR)* Rationale: The action that the nurse should take is to draw a sample for PT and INR level to determine the client's anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client (e.g., if an antidote such as vitamin K or a blood transfusion is needed). The aPTT monitors the effects of heparin therapy.

*Question: A client with eczema has a prescription for a topical corticosteroid. The nurse cautions the client to use the product carefully in which area where the risk of systemic absorption is greater?*

*Answer: Face* Rationale: It is possible for topical corticosteroids to be absorbed into the systemic circulation. This occurs more frequently in areas where the skin is especially permeable (scalp, axillae, face, eyelids, neck, perineum, genitalia) and less in areas where penetration is poorer (back, palms, soles).

*Question: A client is diagnosed with stage I Lyme disease. In addition to the rash, the nurse would check the client for which manifestation?*

*Answer: Flulike symptoms* Rationale: The hallmark of stage I is the development of a skin rash at the tick bite site. The rash develops into a concentric ring that has a bull's-eye appearance. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons develop flulike symptoms that last 7 to 10 days, and these symptoms may recur later. The other options listed occur in stage II (neurological deficits) or stage III (arthralgias and enlarged, inflamed joints).

*Question: A child with a right-to-left cardiac shunt is receiving propranolol. The health care provider visits the child and writes prescriptions in the child's record. The licensed practical nurse (LPN) reviews the prescriptions and notes that the child is placed on a nothing-by-mouth (NPO) status. The LPN consults with the registered nurse and prepares to monitor which parameter closely?*

*Answer: Glucose level* Rationale: Propranolol, a beta blocker, is used in the palliative treatment of hypercyanotic episodes. It can cause hypoglycemia if administered in a child who is NPO or hypovolemic. The nurse should monitor glucose levels every 4 to 6 hours if the child is NPO or hypovolemic and receiving propranolol. The health care provider should be notified if the glucose level is less than 60 mg/dL. The laboratory tests noted in options 1, 3, and 4 are not related to the administration of this medication.

*Question: The nurse has provided diabetic teaching with the family of a client newly diagnosed with diabetes. The nurse determines that the family understands the reason for having glucagon on hand for emergency home use if the family indicates that the purpose of the medication is to treat which condition?*

*Answer: Hypoglycemia from insulin overdose* Rationale: Glucagon is used to treat hypoglycemia resulting from insulin overdose. The family of the client is instructed in how to administer the medication. In an unconscious client, consciousness usually returns within 20 minutes of glucagon injection. Once the client has regained consciousness, oral carbohydrates should be given. The other options are incorrect.

*Question: To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove a brain tumor, the nurse would include which in the plan of care?*

*Answer: Initiating seizure precautions* Rationale: Safety of the child is the nursing priority. Seizure precautions should be implemented for any child with a brain tumor, both preoperatively and postoperatively. A thorough neurological assessment should be performed on the child, and the child's safety should be assessed before allowing the child to get out of bed without help. Assessment of the child's gait should be done daily. However, options 2 and 3 are not required unless functional deficits exist. Isolating the child, option 4, is not necessary.

*Question: The nurse is reinforcing instructions to the client on how to maintain optimal skin integrity during external radiation therapy. The nurse determines that there is a need for further teaching if the client states plans to do which action?*

*Answer: Keep at least 6 feet away from pregnant women, especially in the first 3 months.* Rationale: External radiation treatments cause changes to the skin that increase the risk for injury. The source of radiation is external, and the client is not radioactive. Clients do not need to distance themselves from pregnant women. The client should be encouraged to eat a high-protein diet to have necessary nutrients available for tissue growth and replacement. Other common instructions are to avoid sunlight and to wash the skin with mild soap using the hand and pat dry.

*Question: The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?*

*Answer: Metabolic alkalosis* Rationale: The loss of gastric fluid via nasogastric suction or vomiting causes a metabolic condition. This also results in an alkalotic condition as a result of the loss of hydrochloric acid through gastrointestinal fluid losses. Also, the options denoting a respiratory problem—respiratory acidosis and alkalosis—can be easily eliminated.

*Question: Betaxolol hydrochloride eye drops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication?*

*Answer: Monitoring blood pressure* Rationale: Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are systemic effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. Options 1, 3, and 4 are not specifically associated with this medication.

*Question: The nurse has assisted in developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan and selects which nursing intervention as the highest priority?*

*Answer: Monitoring fetal status* Rationale: The priority in the plan of care includes the intervention that addresses the physiological integrity of the fetus. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, the fetal status is the priority.

*Question: A client has been diagnosed with glaucoma. The nurse who is teaching the client principles of self-care would encourage the client to limit or refrain from which usual activity on a repeated basis?*

*Answer: Picking objects up off the floor* Rationale: The client with glaucoma experiences increased intraocular pressure. The client should avoid activities that cause straining or repeated bending below the waist, which could increase intraocular pressure. Activities that are done at waist level or higher are not contraindicated because they would not adversely affect intraocular pressure.

*Question: The nurse is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test?*

*Answer: Positive culture results* Rationale: With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of tissue. In a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.

*Question: The nurse is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which to enable the client to best tolerate the ambulation?*

*Answer: Premedicate the client with an analgesic before ambulating.* Rationale: The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery because analgesia will promote rest, decrease myocardial oxygen consumption caused by pain, and allow better participation in activities such as coughing, deep breathing, and ambulation.

*Question: The client has begun medication therapy with pancrelipase. The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed?*

*Answer: Reduction of steatorrhea* Rationale: Pancrelipase is a pancreatic enzyme used in clients with pancreatitis as a digestive aid. The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could be improved nutritional status. It is not used to treat abdominal pain or heartburn. Its use could result in weight gain but should not result in weight loss if it is aiding in digestion.

*Question: A child with a tracheal obstruction is brought to the emergency department by emergency medical services. The child aspirated a grape, and the foreign body was removed by direct laryngoscopy. Following the procedure, which information does the nurse plan to give to the parents of the child?*

*Answer: The child will need to be hospitalized for observation.* Rationale: Removal of foreign bodies from the respiratory tract may need to be performed by direct laryngoscopy or bronchoscopy. After the procedure, the child should remain hospitalized for observation for laryngeal edema and respiratory distress. Cool mist is provided, and antibiotic therapy is prescribed if appropriate. Options 2, 3, and 4 are incorrect.

*Question: Which would be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn?*

*Answer: The return of distal pulses* Rationale: Escharotomies are performed to alleviate the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential burn. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. The formation of granulation tissue is not the intent of an escharotomy, and escharotomy will not affect the formation of edema.

*Question: A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which action?*

*Answer: Use a night light and turn off the television.* Rationale: It is important to provide a consistent daily routine and a low-stimulation environment when the client is agitated and confused. Noise levels including a radio and television may add to the confusion and disorientation. Moving the client next to the nurses' station is not the initial intervention.

*Question: A client has reported that crying spells have been a major problem over the past several weeks and that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection would focus on which assessment?*

*Answer: Weight loss* Rationale: All the options are possible issues to address; however, the weight loss is the first item that needs further data collection because ill-fitting clothing could indicate a problem with nutrition. The client has already told the nurse that the crying spells have been a problem. Medication or sleep patterns are not mentioned or addressed in the question.

*Question: The nurse is reading the laboratory results for a client being treated with carbamazepine for prophylaxis of complex-partial seizures. The nurse interprets that which value is consistent with an adverse effect to this medication?*

*Answer: White blood cell count 3200 mm3* Rationale: Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, and leukopenia. Other adverse effects include cardiovascular disturbances, thrombophlebitis, dysrhythmias, and dermatological effects. A low white blood cell count would indicate an adverse effect. The values noted in options 1, 2, and 3 are normal values.

*Question: The nurse is planning to reinforce dietary teaching about following a diet that is low in potassium to a client receiving a potassium-retaining (sparing) diuretic. The nurse would be sure to include which strategies to avoid foods high in potassium in the diet? Select all that apply.*

** Rationale: Potassium is in most foods. Eggs are a protein source that is not as high in potassium as meats, especially organ and preserved meats such as lunch meats and bolognas. Most common salad ingredients such as lettuce, cabbage, carrots, celery, and onions are not rich in potassium. Spinach, however, is a good source of potassium. The client should avoid dried fruits, which are high in potassium. The client may eat bread and cereals that are not rich in potassium.

*Question: A client is recovering from abdominal surgery and has a large abdominal wound. The nurse encourages the client to eat foods from which nutrient categories to promote wound healing? Select all that apply.*

** Rationale: Protein is needed to build new tissues and vitamin C is active in the body in many enzyme processes and with collagen synthesis. A client with a large abdominal wound will require adequate protein and vitamin C intake to heal. Protein is found in meats, poultry, fish, milk, and beans and lentils. Citrus fruits and juices are especially high in vitamin C. Other sources are potatoes, tomatoes, and other fruits and vegetables. Calcium and vitamin K are necessary nutrients but are not specific to wound healing. Unsaturated fats are those fats thought not to contribute to atherosclerosis.

*Question: A client is to receive 1000 mL of 5% dextrose in water (D5W) at a rate of 100 mL/hr. The drop (gtt) factor is 10 drops (gtt) per mL. The nurse adjusts the flow rate to deliver how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.*

** Rationale: Rationale not found

*Question: A client with a history of seizure disorder is having a routine serum phenytoin level drawn. The nurse who receives a telephone report of the results notes that the client's blood level of the medication is within the normal range if which value is reported?*

*Answer: 15 mcg/mL* Rationale: The therapeutic range for serum phenytoin level is 10 to 20 mcg/mL. If the level is below the therapeutic range, the client could experience seizure activity. If the level is too high, the client is at risk for phenytoin toxicity.

*Question: A client has been treated for dehydration and pneumonia. The nurse evaluates that the client has been successfully treated if the blood urea nitrogen (BUN) level is which value?*

*Answer: 19 mg/dL* Rationale: Recalling that the normal BUN is 10 to 20 mg/dL will direct you to the correct option. Thus, option 2 is correct. Values such as those in options 3 and 4 are high and reflect continued dehydration. Option 1 reflects a lower than normal value, which can occur with fluid overload.

*Question: A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions would be implemented? Select all that apply.*

** Rationale: Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Airborne precautions and contact precautions are required; a mask and gloves are worn by those who come in contact with the child. Gowns and gloves are not indicated. Articles that are contaminated should be bagged and labeled. Options 1, 4, and 5 are not indicated for rubeola.

*Question: The nurse assists in creating a nursing care plan for the child with an arm cast and would include which interventions in the plan? Select all that apply.*

** Rationale: The cast should have not rough edges, but cutting the cast is not appropriate; the edges can be covered with waterproof adhesive tape to ensure a smooth cast edge. Instruct the parents and the child to keep the cast clean and dry and not to stick objects down the cast. Monitoring for circulatory impairment is important.

*Question: A nursing instructor asks a nursing student to identify situations that indicate a secondary level of prevention in health care. Which statement made by the student indicates a need for further study of the levels of prevention?*

*Answer: Teaching a stroke client how to use a walker* Rationale: Secondary prevention focuses on the early diagnosis and prompt treatment of disease. Tertiary prevention is represented by rehabilitation services. Options 1, 3, and 4 identify screening procedures and treatment of disease, whereas option 2 identifies a rehabilitative service.

*Question: The nurse notes that an 8-year-old child is choking. As the nurse rushes to aid the conscious and alert child, the nurse plans to place the hands between which landmarks to remove the foreign body?*

*Answer: The umbilicus and xiphoid process* Rationale: To perform abdominal thrusts, the rescuer stands behind the victim and places the arms directly under the victim's axillae and around the victim. The thumb side of one fist is placed against the victim's abdomen in the midline slightly above the umbilicus and well below the tip of the xiphoid process. The xiphoid process and ribs are avoided to prevent damage to internal organs. The fist is grasped with the other hand, and upward thrusts are delivered.

*Question: The nurse is assisting in the care of a client with a new ileostomy on the clinical nursing unit. Which observations indicate to the nurse that the client is at risk for fluid volume deficit? Select all that apply.*

** Rationale: The client with an ileostomy is at risk for fluid volume deficit due to increased gastrointestinal tract losses. An output of 650 mL in 4 hours would amount to a loss of over 3500 mL in 24 hours. Vital signs indicate a risk with the slightly low BP (104/66 mmHg) and a slight tachycardia (106 beats per minute). The borderline normal pulse oximetry reading with crackles that clear with coughing indicates the client may be breathing shallowly and developing atelectasis. The normal skin turgor is not indicative of risk for fluid volume deficit.

*Question: A client is admitted to the hospital with a fever and extreme weakness. Which laboratory studies are likely to be elevated if the client is experiencing an infection? Select all that apply.*

** Rationale: The laboratory tests that display changes with infection are the WBC count, which will increase to fight infections, and the ESR, which is a general test showing elevation when inflammation or infection occurs. The hematocrit, hemoglobin, and red blood cell count are not directly affected by infection.

*Question: The nurse is caring for a client with severe cardiac disease. While the nurse is caring for the client, the client states, "If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me." Which is the appropriate nursing action?*

*Answer: Tell the client that it is necessary to notify the primary health care provider of the client's request.* Rationale: External cardiac massage is one type of treatment that a client can refuse. The most appropriate nursing action is to notify the primary health care provider because a written "do not resuscitate" (DNR) order from the primary health care provider must be present on the client's record. The DNR order must be reviewed or renewed on a regular basis per agency policy. Options 1 and 4 are inaccurate. Option 2 may be appropriate, but only after the primary health care provider is contacted and notified of the client's request.

*Question: A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse trying to enhance the client's respiratory status would avoid performing which actions? Select all that apply.*

** Rationale: The client with respiratory acidosis is experiencing elevated carbon dioxide levels because of insufficient ventilation. The nurse would encourage the client to breathe slowly and deeply (not shallowly) to expand alveoli and to promote better gas exchange. The nurse should increase the client's oxygen flow rate per nasal cannula to no more than 2 L, not 5L. Remember that the client with chronic pulmonary disease often does not respond to a high carbon dioxide level to breathe, but only low oxygen. If the nurse increases the oxygen too high, the client will have no stimulus to breathe. Elevating the head of the bed, monitoring the client's oxygen saturation level, and assisting the client to turn, cough, and deep breathe are helpful actions on the part of the nurse.

*Question: The emergency department triage nurse has 4 clients arrive at the department at the same time. Which client would the nurse assign to be seen first?*

*Answer: A client with a head injury from an automobile accident* Rationale: One of the most common methods for triage of clients uses "ABCDE" as a memory trigger for the sequence of assessment. A is airway, B is breathing, and C is circulation. D is assessment of neurological disability. E is exposure: all areas of the body should be exposed so that injuries are not missed underneath clothing. A client with a head injury should be seen first to assess any neurological disability. The other clients do not have airway, breathing, or circulation issues and can be seen after the client with a head injury.

*Question: The nurse witnesses a person starting to choke in the hospital cafeteria. Before performing abdominal thrusts, which action would the nurse perform?*

*Answer: Ask the client, "Are you choking?"* Rationale: As a first step in performing abdominal thrusts, the nurse verifies that the client cannot breathe. This is done by asking the client, "Are you choking?" If the client nods, the nurse proceeds. The arms are encircled about the waist once the nurse is certain that the client is actually choking. Rescue breathing is done only after successful abdominal thrusts if the client is not breathing. Looking for pallor or cyanosis is incorrect.

*Question: The nurse is assisting in the care of a client who had an ileostomy created a few days ago. The client has high output of drainage from the ileostomy. Based on this the nurse monitors the client for which acid-base imbalance?*

*Answer: Metabolic acidosis* Rationale: Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. These fluids may be lost from the body before they can be reabsorbed in conditions such as diarrhea or creation of an ileostomy. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis. Clients with high intestinal output are not at risk for metabolic acidosis, or respiratory or metabolic alkalosis.

*Question: The nurse is caring for a client who is nervous and is hyperventilating. The nurse would monitor the client for signs of which acid-base imbalance?*

*Answer: Respiratory alkalosis* Rationale: A client who hyperventilates blows off excessive carbon dioxide. This would have the effect of inducing alkalosis. Because a respiratory problem is triggering the alteration, it is called respiratory alkalosis. The client is not at risk for metabolic acidosis or alkalosis or respiratory acidosis from hyperventilating.

*Question: The nurse arrives at the scene of a code and begins to assist in performing cardiopulmonary resuscitation (CPR) on an adult client. The nurse knows that interruptions in performing chest compressions would be limited to less than how many seconds?*

*Answer: 10* Rationale: When performing CPR, interruptions should be limited to less than 10 seconds (i.e., rotating compressors, delivering shock, pulse check). Five seconds would not give adequate time to deliver a shock and take pulse checks. The other options are too lengthy to limit chest compressions.

*Question: The nurse provides information to the parent of a 2-week-old infant who was diagnosed with clubfoot at the time of birth. Which statement by the parent indicates the need for further teaching regarding this disorder?*

*Answer: "I need to bring my child back to the clinic in 1 month for a new cast."* Rationale: Treatment for clubfoot is started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved within 3 to 6 months, surgery is usually indicated. Because clubfoot can recur, all children with the condition require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome.

*Question: An automatic external defibrillator (AED) is available to treat a client who goes into cardiac arrest. The nurse uses this equipment to determine cardiac rhythm by doing which?*

*Answer: Applying the adhesive patch electrodes to the skin and moving away from the client* Rationale: The nurse or rescuer puts two large adhesive patch electrodes on the client's chest in the usual defibrillator positions. The nurse orders anyone near the client to move away and not touch the client (to eliminate movement artifact). The defibrillator analyzes the rhythm, which may take up to 30 seconds. The machine then indicates if it is necessary to defibrillate.

*Question: The nurse reinforces home care instructions to the parents of a child with a brace for scoliosis. Which statement by a parent indicates a need for further teaching?*

*Answer: "I understand that my child needs to wear this brace for 12 hours a day."* Rationale: The brace needs to be worn from 16 to 23 hours a day. Braces are not curative, they slow the progression of the curvature. The skin under the brace needs to be inspected for any redness or breakdown. The child should continue to perform prescribed exercise to help maintain and strengthen the spinal and abdominal muscles.

*Question: The nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. The nurse planning the work assignment for the shift makes a notation to check the IV sites of these clients at which time interval?*

*Answer: Every hour* Rationale: Safe nursing practice includes monitoring an IV infusion at least once per hour in an adult client. The IV may be checked even more frequently, depending on whether medication also is being infused. Therefore, options 2, 3, and 4 are incorrect.

*Question: The nurse is reading a computer printout of the results of a cerebrospinal fluid (CSF) analysis performed on an adult client who underwent lumbar puncture. The nurse knows that a reported value of 0 is normal for which substance in CSF?*

*Answer: Red blood cells* Rationale: The adult with normal CSF has no red blood cells in the CSF. The client may have small numbers of white blood cells (0 to 3 cells/mm3). Protein (15 to 45 mg/dL) and glucose (40 to 80 mg/dL) normally are present in CSF.

*Question: The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. The student correctly identifies which aspect of care as a priority of care?*

*Answer: Actual or life-threatening concerns* Rationale: Setting priorities means deciding which client needs or problems require immediate action and which ones could be delayed until a later time because they are not urgent. Client problems that involve actual or life-threatening concerns always are considered first. Although time constraints, obtaining needed supplies, and completing care in a reasonable time frame are components of time management, these items are not the priority in planning care for the client, based on the options provided.

*Question: The nurse is planning the client assignments for the day. Which is an appropriate assignment for the assistive personnel (AP)?*

*Answer: A client who requires a 24-hour urine collection* Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the appropriate assignment for an AP would be to care for the client who requires urine collection. The client who has difficulty swallowing food and fluids is at risk for aspiration. Colostomy irrigations and tube feedings are not performed by assistive personnel.

*Question: The nurse is caring for a client who is on airborne precautions. The nurse notes that the client is scheduled for a magnetic resonance imaging (MRI) test. Which nursing action would be most appropriate in preparing the client for the test?*

*Answer: Place a surgical mask on the client for transport and for contact with other individuals.* Rationale: If the client is on airborne precautions, client movement and transport should be limited if possible. If transport or movement is necessary, client dispersal of droplet nuclei can be minimized by placing a surgical mask on the client. Option 4 is not within the role of nursing practice. The primary health care provider is the individual who would prescribe cancellation or delay of a diagnostic test. Option 1 is unreasonable. Option 3 would not prevent the dispersal of droplet nuclei by the client.

*Question: A licensed practical nurse (LPN) has been assigned to assist a community nurse, who is the leader of a task force, to identify interventions for teenagers from a local community who are abusing drugs. At the first meeting of the task force, the group members express concern that more information is needed to determine appropriate measures for the target teenagers. The LPN makes which suggestion to the community nurse to direct the group most effectively?*

*Answer: Prepare a survey that can be distributed to community members to determine their understanding of the drug abuse problem.* Rationale: Option 4 is the only option that addresses the subject of the question and will identify the additional information required by the task force. Options 1, 2, and 3 do not provide the additional information required in order for the task force to proceed with the necessary task of the group.

*Question: An anxious client is experiencing respiratory alkalosis from hyperventilation as a result of anxiety. The nurse would do which action to help the client experiencing this acid-base disorder?*

*Answer: Provide emotional support and reassurance.* Rationale: An anxious client benefits from emotional support and reassurance, which in turn reduces anxiety and may lower the respiratory rate. The client may benefit from the administration of a sedative or antianxiety medication, if it is prescribed. The client should try to breathe more slowly and shallowly. Lying supine provides no benefit to the client.

*Question: The licensed practical nurse (LPN) is obtaining a client's signature on an informed consent for a total knee replacement surgery. The client has many questions and seems reluctant to sign the consent. Which best action would the LPN take?*

*Answer: Notify the surgeon that the client has many questions about the procedure.* Rationale: For the client to have sufficient information for informed consent, the person must have been advised of risks, benefits, alternatives, and consequences of refusing the treatment. A client has the right to have all questions answered. The primary health care provider is responsible for obtaining informed consent. Nurses may obtain client signatures and serve as witnesses to the signature as agency policy permits. The nurse should ask the client if he or she understands the procedure. If the nurse suspects the client lacks decision-making capacity or does not fully understand the implications of the consent form, the primary health care provider should be contacted. The supervisor can be notified about the situation.

*Question: An automatic external defibrillator (AED) interprets that the rhythm of a pulseless client is ventricular fibrillation. The nurse takes which action next?*

*Answer: Orders personnel away from the client, charges the machine, and depresses the discharge buttons* Rationale: If the AED advises to defibrillate, the rescuer orders all personnel away from the client, charges the machine, and pushes both of the discharge buttons on the console at the same time. The charge is delivered through the patch electrodes, so this method is known as "hands off" defibrillation, which is safer for the rescuer. The sequence of charges (up to three consecutive attempts at 200, 300, and 360 joules) is similar to that of conventional defibrillation.

*Question: A client with a stroke (brain attack) is experiencing residual dysphagia. The nurse would remove which food item that arrived on the client's meal tray from the dietary department?*

*Answer: Peas* Rationale: In general, flavorful, very warm, or well-chilled foods with texture stimulate the swallowing reflex. Moist pastas, casseroles, egg dishes, and potatoes are usually well tolerated. Raw vegetables; chunky vegetables such as diced beets; and stringy vegetables such as spinach, corn, and peas are commonly excluded from the diet of a client with a poor swallowing reflex.

*Question: In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops. The nurse administers the eye drops knowing that which is the purpose of this medication?*

*Answer: To dilate the pupil of the operative eye* Rationale: Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication. Cyclopentolate is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis.

*Question: A client is admitted to the surgical unit postoperatively with a self-suction Jackson-Pratt wound drain in place. The nurse determines the drain is functioning correctly with which observations? Select all that apply.*

** Rationale: A surgical drain is a device placed during surgery to collect fluid away from the surgical site. The Jackson-Pratt drain is a bulb collection device that is self-suction and is emptied by releasing the suction, removing the drainage, and then again compressing to apply suction. To check patency, the bulb should be compressed and contain drainage that is usually red bloody drainage on the day of surgery. There is no bubbling or tidaling of the fluid with respirations with a Jackson-Pratt drain. The drainage on the surgical dressing should be minimal if the drain is operating properly.

*Question: The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? Select all that apply.*

** Rationale: Some therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information and presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Asking why, giving advice, and approving or disapproving are nontherapeutic.

*Question: Which home care instructions would the nurse plan to reinforce to the mother of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply.*

** Rationale: AIDS is a disorder that is caused by the human immunodeficiency virus (HIV) and is characterized by a generalized dysfunction of the immune system. Home care instructions include the following: frequent hand washing; monitoring for fever, malaise, fatigue, weight loss, vomiting, diarrhea, altered activity level, and oral lesions and notifying the primary health care provider if these occur; monitoring for signs and symptoms of opportunistic infections; administering antiretroviral medications, as prescribed; avoiding exposure to other illnesses; keeping immunizations up to date; avoiding kissing the child on the mouth; monitoring the weight and providing a high-calorie, high-protein diet; washing eating utensils in the dishwasher; and avoiding the sharing of eating utensils. Gloves are worn for care, especially when in contact with body fluids or changing diapers. Diapers are changed frequently and away from food areas, and soiled disposable diapers are folded inward, cl

*Question: The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures would the nurse include in the plan? Select all that apply.*

** Rationale: After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye, and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

*Question: A client is scheduled to receive chemotherapy with a group of medications, one of which is asparaginase. The nurse anticipates that this medication would be removed from the regimen after noting which findings in the client's medical record? Select all that apply.*

** Rationale: Asparaginase is contraindicated if the client has pancreatitis or a history of the same. A significantly elevated serum amylase is associated with acute pancreatitis. Because this medication impairs pancreatic function, tests to monitor pancreatic function should be performed before initiating therapy and when a week or more has elapsed between the administration of the doses. The client also is monitored for signs of pancreatitis, which include nausea, vomiting, and abdominal pain. History of heart failure and chronic obstructive lung disease and having had a thyroidectomy are not contraindications for the use of this medication.

*Question: The client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed? Select all that apply.*

** Rationale: Bleomycin is an antineoplastic medication that can cause interstitial pneumonitis, which can progress to pulmonary fibrosis. During pulmonary fibrosis, the lung tissue becomes very scarred and hard. Pulmonary fibrosis is not reversible and the client is continuously short of breath. Pulmonary function studies and chest x-ray, along with hematological, hepatic, and renal function tests need to be monitored. The nurse needs to monitor lung sounds for dyspnea and adventitious sounds, which could indicate pulmonary toxicity. The medication needs to be discontinued immediately if pulmonary toxicity occurs. Cardiac studies such as an echocardiogram and electrocardiogram, and a cervical radiograph are unrelated to the specific use of this medication.

*Question: A primary health care provider (PHCP) has written a prescription for calcium carbonate for the client with hypocalcemia. The nurse is reinforcing teaching with the client and would include which instructions? Select all that apply.*

** Rationale: Calcium carbonate is best absorbed with or just after meals. Foods that are high in oxalate, such as beets and spinach, or insoluble fiber, such as bran, may interfere with calcium absorption if eaten in excess. The medication should be taken with a full glass of water (8 oz/240 mL). Chewable tablets should be chewed and taken with a full glass of water to improve absorption of the calcium. The client should follow the prescribed dose and contact the PHCP if symptoms such as tremors occur.

*Question: The primary health care provider (PHCP) is going to perform carotid massage on a client with rapid rate atrial fibrillation. Which interventions would the nurse anticipate? Select all that apply.*

** Rationale: Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. This eliminates option 3. The PHCP or cardiologist will massage only one carotid artery for a few seconds to determine whether a change in cardiac rhythm occurs. This eliminates option 2. The client needs to be on a cardiac monitor throughout the procedure, and rhythm strips should be obtained before, during, and after the procedure. Continue to monitor the client's cardiac rhythm as well as vital signs and level of consciousness.

*Question: The licensed practical nurse (LPN) is assisting the registered nurse (RN) to create a teaching plan for the client receiving an antineoplastic medication. The LPN expects which information to be included? Select all that apply.*

** Rationale: Clients with cancer treated with antineoplastic medications must be aware of how to care for themselves, and it is important that client teaching is included in the care plan. Because antineoplastic medications affect the bone marrow, clients are often anemic, have lower immunity, and may be at risk for bleeding. Oral hygiene is important, and clients should inspect their mouths daily, rinse after meals, and use a soft toothbrush. The client should check with the primary health care provider (PHCP) before receiving any immunizations. The client should notify the PHCP for a low-grade temperature such as 99.5°F (39.7°C) and a sore throat. These are often associated with low white blood cell counts.

*Question: The nurse is reviewing the record of a pregnant client and notes that the primary health care provider has documented the presence of Chadwick's sign. The prenatal client asks the nurse to explain Chadwick's sign. Which information provided by the nurse is accurate? Select all that apply.*

** Rationale: The cervix undergoes significant changes following conception. The most obvious changes occur in color and consistency. Chadwick's sign is a probable sign of pregnancy and may occur as early as 6 weeks' gestation. In response to the increasing levels of estrogen, the cervix becomes congested with blood, resulting in the characteristic bluish color that extends to include the vagina, labia, and cervix. This discoloration, referred to as Chadwick's sign, is one of the earliest signs of pregnancy. Chadwick's sign does not relate to fundal height, and initial fetal movement felt by the pregnant woman is known as quickening.

*Question: A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. The nurse is considering seclusion and restraints for this client even though staffing is lacking for close supervision and direct observation. Which are some contraindications to seclusion and restraints without close supervision and observation? Select all that apply.*

** Rationale: Contraindications to seclusion and restraints without close supervision and observation include severe suicidal tendencies, extremely unstable medical and psychiatric conditions, desire for punishment of client or convenience of staff, delirium or dementia leading to inability to tolerate decreased stimulation, and severe drug reactions or overdoses or need for close monitoring of drug dosages. Immediate family's request does not affect whether seclusion and/or restraints are applied or not. The nurse must carefully document restraint or seclusion in the treatment plan, including noting the behavior leading to restraint or seclusion, and the actual time when the client is placed in and released from restraint. The client then must be assessed at regular and frequent intervals (e.g., every 15 to 30 minutes) for physical needs (e.g., food, hydration, and toileting), safety, and comfort. These observations must also be documented every 15 to 30 minutes. While in restraints,

*Question: The nurse is reinforcing instructions to a client and family regarding home care following cataract removal with lens implantation in the left eye. The nurse would provide the client with instructions to contact the surgeon promptly for which signs or symptoms? Select all that apply.*

** Rationale: Following cataract surgery, in which the cloudy lens is removed and a new lens is implanted in the eye, clients are sent home to recover. Clients should contact the surgeon immediately if there is the presence of new floaters (seeing small dots) because this could be a sign of a detached retina. Some redness in the eye may be present, but increased redness could indicate bleeding or infection and should also be promptly reported. Clients usually experience improved vision, a sensation of grittiness in the eye, and pain that is controlled with acetaminophen.

*Question: The nurse is reinforcing instructions to the parents of an infant with clubfoot about the care of a plaster cast. Which statement would the nurse include in the instructions? Select all that apply.*

** Rationale: For a plaster cast, reposition every 2 to 4 hours to ensure thorough drying. Plaster casts may be used when the primary health care provider wants to "mold" the cast to apply corrective forces to a body part, such as in the treatment of a clubfoot. Plaster casts will set within 10 to 15 minutes, but will not fully dry for 24 to 48 hours so they should not be handled until after that time as indentations can be left. The foot should be elevated to decrease edema in the first 24 to 48 hours. Plaster is not water-resistant and will break down if it gets wet. Plaster casts can be petaled with moleskin to prevent rough edges. It is fiberglass casts, not plaster casts, that dry quickly and can be wiped gently on the outside to cleanse the cast.

*Question: A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions would the nurse initiate? Select all that apply.*

** Rationale: For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas, to which these children are very susceptible. Fruits and vegetables not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises. The child is placed on a low-bacteria diet. Dressings are always changed with sterile technique. Not all visitors need to be restricted, but anyone who is ill should not be allowed in the child's room. Meticulous hand washing is required before caring for the child. In addition, gloves, a mask, and a gown are worn (per agency policy).

*Question: The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. The nurse would take which actions? Select all that apply.*

** Rationale: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. The connecting tubing on the peritoneal dialysis system is also checked for kinks or twisting, and the clamps on the system are checked to ensure that they are open. There is no reason to contact the nephrologist. Increasing the flow rate is an inappropriate action and is unassociated with the amount of outflow solution.

*Question: A licensed practical nurse (LPN) is assisting in the care of a client who is receiving oxytocin to induce labor. The LPN plans to notify the registered nurse immediately if which signs and symptoms are noted? Select all that apply.*

** Rationale: Induction of labor is the initiation of labor through mechanical or pharmacological means. Oxytocin is a synthetic hormone that stimulates uterine contractions and is a medication commonly used to induce labor. Oxytocin will increase contraction frequency, intensity, and duration; however, the primary health care provider needs to be notified of durations greater than 1 minute. Blood pressure and pulse need to be monitored for signs of hemorrhage. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress.

*Question: A client at risk for pulmonary embolism (PE) suddenly develops respiratory distress, chest pain, and anxiety. The nurse would plan to take which actions? Select all that apply.*

** Rationale: Initial care for a client who might be experiencing a PE is to remain calm, stay with the client, raise the head of the bed to a high-Fowler's position, begin low-flow O2 therapy, check vital signs, notify the registered nurse and primary health care provider of the client's symptoms, start a peripheral intravenous line if one is not already established, and assist to administer heparin when it is prescribed. A low-Fowler's position would not be used initially, and heparin is administered in the initial stage of a suspected pulmonary embolism.

*Question: The nurse is told that a client will be admitted to the hospital for a radiation implant. The nurse is asked to prepare for the admission of the client and plans which measure for this client?*

*Answer: Admit the client to a private room.* Rationale: The client who has a radiation implant is placed in a private room, which is often located near the end of the hall. There would be no reason to be near the nurse's station. These measures enhance radiation safety by reducing exposure for others in the clinical unit. The client also has limited visitors for the same reason. Protective isolation is unnecessary.

*Question: The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions would the nurse perform for this procedure? Select all that apply.*

** Rationale: Intermittent suction is applied while rotating the catheter for up to 10 seconds. The nurse should hyperoxygenate the client with a resuscitator bag/Ambu-bag connected to an oxygen source before suctioning because suction depletes the client's oxygen supply (option 2). The catheter should be inserted gently until resistance is met or the client coughs, then pulled back 1 cm or ½ inch. Intermittent suction is applied while rotating and withdrawing the catheter. Option 3 is incorrect because wall suction should be set to 80 mm Hg to 120 mm Hg. Pressure set at a higher level can cause trauma to respiratory tract tissues. Strict asepsis needs to be maintained, and the nurse would wear sterile gloves to perform this procedure. Suction is never applied when inserting the catheter because it will deplete oxygen and can traumatize tissues.

*Question: Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.*

** Rationale: Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding limits set; following through with the consequences in a nonpunitive manner; and assisting the client with developing a means for setting limits on personal behaviors. Enforcing rules and informing the client that he or she will not be allowed to attend therapy groups are violations of a client's rights. Ensuring that the client knows that he or she is not in charge of the nursing unit is inappropriate; power struggles need to be avoided.

*Question: A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which characteristics describe this type of a lesion? Select all that apply.*

** Rationale: Melanomas are pigmented malignant lesions that originate in the melanin-producing cells of the epidermis. The lesion is a nevus that changes in color. This skin cancer is highly metastatic and a person's survival depends on early diagnosis and treatment. Basal cell carcinomas arise in the basal cell layer of the epidermis. Early malignant basal cell lesions often go unnoticed, and although metastasis is rare, underlying tissue destruction can progress to include vital structures. Squamous cell carcinomas are malignant neoplasms of the epidermis. They are characterized by local invasion and the potential for metastasis.

*Question: Which medications cause ototoxicity? Select all that apply.*

** Rationale: Ototoxicity is caused by medications or chemicals that damage the inner ear or the vestibulocochlear nerve. There are more than 200 medications that cause toxicity. The vestibulocochlear nerve sends balance and hearing information from the inner ear to the brain. Ototoxicity may result in temporary or permanent disturbances of hearing, balance, or both. This is especially true if a very high dose of the medication is given or if it is given incorrectly. Ototoxic medications include furosemide, ibuprofen, and vancomycin.

*Question: The nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit after abdominal surgery. The client has an indwelling urinary catheter in place. The vital signs are temperature 99.6°F (37.6°C), pulse 104 beats per minute, respirations 16 breaths per minute, and blood pressure (BP) 100/70 mm Hg. Urinary output is 20 mL for the past hour. Based on this data, which actions would the nurse take before notifying the registered nurse? Sel

** Rationale: Postoperative vital signs and urinary output are important parameters to determine how the client is recovering from the surgical procedure. The nurse needs to consider if this data is an early sign of a complication. The nurse should review the previous vital signs to determine whether this is a change from how the vital signs have been trending since the BP is slightly low and the pulse rate is slightly fast. Noting when the last pain medication was administered will help the nurse determine whether the vital signs may be affected from the medication since opioids lower blood pressure. The nurse should determine whether the IV fluid is infusing correctly and whether the catheter is patent. Urine output should be maintained at a minimum of 30 mL/hr for an adult. An output of less than 30 mL for each of 2 consecutive hours should be reported. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Auscultation of breath so

*Question: The nurse has a prescription to give a dose of Rho(D) immune globulin to a client who has delivered an infant. Which criteria need to be met in order to administer this medication? Select all that apply.*

** Rationale: Rh incompatibility occurs when an Rh-negative mother is sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman carries and delivers a fetus who is Rh positive. During pregnancy and delivery, some of the baby's Rh-positive blood can enter the maternal circulation. The woman's immune system then forms antibodies against Rh-positive blood, which can be detected in the indirect Coombs' test. Administration of RhoGAM blocks this response by providing passive antibody protection against the Rh antigen. If both the mother and father are Rh negative, the infant cannot be Rh positive.

*Question: Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. The nurse would monitor for which side/adverse effects of the medication? Select all that apply.*

** Rationale: Rifabutin may be prescribed for a client with active MAC disease and tuberculosis. It inhibits mycobacterial DNA-dependent RNA polymerase and suppresses protein synthesis. Side effects include rash, GI disturbances, neutropenia (low neutrophil count), red-orange body secretions, uveitis (blurred vision and eye pain), myositis, arthralgia, hepatitis, chest pain with dyspnea, and flu-like syndrome. Vitamin B6 deficiency and numbness and tingling in the extremities are associated with the use of isoniazid. Ethambutol also causes peripheral neuritis.

*Question: The nurse educator is asking the nursing student to recall the signs/symptoms of hypothyroidism. The nurse educator determines that the student understands this disorder if which are included in the student's response? Select all that apply.*

** Rationale: Signs of hypothyroidism include dry skin, hair, and loss of body hair; constipation; cold intolerance; lethargy and fatigue; weakness; muscle aches; paresthesia; weight gain; bradycardia; generalized puffiness and edema around the eyes and face; forgetfulness; menstrual disturbances; cardiac enlargement; and goiter. Irritability, palpitations, and weight loss are signs of hyperthyroidism.

*Question: The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques would the nurse use when communicating with the family? Select all that apply.*

** Rationale: The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears, as well as reminiscing. The nurse needs to be honest and truthful and let the client and family know that they will not be abandoned. It is important to extend touch and to hold the client or family member's hand if appropriate.

*Question: A client with a seizure disorder is being admitted to the hospital. Which would the nurse plan to implement for this client? Select all that apply.*

** Rationale: The nurse should plan seizure precautions for a client with a seizure disorder. The precautions include padded side rails and an airway (to maintain airway patency if required) and oxygen and suction equipment at the bedside. Attempts to force a padded tongue blade between clenched teeth may result in injury to the teeth and mouth; therefore, a padded tongue blade is not placed at the bedside.

*Question: The nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for tuberculosis. Which instructions would the nurse reinforce? Select all that apply.*

** Rationale: The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client is reassured that after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. The client is also informed that activities should be resumed gradually. The client and family are informed that respiratory isolation is not necessary because family members have already been exposed. The client is instructed about thorough hand washing, to cover the mouth and nose when coughing or sneezing, and to confine used tissues to plastic bags. The client is informed that a sputum culture is needed every 2 to 4 weeks once medication is initiated and that when the results of three sputum cultures are negative, the client is no longer considered infectious and can usually return to his or her former employment.

*Question: A hospitalized client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, the nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, "My chest still hurts." Which appropriate actions would the nurse take? Select all that apply.*

** Rationale: The usual guideline for administering nitroglycerin tablets for a hospitalized client with chest pain is to administer one tablet every 5 minutes as needed (PRN) for chest pain for a total dose of 3 tablets. The registered nurse is notified immediately if a client complains of chest pain. In this situation, because the client is still complaining of chest pain, the nurse would administer a second nitroglycerin tablet. The nurse would check the client's pain level and the client's blood pressure before administering each nitroglycerin dose. There are no data in the question that indicate the need to call a code blue. In addition, it is not necessary to contact the client's family unless the client has requested this.

*Question: The nurse is preparing to administer eye drops. Which interventions would the nurse take to administer the drops? Select all that apply.*

** Rationale: To administer eye medications, the nurse would wash hands and put on gloves. The client is instructed to tilt the head backward, open the eyes, and look up. The nurse pulls the lower lid down against the cheekbone and holds the bottle like a pencil, with the tip downward. Holding the bottle, the nurse gently rests the wrist of the hand on the client's cheek and squeezes the bottle gently to allow the drop to fall into the conjunctival sac. The client is instructed to close the eyes gently and not to squeeze the eyes shut to prevent the loss of medication.

*Question: A nurse is monitoring a pregnant client for the warning signs/symptoms of gestational hypertension. Which are signs/symptoms of this complication of pregnancy? Select all that apply.*

** Rationale: Vasospasm that occurs with gestational hypertension impedes blood flow to the mother's organs and placenta, resulting in one or more of these signs: hypertension, edema, and proteinuria (protein in the urine). Severe gestational hypertension can also affect the central nervous system, eyes, urinary tract, liver, gastrointestinal system, and blood clotting function (which results in thrombocytopenia). Oliguria, not polyuria, is a sign. Braxton Hicks contractions are the normal irregular, painless contractions of the uterus that may occur throughout the pregnancy.

*Question: The nurse in the mental health clinic hears a client yelling and threatening to hurt his sister. The nurse reports this episode to the mental health therapist. Which would the nurse anticipate the therapist to do? Select all that apply.*

** Rationale: When a therapist determines that a client presents a serious danger of violence to another, the therapist has the duty to protect that other person. Most states currently have similar laws regarding the duty to protect third parties of potential life threats. The duty to protect usually includes assessing and predicting the client's danger of violence toward another, identifying the specific person(s) being threatened, and taking appropriate action to protect the identified victims. Taking appropriate action might include calling and warning the intended victim, the victim's family, or the police or taking whatever steps are reasonably necessary under the circumstances.

*Question: Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time would respond with which question or statement?*

*Answer: "Are you fearful and think that others may want to hurt you?"* Rationale: Option 2 is the only option that recognizes the client's need. This response helps the client focus on the emotion underlying the delusion but does not argue with it. If the nurse attempts to change the client's mind, the delusion may, in fact, be even more strongly held. Options 1, 3, and 4 do not focus on the client's feelings.

*Question: A pregnant client who has gestational diabetes mellitus tells the nurse that she is concerned about what her baby's condition will be following delivery. Which nursing response best supports the client?*

*Answer: "Better blood glucose control means fewer effects; let's review your plan of care."* Rationale: When the maternal blood glucose is high, the fetus produces more insulin, which is a process that continues after delivery. Keeping the maternal glucose in better control lessens this effect. Options 1 and 2 provide a false reassurance to the client. Option 3 will cause further concern in the client. Option 4 provides the most realistic support for the client and allows the nurse an opportunity to review the client's plan of care to clarify information and reassure the mother.

*Question: A 5-week-old infant is brought to the well-baby clinic by the mother because the mother has noted white patches in the infant's mouth. Following examination, the infant is diagnosed with oral candidiasis (thrush). Nystatin oral suspension is prescribed. The mother is concerned because she is breastfeeding the infant and asks the nurse if breastfeeding can be continued. Which response is appropriate?*

*Answer: "Breastfeeding can continue, but your breasts should also be treated with nystatin."* Rationale: If an infant with thrush is being breast-fed, the mother's breasts should also be treated with nystatin. Options 1 and 2 are inaccurate and unnecessary. Although an infant can acquire thrush from exposure to infected breasts, this option 4 is a nontherapeutic nursing response.

*Question: The nurse is reinforcing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse plans to include which instruction?*

*Answer: "Call the primary health care provider if the infant has a high-pitched cry."* Rationale: If the shunt is broken or malfunctioning, the fluid from the ventricular part of the brain will not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial area. The result is increased intracranial pressure, which then causes a high-pitched cry in the infant. The infant should not be positioned on the side of the shunt because this will cause pressure on the shunt and skin breakdown. This type of shunt affects the gastrointestinal system, not the genitourinary system, and an increased urinary output is not expected. Option 1 is a concern only if other signs indicative of a complication are occurring.

*Question: The nurse is collecting data on a child recently diagnosed with glomerulonephritis. Which question to the mother would elicit information about the cause of this disease?*

*Answer: "Did your child recently complain of a sore throat?"* Rationale: Group A beta-hemolytic streptococcal infection is a cause of glomerulonephritis. Often the child becomes ill with streptococcal infection of the upper respiratory tract and then develops symptoms of acute poststreptococcal glomerulonephritis after an interval of 1 to 2 weeks. The questions to the mother in options 1, 2, and 4 are unrelated to a diagnosis of glomerulonephritis.

*Question: A client with cancer has received a course of chemotherapy with fluorouracil. The nurse would plan to reinforce which instructions?*

*Answer: "Do not get any immunizations without primary health care provider approval."* Rationale: Because antineoplastic medications lower the body's resistance, the nurse teaches the client to avoid getting immunizations without primary health care provider approval. The client also should avoid contact with individuals who recently have received a live virus vaccine. Aspirin and aspirin-containing products should be avoided to minimize the risk of bleeding. Alcohol should be avoided to minimize the risk of toxicity.

*Question: The nurse is reinforcing instructions to a group of high school males in a health class about how to perform a testicular self-examination (TSE). The nurse would make which statement?*

*Answer: "Do the examination after a warm bath or shower."* Rationale: Testicular cancer is rare but occurs most frequently in males 20 to 35 years of age; therefore, education of high school-aged males is important. TSE is recommended monthly after a warm bath or shower when the scrotal skin is relaxed. It also could be done near the end of the shower. The client should be standing to examine the testicles. The client should use both hands, placing fingers under the scrotum and thumbs on top, and should gently roll the testicles, feeling for any lumps.

*Question: TThe nurse is preparing to give a full bed bath to a client. Which question is most important for the nurse to ask the client before beginning the bed bath?*

*Answer: "Do you have any allergies?"* Rationale: Bed baths involve applying water and a cleansing agent, such as soap or chlorhexidine gluconate (CHG). to the skin. The nurse needs to first ask the client if they have any allergies to ensure the client is not allergic to the cleansing agent that will be used. Although options 2, 3 and 4 are appropriate questions to ask the client, the determination of any client allergies is the most important client data to obtain before beginning the bed bath.

*Question: The nurse is collecting data on an infant with a diagnosis of suspected Hirschsprung's disease. Which question to the mother will most specifically elicit information regarding this disorder?*

*Answer: "Does your infant have foul-smelling, ribbon-like stools?"* Rationale: Chronic constipation, beginning in the first month of life and resulting in pellet-like or ribbon-like stools that are foul smelling, is a clinical manifestation of Hirschsprung's disease. Delayed passage or absence of meconium stool in the neonatal period is the cardinal sign. Bowel obstruction, especially in the neonatal period, abdominal pain and distention, and failure to thrive are also signs and symptoms. Options 1, 2, and 3 are not specific signs and symptoms of this disorder.

*Question: On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urine sample is collected for urinalysis, and the results indicate the presence of a urinary tract infection. The nurse reinforces instructions to the new mother regarding measures to take for the treatment of the infection. Which statement by the mother indicates the need for further teaching?*

*Answer: "Foods and fluids that will increase urine alkalinity should be consumed."* Rationale: The woman with a urinary tract infection should be instructed to drink at least 3000 mL of fluid each day to flush the infection from the bladder and to urinate frequently throughout the day. The woman must be encouraged to take the medication for the entire time it is prescribed. Foods and fluids that acidify the urine need to be encouraged.

*Question: The nurse is collecting data on a child with a diagnosis of rheumatic fever. Which question should the nurse initially ask the mother of the child?*

*Answer: "Has the child complained of a sore throat within the past few months?"* Rationale: Rheumatic fever characteristically presents 2 to 6 weeks following an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether any family members have had a sore throat or unexplained fever within the past 2 months. Although options 1, 2, and 3 may be asked during data collection, they would not be the initial concerns for a child with rheumatic fever.

*Question: The nurse is explaining causes and reasons of hemophilia A to the parents of a child with the disease. The nurse would make which statement about hemophilia A?*

*Answer: "Hemophilia A results from deficiency of factor VIII."* Rationale: The term hemophilia refers to a group of bleeding disorders. The identification of the specific factor deficiencies allows for definitive treatment with replacement agents. Hemophilia A results from a deficiency of factor VIII. Hemophilia B (Christmas disease) is a deficiency of factor IX. Hemophilia is inherited in a recessive manner via a genetic defect on the X chromosome, not the Y chromosome. But hemophilia A may also occur as a result of a gene mutation.

*Question: The nurse is caring for a client who is suspected of being dependent on drugs. Which question would be appropriate for the nurse to ask when collecting data from the client regarding drug abuse?*

*Answer: "How much do you use, and what effect does it have on you?"* Rationale: Whenever the nurse collects data from a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental, off focus, and reflects the nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention.

*Question: The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement?*

*Answer: "I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone."* Rationale: There may be an increased risk for impulsive and/or aggressive behavior if a client is receiving command hallucinations to harm self or others. Talking about the auditory hallucinations can interfere with the subvocal muscular activity associated with a hallucination. Option 4 is a specific agreement to seek help and evidences self-responsible commitment and control over his or her own behavior.

*Question: The nurse is caring for an older client with a diagnosis of myasthenia gravis and has reinforced self-care instructions. Which statement by the client indicates a need for further teaching?*

*Answer: "I can change the time of my medication on the mornings that I feel strong."* Rationale: The client with myasthenia gravis should be taught that timing of anticholinesterase medication is critical. It is important to instruct the client to administer the medication on time to maintain a chemical balance at the neuromuscular junction. If not given on time, the client may become too weak to swallow. Options 1, 2, and 3 include the necessary information that the client needs to understand to maintain health with this neurological degenerative disease.

*Question: The nurse is giving discharge instructions to the client concerning theophylline. Which client statement indicates a need for further teaching?*

*Answer: "I can keep on being the charcoal grill king and eat a lot of beef steak."* Rationale: Client instructions concerning theophylline include not to drink alcohol or caffeine products (tea, coffee, chocolate, colas) and to avoid large amounts of charcoal-grilled beef. The client needs to avoid hazardous activities because of possible dizziness. The client needs to notify primary health care provider about changes in smoking habits because a change in dose may be required.

*Question: The home care nurse visits a client at home who has been prescribed prednisone 5 mg orally daily. The nurse reinforces teaching for the client about the medication. Which statement made by the client indicates a need for further teaching?*

*Answer: "I can take aspirin or my antihistamine if I need it."* Rationale: Aspirin and other over-the-counter medications should not be taken unless the client consults with the PHCP. The client needs to take the medication at the same time every day and should be instructed not to stop. A slight weight gain as a result of an improved appetite is expected, but after the dosage is stabilized, a weight gain of 5 lb or more weekly should be reported to the PHCP. Caffeine-containing foods and fluids need to be avoided because they may contribute to steroid-ulcer development.

*Question: The nurse is working with a client who is delusional. The client says to the nurse, "The leaders of a religious cult are being sent to assassinate me." Which is the best response by the nurse?*

*Answer: "I don't know about a religious cult. Are you afraid that people are trying to hurt you?"* Rationale: When planning care for this client, the nurse would provide assistance with grooming and nutrition until the client's thinking is cleared. In the acute phase of schizophrenia, the nurse must assume responsibility for planning the client's basic human needs, such as nutrition, hygiene, sleep, and activities of daily living. As the nurse plans care for the schizophrenic client, it is important to understand the client's developmental stage and ability to accept the disease. The client lacks insight and may not be aware of the illness because of the severe decompensation in thinking. Options 1 and 2 are incorrect because these actions do not provide a structured routine. Option 4 is a nontherapeutic communication technique.

*Question: The nurse is reinforcing discharge instructions for a client who underwent left total knee replacement (TKR) with insertion of a metal prosthesis. Which statement by the client indicates the need for further teaching?*

*Answer: "I don't need to be worried if the shape of my knee changes."* Rationale: There is a need for further teaching when the client states that there is no need to worry if the shape of the knee changes. After TKR, the client would report signs/symptoms of infection or any changes in the shape of the knee, which could indicate developing complications. With a metal implant, the client requires anticoagulant therapy and would know to report adverse effects of this therapy, such as bleeding. The client would tell all caregivers about the metal implant because certain diagnostic tests will need to be avoided, and antibiotic prophylaxis will be needed before invasive procedures.

*Question: The nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further teaching?*

*Answer: "I need to be sure to place my cup of coffee on the counter."* Rationale: Toddlers, with their increased mobility and developing motor skills, can reach hot water, open fires, or hot objects placed on counters and stoves above their eye level. Parents should be encouraged to remain in the kitchen when preparing a meal and reminded to use the back burners on the stove and to turn pot handles inward and toward the middle of the stove. Hot liquids should never be left unattended, and the toddler should always be supervised. Option 3 does not reflect an adequate understanding of the principles of safety.

*Question: The nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diabetic diet. Which statement made by the client indicates the need for further teaching?*

*Answer: "I need to buy special dietetic foods."* Rationale: It is important to emphasize to the client and family that they are not eating a diabetic diet, but rather following a balanced meal plan. Adherence to nutrition principles is an important component of diabetic management, and an individualized meal plan should be developed for the client. It is not necessary for the client to purchase special dietetic foods.

*Question: An adolescent is seen in the health care clinic with complaints of chronic fatigue. On physical examination, the nurse notes that the adolescent has swollen lymph nodes. A laboratory test is performed, and the results indicate the presence of Epstein-Barr virus (mononucleosis). The nurse calls the mother of the adolescent to inform the mother of the test results and reinforces instructions regarding the care of the adolescent. Which statement by the mother indicates an understanding o

*Answer: "I need to call the primary health care provider if my child complains of abdominal pain or left shoulder pain."* Rationale: The mother needs to be instructed to notify the primary health care provider if abdominal pain, especially in the left upper quadrant, or left shoulder pain occurs because this may indicate splenic rupture. Children with enlarged spleens are also instructed to avoid contact sports until splenomegaly resolves. Bed rest is not necessary, and children usually self-limit their activity. No isolation precautions are required, although transmission can occur via saliva, close intimate contact, or contact with infected blood. The child may still feel tired in 1 week as a result of the virus.

*Question: The nurse reinforces home care instructions to the mother of a child recovering from Reye's syndrome. Which statement by the mother indicates a need for further teaching?*

*Answer: "I need to give frequent, small, nutritious meals if my child starts to vomit."* Rationale: The vomiting that occurs in Reye's syndrome is caused by cerebral edema and is a symptom of increased intracranial pressure. Small, frequent meals will not affect the amount of vomiting, and the PHCP is notified if vomiting occurs. Options 1, 2, and 3 are all correct statements. Decreasing stimuli and providing rest decrease stress on the brain tissue. Checking for jaundice will assist in identifying the presence of liver complications, which are characteristic of Reye's syndrome.

*Question: The nurse is caring for a client who delivered a healthy newborn via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse reinforces instructions to the mother regarding care related to the infection. Which statement by the mother indicates the need for further teaching?*

*Answer: "I need to isolate my infant for 48 hours after starting the antibiotics."* Rationale: Broad-spectrum antibiotics will be prescribed for the mother, and she should be instructed to take them as prescribed. Analgesics often are necessary, and warm compresses or sitz baths may be used to provide comfort. The infant is not routinely isolated from the mother with a wound infection, but the mother must be taught how to protect the infant from contact with contaminated articles.

*Question: The nurse is reinforcing instructions to a mother of a child with atopic dermatitis (eczema) regarding the application of topical cortisone cream to the affected skin sites. Which statement made by the mother indicates an understanding of the use of this medication?*

*Answer: "I need to wash the sites gently before I apply the medication."* Rationale: Topical corticosteroids should be applied sparingly and rubbed into the area thoroughly. The affected area should be cleansed gently before application. The cream should not be applied over extensive areas. Systemic absorption is more likely to occur with extensive application.

*Question: The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife make which statement?*

*Answer: "I no longer feel that I deserve the beatings my husband inflicts on me."* Rationale: Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain suggestions about successful behavioral changes. Option 1 is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. The nonalcoholic partner should not feel responsible when the spouse loses control (option 2). Option 3 indicates that the group is being seen as an escape, not a place to work on issues. Option 4 indicates that the wife remains codependent.

*Question: The nurse is caring for a client in labor. The nurse reviews the primary health care provider's prescriptions and notes that the client has a prescription for butorphanol tartrate. Which client statement indicates that the client understands the purpose of receiving this medication?*

*Answer: "I should experience at least some pain relief shortly after receiving this medication."* Rationale: The woman in labor may be given parenteral analgesia during the first stage of labor, up to 2 to 3 hours before the anticipated delivery. Butorphanol tartrate is a medication that may be prescribed for pain relief. Altering the contraction pattern and assisting with fetal lung development are not actions of this medication.

*Question: The nurse has reinforced information to the mother of a toddler regarding toilet training. Which statement by the mother would indicate a need for further teaching?*

*Answer: "I should have my child sit on the potty until my child urinates."* Rationale: The mother should wait until the child is 24 to 30 months old because this makes the task of toilet training considerably easier. Toddlers of this age are less negative and usually are more willing to control their sphincters to please their parents. Bowel control is usually achieved before bladder control. The child should not be forced to sit on the potty for long periods. The ability to sit, squat, and walk well are physical signs of readiness.

*Question: The nurse is reinforcing discharge teaching to a client diagnosed with tuberculosis who has been taking medication for 1½ weeks. The nurse knows that the client has understood the information if which statement is made?*

*Answer: "I should not be contagious after 2 to 3 weeks of medication therapy."* Rationale: The client continues medication therapy for 6 to 12 months depending on the situation. The client is generally considered to not be contagious after 2 to 3 weeks of medication. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to employment when the results of three sputum cultures are negative.

*Question: A licensed practical nurse is precepting a student assigned to care for a client with chronic pain. Which statement, if made by the student, indicates the need for further teaching regarding pain management?*

*Answer: "I will be sure to cue in to any indicators that the client may be exaggerating their pain."* Rationale: Pain is a highly individual experience, and the nurse should not assume that the client is exaggerating the pain. Rather, the nurse should frequently assess the pain and intervene accordingly through the use of both nonpharmacological and pharmacological interventions. The nurse should assess pain using a number-based scale or a picture-based scale for clients who cannot verbally describe their pain to rate the degree of pain. The nurse should follow-up with the client after giving medication to ensure the medication is effective in managing the pain. Pain experienced by the older client may be manifested differently than pain experienced by members of other age groups, and they may have sleep disturbances, changes in gait and mobility, decreased socialization, and depression; the nurse should be aware of this attribute of this population.

*Question: When the nurse is reinforcing instructions to a client who has been newly diagnosed with type 1 diabetes mellitus, which statement by the client would indicate that teaching has been effective?*

*Answer: "I will notify my primary health care provider (PHCP) if my blood glucose level is consistently greater than 250."* Rationale: During illness, the client should monitor the blood glucose level, and he or she should notify the PHCP if the level is greater than 250. Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the PHCP's advice.

*Question: Saquinavir is prescribed for a client diagnosed as human immunodeficiency virus (HIV) seropositive. The nurse would reinforce medication instructions and determine that the client needs further teaching if the client makes which statement?*

*Answer: "I will take the medication on an empty stomach."* Rationale: Saquinavir is an antiretroviral (protease inhibitor) used in combination with other antiretroviral medications in the management of HIV infection. It is administered with meals and is best absorbed if the client consumes high-calorie, high-fat meals. It can cause photosensitivity, and the client is instructed to avoid sun exposure.

*Question: Phenytoin, 100 mg orally three times daily, has been prescribed for a client for seizure control. The nurse reinforces instructions regarding the medication to the client. Which statement by the client indicates an understanding of the instructions?*

*Answer: "I will use a soft toothbrush to brush my teeth."* Rationale: Phenytoin is an anticonvulsant. Gingival hyperplasia, bleeding, swelling, and tenderness of the gums can occur with the use of this medication. The client needs to be taught good oral hygiene, gum massage, and the need for regular dentist visits. The client should not skip medication doses because this could precipitate a seizure. Capsules should not be chewed or broken, and they must be swallowed. The client needs to be instructed to report a sore throat, fever, glandular swelling, or any skin reaction because this indicates hematological toxicity.

*Question: The home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL (9.95 mmol/L). The client is taking cholestyramine. Which statement made by the client indicates the need for further teaching?*

*Answer: "I'll continue my nicotinic acid from the health food store."* Rationale: Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver abnormalities. All lipid-lowering medications can also cause liver abnormalities so a combination of nicotinic acid and cholestyramine resin is to be avoided. Constipation and bloating are the two most common side effects. Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels.

*Question: A client is taking nicotinic acid for hyperlipidemia, and the nurse reinforces instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions?*

*Answer: "Ibuprofen taken 30 minutes before the nicotinic acid should decrease the flushing."* Rationale: Flushing is a side effect of this medication. Aspirin or a nonsteroidal antiinflammatory drug can be taken 30 minutes before taking the medication to decrease flushing. Alcohol consumption needs to be avoided because it will enhance this side effect. The medication should be taken with meals; this will decrease gastrointestinal upset. Taking the medication with meals has no effect on the flushing. Clay-colored stools are a sign of hepatic dysfunction and should be immediately reported to the PHCP.

*Question: The nurse is reinforcing instructions to an adolescent who is taking phenytoin for the control of seizures. Which statement by the adolescent indicates a need for further teaching regarding the medication?*

*Answer: "If my gums become sore, I need to stop the medication."* Rationale: The adolescent should not stop taking antiepileptic medications suddenly or without discussing it with a primary health care provider or nurse. Acne or oily skin may be a problem for the adolescent, and the adolescent is advised to call a primary health care provider for skin problems. Alcohol will lower the seizure threshold, and it is best to avoid the use of alcohol. Birth control pills may be less effective when the client is taking antiseizure medication.

*Question: The nurse is preparing a 2-year-old child with suspected nephrotic syndrome for a renal biopsy to confirm the diagnosis. The mother asks the nurse, "Will my child ever look thin again?" The nurse would respond by giving which statement?*

*Answer: "In most cases, medication and diet will control fluid retention."* Rationale: It is important to give the mother information that addresses the issue that is the parent's concern. Most children experience remission with treatment. Options 1 and 3 are nontherapeutic and may add to the mother's guilt. Option 4 does not acknowledge the concern and is a stereotypical response.

*Question: The nurse is preparing to administer a measles, mumps, rubella (MMR) vaccine to a 15-month-old child. Before administering the vaccine, which question would the nurse ask the mother of the child?*

*Answer: "Is the child allergic to any antibiotics?"* Rationale: Before administration of the MMR vaccine, a thorough health history must be obtained. MMR is used with caution in a child with a history of an allergy to gelatin, eggs, or neomycin because the live measles vaccine is produced by chick embryo cell culture, and MMR also contains a small amount of the antibiotic neomycin. Sore throat, improper eating, and exposure to infections are not contraindications to administering immunizations.

*Question: The nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There's no one left to care about me. Everyone that I have loved is now gone." The nurse would make which appropriate response?*

*Answer: "It sounds as though you are feeling all alone right now."* Rationale: The client is experiencing loss due to the recent death of her husband and is expressing feelings of hopelessness. The therapeutic response by the nurse is, "It sounds as though you are feeling all alone right now." This response is the one that attempts to translate words into feelings. Options 2 and 4 deny the client's feelings. Option 1 puts distance between the nurse and client because it does not address the client's concerns.

*Question: A client is admitted to the inpatient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. The client's mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this?" The nurse would make which therapeutic response?*

*Answer: "It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"* Rationale: The nurse needs to encourage the family and client to verbalize their fears and concerns. Option 4 is the only option that encourages verbalization. Options 1, 2, and 3 avoid dealing with the client or family concerns.

*Question: The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client makes which statement?*

*Answer: "Moving to a warmer climate should help."* Rationale: Raynaud's disease responds favorably to the elimination of nicotine and caffeine. Medications such as calcium channel blockers may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is very important. However, moving to a warmer climate may not necessarily be beneficial because the symptoms could still occur with the use of air conditioning and during periods of cooler weather.

*Question: A mother brings her child to the health care clinic because the child has developed lesions located around the mouth and nose, and mild impetigo is diagnosed. The nurse reinforces instructions to the mother regarding care of the child. Which statement by the mother indicates the need for further teaching?*

*Answer: "My child will need to be treated with oral antibiotics."* Rationale: Impetigo is extremely contagious and may spread to other parts of the child's skin or to others who touch the child, use the same towel, or drink from the same glass. Lesions should be washed gently three times a day with a warm, soapy face cloth and crusts soaked and carefully removed. Mild cases are treated with topical antibiotic ointment. The topical antibiotic ointment is applied to the lesions after they are washed. Severe cases are treated with oral antibiotics.

*Question: The nurse is assisting with collecting data on a child with seizures. The nurse is interviewing the child's parents to establish their adjustment to caring for their child with a chronic illness. Which statement by the parents indicates a need for further teaching?*

*Answer: "Our child sleeps in our bedroom at night."* Rationale: Parents are especially concerned about seizures that might go undetected at night. The nurse should suggest a baby monitor. Reassurance by the nurse should ensure parental confidence and decrease parental overprotection. Option 2 is a common concern. Options 3 and 4 demonstrate the parents' ability to choose respite care and activities appropriately. The parents need to be reminded that as the child grows, they cannot always observe their child, but their knowledge of seizure activity and care is appropriate to minimize complications.

*Question: The nurse has been caring for a client with a diagnosis of depression. The client says to the nurse, "I wish you would just be my friend." The appropriate response by the nurse is which?*

*Answer: "Our relationship is a therapeutic and a helping one."* Rationale: When this occurs, the appropriate response by the nurse would be to make it clear that the relationship is a therapeutic and helping one. Nurses may receive requests by clients to "be my friend." This does not mean that the nurse is not friendly toward the client at times. It does mean, however, that the nurse follows the stated guidelines regarding a therapeutic relationship. The other responses are inappropriate.

*Question: The nurse is reinforcing instructions to the mother of a 2-year-old child regarding dental care. Which statement by the mother indicates the need for further teaching?*

*Answer: "Proper dental care is not necessary for toddlers until their permanent teeth erupt."* Rationale: The nurse should instruct the mother that proper dental care to a toddler is important. It is important to instruct the mother to substitute sweets with healthy food items to prevent dental caries. The first dental visit should be made after the first primary tooth erupts and no later than 30 months of age. It will not hurt the child if some of the toothpaste is swallowed.

*Question: The client is prescribed trimethoprim-sulfamethoxazole for a recurrent urinary tract infection (UTI). The nurse would reinforce which most appropriate instructions to the client regarding this medication?*

*Answer: "Take each dose with 8 ounces of water, and drink extra water each day."* Rationale: Trimethoprim-sulfamethoxazole is a sulfonamide. The client takes each dose with 8 ounces of water and drinks several extra glasses of water each day. The client should space doses evenly around the clock for stable blood levels and should take medication for the full course of therapy. The client should report rashes or other skin changes, which could indicate an allergy to sulfa.

*Question: The nurse working in an urgent care center is interviewing a woman with vague somatic complaints. The client states that she was raped a few weeks ago but still feels "as if it just happened to me." The nurse would make which therapeutic response to the client?*

*Answer: "Tell me more about what happened that causes you to feel like the rape just occurred."* Rationale: The correct response, "Tell me more about what happened that causes you to feel like the rape just occurred," explores the client's thoughts and feelings directly and fully. At the same time, it conveys a nonhurried, nonjudgmental, and supportive attitude that is therapeutic. The client needs reassurance that these feelings are normal and may be expressed in this safe care environment. Option 1 places the client's feelings on hold, and option 4 blocks further communication. Option 2 is likely to increase the client's fear.

*Question: A child is brought to the emergency department, and a fracture of the left lower arm is suspected. The mother states that the child was rollerblading and attempted to break a fall with an outstretched arm. The child receives diagnostic x-rays, from which it has been determined that a fracture is present. A plaster of Paris cast is applied to the arm, and the nurse reinforces instructions to the mother regarding cast care at home. Which instructions would the nurse provide to the mothe

*Answer: "The cast needs to be kept dry because when wet it will begin to disintegrate."* Rationale: Plaster of Paris is a heavier material than that used in a synthetic cast. It molds easily to the extremity and is less expensive than a synthetic cast. It takes about 24 hours to dry, and drying time could be longer depending on the size of the cast. Plaster of Paris is not water resistant, and when wet, it will begin to disintegrate.

*Question: A 4-year-old child sustains a fall at home and is brought to the emergency department by the mother. Following x-ray examination, it has been determined that the child has a fractured arm, and a plaster cast is applied. The nurse reinforces instructions to the mother regarding cast care for the child. Which statement by the mother indicates a need for further teaching?*

*Answer: "The cast will feel warm when it is dried."* Rationale: Once the cast dries, the cast will sound hollow and will be cool (not warm) to touch. A fan can be directed toward the cast to facilitate drying. The mother must be instructed to call the primary health care provider if any blood or drainage appears on the cast. Ice can be applied to the casted area to prevent swelling.

*Question: A nursing student is assigned to care for a hospitalized 2-year-old child. The nursing instructor reviews the plan of care with the student and asks the student to identify the expected behavior of the child in regard to separation anxiety. Which statement by the student indicates an understanding of separation anxiety that can occur in a 2-year-old child?*

*Answer: "The child may ignore the parents when they visit."* Rationale: The toddler is particularly vulnerable to separation. A toddler often shows anger at being left by ignoring the parent or by pretending to be more interested in play than in going home. Parents of hospitalized toddlers frequently are distressed by such behavior. The toddler engages in parallel play and plays alongside but not with other children.

*Question: The nurse is providing information to the mother of a child with nephrotic syndrome regarding the edematous appearance of the child. Which statement would the nurse make to the mother?*

*Answer: "The fluid retention should be controlled by medication and diet."* Rationale: Most children experience remission with treatment and corticosteroids. Diuretics also may be a component of the treatment plan, and a restricted sodium diet is recommended. It is important to give the parent information in a matter-of-fact manner and address the issue that is the parent's concern. Options 1, 2, and 4 are inaccurate and inappropriate statements to the mother.

*Question: The nurse is reinforcing instructions to the mother of a child with juvenile idiopathic arthritis regarding measures to take if a painful exacerbation of the disease occurs. Which statement by the mother indicates the need for further teaching?*

*Answer: "The full range-of-motion (ROM) exercises must be performed every day, even during the exacerbations."* Rationale: During painful episodes, hot or cold packs and splinting and positioning the affected joint in a neutral position help reduce the pain. Full ROM exercises will cause significant pain during exacerbation and should be avoided during this time. Although resting the extremity is appropriate, it is important to begin simple isometric or tensing exercises as soon as the child is able. These exercises do not involve joint movement.

*Question: The nurse is assisting a client who has just been given a hearing aid to wear for the first time. When reinforcing client teaching, the nurse would include which instruction?*

*Answer: "The hearing aid should not be worn if an ear infection is present."* Rationale: The client should be instructed that the hearing aid should not be worn if an ear infection is present. The client should be instructed to turn off the hearing aid before removing it from the ear to prevent noisy feedback. The hearing aid should be turned off when not in use, and extra batteries should be kept on hand. The client should wash the ear mold frequently with mild soap and water, using a pipe cleaner to cleanse the cannula.

*Question: A new mother is seen in the health care clinic 2 weeks after the birth of a healthy newborn. The mother says that she feels as though she has the flu and complains of fatigue and aching muscles. On further data collection the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse how the condition occurs. Which nursing response is appropriate?*

*Answer: "The infection can occur at any time during breastfeeding."* Rationale: Mastitis is an infection of the lactating breasts and occurs most often during the second and third weeks after birth, although it may develop at any time during breastfeeding. It is more common in mothers nursing for the first time and usually affects one breast at a time but can affect both breasts. Constriction of the breasts from a bra that is too tight may interfere with emptying of all the ducts and may lead to infection.

*Question: Silver sulfadiazine is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments?*

*Answer: "The medication is likely to cause stinging initially."* Rationale: Silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not cause stinging when applied.

*Question: The mother of a 4-year-old who was recently hospitalized brings the child to the clinic for a follow-up visit. The mother tells the nurse that the child has begun to wet the bed and that it started when the child was brought home from the hospital. The mother is concerned and asks the nurse what to do. Which nursing response is appropriate?*

*Answer: "This is a normal occurrence following hospitalization."* Rationale: Regression can occur in a preschooler and is most often caused by the stress of the hospitalization. It is best to accept the regression if it occurs. Parents may be overly concerned about regression and should be told that regression is normal following hospitalization. It is premature to discuss the situation with the primary health care provider. Options 1 and 4 are inappropriate responses to the mother.

*Question: The nurse is providing instructions to a child with cystic fibrosis regarding how to perform the "huff" maneuver. The child asks the nurse about the purpose of this type of breathing. Which nursing response is appropriate?*

*Answer: "This type of breathing is used to mobilize secretions so that they can be easily coughed out."* Rationale: The "huff" maneuver (forced expiratory technique) is used to mobilize secretions. This technique reduces the likelihood of bronchial collapse. The child is taught to cough with an open glottis by taking a deep breath, then exhaling rapidly whispering the word, "huff." Neither option 1, 2, nor 3 is the purpose of this breathing technique.

*Question: The nurse is assigned to assist in caring for a client diagnosed with a pneumothorax who has a chest tube connected to a closed-chest drainage system. The client asks the nurse why a chest tube was inserted. Which response by the nurse explains the purpose of a chest tube?*

*Answer: "To allow for reexpansion of the lung."* Rationale: A chest tube may be inserted after a pneumothorax and connected to water-seal drainage to remove the air and allow reexpansion of the lung. It does not lessen discomfort, prevent further damage to the lung, or help prevent lung infections.

*Question: A client has been instructed by the primary health care provider to alternate the use of hydrogen peroxide and glycerin eardrops to loosen an impacted accumulation of earwax. The nurse gives the client which directions to accomplish this daily procedure safely and independently?*

*Answer: "Use the solutions at body temperature for 7 to 14 days."* Rationale: The solutions should be used at body temperature for 7 to 14 days. This prevents injury to the ear and allows sufficient time for the material to soften. The other options are incorrect procedures.

*Question: The nurse reinforces home care instructions to the parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further teaching?*

*Answer: "We need to maintain respiratory precautions and a quiet environment for at least 2 weeks."* Rationale: Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase. Options 1, 2, and 4 are components of home care instructions.

*Question: A client with acute muscle spasms has been taking baclofen. The client calls the clinic nurse because of continuous feelings of weakness and fatigue and asks the nurse about discontinuing the medication. The nurse would make which appropriate response to the client?*

*Answer: "Weakness and fatigue commonly occur and will diminish with continued medication use."* Rationale: The client should be instructed that symptoms such as drowsiness, weakness, and fatigue are more intense in the early phase of therapy and diminish with continued medication use. The client should be instructed never to withdraw or stop the medication abruptly because abrupt withdrawal can cause visual hallucinations, paranoid ideation, and seizures. It is best for the nurse to inform the client that these symptoms will subside and encourage the client to continue the use of the medication.

*Question: The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which would be a therapeutic response by the nurse?*

*Answer: "What aspects of this situation are the most difficult for you?"* Rationale: The most helpful response is "What aspects of this situation are the most difficult for you?" This response encourages the spouse to explore the problem and problem-solve. Option 2 disregards the spouse's concern and focuses instead on the reaction of the alcoholic client. The nurse needs to neither agree, as in option 4, nor disagree, as in option 1, with the spouse. Giving advice implies that the nurse knows what is best and can also foster dependency.

*Question: The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse would be which statement?*

*Answer: "What do you find difficult about this situation?"* Rationale: The most helpful response is the one that encourages the client to problem solve. Giving advice implies that the nurse knows what is best and can also foster dependency. The nurse should not agree with the client, nor should the nurse request that the client provide explanations.

*Question: The nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement is appropriate to make to this client?*

*Answer: "What is causing you to become agitated?"* Rationale: The best statement is to ask the client what is causing the agitation. This will assist the client with becoming aware of the behavior and will assist the nurse with planning appropriate interventions for the client. Option 1 is demanding behavior, which could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate.

*Question: A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. Which comments by the nurse would be therapeutic at this time?*

*Answer: "What is causing you to become agitated?"* Rationale: The therapeutic comment is to ask the client what is causing the agitation. This helps make the client aware of the behavior and may assist the nurse in planning appropriate interventions. Options 2 and 4 constitute threats to the client that are inappropriate. Option 3 is confrontational and could further escalate the client's behavior.

*Question: The nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, which is the most appropriate question to ask?*

*Answer: "What leads you to seek help now?"* Rationale: The nurse's initial task when gathering data from a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. Option 3 will assist with determining data related to the precipitating event that led to the crisis. Options 1 and 2 identify situational supports. Option 4 identifies personal coping skills.

*Question: The nurse is collecting data on a client in crisis. Which question would the nurse ask to determine the client's perception of the precipitating event that led to the crisis?*

*Answer: "What leads you to seek help now?"* Rationale: The question the nurse would ask to determine the client's perception of the precipitating event is, "What leads you to seek help now?" The first task of the nurse who is assessing a client in crisis is to gather information about the individual or family and the problem. The more clearly the problem can be defined, the higher the likelihood of a successful outcome. Once the precipitating event or problem has been assessed, the nurse then assesses situational supports, as in options 1 and 2, and coping skills, as in option 4.

*Question: The nurse assists in making a plan of care for a client and is developing goals that will help the client achieve an optimal level of functioning and use resources. When the nurse enters the client's room, the client says to the nurse, "Could you ask my psychiatrist to let me have a pass for the weekend?" Which nursing response is appropriate to assist the client in achieving the goal that has been set for this client?*

*Answer: "When the psychiatrist arrives on the unit, I will let her know that you have a question."* Rationale: The appropriate nursing response is to tell the client that "when the psychiatrist arrives on the unit, I will tell her that you have a question." The nurse would become aware of the client's strengths and encourage the client to work at the optimal level of functioning. In option 2 the nurse is helping the client develop resources. The nurse does not act for clients unless absolutely necessary, and then only as a step toward helping clients act on their own. Consistently encouraging clients to use their own resources helps minimize clients' feelings of helplessness and dependency and validates their potential for change.

*Question: The nurse is collecting data on a client diagnosed with mild depression. The client says to the nurse, "I haven't had an appetite at all for the last few weeks." Which response by the nurse would be therapeutic?*

*Answer: "You haven't had an appetite at all?"* Rationale: The therapeutic response by the nurse is "You haven't had an appetite at all?" This communication technique is a form of restatement. Although it is a technique that has a prompting component to it, it repeats the client's major theme, which helps the nurse obtain a more specific perception of the problem from the client. Options 3 and 4 block the communication process. Option 1 focuses on the number of weeks that the lack of appetite has been present rather than the specific problem.

*Question: The nurse in a newborn nursery is told that a newborn with spina bifida (myelomeningocele type) will be transported from the delivery room. The nurse is asked to prepare for the arrival of the newborn. The nurse places which priority item at the newborn's bedside?*

*Answer: A bottle of sterile normal saline* Rationale: The newborn with spina bifida is at risk for infection before the closure of the gibbus. A sterile normal-saline dressing is placed over the gibbus to maintain moisture of the gibbus and its contents. This prevents tearing or breakdown of the skin integrity at the site. Blood pressure is difficult to assess during the newborn period and is not the best indicator of infection. Urine concentration is not well developed in the newborn stage of development. A thermometer will be needed to assess the temperature, but in this newborn the priority is to maintain sterile normal-saline dressings over the gibbus.

*Question: The nurse is caring for a client with respiratory insufficiency. The arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco2 of 30 mm Hg (30 mm Hg), and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value would the nurse expect to note?*

*Answer: A potassium level of 3.0 mEq/L* Rationale: Signs/symptoms of respiratory alkalosis include tachypnea, change in mental status, dizziness, pallor around the mouth, spasms of the muscles of the hands, and hypokalemia. The remaining options identify normal laboratory results.

*Question: Phenazopyridine hydrochloride is prescribed for a client for symptomatic relief of pain resulting from a lower urinary tract infection. Which would the nurse reinforce to the client?*

*Answer: A reddish-orange discoloration of the urine may occur.* Rationale: The nurse should instruct the client that a reddish-orange discoloration of urine may occur. The nurse also should instruct the client that this discoloration can stain fabric. The medication should be taken after meals to reduce the possibility of gastrointestinal upset. A headache is an occasional side effect of the medication and does not warrant discontinuation of the medication.

*Question: The client with diagnosed acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temperature of 101° F (38.3° C). The nurse continues to monitor the client, knowing that this sign would most likely indicate which condition?*

*Answer: A result of another infection caused by the leukopenic effects of the medication.* Rationale: Frequent side/adverse effects of this medication include leukopenia, thrombocytopenia, and anemia. The client should be monitored routinely for signs and symptoms of infection. Options 1, 2, and 3 are inaccurate interpretations.

*Question: The nurse is reviewing the record of a client who has been prescribed baclofen. Which disorder would alert the nurse to contact the primary health care provider (PHCP)?*

*Answer: A seizure disorder* Rationale: Clients with seizure disorders may have a lowered seizure threshold when baclofen is administered. Concurrent therapy may require an increase in the anticonvulsive medication. The disorders in options 2, 3, and 4 are not a concern when the client is taking baclofen.

*Question: The nurse is assigned to care for a client with a detached retina. Which finding would the nurse expect to be documented in the client's record?*

*Answer: A sense of a curtain falling across the field of vision* Rationale: A characteristic clinical manifestation of retinal detachment described by clients is the feeling that a shadow or curtain is falling across the field of vision. There is no pain associated with detachment of the retina. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal. Options 1 and 3 are not specifically associated with a detached retina.

*Question: The client with myasthenia gravis becomes increasingly weak. The primary health care provider (PHCP) prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which change in condition indicates that the client is in cholinergic crisis?*

*Answer: A temporary worsening of the condition* Rationale: An edrophonium injection makes the client experiencing cholinergic crisis temporarily worse. This is known as a negative test. An improvement of weakness would occur if the client were experiencing myasthenia gravis. Options 1 and 2 would not occur in either crisis.

*Question: When reinforcing teaching about signs and symptoms of ovarian cancer with a community group of women, the nurse emphasizes which sign/symptom as being a typical manifestation of the disease recognized by persons diagnosed with the condition?*

*Answer: Abdominal distention or fullness* Rationale: Ovarian cancer is the leading cause of death from gynecological cancers and occurs in women older than 50 years. The most common sign and symptom of ovarian cancer is abdominal distention or fullness. Less common are vague symptoms of urinary frequency and urgency and gastrointestinal symptoms such as a change in bowel habits. Pelvic cramping, sharp abdominal pain, or postmenopausal vaginal bleeding are not the most typical signs and symptoms.

*Question: A client with schizophrenia has been started on medication therapy with loxapine. The nurse determines that the client is experiencing the intended effects of the medication if which client behavior is observed?*

*Answer: Absence of delusional statements* Rationale: The nurse knows that the client is experiencing the intended effects of Loxapine if there is an absence of delusional statements. Loxapine is an antipsychotic medication used to treat psychotic symptoms in clients. Hallucinations, delusions, and altered thought processes are characteristic of this disorder and would decrease with effective treatment. Presence of fixed stare and taking sips of water for dry mouth are side effects of therapy. Decreased appetite is unrelated to the question.

*Question: The nurse is reinforcing instructions to a group of adults about the seven warning signs of cancer. The nurse determines that a member of the group needs further teaching if the member states which sign/symptom is a warning sign?*

*Answer: Absence or decreased frequency of menses* Rationale: Each of the seven warning signs of cancer begins with a letter from the word CAUTION. The one that is not part of the seven is absence or decreased frequency of menses. This particular item could be indicative of pregnancy or menopause, as well as other pathological problems. Unusual bleeding or discharge, however, is one of the warning signs.

*Question: The nurse is reviewing the medication list for an assigned client. Which medication is the only one on the client's prescription sheet that does not have an ototoxic effect?*

*Answer: Acetaminophen* Rationale: Acetaminophen is toxic to the liver (hepatotoxic) in large doses. It does not result in ototoxicity. The medications listed in options 1, 3, and 4 carry ototoxicity as a risk of therapy.

*Question: A client was just admitted to the hospital to rule out a gastrointestinal bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication would the nurse determine to be the cause of the client's complaint?*

*Answer: Acetylsalicylic acid* Rationale: Aspirin is contraindicated for gastrointestinal bleeding and is potentially ototoxic. The client should be advised to notify the prescribing primary health care provider (PHCP) so that the medication can be discontinued and/or a substitute that is less toxic to the ear can be taken instead. Options 1, 2, and 4 do not have side effects that are potentially associated with hearing difficulties.

*Question: The nurse is assisting with the administration of immunizations at a health care clinic. The nurse would understand that immunization provides which protection?*

*Answer: Acquired immunity from disease* Rationale: Acquired immunity can occur by receiving an immunization that causes antibodies to a specific pathogen to form. Natural (innate) immunity is present at birth. No immunization protects the client from all diseases.

*Question: A client is scheduled to receive digoxin 0.125 mg by mouth. The licensed practical nurse (LPN) reads the medication label and notes that each tablet contains 0.25 mg. The LPN would perform which action?*

*Answer: Administer half of a medication tablet.* Rationale: If the primary health care provider has prescribed 0.125 mg and the bottle of medication reads 0.25 mg, then the nurse would administer half a tablet. The 2 tablets would be 4 times the correct dose. There is no need to contact the pharmacist or the registered nurse.

*Question: The client is receiving an eye drop and an eye ointment to the right eye. Which action would the nurse take?*

*Answer: Administer the eye drop first, followed by the eye ointment.* Rationale: When an eye drop and an eye ointment is scheduled to be administered at the same time, the eye drop is administered first. Options 2, 3, and 4 are incorrect.

*Question: The child is diagnosed with tinea capitis of the scalp. Oral griseofulvin has been prescribed for the child, and the nurse provides instructions regarding the administration of the medication. Which instructions would the nurse include to the mother?*

*Answer: Administer the medication with milk.* Rationale: Griseofulvin (topical and oral) is the treatment of choice for tinea capitis. For topical treatment to be effective, topical medication must penetrate the hair follicles. Topical therapy alone is not effective, and oral medication is prescribed. Because the medication is insoluble in water, absorption of the medication is improved if it is taken with a high-fat meal or with milk.

*Question: The nurse in the labor room is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal heart rate pattern shows multiple late decelerations on the monitor strip. Based on this information, the nurse prepares for which appropriate nursing action?*

*Answer: Administering oxygen via face mask* Rationale: Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore, oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An IV oxytocin infusion is decreased or discontinued when a late deceleration is noted; otherwise, the oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions caused by the oxytocin. Documenting findings and continuing to monitor delay necessary treatment.

*Question: A client has just been admitted with a diagnosis of myxedema coma. If all of the following interventions were prescribed, the nurse would place highest priority on completing which action first?*

*Answer: Administering oxygen* Rationale: As part of maintaining a patent airway, oxygen would be administered first. This would be quickly followed by fluid replacement, keeping the client warm, monitoring vital signs, and administering thyroid hormones.

*Question: A client receiving desmopressin begins to complain of a headache. The nurse notes that the client is listless and falls asleep easily. The nurse interprets that the client is most likely experiencing which reaction?*

*Answer: Adverse medication effects* Rationale: Desmopressin is used in the management of diabetes insipidus. Thus the action of the medication is to cause water retention. Adverse effects of desmopressin then could include water intoxication or hyponatremia. Early signs include drowsiness, listlessness, and headache. Decreased urination, rapid weight gain, confusion, seizures, and coma also may occur as a result of overhydration.

*Question: The nurse is orienting a new nurse to the care of a client who has an internal radiation implant. Which statement by the new nurse demonstrates the need for further teaching?*

*Answer: After visiting hours, the client may be put in a wheel chair and taken out of the room.* Rationale: Precautions must be enforced to protect health care workers and visitors when a client has an internal radiation implant. The client must stay in the room and be taken out only for medical reasons approved by the radiologist. If the client sits in a wheelchair the implant may move. Children younger than 16 years of age and pregnant women are not allowed in the client's room. The time that the nurse spends in a room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The dosimeter badge must be worn when in the client's room.

*Question: A client is unwilling to get out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The spouse asks the nurse, "What is the name of my wife's disorder?" Which answer would the nurse give to the spouse?*

*Answer: Agoraphobia* Rationale: Agoraphobia is a fear of being alone in open or public places where escape might be difficult. Agoraphobia includes experiencing fear or a sense of helplessness or embarrassment if a phobic attack occurs. Avoidance of such situations usually results in the reduction of social and professional interactions. Hematophobia is the fear of blood. Claustrophobia is a fear of closed-in places. Clients with somatic symptom disorder focus their anxiety on physical complaints and are preoccupied with their health.

*Question: The wife of a client who abuses alcohol tells the nurse she cannot "do it alone" any longer and asks the nurse about the availability of any free support services for "people like me." The nurse refers the client's wife to which community group?*

*Answer: Al-Anon* Rationale: Al-Anon is a support group for families of alcoholics. Fresh Start is a self-help group for those with addiction to nicotine. Families Anonymous is a support group for parents of children who abuse substances. Alcoholics Anonymous is a major self-help organization for those who suffer from alcoholism.

*Question: Glimepiride is prescribed for a client with diabetes mellitus. The nurse reinforces instructions for the client and tells the client to avoid which while taking this medication?*

*Answer: Alcohol* Rationale: When alcohol is combined with glimepiride, a disulfiram-like reaction may occur. This syndrome includes flushing, palpitations, and nausea. Alcohol can also potentiate the hypoglycemic effects of the medication. Clients need to be instructed to avoid alcohol consumption while taking this medication. The items in options 2, 3, and 4 do not need to be avoided.

*Question: A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse would encourage the client to attend which community group?*

*Answer: Alcoholics Anonymous* Rationale: Alcoholics Anonymous is a major self-help organization for the treatment of alcoholism. Option 1 is a group for families of alcoholics. Option 2 is for nicotine addicts. Option 3 is for parents of children who abuse substances.

*Question: A client with spinal cord injury has experienced more than one episode of autonomic dysreflexia. The nurse would avoid which action that could trigger an episode of this complication?*

*Answer: Allowing the client's bladder to become distended* Rationale: Autonomic dysreflexia is triggered most frequently by a distended bladder. To prevent this, straight catheterization is done every 4 to 6 hours, and indwelling urinary catheters are checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas. Preventing pressure in the client's lower limbs, rigidly adhering to a bowel retraining program, and keeping the linen under the client free of wrinkles would not trigger an episode of autonomic dysreflexia.

*Question: A client with chronic kidney disease has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now has mental cloudiness, dementia, and complaints of bone pain. Which does this data indicate?*

*Answer: Aluminum intoxication* Rationale: Aluminum intoxication may occur when there is accumulation of aluminum, an ingredient in many phosphate-binding antacids. It results in mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. This condition was formerly known as dialysis dementia. It may be treated with aluminum-chelating agents, which make aluminum available to be dialyzed from the body. It can be prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum.

*Question: A client has just undergone renal biopsy. In planning care for this client, the nurse would avoid which intervention?*

*Answer: Ambulate in the room and hall for short distances.* Rationale: After renal biopsy, bed rest is maintained for at least 24 hours. The client's vital signs and puncture site are assessed frequently during this time. Urine is tested periodically for occult blood to detect bleeding as a complication. Fluids are encouraged to reduce possible clot formation at the biopsy site. Opioid analgesics often are needed to manage the renal colic pain that some clients feel after this procedure.

*Question: The nurse employed in an emergency department is instructed to monitor a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. The nurse interprets this observation as indicating which finding?*

*Answer: An airway obstruction* Rationale: Signs and symptoms suggestive of airway obstruction include tripod positioning (leaning forward supported by arms, chin thrust out, mouth open), nasal flaring, tachycardia, a high fever, and sore throat. The data in the question do not relate to options 1, 2, or 4.

*Question: The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse monitors for the most serious complication associated with this type of traction by checking for which?*

*Answer: An elevated temperature* Rationale: The most serious complication associated with skeletal traction is osteomyelitis, an infection involving the bone. Organisms gain access to the bone systemically or through the opening created by the metal pins or wires used with the traction. Osteomyelitis may occur with any open fracture. Signs and symptoms include complaints of localized pain, swelling, warmth, tenderness, an unusual odor from the fracture site, and an elevated temperature.

*Question: The client has an as-needed prescription for loperamide hydrochloride. For which condition would the nurse administer this medication?*

*Answer: An episode of diarrhea* Rationale: Loperamide is an antidiarrheal agent. It is used to manage acute and also chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy. It is not used for the conditions in options 1, 2, and 4.

*Question: The nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which sign noted in the mother indicates an early sign of excessive blood loss and shock?*

*Answer: An increase in the pulse rate from 88 to 102 beats per minute* Rationale: During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure is not the earliest sign of hemorrhage. An elevation in temperature is not a sign of excessive blood loss. Although the respiratory rate may increase, this is not an early sign of hemorrhage. In addition, an increase in the respiratory rate from 18 to 22 breaths per minute is not significant.

*Question: The client diagnosed with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been prescribed pentamidine isethionate. The nurse assisting in caring for the client should monitor the client most closely for which adverse effect?*

*Answer: Anemia* Rationale: Pentamidine isethionate is an anti-infective medication. Adverse effects of this medication include leukopenia, thrombocytopenia, and anemia. The client should be monitored routinely for signs and symptoms of these adverse effects. The client also should have ongoing monitoring of a number of parameters because of the nature and side effects of the medication, including blood glucose, blood urea nitrogen, serum creatinine, complete blood cell count, liver function studies, and serum calcium and magnesium levels.

*Question: A licensed practical nurse (LPN) is reviewing the medical record of a newly assigned client and notes that the client is receiving cyclobenzaprine hydrochloride for the treatment of muscle spasms. The LPN questions the prescription if which disorder is noted in the admission history?*

*Answer: Angle-closure glaucoma* Rationale: Cyclobenzaprine hydrochloride is a skeletal muscle relaxant. Because cyclobenzaprine hydrochloride has anticholinergic effects, it should be used cautiously in clients with a history of urinary retention, angle-closure glaucoma, and increased intraocular pressure. It is intended for short-term (2- to 3-week) therapy. The other disorders are not contraindications or concerns for the client receiving cyclobenzaprine hydrochloride.

*Question: A 6-month-old infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at the well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which instruction by the nurse is appropriate?*

*Answer: Apply an ice pack to the injection site.* Rationale: Occasionally tenderness, redness, or swelling may occur at the site of the injection. This can be relieved with cool packs for the first 24 hours and followed by warm or cool compresses if the inflammation persists. It is not necessary to bring the infant back to the clinic. Option 1 may be an appropriate intervention, but it is not specific to the question.

*Question: The client calls the office of the primary health care provider (PHCP) and states to the nurse that they were just stung by a bumblebee while gardening. The client is afraid of a severe reaction because their neighbor experienced such a reaction just 1 week ago. Which would be the appropriate nursing action?*

*Answer: Ask the client if they ever sustained a bee sting in the past.* Rationale: In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. Therefore, the appropriate action would be to ask the client if he ever received a bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told "not to worry."

*Question: The nurse is preparing to assist in performing a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment?*

*Answer: Ask the client to urinate and empty her bladder.* Rationale: Before fundal assessment is started, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. The nurse can then assess the bladder for complete emptying and accurately assess uterine involution. When fundal assessment is performed, the woman is asked to lie flat on her back with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy or soft, in which case it should be massaged gently until firm.

*Question: The nurse has a prescription to collect a 24-hour urine specimen from a client. The assistive personnel (AP) has been instructed on the collection technique. Which action by the AP demonstrates the AP needs further teaching?*

*Answer: Asks the client to void, save the specimen, and note the start time* Rationale: Because the 24-hour urine test is a timed quantitative determination, the test must be started with an empty bladder. Therefore, the first urine is discarded. Fifteen minutes before the end of the collection time, the client should be asked to void, and this specimen is added to the collection. The urine collection should be refrigerated or placed on ice to prevent changes in urine.

*Question: A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. What is the nurse's most important intervention to maintain client safety?*

*Answer: Assign a staff member to the client who will remain with him or her at all times.* Rationale: Hanging is a serious suicide attempt. The plan of care must reflect action that will promote the client's safety. Constant observation status (one-on-one) with a staff member who is never less than an arm's length away is the safest intervention.

*Question: The nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse would avoid which intervention in the plan of care?*

*Answer: Assigning the client to a room at the end of the hall to prevent disturbing the other clients* Rationale: The client should be placed in a room near the nurses' station and not at the end of a long, relatively unprotected corridor. The nurse should not isolate himself or herself with a potentially violent client. The door to the client's room should be kept open, and the nurse should never turn away from the client. A security officer should be within immediate call in case the possibility of violence is suspected.

*Question: The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task would the nurse appropriately plan for during this phase?*

*Answer: Assist with making appropriate referrals.* Rationale: Tasks of the termination phase include evaluating client performance, evaluating achievement of expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with termination. Options 1, 2, and 4 identify the tasks of the working phase of the relationship.

*Question: The nurse is reviewing the health care provider's prescription sheet for the preoperative client, which states that the client must be on nothing by mouth (NPO) status after midnight. The nurse would clarify whether which medication would be given to the client rather than withheld?*

*Answer: Atenolol* Rationale: Atenolol is a beta blocker. Beta blockers should not be stopped abruptly, and the health care provider should be contacted about the administration of this medication before surgery. If a beta blocker is stopped abruptly, the myocardial need for oxygen is increased. Cyclobenzaprine is a skeletal muscle relaxant. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Conjugated estrogen is an estrogen used for hormonal replacement therapy in postmenopausal women. The other three medications may be withheld before surgery without undue effects on the client.

*Question: The nurse is preparing a subcutaneous dose of bethanechol chloride prescribed for a client with urinary retention. Before giving the dose, the nurse checks to see that which medication is available on the emergency cart?*

*Answer: Atropine sulfate* Rationale: Administration of bethanechol chloride could result in cholinergic overdose. The antidote is atropine sulfate (an anticholinergic), which should be readily available for use if overdose occurs. Acetylcysteine is the antidote for acetaminophen overdose. Protamine sulfate is the antidote for heparin. Vitamin K is the antidote for warfarin.

*Question: A licensed practical nurse (LPN) is reviewing the medication list of a client with a history of glaucoma. The LPN would consult with the registered nurse if which medication is prescribed for the client?*

*Answer: Atropine sulfate* Rationale: Pilocarpine and carteolol are examples of miotic agents used in the treatment of glaucoma. Atropine sulfate is a mydriatic and cycloplegic medication that is contraindicated for use in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye.

*Question: Pilocarpine hydrochloride is prescribed for the client with glaucoma. Which medication would the nurse plan to have available in the event of systemic toxicity?*

*Answer: Atropine sulfate* Rationale: Systemic absorption of pilocarpine hydrochloride can produce toxicity and includes manifestations of vertigo, bradycardia, tremors, hypotension, and seizure. Atropine sulfate must be available in the event of systemic toxicity. Pindolol, timolol maleate, and carteolol hydrochloride are beta-blockers.

*Question: The client with myasthenia gravis is receiving pyridostigmine. The nurse monitors for signs and symptoms of cholinergic crisis caused by overdose of the medication. The nurse checks the medication supply to ensure that which medication is available for administration if a cholinergic crisis occurs?*

*Answer: Atropine sulfate* Rationale: The antidote for cholinergic crisis is atropine sulfate. Acetylcysteine is the antidote for acetaminophen. Vitamin K is the antidote for warfarin and protamine sulfate is the antidote for heparin.

*Question: A licensed practical nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 36.2° C (97.2° F) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action would the

*Answer: Attempt to arouse the client.* Rationale: The primary concern with opioid analgesics is respiratory depression and hypotension. Based on the findings, the nurse should suspect opioid overdose. The nurse should first attempt to arouse the client and then reassess the vital signs. The vital signs may begin to normalize once the client is aroused because sleep can also cause decreased heart rate, blood pressure, respiratory rate, and oxygen saturation. The nurse should also check to see how much medication has been taken via the PCA pump and should continue to monitor the client closely to determine whether further action is needed. The nurse should notify the registered nurse as the next step after attempting to arouse the client. The nurse would also then document the findings after all data is collected, the client is stabilized, and if an abnormality still exists after arousing the client.

*Question: The nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding preventing the transmission of the infection to the other children in the family and the other household members. Which instructions would the nurse reinforce to the mother?*

*Answer: Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through the saliva.* Rationale: Roseola, a viral disease affecting infants from 6 months to 2 years, involves an upper respiratory infection and a pink to red rash that occurs after several days of high fever have ended. It is transmitted via saliva; therefore, others should not share drinking glasses or eating utensils. Isolating the child, washing linens in bleach separately, and having the child use a separate bathroom are not accurate instructions regarding the prevention of the transmission of roseola.

*Question: The nurse has provided discharge instructions to a client being placed on long-term anticoagulant therapy with warfarin sodium. The nurse reminds the client to do which?*

*Answer: Avoid taking products containing acetylsalicylic acid.* Rationale: Warfarin sodium is an anticoagulant. The client should avoid taking aspirin because of its antiplatelet properties and should avoid taking other over-the-counter medications without checking with the primary health care provider first because they could contain ingredients that would interact with the warfarin sodium. The client should avoid alcohol while taking warfarin sodium per primary health care provider's directions. The client should take the medication at the same time each day to increase compliance and keep therapeutic blood levels stable.

*Question: The nurse is reinforcing discharge instructions to a client receiving baclofen. Which would the nurse include in the instructions?*

*Answer: Avoid the use of alcohol.* Rationale: Baclofen is a central nervous system (CNS) depressant. The client should be cautioned against the use of alcohol and other CNS depressants because baclofen potentiates the depressant activity of these agents. It is not necessary to restrict fluids, but the client should be warned that urinary retention can occur. Constipation rather than diarrhea is an adverse effect of baclofen. Fatigue is related to a CNS effect that is most intense during the early phase of therapy and diminishes with continued medication use. It is not necessary that the client notify the PHCP if fatigue occurs.

*Question: The nurse working in an obstetrical-gynecological primary health care provider's office is instructing a small group of premenopausal female clients about breast self-examination (BSE). Which instruction would the nurse reinforce as the first step to begin the BSE?*

*Answer: BSE begins with inspection of the breast standing before a mirror.* Rationale: BSE begins with inspection of the breasts while the woman is standing before a mirror. After this is completed the woman then palpates her axilla with her arm only slightly (not fully) raised. The second step of the BSE is vertical pattern palpation of the breasts and the axillary area. The ACS and women's health care experts recommend that the woman lie on her back with a folded towel under the shoulder of the breast to be examined. The arm on the same side is raised above her head.

*Question: The nurse employed in the emergency department is collecting data on a 7-year-old child with a fractured arm. The child is hesitant to answer questions that the nurse is asking and consistently looks at the parents in a fearful manner. The nurse suspects physical abuse and continues with the data collection procedures. Which finding would most likely assist in verifying the suspicion?*

*Answer: Bald spots on the scalp* Rationale: Bald spots on the scalp are most likely to be associated with physical abuse. The most likely findings in sexual abuse include difficulty walking or sitting; torn, stained, or bloody underclothing; pain; swelling or itching of the genitals; and bruises, bleeding, or lacerations in the genital or anal area. Poor hygiene may be indicative of physical neglect.

*Question: The nurse is providing vaccine information to the second-day postpartum client who received a rubella vaccine. The nurse would instruct the client to avoid which action after receiving this vaccine?*

*Answer: Becoming pregnant for 2 to 3 months* Rationale: Rubella vaccine is a live attenuated virus that provides active immunity for 15 years. Because rubella is a live vaccine, it is potentially teratogenic during the organogenesis phase of fetal development. To avoid this risk, the nurse advises the client to avoid becoming pregnant for 2 to 3 months after receiving the vaccine. Abstinence from sexual intercourse is unnecessary, but an effective form of contraception should be used. The vaccine may cause local or systemic reactions that are mild and self-limiting. Injuries to the injection site and eating highly acidic foods are not significant or related to this vaccine.

*Question: A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements should be noted at which time interval?*

*Answer: Between 16 and 20 weeks' gestation* Rationale: Fetal movement, called quickening, is not perceived until the second trimester. Between 16 and 20 weeks of gestation the expectant mother first notices subtle fetal movements that gradually increase in intensity.

*Question: Oral iron is prescribed for a child with an iron deficiency anemia, and the nurse provides instructions to the mother regarding the administration of the iron. The nurse instructs the mother to administer the iron in which way?*

*Answer: Between meals* Rationale: The mother should be instructed to administer oral iron supplements between meals. The iron should be given with a citrus fruit or juice high in vitamin C because vitamin C increases the absorption of iron by the body.

*Question: A client has a history of left-sided heart failure. The nurse would look for the presence of which finding to determine whether the problem is currently active?*

*Answer: Bilateral lung crackles* Rationale: The client with heart failure may present with different symptoms depending on whether the right or the left side of the heart is failing. Breath sounds are an accurate indicator of left-sided heart function. Peripheral edema, jugular vein distention, and ascites can be present as a result of insufficiency of the pumping action of the right side of the heart.

*Question: A client with myocardial infarction is a candidate for alteplase therapy. The nurse assisting in the care of this client is aware that it will be necessary to monitor for which adverse effect of this therapy?*

*Answer: Bleeding* Rationale: Alteplase is a thrombolytic medication, which means that it breaks down or dissolves clots. Because of its action, the principal adverse effect is bleeding. Local or systemic infection could occur with poor aseptic technique during medication administration, but it is rare. Allergic reaction is not a frequent response. Muscle weakness is not an adverse effect of this medication.

*Question: The nurse is preparing to administer pentamidine isethionate to an assigned client by the intramuscular route. Which most appropriate parameter would the nurse monitor while administering this medication?*

*Answer: Blood pressure (BP)* Rationale: Pentamidine isethionate is an anti-infective medication. Life-threatening and fatal hypotension can occur following the administration of this medication. The client must be in a supine position with frequent BP checks following administration. Capillary refill, peripheral pulses, and level of consciousness are not associated with the administration of this medication.

*Question: A client is admitted with a diagnosis of pheochromocytoma. The nurse would monitor which parameter to detect the most common sign of pheochromocytoma?*

*Answer: Blood pressure elevation* Rationale: Hypertension is the major symptom associated with pheochromocytoma and is monitored by taking the client's blood pressure. Glycosuria, weight loss, and diaphoresis are other clinical manifestations of pheochromocytoma; however, hypertension is the most common sign.

*Question: Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication?*

*Answer: Blood urea nitrogen level of 25 mg/dL (8.8 mmol/L)* Rationale: Cyclosporine is an immunosuppressant. Nephrotoxicity can occur from the use of cyclosporine. Nephrotoxicity is evaluated by monitoring for elevated blood urea nitrogen and serum creatinine levels. The normal blood urea nitrogen level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). The normal creatinine level for a male is 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) and for a female 0.5 to 1.1 mg/dL (44 to 97 mcmol/L). Cyclosporine can lower complete blood cell count levels. A normal hemoglobin is Male: 14 to 18 g/dL (140 to 180 mmol/L); Female: 12 to 16 g/dL (120 to 160 mmol/L). Anormal hemoglobin is not an adverse effect. Cyclosporine does affect the glucose level. The normal fasting glucose is 70 to 110 mg/dL (4 to 6 mmol/L).

*Question: The nurse is administering a dose of prochlorperazine to the client for nausea and vomiting. The nurse would instruct the client to report which frequent side effect of this medication?*

*Answer: Blurred vision* Rationale: The nurse would assess the client for blurred vision as a frequent side effect of prochlorperazine. Other frequent side effects of this phenothiazine-type antiemetic and antipsychotic are dry eyes, dry mouth, and constipation. Diarrhea, drooling, and excessive perspiration are incorrect.

*Question: A client with benign prostatic hypertrophy (BPH) undergoes a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigations postoperatively. Which are the signs/symptoms of transurethral resection (TUR) syndrome?*

*Answer: Bradycardia and confusion* Rationale: TUR syndrome is caused by increased absorption of nonelectrolyte irrigating fluid used during surgery. The client may show signs of cerebral edema and increased intracranial pressure, such as increased blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual disturbances, and nausea and vomiting.

*Question: The nurse who is administering bethanechol chloride is monitoring for acute toxicity associated with the medication. The nurse would check the client for which sign of toxicity?*

*Answer: Bradycardia* Rationale: Toxicity (overdose) produces manifestations of excessive muscarinic stimulation such as salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension. Treatment includes supportive measures and the administration of atropine sulfate subcutaneously or intravenously.

*Question: A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. The nurse would take which action?*

*Answer: Call for the registered nurse.* Rationale: The nurse would call for the registered nurse, who will assess the situation and contact the nursing supervisor. When clients leave AMA, most health care facilities have documents relating to the client's responsibilities that the client is asked to sign before leaving. The nurse would request that the client speak to the primary health care provider before leaving, but if the client refuses, the nurse cannot hold the client against his or her will. Any client has a right to health care and cannot be told otherwise as in option 4. The nurse can be charged with false imprisonment if a client is made to wrongfully believe that he or she cannot leave the hospital, as would occur with options 2 and 3.

*Question: A client is brought to the emergency department by the ambulance team after collapse at home. Cardiopulmonary resuscitation is attempted but is unsuccessful. The wife of the client tells the nurse that the client is an organ donor and that their eyes are to be donated. Which action would the nurse take next?*

*Answer: Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes.* Rationale: When a corneal donor dies, antibiotic eye drops may be prescribed and instilled. The eyes are closed, and a small ice pack is placed on the closed eyes. The head of the bed is raised to 30 degrees to prevent edema. Within 2 to 4 hours, the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. Option 1 is incorrect because dry dressings are not applied. Some organ donation protocols indicate using normal saline-moistened gauze. Option 2 is not an immediate action. In addition, the client should have a signed donor card, living will, or an organ donor-identified driver's license stating his or her wishes. Additional legal documentation should not be required. Agency procedures regarding donor care should be followed.

*Question: A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. Which is the appropriate nursing action?*

*Answer: Call the nursing supervisor.* Rationale: The nurse can be charged with false imprisonment if a client is made to wrongfully believe that he or she cannot leave the hospital. Notifying the nurse supervisor is the correct option. Most health care facilities have documents that the client is asked to sign that relate to the client's responsibilities when he or she leaves against medical advice (AMA). The client should be asked to sign this document before leaving. The nurse should request that the client wait to speak to the PHCP before leaving, but if the client refuses to do so, the nurse cannot hold the client against his or her will. Restraining the client and calling security to block exits constitutes false imprisonment. Any client has a right to health care (option 3) and cannot be told otherwise.

*Question: The nurse must ambulate a client who has a nephrostomy tube attached to a drainage bag. The nurse plans to do this most safely by performing which action?*

*Answer: Changing the drainage bag to a leg collection bag* Rationale: The safest approach to protect the integrity and safety of the nephrostomy tube with a mobile client is to attach the tube to a leg collection bag. This allows for greater freedom of movement while alleviating worry over accidental disconnection or dislodgement. The other options do not present the most safe and effective methods to ensure the integrity of the tube.

*Question: A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The nurse would do which action first?*

*Answer: Check the client status and lead placement.* Rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Checking of the client and equipment is the first action by the nurse.

*Question: The nurse is caring for a client who has had skeletal traction applied to the left leg. The client is complaining of severe left leg pain. Which action would the nurse take first?*

*Answer: Check the client's alignment in bed.* Rationale: A client who complains of severe pain may need realignment or may have had traction weights prescribed that are too heavy. The nurse realigns the client and, if ineffective, calls the PHCP. Severe leg pain, once traction has been established, indicates a problem. Medicating the client should be done after trying to determine and treat the cause. Providing pin care is unrelated to the problem as described.

*Question: The nurse is assisting in caring for a client with a tracheal tube attached to a ventilator when an alarm sounds. Which action would the nurse do first?*

*Answer: Check the client.* Rationale: For a client receiving mechanical ventilation, always check the client first and then check the ventilator. A resuscitation bag should be available at the bedside for all clients receiving mechanical ventilation. If the cause of the alarm cannot be determined, ventilate the client manually with a resuscitation bag until the problem is corrected. The nurse needs to determine if the respiratory therapist or rapid response team needs to be called.

*Question: The nurse is monitoring a child with a cast on the forearm for signs of compartment syndrome. The nurse understands that which data collection technique is unlikely to provide information about this complication?*

*Answer: Checking the child's ability to perform range of motion to the shoulder area of the affected extremity* Rationale: Compartment syndrome occurs when swelling causes pressure to rise within a compartment (sheath of inelastic fascia). The increased pressure compromises circulation to the muscles and nerves within the compartment and can result in paralysis and necrosis of tissues. Signs of compartment syndrome include severe pain, often unrelieved by analgesics, and signs of neurovascular impairment. Compartment syndrome is not uncommon in fractures of the forearms; therefore, the quality of the radial pulse and the ability to extend the fingers should be assessed. If extension of the fingers produces pain, the primary health care provider should be notified. Option 4 is unlikely to provide information about compartment syndrome.

*Question: A client with Crohn's disease is scheduled to receive an infusion of infliximab. The nurse assisting with caring for the client would take which action to monitor the effectiveness of treatment?*

*Answer: Checking the frequency and consistency of bowel movements* Rationale: The principal manifestations of Crohn's disease are diarrhea and abdominal pain. Infliximab is an immunomodulator that reduces the degree of inflammation in the colon, thereby reducing the diarrhea. Options 1, 3, and 4 are unrelated to this medication.

*Question: The nurse is reinforcing medication instructions to a client with peptic ulcer disease. Which represents correct information given by the nurse?*

*Answer: Cimetidine results in decreased secretion of stomach acid.* Rationale: Cimetidine and other histamine H2-receptor antagonists decrease the secretion of gastric acid in the stomach. Antacids neutralize acid in the stomach. Omeprazole inhibits gastric acid secretion. Sucralfate promotes healing by coating the ulcer.

*Question: The nurse has a prescription to give 30 mL of an antacid through a nasogastric (NG) tube connected to wall suction. The nurse would do which best action to perform this procedure correctly?*

*Answer: Clamp the NG tube for 30 minutes following administration of the medication.* Rationale: If a client has an NG tube connected to suction, the nurse clamps the tube and waits 20 to 30 minutes before reconnecting the tube to the suction. This allows adequate time for medication absorption. Options 2 and 4 both result in removal of the medication that has just been administered. The client should not be placed in the supine position because of risk of aspiration.

*Question: The nurse is assigned to care for an infant with cryptorchidism. One testis cannot be palpated. The nurse anticipates that which diagnostic study will be prescribed to determine where the undescended testis is located in the body?*

*Answer: Computed tomography scan* Rationale: If the testis is not palpable, an ultrasonography, computed tomography scan, or magnetic resonance imaging can determine its location. The missing testis may be found at any point along the process vaginalis, may be located in the abdomen, or may follow an aberrant course and come to lie in the inguinal area, base of the penis, or perineum. A cystoscopy is an examination of the bladder and lower urinary tract. An abdominal x-ray would not show the presence of the testis in the abdominal cavity. A urodynamic study is done to determine voiding dysfunction and an abnormal urinary tract.

*Question: A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse identifies which signs/symptoms or behaviors as requiring immediate intervention?*

*Answer: Constant physical activity and poor oral intake* Rationale: Immediate intervention is required when the nurse identifies constant physical activity and poor oral intake in the client with bipolar affective disorder and mania. Mania is a period when the mood is predominantly elevated, expansive, or irritable. The client's mood may be characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. Each of the signs/symptoms of behavior is reflective of possible signs/symptoms of mania. However, option 1 identifies the priority, a physiological need.

*Question: A primary health care provider has prescribed codeine sulfate for a client with a nonproductive cough to suppress the cough reflex. The nurse reinforces instructions given to the client about the medication and tells the client to monitor for which side effect?*

*Answer: Constipation* Rationale: A frequent side effect of codeine sulfate is constipation. Additional side effects include drowsiness, nausea, and vomiting. Urinary retention is also a concern, and urine output should be monitored. Options 3 and 4 are unrelated to the administration of this medication.

*Question: The nurse enters a client's room, and the client immediately demands to be released from the hospital. During review of the client's record, the nurse notes that the client was admitted 2 days ago for the treatment of an anxiety disorder and that the admission was a voluntary one. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?*

*Answer: Contact the primary health care provider (PHCP).* Rationale: Generally, voluntary admission is sought by the client or client's guardian. Voluntary clients have the right to demand and obtain release. The best nursing action is to contact the PHCP. Option 1 violates client confidentiality. Option 2 is not therapeutic or appropriate. Option 4 does not apply to a voluntary admission status.

*Question: A client has epididymitis as a complication of a urinary tract infection (UTI). The nurse is giving the client instructions to prevent recurrence. The nurse determines that the client needs further teaching if the client states the intention to do which action?*

*Answer: Continue to take antibiotics until all symptoms are gone.* Rationale: The client who experiences epididymitis from UTI should increase intake of fluids to flush the urinary system. Because organisms can be forced into the vas deferens and epididymis from strain or pressure during voiding, the client should limit the force of the stream. Condom use can help prevent urethritis and epididymitis from STIs. Antibiotics are always taken until the full course of therapy is completed.

*Question: A client with a burn injury is applying mafenide acetate to the wound. The client calls the health care provider's office and tells the nurse that the medication is uncomfortable and is causing a burning sensation. Which instructions would the nurse reinforce to the client?*

*Answer: Continue with the treatment because this is expected.* Rationale: Mafenide acetate is used to treat burn injuries. It is bacteriostatic for both gram-negative and gram-positive organisms that are present in avascular tissues. The client should be warned that the medication will cause local discomfort and burning. The nurse does not instruct a client to alter a medication prescription (options 1 and 2). It is not necessary that the client see the health care provider immediately at this time.

*Question: The nurse caring for a child with nephrotic syndrome reviews the medication record. The nurse notes that prazosin hydrochloride is prescribed for the child. The nurse determines that this medication has been prescribed to achieve which result?*

*Answer: Control hypertension.* Rationale: Prazosin hydrochloride may be used to control hypertension. The child also may be placed on diuretic therapy until protein loss is controlled. Corticosteroids, such as prednisone, may be prescribed to decrease inflammation. Corticosteroids also suppress the autoimmune response and stimulate vascular reabsorption of edema. Cyclophosphamide is an alkylating agent.

*Question: The nurse of a well-baby clinic prepares to administer an immunization to a child. The mother of the child tells the nurse that the child has had a fever and is taking antibiotics. The nurse takes the child's temperature and notes that it is 101.5° F rectally. The nurse plans to take which action?*

*Answer: Delay the immunization.* Rationale: High fevers and severe illnesses are reasons to delay immunization, but only until the child has recovered from the acute stage of the illness. Minor illnesses such as a cold, otitis media, or mild diarrhea without fever are not contraindications to immunization.

*Question: A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which diagnosis?*

*Answer: Conversion disorder* Rationale: A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. It is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the person's capacity to deal with life's demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness.

*Question: A child with leukemia is experiencing nausea related to medication therapy. The nurse, concerned about the child's nutritional status, would offer which items during an episode of nausea?*

*Answer: Cool, clear liquids* Rationale: When the child is nauseated, it is best to offer frequent intake of cool, clear liquids in small amounts because small portions are usually better tolerated. Cool, clear fluids are also soothing and better tolerated when a client is nauseated. It is best not to offer favorite foods when the child is nauseated because foods eaten during times of nausea will be associated with being sick. It is best to offer small, frequent meals of high-protein and high-calorie content once the nausea has been controlled with medication or has subsided.

*Question: The nurse is assisting in the care of a client diagnosed with systemic lupus erythematosus (SLE). The nurse would most appropriately administer which prescribed medication to manage the condition?*

*Answer: Corticosteroid* Rationale: Treatment of SLE is based on the systems involved and symptoms. Treatment normally consists of anti-inflammatory medications, corticosteroids, and immunosuppressants. The other options are not standard components of medication therapy for this disorder.

*Question: The clinic nurse periodically cares for a client diagnosed with acquired immunodeficiency syndrome. The nurse would assess for an early manifestation of Pneumocystis jiroveci infection by monitoring for which sign/symptom at each client visit?*

*Answer: Cough* Rationale: The client with P. jiroveci infection usually has a cough as the first symptom, which begins as nonproductive and then progresses to productive. Later signs include fever, dyspnea on exertion, and finally dyspnea at rest.

*Question: A nursing instructor is observing a nursing student caring for an infant with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by performing which action?*

*Answer: Covering the bladder with a nonadhering plastic wrap* Rationale: Care should be taken to protect the exposed bladder tissue from drying while allowing drainage of urine. This is best accomplished by covering the bladder with a nonadhering plastic wrap. The use of wet-to-dry dressings should be avoided because this type of dressing adheres to the mucosa and may damage the delicate tissue when removed. Sterile dressings and dressings soaked in solutions can also dry out and damage the mucosa when removed.

*Question: A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds expecting to hear which breath sounds bilaterally?*

*Answer: Crackles* Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Wheezes, rhonchi, and diminished breath sounds are not associated with pulmonary edema.

*Question: The client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client would be questioned about the use of which class of medications?*

*Answer: Decongestants* Rationale: Episodes of urinary retention can be triggered by certain medications such as decongestants, anticholinergics, and antidepressants. Diuretics, antibiotics, and antitussives generally do not trigger urinary retention. Retention also can be precipitated by other factors such as alcoholic beverages, infection, bed rest, and becoming chilled.

*Question: A complete blood cell count is performed on a client with a diagnosis of systemic lupus erythematosus (SLE). The nurse would suspect that which finding will most likely be reported from this blood test?*

*Answer: Decrease of all cell types* Rationale: In the client with SLE, a complete blood count commonly shows pancytopenia, a decrease of all cell types, probably caused by a direct attack of all blood cells or bone marrow by immune complexes. The other options are incorrect.

*Question: The nurse is collecting data from a client who has had benign prostatic hyperplasia (BPH) in the past. To determine whether the client is currently experiencing exacerbation of BPH, the nurse would ask the client about the presence of which early symptom?*

*Answer: Decreased force in the stream of urine* Rationale: Decreased force in the stream of urine is an early sign of BPH. The stream later becomes weak and dribbling. The client may then develop hematuria, frequency, urgency, urge incontinence, and nocturia. If untreated, complete obstruction and urinary retention can occur.

*Question: Desmopressin acetate is prescribed for the treatment of diabetes insipidus. The nurse monitors the client after medication administration for which therapeutic response?*

*Answer: Decreased urinary output* Rationale: Desmopressin promotes renal conservation of water. The hormone carries out this action by acting on the collecting ducts of the kidney to increase their permeability to water, which results in increased water reabsorption. The therapeutic effect of this medication would be manifested by a decreased urine output. Options 2, 3, and 4 are unrelated to the effects of this medication.

*Question: A client is admitted with an arterial ischemic leg ulcer. The nurse expects to note that this ulcer has which typical characteristic?*

*Answer: Deep and painful* Rationale: Arterial leg ulcers tend to be deep and painful. The client usually has rest pain, and the ulcer site is painful. Surrounding skin has coloration consistent with peripheral arterial disease. Options 1, 3, and 4 are not characteristics of an arterial leg ulcer.

*Question: The nurse is collecting data from a client, and the client's spouse reports that the client is taking donepezil hydrochloride. Which disorder would the nurse suspect that this client may have based on the use of this medication?*

*Answer: Dementia* Rationale: Donepezil hydrochloride is a cholinergic agent used in the treatment of mild to moderate dementia of the Alzheimer's type. It enhances cholinergic functions by increasing the concentration of acetylcholine. It slows the progression of Alzheimer's disease. This medication is not used to treat the disorders in options 2, 3, and 4.

*Question: A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which defense mechanism?*

*Answer: Denial* Rationale: Denial is the refusal to admit to a painful reality and is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other people, objects, or situations. In regression, the client returns to an earlier, more comforting, although less mature, way of behaving. Rationalization is justifying the unacceptable attributes about oneself.

*Question: The nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse would expect to note which specific characteristic of this condition?*

*Answer: Dependent edema* Rationale: Right-sided heart failure is characterized by signs of systemic congestion that occur as a result of right ventricular failure, fluid retention, and pressure buildup in the venous system. Edema develops in the lower legs and ascends to the thighs and abdominal wall. Other characteristics include jugular (neck vein) congestion, enlarged liver and spleen, anorexia and nausea, distended abdomen, swollen hands and fingers, polyuria at night, and weight gain. Left-sided heart failure produces pulmonary signs. These include dyspnea, crackles on lung auscultation, and a hacking cough.

*Question: The nurse is monitoring a client with a history of opioid abuse for signs/symptoms of withdrawal. The nurse monitors this client for which signs/symptoms associated with opioid withdrawal?*

*Answer: Depression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), agitation, and paranoia* Rationale: The signs/symptoms associated with opioid withdrawal are depression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), agitation, and paranoia. Opioids are central nervous system depressants. They generally cause drowsiness and the feeling of being out of touch with the world. Withdrawal occurs within 12 hours after the last consumed dose. The signs/symptoms identified in option 1 are associated with nicotine withdrawal. Option 2 describes alcohol withdrawal. Option 4 describes cocaine withdrawal. Option 3 identifies factors associated with opioid withdrawal.

*Question: A client who sustained a closed head injury has a new onset of copious urinary output. Urine output for the previous 8-hour shift was 3300 mL, and 2800 mL for the shift before that. The findings have been reported to the primary health care provider, and the nurse anticipates a prescription for which medication?*

*Answer: Desmopressin* Rationale: A complication of closed head injury is diabetes insipidus (DI). This may occur if the injury affects the hypothalamus, antidiuretic hormone storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9 L/day generally requires treatment with desmopressin, an antidiuretic. Ethacrynic acid and mannitol are both diuretics, which would be contraindicated for this client. Dexamethasone is a glucocorticoid that is used to treat cerebral edema. This medication already may be prescribed for the head-injured client but does not relate to DI.

*Question: A client is scheduled for intravenous pyelography (IVP). Which priority nursing action would the nurse take?*

*Answer: Determine if there is a history of allergies.* Rationale: An iodine-based dye may be used during the IVP and can cause allergic reactions such as itching, hives, rash, tight feeling in the throat, shortness of breath, and bronchospasm. Checking for allergies is the priority. Options 1, 2, and 4 are unnecessary.

*Question: The nurse is monitoring a client in labor whose membranes rupture spontaneously. Which is the initial nursing action?*

*Answer: Determine the fetal heart rate.* Rationale: When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Options 1 and 4 are also appropriate actions but are not the initial actions in this situation. The nurse may assist the client in cleansing and changing clothing and may provide peripads to the client, but determining the fetal heart rate is the initial action.

*Question: The nurse is reviewing the medical record of a client with a diagnosis of pyelonephritis. Which disorder noted on the client's record would the nurse identify as a risk factor for this diagnosis?*

*Answer: Diabetes mellitus* Rationale: Risk factors associated with pyelonephritis include diabetes mellitus, hypertension, chronic renal calculi, chronic cystitis, structural abnormalities of the urinary tract, presence of urinary stones, and indwelling or frequent urinary catheterization.

*Question: The nurse is caring for an infant with congenital heart disease. Which signs, if noted in the infant, would alert the nurse to the early development of heart failure (HF)?*

*Answer: Diaphoresis during feeding* Rationale: The early symptoms of HF include tachypnea, poor feeding, and diaphoresis during feeding. Tachycardia would occur during feeding. Pallor may be noted in the infant with heart failure, but it is not an early symptom. A strong sucking reflex is unrelated to the development of heart failure.

*Question: The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic would the nurse expect to see documented in the record?*

*Answer: Diarrhea* Rationale: Crohn's disease is characterized by nonbloody diarrhea of usually not more than four or five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Options 2, 3, and 4 are not characteristics of Crohn's disease.

*Question: The nurse is performing a follow-up teaching session with a client discharged 1 month ago who is taking fluoxetine. Which information would be important for the nurse to gather regarding the adverse effects related to the medication?*

*Answer: Gastrointestinal dysfunctions* Rationale: The most common adverse effects related to fluoxetine include CNS and GI system dysfunction. This medication affects the GI system by causing nausea and vomiting, cramping, and diarrhea. Options 1, 3, and 4 are not adverse effects of this medication.

*Question: The nurse reinforces client instructions about ethambutol. The nurse determines that the client understands the instructions if the client indicates to report which occurrence?*

*Answer: Difficulty discriminating the color red from green* Rationale: Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when driving a motor vehicle. The client is taught to report this symptom immediately. The client is also taught to take the medication with food if gastrointestinal upset occurs. Impaired hearing results from antitubercular therapy with streptomycin. Orange-red discoloration of secretions occurs with rifampin.

*Question: The nurse is gathering data from a client with a history of untreated cataracts. The nurse asks the client about the presence of which sign of a cataract?*

*Answer: Difficulty with driving at night and blurred vision* Rationale: A cataract is characterized by a cloudy lens that leads to blurred vision and difficulty driving at night. Sometimes the client with a cataract experiences monocular diplopia, photophobia, and glare. The client does not experience eye pain. The other options are incorrect.

*Question: The nurse has reinforced instructions to a client with tuberculosis about proper handling and disposal of respiratory secretions. The nurse determines that the client understands the instructions if the client verbalizes to take which measure?*

*Answer: Discard used tissues in a plastic bag.* Rationale: Used tissues are discarded in a plastic bag, so contaminated respiratory secretions can be contained. The client with tuberculosis should wash hands carefully after each contact with respiratory secretions. Oral care should be performed more than once a day. The client should be instructed to cover the mouth and nose when laughing, sneezing, or coughing and to wear a mask when in contact with others until drug therapy suppresses the infection.

*Question: A glucocorticoid is prescribed for a client with adrenal insufficiency, and the nurse reinforces medication instructions to the client. The nurse determines that the client needs further teaching if the client states which action is necessary?*

*Answer: Discontinue the medication when symptoms subside.* Rationale: Glucocorticoids should not be discontinued abruptly to prevent acute adrenal insufficiency. Because glucocorticoids cause sodium and water to be retained while causing loss of potassium, the client should limit sodium intake and increase potassium intake. These medications can increase the risk of infection, and the client should avoid contact with persons who are ill. Eating breakfast each day is a general health-promoting behavior.

*Question: The nurse is preparing to reinforce instructions to the client who has been given a prescription for diphenoxylate with atropine. Which instructions would the nurse include?*

*Answer: Do not exceed the recommended dose because it can be habit forming.* Rationale: Diphenoxylate with atropine is an antidiarrheal, and the client should not exceed the recommended dose because it may be habit forming. Because it is an antidiarrheal, it should not be taken with a laxative. Side effects of the medication include dry mouth and drowsiness.

*Question: The nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure (ICP). The nurse notes that the anterior fontanel bulges when the infant cries. Based on this finding, which action would the nurse take?*

*Answer: Document the findings.* Rationale: The anterior fontanel is diamond shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 18 to 24 months of age. The posterior fontanel closes by 2 to 3 months of age. A bulging or tense fontanel may result from crying or increased intracranial pressure. If the nurse notes a bulging fontanel when the infant cries, this is a normal finding that should be documented and monitored. It is not necessary to notify the primary health care provider of this finding. Lowering the head of the bed and placing the infant on NPO status are inappropriate actions.

*Question: The nurse is caring for a newborn following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is appropriate?*

*Answer: Document the findings.* Rationale: The penis is normally red during the healing process. The nurse should expect that the area would be red with a small amount of bloody drainage. If the bleeding is excessive, the nurse should apply gentle pressure with sterile gauze. If bleeding is not controlled, then the blood vessel may need to be ligated, and the nurse should notify the RN, who would contact the primary health care provider. Because the findings identified in the question are normal, the nurse documents the findings.

*Question: The nurse has a prescription to give ear drops to a 2-year-old child. To administer the drops, the nurse would pull the pinna of the ear in which direction?*

*Answer: Downward and backward* Rationale: To properly administer ear drops to a child younger than 3 years of age, the pinna of the ear should be pulled downward and backward. When ear drops are given to an adult, the pinna is pulled upward and outward (option 1). The other options are incorrect.

*Question: A client is taking brompheniramine. The nurse reinforces instructions to the client to expect which side effect of this medication?*

*Answer: Drowsiness* Rationale: This medication is an antihistamine, and frequent side effects are drowsiness or sedation. Others include blurred vision, hypertension (and sometimes hypotension), dry mouth, constipation, urinary retention, and sweating. The other options are incorrect.

*Question: An adolescent with type 1 diabetes mellitus will become a member of the school's football cheerleader team. The adolescent excitedly reports to the school nurse to obtain information regarding adjustments needed in the treatment plan for the diabetes. The school nurse would instruct the adolescent to take which action?*

*Answer: Eat six graham crackers or drink a cup of orange juice before practice or game time.* Rationale: An extra snack of 15 to 30 g of carbohydrate eaten before activities such as cheerleader practice will prevent hypoglycemia. Six graham crackers or a cup of orange juice will provide 15 to 30 g of carbohydrate. The adolescent should not be instructed to adjust the amount or time of insulin administration. Meal amounts should not be decreased.

*Question: The nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the casted leg, the nurse would perform which intervention?*

*Answer: Elevate the leg on pillows continuously for 24 to 48 hours.* Rationale: A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and to promote venous drainage. Therefore, the other options are incorrect.

*Question: The nurse is caring for a client with a fresh application of a plaster leg cast. The nurse would plan to prevent the development of compartment syndrome by which action?*

*Answer: Elevating the limb and applying ice to the affected leg* Rationale: Compartment syndrome is prevented by controlling edema. This is achieved most optimally with elevation and application of ice. Therefore, the other options are incorrect.

*Question: The nurse is assisting with preparing a plan of care for a 4-year-old child hospitalized with nephrotic syndrome. Which intervention is most appropriate for this child?*

*Answer: Encourage the child to eat in the playroom.* Rationale: Mealtimes should center on pleasurable socialization. The child should be encouraged to eat meals with other children on the unit. A diet that is normal in protein with a sodium restriction is normally prescribed for a child with nephrotic syndrome. Parents or other family members should be encouraged to be present at mealtimes with a hospitalized child.

*Question: In planning activities for the depressed client, especially during the early stages of hospitalization, which action is best?*

*Answer: Encourage the client to participate in a structured daily program of activities.* Rationale: A depressed person suffers with depressed mood and is often withdrawn. Also, the person experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment rather than a quiet and solitary one.

*Question: A client has the following laboratory values: a pH of 7.55, an HCO3- level of 22 mEq/L (22 mmol/L), and a Pco2 of 30 mm Hg (30 mm Hg). Which action would the nurse plan to take?*

*Answer: Encourage the client to slow down breathing.* Rationale: The client is experiencing respiratory alkalosis based on the laboratory results of a high pH and a low Pco2 level. Interventions for respiratory alkalosis are the voluntary holding of breath or slowed breathing and the rebreathing of exhaled CO2 by methods such as using a paper bag or a rebreathing mask as prescribed. Performing Allen's test would be incorrect, because the blood specimen has already been drawn, and the laboratory results have been completed. Dialysis and insulin administration are interventions for metabolic acidosis.

*Question: A client has just had skeletal traction applied following insertion of pins. The nurse would place highest priority on performing which action?*

*Answer: Ensuring that the weights on the traction setup are hanging free* Rationale: When a client has skeletal traction, the highest priority is to assess the traction setup. The nurse must ensure that the weights on the traction setup are hanging free. If the weights are resting on or against any support, the purpose of the traction is defeated. The other actions are components of care.

*Question: A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action would be which intervention?*

*Answer: Escort the manic client to his or her room.* Rationale: The client is at risk for injury to self and others and therefore should be escorted out of the dayroom. Option 4 may increase the agitation that already exists in this client. Orientation will not halt the behavior. Telling the client that the behavior is not appropriate has already been attempted by the psychiatric nurse's aide.

*Question: A client with a urinary tract infection with dysuria is given a prescription for phenazopyridine hydrochloride for symptom relief. Which would the nurse reinforce instructing the client about this medication?*

*Answer: Expect the urine to become reddish orange.* Rationale: Phenazopyridine hydrochloride is a urinary tract analgesic with no antimicrobial properties. It can cause a reddish orange discoloration of urine and tears and can stain undergarments and soft contact lenses. The medication should be taken after meals to reduce the possibility of gastrointestinal upset. A headache is an occasional side effect of the medication and does not warrant notifying the primary health care provider.

*Question: The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising?*

*Answer: Increasing temperature, decreasing pulse, decreasing respirations, increasing BP* Rationale: A change in vital signs may be a late sign of increased ICP. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities may also arise.

*Question: Rho(D) immune globulin is prescribed for a client after delivery of a full-term infant. Before administering the medication, the nurse reviews the client's history, recognizing which circumstance as a contraindication for administering this medication?*

*Answer: Experiencing a severe reaction to prior administered human globulin* Rationale: Rho(D) immune globulin is not administered if a client has experienced a severe reaction to its component, human globulin. Rho(D) immune globulin is indicated when Rh-negative clients are exposed to Rh-positive fetal blood cells in any way, including abortion and amniocentesis. This medication is made from human plasma (a consideration if the woman is a member of the Jehovah's Witness denomination). Additionally, there is a risk of transmitting infectious agents, including viruses, when this medication is administered.

*Question: Skin breakdown occurs on a client's hand at the site of an intravenous catheter that had medication infusing. The nurse determines that which adverse effect occurred? Refer to figure.View Figure*

*Answer: Extravasation* Rationale: Extravasation refers to the tissue injury that occurs from leakage of medication into surrounding skin and subcutaneous tissue; it can also cause tissue necrosis. Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local infection. Phlebitis can cause the development of a clot (thrombophlebitis). Infiltration is seepage of the intravenous fluid out of the vein and into the surrounding interstitial spaces. It is a form of tissue injury, but the injury is not to the extent that occurs with extravasation.

*Question: The client with ovarian cancer is being treated with vincristine. The nurse monitors the client, knowing that which adverse effect is specific to this medication?*

*Answer: Extremity numbness* Rationale: Vincristine is a vinca alkaloid antineoplastic (miotic inhibitor) medication that has an adverse effect, specifically peripheral neuropathy. Peripheral neuropathy can be manifested as numbness and tingling in the fingers and toes. Depression of the Achilles tendon reflex may be the first clinical sign indicating peripheral neuropathy. Constipation, rather than diarrhea, is most likely to occur with this medication, although diarrhea may occur occasionally. Hair loss occurs with nearly all the antineoplastic medications. Chest pain is unrelated to this medication.

*Question: The nurse is assisting with developing a teaching plan for the client with glaucoma. Which instruction would the nurse suggest to include in the plan of care?*

*Answer: Eye medications may need to be administered for the rest of your life.* Rationale: The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications may need to be taken for the rest of his or her life. Limiting fluids and reducing salt will not decrease intraocular pressure. Option 3 is not necessary.

*Question: The nurse is conducting a session on the process of fertilization with a group of nursing students. The nurse asks a nursing student to identify the structure in which fertilization of an ovum takes place. The nurse midwife recognizes the teaching has been effective if the student selects which location?*

*Answer: Fallopian tube* Rationale: Fallopian tubes, also called oviducts, are 8 to 14 cm long and quite narrow. The fallopian tubes are pathways for the ovum between the ovary and the uterus. Fertilization occurs in the fallopian tube.

*Question: A client has just undergone lumbar puncture (LP). The nurse assists the client into which optimal position?*

*Answer: Flat, turning from side to side as needed* Rationale: Keep the client flat in bed to reduce headache for 1 hour or longer after procedure. It is important that the head of the bed remain flat to prevent cerebrospinal fluid (CSF) leakage and to prevent postprocedure headache.

*Question: The nurse is assisting in the care of a client receiving codeine sulfate for pain. The nurse would make note of which finding to detect an adverse effect of this medication?*

*Answer: Frequency of bowel movements* Rationale: The client taking codeine sulfate is at risk for constipation. Thus, the nurse monitors the frequency of bowel movements. The nurse also would monitor the client for hypotension, decreased respirations, and urinary retention. The nurse would plan measures to counteract these expected effects such as encouraging fluids, coughing and deep breathing, and increasing mobility to the extent tolerated by the client.

*Question: A licensed practical nurse (LPN) is assisting in the insertion of a nasogastric (NG) tube for an adult client. The LPN helps determine the correct length to insert the tube by performing which measurement?*

*Answer: From the tip of the client's nose to the earlobe and then down to the xiphoid process* Rationale: The correct method for measuring the length of tube is to place the tube at the tip of the client's nose and measure by extending the tube to the earlobe and then down to the xiphoid process. The average length for an adult is about 22 to 26 inches.

*Question: A client who is diagnosed with human immunodeficiency virus (HIV) seropositive has been taking stavudine. The nurse would monitor which parameter closely while the client is taking this medication?*

*Answer: Gait* Rationale: Stavudine is an antiretroviral used to manage HIV infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy, and the nurse would monitor the client's gait closely and ask the client about paresthesia. Options 2, 3, and 4 are unrelated to the use of this medication.

*Question: The nurse is assisting in preparing a plan of care for a client who just delivered a dead fetus. Which initial intervention in meeting the emotional needs of the client and her spouse is appropriate?*

*Answer: Gather data from the client and spouse about the perception of the event.* Rationale: The most appropriate initial intervention in planning to meet the emotional needs of the client and her spouse is to gather data about the perception of the event. Although options 1, 2, and 3 are likely to be a components of the plan of care, the initial intervention is to assess the perception of the event.

*Question: Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?*

*Answer: Get a written prescription from the primary health care provider (PHCP) and obtain an informed consent.* Rationale: A client may request to be secluded or restrained. Federal laws require the consent of the client unless an emergency situation exists in which an immediate risk to the client or others can be documented. The use of seclusion and restraint is permitted only with the written prescription of the PHCP, which must be reviewed and renewed every 24 hours, depending on state law requirements. It must also specify the type of restraint to be used.

*Question: The nurse administering medications to a client notes a prescription to give a subcutaneous dose of heparin sodium. The nurse would perform which action to give this medication safely?*

*Answer: Give the injection using a 25- to 27-gauge, ½-inch needle.* Rationale: Subcutaneous heparin sodium is given using a 25- to 27-gauge, ½-inch needle to prevent tissue trauma and inadvertent injection into muscle. (A 1-inch needle could inject the heparin sodium into the muscle.) The nurse does not aspirate or massage to prevent tissue trauma and bleeding.

*Question: The nurse is assisting a client who will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. The nurse takes which action to assist the client?*

*Answer: Gives the client a device holder to wear around the waist* Rationale: The nurse applies electrocardiographic (ECG) monitoring leads to the chest in the usual fashion and gives the client a sling or holder to carry the transistor-sized monitor that is worn around the chest or waist. The nurse would remind the client to maintain a normal schedule and to keep a diary of all activity and symptoms. The client should avoid activities that could interfere with the ECG recorder such as using heavy machinery, electric shavers, hair dryers, or bathing or showering. Therefore, options 1, 3, and 4 are incorrect.

*Question: Cyclobenzaprine is prescribed for a client to treat muscle spasms, and the nurse is reviewing the client's record. Which disorder would indicate a need to contact the primary health care provider (PHCP) regarding the administration of this medication?*

*Answer: Glaucoma* Rationale: Because this medication has anticholinergic effects, it should be used with caution in clients with a history of urinary retention, angle-closure glaucoma, and increased intraocular pressure. Cyclobenzaprine hydrochloride should be used only for short-term 2- to 3-week therapy. The disorders in options 2, 3, and 4 are not a concern when the client is taking cyclobenzaprine.

*Question: A client is having problems with blood clotting. Which food item would the nurse encourage the client to eat?*

*Answer: Green, leafy vegetables* Rationale: Green, leafy vegetables are high in vitamin K, which acts as a catalyst for facilitating blood-clotting factors. Legumes are high in folic acid and thiamine. Citrus fruits are high in vitamin C, which helps with wound healing. Vegetable oil is high in vitamin E, which acts as an antioxidant.

*Question: The nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse would plan to place the client in which position postoperatively?*

*Answer: Head of bed elevated 30 to 45 degrees, head and neck midline* Rationale: Following supratentorial surgery, the head of the bed is kept at a 30- to 45-degree angle. The head and neck should not be angled either anteriorly or laterally, but rather should be kept in a neutral (midline) position. This will promote venous return through the jugular veins, which will help prevent a rise in intracranial pressure.

*Question: The nurse observes the assistive personnel (AP) positioning the client with increased intracranial pressure (ICP). Which position would require intervention by the nurse?*

*Answer: Head turned to the side* Rationale: The head of the client with increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep ICP down.

*Question: A client with new-onset renal failure is having a first hemodialysis treatment. The nurse is especially careful to monitor the client for which signs/symptoms after the dialysis treatment?*

*Answer: Headache, decreasing level of consciousness, and seizures* Rationale: Disequilibrium syndrome occurs most often in clients who are new to dialysis. It is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. It results from rapid removal of solutes from the body during hemodialysis with a higher residual concentration gradient in the brain because of the blood-brain barrier. Water goes into cerebral cells because of the osmotic gradient, causing brain swelling and the onset of symptoms. It is prevented by dialyzing for shorter times or at reduced blood flow rates.

*Question: The nurse is assisting in developing a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse suggests that the child should be monitored for which signs?*

*Answer: Heart failure (HF)* Rationale: Nursing care for Kawasaki disease initially centers on observing for signs of HF. The nurse monitors for increased respiratory rate, increased heart rate, dyspnea, lung congestion, and abdominal distention. Options 1, 2, and 4 are not findings directly associated with this disorder.

*Question: A client is brought to the emergency department with suspected diabetic ketoacidosis (DKA). Which finding would the nurse note as being consistent with this diagnosis?*

*Answer: High serum glucose level and low serum bicarbonate level* Rationale: In DKA the blood glucose level is higher than 250 mg/dL, and ketones are present in the blood and urine. The arterial pH is low (less than 7.35.) The plasma bicarbonate is also low. The client would exhibit polyuria and Kussmaul's respirations. The potassium level usually is elevated as a result of dehydration.

*Question: The nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which finding would the nurse expect to note documented in the infant's record regarding this condition?*

*Answer: Hip joint laxity* Rationale: In the newborn period dysplasia usually appears as hip joint laxity rather than as outright dislocation. Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table is noted in hip dysplasia. An apparent short femur on the affected side is noted, as well as limited range of motion.

*Question: The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication?*

*Answer: Hyperglycemia* Rationale: An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis. Peritonitis is a risk associated with breaks in aseptic technique. Hyperphosphatemia is an electrolyte imbalance that occurs with renal dysfunction. Disequilibrium syndrome is a complication associated with hemodialysis.

*Question: The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the priority?*

*Answer: Immobilize the leg before moving the client.* Rationale: When a fracture is suspected, it is imperative that the area is splinted before the client is moved. Emergency help should be called if the client is not hospitalized; a PHCP is called for the hospitalized client. The nurse should remain with the client and provide realistic reassurance. The nurse does not prescribe radiology tests.

*Question: A postpartum nurse is reinforcing instructions to the mother of a breast-fed newborn who has hyperbilirubinemia. Which instructions would the nurse provide to the mother?*

*Answer: Increase the frequency of the breast-feeding.* Rationale: Breast-feeding should be initiated within 2 hours after birth and should be done every 2 to 3 hours thereafter. Supplementation with water does not reduce hyperbilirubinemia and should be discouraged because supplemental feedings with water do not promote stool excretion. The infant should not be fed less frequently. It is not necessary to stop breast-feeding permanently.

*Question: The nurse is assessing a client with multiple traumas who is at risk for developing acute respiratory distress syndrome (ARDS). The nurse would assess for which earliest sign of acute respiratory distress syndrome?*

*Answer: Increased respiratory rate* Rationale: The first sign of ARDS is usually increased respiratory rate. Auscultation of the lungs may reveal fine crackles. The client may be restless, agitated, and confused. The pulse rate increases, and a cough may be present. These early signs are followed by progressively worsening dyspnea with retractions, cyanosis, and diaphoresis. Diffuse crackles and rhonchi may be heard on auscultation.

*Question: The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding would the nurse expect to note as a result of this long-term use?*

*Answer: Increased specific gravity of the urine* Rationale: Clients taking diuretics on a long-term basis are at risk for fluid volume deficit. Findings of fluid volume deficit include increased respiration and heart rate, decreased central venous pressure, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, dark-colored and odorous urine, an increased hematocrit level, and an altered level of consciousness. Gurgling respirations, increased blood pressure, and decreased hematocrit as a result of hemodilution are seen in a client with fluid volume excess.

*Question: The nurse is reviewing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory finding is indicative of the massive cell destruction that occurs with the chemotherapy?*

*Answer: Increased uric acid level* Rationale: Hyperuricemia, elevated levels of uric acid, is especially common after treatment for leukemias and lymphomas, because the therapy results in massive cell destruction and the release of uric acid. Anemia (low red blood cell count), low platelet levels, and low white blood cell counts are associated with the bone marrow abnormalities that are a part of the leukemias and lymphoma disease process.

*Question: The nurse is preparing to care for a child who received an allogenic bone marrow transplant (BMT). The nurse understands that which is the priority concern?*

*Answer: Infection* Rationale: Once the marrow is infused, nursing care focuses on preventing immunocompromised children from developing a life-threatening infection until they engraft and produce their own white blood cells to fight infections. Although options 1, 3, and 4 are considerations in the plan of care, the potential for infection is the priority for a child following a BMT.

*Question: The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed, and the serum calcium level is 12.0 mg/dL (3.0 mmol/L). Based on this laboratory value, the nurse would take which action?*

*Answer: Inform the registered nurse of the laboratory value.* Rationale: The normal serum calcium level ranges from 9 to 10.5 mg/dL (2.25-2.75 mmol/L). The client is experiencing hypercalcemia, and the nurse would inform the registered nurse of the laboratory value. Because the client is experiencing hypercalcemia, the remaining options are incorrect actions.

*Question: The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis?*

*Answer: Inquiring about the client's feelings that may affect coping* Rationale: The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis. Option 3 pertains directly to the client's feelings. Options 1, 2, and 4 do not directly address the client's feelings.

*Question: A 4-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering over 40% of the body. The burns are partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies anticipating that which will be prescribed initially?*

*Answer: Insertion of a Foley catheter* Rationale: A Foley catheter is inserted into the child's bladder so that urine output can be measured accurately on an hourly basis. Although pain medication may be required, the child would not receive an anesthetic agent and should not be sedated. The burn wounds would be cleansed and treated after assessment, but this would not be the initial action. Intravenous fluids are administered at a rate sufficient to keep the child's urine output at 1 mL/kg of body weight per hour, thus reflecting adequate tissue perfusion. A nasogastric tube may or may not be required but would not be the priority intervention.

*Question: The nurse is asked to prepare for the admission of a child to the pediatric unit with a diagnosis of Wilms' tumor. The nurse assists in developing a plan of care for the child and suggests including which intervention in the plan of care?*

*Answer: Inspect the urine for the presence of hematuria at each voiding.* Rationale: If Wilms' tumor is suspected, the tumor mass should not be palpated. Excessive manipulation can cause seeding of the tumor and cause spread of the cancerous cells. Fever (not hypothermia), hematuria, and hypertension (not hypotension) are signs and symptoms associated with Wilms' tumor.

*Question: The nurse is preparing to perform an abdominal examination. Which step would be taken first?*

*Answer: Inspection* Rationale: The appropriate technique for abdominal examination is inspection, auscultation, percussion, and palpation. Auscultation is performed after inspection and before percussion and palpation to ensure that the motility of the bowel and bowel sounds are not altered. The sequence of maneuvers is inspect, auscultate, percuss, and palpate.

*Question: A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which initial intervention would the nurse anticipate to be prescribed?*

*Answer: Instillation of mineral oil or diluted alcohol* Rationale: Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed by using ear forceps. When the foreign object is vegetable matter, irrigation is not used because this material expands with hydration and the impaction becomes worse. Options 1, 2, and 3 may be prescribed after the initial treatment if necessary and if inflammation or infection is a concern.

*Question: A client has been given a prescription for chloral hydrate for short-term use. The nurse includes which nursing intervention in caring for this client?*

*Answer: Instruct the client to call for help to get out of bed.* Rationale: Chloral hydrate is a sedative-hypnotic. This medication promotes sleep, and the client is at risk for falls due to sedative effects. The nurse should instruct the client to ask for assistance getting out of bed. It is not necessary to leave the room lights on; this would interfere with sleep. Awakening the client for vital sign measurement and neurological assessment is unnecessary and interferes with sleep as well.

*Question: The client arrives at the health care clinic and states to the nurse that they were just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that they removed the tick and flushed it down the toilet. Which nursing action is appropriate?*

*Answer: Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable.* Rationale: A blood test is available to detect Lyme disease; however, the test is not reliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following manner: immunoglobulin M is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, and then gradually disappears; immunoglobulin G is detected 2 to 3 months after infection and may remain elevated for years. Options 1, 2, and 3 are incorrect.

*Question: The nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate?*

*Answer: Interrupt the client and offer to take her for a walk.* Rationale: Clients with anorexia nervosa are frequently preoccupied with vigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise as well as place limits on vigorous activities. Options 1, 3, and 4 are inappropriate nursing actions.

*Question: The nurse is caring for a postoperative parathyroidectomy client. Which would require the nurse's immediate attention?*

*Answer: Laryngeal stridor* Rationale: During the postoperative period, the nurse carefully observes the client for signs of hemorrhage, which causes swelling and the compression of adjacent tissue. Laryngeal stridor is a harsh, high-pitched sound heard during inspiration and expiration that is caused by the compression of the trachea and leads to respiratory distress. It is an acute emergency situation that requires immediate attention to avoid the complete obstruction of the airway.

*Question: A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin (aPTT) time is 65 seconds. The licensed practical nurse reviews the laboratory results with the registered nurse, anticipating that which action is needed?*

*Answer: Leaving the rate of the heparin infusion as is* Rationale: The normal aPTT varies between 28 seconds and 35 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal. This means that the client's value should not be less than 40 seconds or greater than 87.5 seconds. Thus the client's aPTT is within the therapeutic range, and the dose should remain unchanged.

*Question: A client with right pleural effusion by chest x-ray is being prepared for a thoracentesis. The client experiences dizziness when sitting upright. The nurse assists the client to which position for the procedure?*

*Answer: Left side-lying with the head of the bed elevated at 45 degrees* Rationale: To facilitate removal of fluid from the chest wall, two positions may be used. The client may be positioned sitting on the edge of the bed, leaning over the bedside table with his or her feet supported on a stool. The other position is lying in bed on the unaffected side with the head of the bed elevated 45 degrees (Fowler's position). The other options are incorrect because they do not facilitate drainage of fluid to an area where it can be easily removed with thoracentesis.

*Question: The nurse is caring for a child who was burned in a house fire. The nurse assists in developing a plan of care for monitoring the child during the treatment for burn shock. The nurse identifies which assessment as providing the most accurate guide to determine the adequacy of fluid resuscitation?*

*Answer: Level of consciousness* Rationale: The sensorium, or level of consciousness, is an important guide to the adequacy of fluid resuscitation. The burn injury itself does not affect the sensorium, so the child should be alert and oriented. Any alteration in sensorium should be evaluated further. A neurological assessment would determine the level of consciousness in the child. Options 1, 2, and 4, although important in the assessment of the child with a burn injury, would not provide an accurate assessment of the adequacy of fluid resuscitation.

*Question: A client is being discharged to home with a prescription for eye drops to be given in the left eye. The nurse has shown the client how to self-administer the drops. The nurse determines that the client needs further teaching if the client performs which actions during a return demonstration?*

*Answer: Lies supine, pulls up on the upper lid, and puts the drop in the upper lid* Rationale: It is correct procedure for the client to either lie down or sit with the head tilted back. The thumb or finger is used to pull down on the lower lid. The client holds the bottle like a pencil (tip facing downward) and squeezes the bottle so that one drop falls into the sac. The client then gently closes the eye. An alternative method for clients who blink very easily is to place the client in the supine position with the head turned to one side. The eye to be used is uppermost. With the eye closed, the client squeezes the drop onto the inner canthus of the eye. The client turns from this side to the other while blinking. Surface tension and gravity then cause the drop to move into the conjunctival sac.

*Question: The nurse is reinforcing discharge instructions to a client after a gastrectomy. Which measure would the nurse include during client teaching to help prevent dumping syndrome?*

*Answer: Limit the fluids taken with meals.* Rationale: The client should be instructed to decrease the amount of fluid taken at meals. The client should also be instructed to avoid high-carbohydrate foods, including fluids such as fruit nectars; assume a low-Fowler's position during meals; lie down for 30 minutes after eating to delay gastric emptying; and take antispasmodics as prescribed.

*Question: In preparing to care for a hospitalized child with a diagnosis of measles (rubeola), which supplies would the nurse bring to the child's room to prevent the transmission of the virus?*

*Answer: Mask and gloves* Rationale: Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Respiratory isolation is required, and a mask should be worn by those in contact with the child. Gloves should be worn to prevent transmission via direct contact. Gowns and goggles are not specifically indicated for care of the child with rubeola. Any articles that are contaminated should be bagged and labeled.

*Question: The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action?*

*Answer: Limiting bladder catheterization to once every 12 hours* Rationale: The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be performed every 4 to 6 hours, and indwelling bladder catheters should be checked frequently for kinks in the tubing. It is not appropriate to catheterize the client every 12 hours. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

*Question: The nurse is assisting with caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention?*

*Answer: Limiting movement and abduction of the right arm* Rationale: In the first several hours after insertion of either a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgment. The nurse helps prevent this complication by limiting the client's activities.

*Question: A client with tuberculosis is being started on antituberculosis therapy with isoniazid. Before giving the client the first dose, the nurse ensures that which baseline study has been completed?*

*Answer: Liver enzyme levels* Rationale: Isoniazid therapy can cause an elevation of hepatic enzyme levels and hepatitis. Therefore, liver enzyme levels are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is greater than age 50 or abuses alcohol.

*Question: A client diagnosed as human immunodeficiency virus (HIV) seropositive has been prescribed zalcitabine as a component of treatment. The nurse would instruct the client that which laboratory test will need to be monitored while taking this medication?*

*Answer: Liver function studies* Rationale: Zalcitabine is an antiretroviral (nucleoside reverse transcriptase inhibitor) used in the management of HIV infection with other antiretrovirals. It also has been used as a single agent in clients who are intolerant of or who progress on other regimens. It can cause serious liver damage, and liver function studies should be monitored closely. Glucose level, platelet count, and red blood cell count are not specifically associated with the use of this medication.

*Question: The nurse is reviewing the laboratory studies on a client receiving dantrolene sodium. Which laboratory test(s) would identify an adverse effect associated with the administration of this medication?*

*Answer: Liver function tests* Rationale: Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce the risk of liver damage, liver function tests should be performed before treatment and periodically throughout the treatment course. It is administered in the lowest effective dosage for the shortest time necessary. Options 1 and 3 are tests that assess kidney function.

*Question: The nurse has a prescription to give a client a scheduled dose of digoxin. Before administering the medication, the nurse routinely screens for which signs/symptoms that could indicate early signs of digoxin toxicity?*

*Answer: Loss of appetite, nausea, and vomiting* Rationale: Loss of appetite and nausea are early signs of digoxin toxicity. Other signs of digoxin toxicity include bradycardia, visual alterations (e.g., green and yellow vision or seeing spots or halos), confusion, vomiting, or diarrhea. The other options are incorrect.

*Question: A client with diabetes mellitus who has been controlled with daily insulin has been placed on atenolol for the control of angina pectoris. Because of the effects of atenolol, the nurse determines that which is the most reliable indicator of hypoglycemia?*

*Answer: Low blood glucose level* Rationale: β-Adrenergic blocking agents, such as atenolol, inhibit the appearance of signs and symptoms of acute hypoglycemia, which would include nervousness, increased heart rate, and sweating. Therefore, the client receiving this medication should adhere to the therapeutic regimen and monitor blood glucose levels carefully. Option 4 is the most reliable indicator of hypoglycemia.

*Question: The nurse is assigned to care for a client hospitalized with Ménière's disease. The nurse expects that which would most likely be prescribed for the client?*

*Answer: Low-sodium diet* Rationale: Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Options 1, 3, and 4 are not specific dietary prescriptions for this condition.

*Question: A client with which type of cancer is at greatest risk for experiencing the complication vena cava syndrome?*

*Answer: Lung cancer* Rationale: Vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Lung cancer is associated with development of vena cava syndrome. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms. Mental status changes and cyanosis are late signs. Blood cancers such as leukemia and multiple myeloma are not associated with tumor formation. Early stages of cancers usually are abnormal cells in tissues that then develop into tumors that enlarge with time.

*Question: A client is admitted to the emergency department, and a diagnosis of myxedema coma is made. Which action would the nurse prepare to carry out initially?*

*Answer: Maintain a patent airway.* Rationale: The initial nursing action would be to maintain a patent airway. Oxygen would be administered, followed by fluid replacement. The nurse would also keep the client warm, monitor intravenous fluids, and administer thyroid hormones.

*Question: A nursing student is assigned to care for a child with hemophilia. The nursing instructor reviews the plan of care with the student and asks the student to describe the characteristics of this disorder. Which statement by the student indicates a need for further research?*

*Answer: Males inherit hemophilia from their fathers.* Rationale: Males inherit hemophilia from their mothers, and females inherit the carrier status from their fathers. Some females who are carriers have an increased tendency to bleed, and although it is rare, females can have hemophilia if their fathers have the disorder and their mothers are carriers of the genetic disorder. Hemophilia is inherited in a recessive manner via a genetic defect on the X chromosome. Hemophilia A results from a deficiency of factor VIII. Hemophilia B (Christmas disease) is a deficiency of factor IX.

*Question: The nurse is assisting in conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by taking which action?*

*Answer: Massaging the abdomen during contractions using both hands in a circular motion* Rationale: Effleurage is massage of the abdomen during contractions. Women learn to do effleurage using both hands in a circular motion. Progressive relaxation involves contracting and then consciously releasing different muscle groups. Neuromuscular disassociation helps the woman relax her body even when one group of muscles is strongly contracted. In this procedure, the woman contracts an area such as an arm or leg then concentrates on letting tension go from the rest of her body. Touch relaxation helps the woman learn to loosen taut muscles when she is touched by her partner.

*Question: The nurse admitting a client to the hospital is reviewing the client's history and medications taken at home. Which condition in the client's history is being treated with tamoxifen citrate?*

*Answer: Metastatic breast cancer* Rationale: Tamoxifen citrate is used to treat metastatic breast cancer Tamoxifen competes with estradiol for binding to estrogen in tissues containing high concentrations of receptors. Diabetes mellitus, a positive tuberculin test, and a history of cholecystectomy are not treated with the medication.

*Question: The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse would expect to document that the fundus of the uterus is located at which area?*

*Answer: Midway between the symphysis pubis and the umbilicus* Rationale: At 12 weeks' gestation, the uterus extends out of the maternal pelvis and can be palpated above the symphysis pubis. At 16 weeks, the fundus reaches midway between the symphysis pubis and the umbilicus. At 20 weeks, the fundus is located at the umbilicus. By 36 weeks, the fundus reaches its highest level at the xiphoid process.

*Question: The client was seen and treated in the emergency department (ED) for a concussion. Before discharge, the nurse explains the signs/symptoms of a worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign/symptom?*

*Answer: Minor headache* Rationale: A concussion after head injury is a temporary loss of consciousness (from a few seconds to a few minutes) without evidence of structural damage. After concussion, the family is taught to monitor the client and call the PHCP or return the client to the emergency department if certain signs and symptoms are noted. These include confusion, difficulty awakening or speaking, one-sided weakness, vomiting, or severe headache. Minor headache is expected.

*Question: The nurse is reinforcing teaching to a client about an upcoming colonoscopy procedure. The nurse would include in the instructions that the client will be placed in which position for the procedure?*

*Answer: Modified left lateral recumbent position* Rationale: The client is placed in the modified left lateral recumbent position for the procedure. This position takes the best advantage of the client's anatomy for ease with introducing the colonoscope. The other options are incorrect.

*Question: The nurse is reinforcing instructions to a client with diabetes mellitus who is recovering from diabetic ketoacidosis (DKA) regarding measures to prevent a recurrence. Which instruction is important for the nurse to emphasize?*

*Answer: Monitor blood glucose level frequently.* Rationale: Client education after DKA should emphasize the need for home glucose monitoring four to five times per day. It is also important to instruct the client to notify the PHCP when illness occurs. The presence of urinary ketones indicates that DKA has already occurred. The client should eat well-balanced meals with snacks, as prescribed.

*Question: The nurse will be providing postprocedure care to a client who has undergone esophagogastroduodenoscopy (EGD). Based on the procedure done, the nurse would plan to do which action first?*

*Answer: Monitor for return of the gag reflex.* Rationale: The nurse should place highest priority on monitoring for return of the gag reflex, which is part of managing the client's airway. The client's vital signs should be monitored next; a sudden, sharp increase in temperature could indicate perforation of the gastrointestinal tract. (This would be accompanied by other signs, such as pain.) Monitoring for sore throat and heartburn also is important but is of lesser priority than monitoring the client's airway.

*Question: A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase. Which action is a priority nursing intervention?*

*Answer: Monitor for signs of bleeding.* Rationale: Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding. Monitoring for renal failure and monitoring the client's psychosocial status are important but are not the most critical interventions. Heparin is given after thrombolytic therapy, but the question is not asking about follow-up medications.

*Question: The nurse is evaluating the client's use of a cane for left-sided weakness. The nurse would intervene and correct the client if the nurse observed that the client performed which action?*

*Answer: Moves the cane when the right leg is moved* Rationale: The cane is held on the stronger side to minimize stress on the affected extremity and provide a wide base of support. The cane is held 6 inches lateral to the fifth great toe. The cane is moved forward with the affected leg. The client leans on the cane for added support while the stronger side swings through.

*Question: The nurse is providing instructions to a client beginning medication therapy with divalproex sodium for the treatment of absence seizures. The nurse instructs the client that which is the most frequent side effect of this medication?*

*Answer: Nausea and vomiting* Rationale: Divalproex sodium is an anticonvulsant. The most frequent side effects of medication therapy are gastrointestinal (GI) disturbances such as nausea, vomiting, and indigestion. The items in the other options are not side effects.

*Question: The nurse assists with developing a plan of care for the child with meningitis. Which would be the priority client problem for a child with a meningitis diagnosis?*

*Answer: Neurological dysfunction* Rationale: Neurological dysfunction is the priority client care concern for the child with meningitis. Pain related to meningeal irritation may also be a concern, but it is not the priority. There are no data in the question to indicate that there are psychosocial issues.

*Question: The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL (2.0 mmol/L). The nurse understands that which condition would cause this serum calcium level?*

*Answer: Prolonged bed rest* Rationale: The normal serum calcium level is 9 to 10.5 mg/dL (2.25-2.75 mmol/L). A client with a serum calcium level of 8.0 mg/dL (2.0 mmol/L) is experiencing hypocalcemia. The excessive ingestion of vitamin D, adrenal insufficiency, and hyperparathyroidism are causative factors associated with hypercalcemia. Although immobilization can initially cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia.

*Question: The nurse is instructing a client about pursed-lip breathing, and the client asks the nurse about its purpose. The nurse would tell the client that the primary purpose of pursed-lip breathing is which?*

*Answer: Promote carbon dioxide elimination* Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease and promotes carbon dioxide elimination. This type of breathing allows better expiration by increasing airway pressure, which keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing.

*Question: The client is diagnosed with an immune deficiency. The nurse focuses on which nursing responsibility as the highest priority when providing care to this client?*

*Answer: Protecting the client from infection* Rationale: The client with immune deficiency has inadequate immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. The other options are also part of the plan of care but are not the highest priority.

*Question: The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation would indicate that a prolapse has occurred?*

*Answer: Protruding and swollen* Rationale: A prolapsed stoma is one in which bowel protrudes through the stoma, with an elongated and swollen appearance. A stoma retraction is characterized by sinking of the stoma. Ischemia of the stoma would be associated with dusky or bluish color. A stoma with a narrowed opening, either at the level of the skin or fascia, is said to be stenosed.

*Question: The nurse assisting in the labor room is preparing to care for a client with hypertonic dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which nursing intervention is the priority in caring for the client?*

*Answer: Provide pain relief measures.* Rationale: Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows. The client with hypertonic uterine dysfunction should not be encouraged to ambulate every 30 minutes but should be encouraged to rest.

*Question: The nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid, and the client's effect is belligerent. Based on these observations, which is the nurse's immediate priority of care?*

*Answer: Provide safety for the client and other clients on the unit.* Rationale: Safety of the client and other clients is the priority. Option 1 is the only option that addresses the client and other clients' safety needs. Option 2 addresses other clients' needs. Option 3 is not client centered. Option 4 addresses the client's needs.

*Question: A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction has which primary function?*

*Answer: Provides comfort by reducing muscle spasms and provides fracture immobilization* Rationale: Buck's extension traction is a type of skin traction often applied after hip fracture, before the fracture is reduced in surgery. It reduces muscle spasms and helps immobilize the fracture. It does not lengthen the leg for the purpose of preventing blood vessel severance. It also does not allow for bony healing to begin.

*Question: The nurse is admitting a 10-month-old infant who is being hospitalized for a respiratory infection. The nurse develops a plan of care for the infant and includes which intervention?*

*Answer: Providing a consistent routine such as touching, rocking, and cuddling throughout the hospitalization* Rationale: A 10-month-old is in the trust vs. mistrust stage of psychosocial development, according to Erikson. The infant is developing a sense of self, and the nurse should most appropriately provide a consistent routine for the child. Hospitalization may have an adverse effect, and the nurse should touch, rock, and cuddle the infant to promote a sense of trust and to provide sensory stimulation. Placing small toys in the crib is an unsafe action. Keeping the child as quiet as possible will not provide sensory stimulation. The infant should not be restrained.

*Question: The nurse is assisting in planning care to meet the emotional needs of a pregnant woman. Which nursing intervention is least likely to assist in meeting her emotional needs?*

*Answer: Providing the mother with pamphlets and booklets to read about the pregnancy* Rationale: The woman's emotional needs can be met by providing regular opportunities for discussing aspects of her pregnancy and prenatal care, by using a caring and supportive approach, and by offering praise and reinforcement. The nurse also should discuss the emotional changes of pregnancy, family alterations, and changes in marital relationships that may occur. Providing written materials does not provide nurse-client interaction.

*Question: The nurse caring for a client taking tamsulosin determines that which finding indicates the need for follow-up?*

*Answer: Pulse rate of 120 beats per minute* Rationale: Tamsulosin is classified as benign prostatic hyperplasia agent and acts by relaxing smooth muscle and increasing urinary flow. An adverse effect of this medication is first-dose syncope, which usually occurs within the first 30 to 90 minutes of the initial dose. This is commonly preceded by tachycardia (pulse of 120 to 160 beats per minute). Side effects of this medication include dizziness, drowsiness, nasal congestion, and vertigo.

*Question: A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse would determine that this has been confirmed by which finding?*

*Answer: Punch biopsy of the cutaneous lesions* Rationale: Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.

*Question: The client is suspected of having systemic lupus erythematous (SLE). The nurse monitors the client, knowing that which is one of the initial characteristic signs of SLE?*

*Answer: Rash on the face across the nose and on the cheeks* Rationale: Skin lesions or a rash on the face across the bridge of the nose and on the cheeks is an initial characteristic sign of SLE. Fever and weight loss may also occur. Anemia is most likely to occur later in SLE.

*Question: The nurse assists with creating a plan of care for a client with hyperparathyroidism receiving calcitonin-human. Which outcome has the highest priority regarding this medication?*

*Answer: Reaching normal serum calcium levels* Rationale: Hypercalcemia can occur in clients with hyperparathyroidism, and calcitonin is used to lower plasma calcium levels. The highest-priority outcome in this client situation would be a reduction in serum calcium level. Option 1 is unrelated to this medication. Although options 2 and 4 are expected outcomes, they are not the highest priority for administering this medication.

*Question: A client has been started on medication therapy with alprazolam. When the nurse teaches the client that the medication should not be discontinued abruptly, the client asks why. The nurse would incorporate which information in formulating a reply?*

*Answer: Rebound central nervous system (CNS) excitation could occur, including seizure activity.* Rationale: The information the nurse would include in formulating a reply to the client is that rebound central nervous system (CNS) excitation could occur, including seizure activity. Alprazolam is a benzodiazepine anxiolytic. The abrupt withdrawal of alprazolam could result in seizure activity from CNS excitation. All clients receiving this medication need to be warned of this danger. The other options are incorrect and unrelated to this medication.

*Question: The nurse is assigned to assist in caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per minute, respirations 16 breaths per minute. Preoperative vital signs were BP 124/78 mm Hg, pulse 74 beats per minute, respirations 20 breaths per minute. Which action would the nurse plan to take first?*

*Answer: Recheck the vital signs in 15 minutes.* Rationale: A drop in blood pressure slightly below a client's preoperative baseline reading is common after surgery. The nurse should recheck the vital signs. There are no data in the question suggesting that the client is unarousable or requiring a warm blanket. Warm blankets are applied to maintain the client's body temperature or in the case of shivering. Level of consciousness can be assessed by the evaluation of the client's response to light touch and verbal stimuli. It is not necessary to contact the surgeon immediately.

*Question: The home care nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse would provide which information?*

*Answer: Refrigerate the insulin.* Rationale: Insulin in unopened vials should be stored under refrigeration until needed. Vials should not be frozen because freezing affects the chemical composition of the insulin. When stored unopened under refrigeration, insulin can be used up to the expiration date on the vial. Freezing insulin, storing insulin in a dark, dry place and keeping the insulin at room temperature are all incorrect actions.

*Question: A primary health care provider asks the licensed practical nurse (LPN) to reinforce preprocedure instructions to a client who will undergo a barium swallow (esophagography) in a few days. The LPN would include which instruction in this discussion?*

*Answer: Remove all metal and jewelry before the test.* Rationale: A barium swallow, or esophagography, is an x-ray that uses a substance called barium for contrast to highlight abnormalities in the gastrointestinal (GI) tract. The client is told to remove all jewelry before the test, so it won't interfere with x-ray visualization of the field. The client should fast for 8 to 12 hours before the test, depending on primary health care provider instructions. Most oral medications also are withheld before the test. The client should self-monitor for constipation after the procedure, which can occur from barium in the GI tract.

*Question: Oxybutynin chloride is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication?*

*Answer: Restlessness* Rationale: Toxicity (overdose) of this medication produces central nervous system excitation, such as nervousness, restlessness, hallucinations, and irritability. Other signs of toxicity include hypotension or hypertension, confusion, tachycardia, flushed or red face, and signs of respiratory depression. Drowsiness is a frequent side effect of the medication but does not indicate overdose.

*Question: The nurse in a primary health care provider's office receives a telephone call from the mother of a child who tells the nurse that the child was just stung by a bee. The mother asks the nurse for instructions regarding removal of the stinger. Which instruction would the nurse reinforce to the mother?*

*Answer: Remove the stinger by carefully scraping it out horizontally.* Rationale: The stinger from a bee should be removed carefully by scraping it out horizontally. The mother should be instructed to avoid squeezing the stinger because more venom will be released. Following removal of the stinger, the area is washed with soap and water, and ice may be applied for discomfort. Squeezing the stinger out of the skin, leaving the stinger alone, and applying heat after washing the area are incorrect.

*Question: Dapsone is prescribed for the client diagnosed with acquired immunodeficiency syndrome for the treatment of toxoplasmosis. The nurse should reinforce medication instructions and determine that the client understands the instructions if the client makes which statement?*

*Answer: Report a sore throat to the primary health care provider.* Rationale: Dapsone may be prescribed for the treatment of toxoplasmosis. The medication is taken orally on a daily basis. The medication suppresses bone marrow activity, and the complete blood count is monitored closely. If the client develops fever, sore throat, purpura, or jaundice, the PHCP is notified because this could indicate infection. Medications are available to treat nausea and vomiting; the client should not discontinue the medication if these symptoms occur, but she should contact the PHCP.

*Question: A licensed practical nurse has observed a client self-administer a dose of an adrenergic bronchodilator via metered-dose inhaler. Within a short time, the client begins to wheeze loudly. Which action should the nurse take?*

*Answer: Report the client's symptoms to the registered nurse (RN).* Rationale: The client taking an adrenergic bronchodilator may experience paradoxical bronchospasm, which is evidenced by the client's wheezing. This can occur with excessive use of inhalers. If this occurs, further medication should be withheld, and the RN immediately notified.

*Question: The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse would take which appropriate action?*

*Answer: Report the finding to the registered nurse (RN).* Rationale: If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the registered nurse because this can indicate hemorrhage. Options 1, 2, and 4 will delay necessary treatment.

*Question: A client with cancer develops white, dough-like patches on the mucous membranes of the oral cavity. Which action would the nurse take when noting this?*

*Answer: Report these symptoms, which are consistent with candidiasis.* Rationale: Candidiasis is an infection caused by the fungus Candida albicans. It appears as white plaques on the mucous membranes and corners of the mouth with an underlying red base and fissures. It is not a common infection, although it can occur in an immunocompromised client. The fungus overgrows due to a change in normal oral flora. The client requires treatment with an antifungal agent to eliminate the infection. The finding has nothing to do with electrolyte imbalance.

*Question: The client is to begin a 6-month course of therapy with isoniazid. The nurse would plan to provide which information to the client?*

*Answer: Report yellow eyes or skin immediately.* Rationale: Isoniazid is hepatotoxic, and therefore the client is taught to report signs/symptoms of hepatitis immediately (which include yellow skin and sclera). For the same reason, alcohol should be avoided during therapy. The client should avoid intake of Swiss cheese, fish such as tuna, and foods containing tyramine because they may cause a reaction characterized by redness and itching of the skin, flushing, sweating, tachycardia, headache, or lightheadedness. The client can avoid developing peripheral neuritis by increasing the intake of pyridoxine during the course of isoniazid therapy.

*Question: A licensed practical nurse (LPN) is collecting data on a child and notes the presence of old and new bruises on the child's back and legs. The LPN suspects physical abuse and reports the findings to the registered nurse knowing that which action is necessary?*

*Answer: Reporting the case to legal authorities* Rationale: The primary legal nursing responsibility when child abuse is suspected is to report the case. All 50 states require health care professionals to report all cases of suspected abuse. It is not appropriate for the nurse to file charges against the father or mother. It is also inappropriate to ask the mother to identify the abuser because the abuser may be the mother. If so, the mother may become defensive and attempt to leave the emergency department with the child. Option 4 is clearly inappropriate and will produce fear in the child.

*Question: The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse would monitor the client for which acid-base imbalance?*

*Answer: Respiratory acidosis* Rationale: Respiratory acidosis most often occurs as a result of primary defects in the function of the lungs or changes in normal respiratory patterns from secondary problems. Chronic respiratory acidosis is most commonly caused by chronic obstructive pulmonary disease (COPD). Acute respiratory acidosis also occurs in clients with COPD when superimposed respiratory infection or concurrent respiratory disease increases the work of breathing. The remaining options are not likely to occur unless other conditions complicate the COPD.

*Question: The nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which?*

*Answer: Respiratory distress* Rationale: Signs of allergic reaction to the contrast medium include localized itching and edema, respiratory distress, stridor, and decreased blood pressure. Hypothermia is an unrelated event. Hematoma formation is a complication of the procedure, but does not indicate an allergic reaction. Discomfort is expected.

*Question: A licensed practical nurse (LPN) is assisting in the care of a pregnant teenaged client with preeclampsia receiving magnesium sulfate. The LPN plans to notify the registered nurse immediately if which sign of magnesium toxicity is noted?*

*Answer: Respiratory rate of 10 breaths per minute* Rationale: Magnesium toxicity is a risk associated with magnesium sulfate therapy. Signs of magnesium toxicity relate to central nervous system (CNS) depression and include respiratory depression, loss of deep tendon reflexes, sudden drop in fetal heart rate, and/or maternal heart rate and blood pressure. Magnesium is excreted through the kidneys. If renal impairment is present, magnesium toxicity can develop very quickly. Therapeutic serum levels of magnesium are 4 to 7 mEq/L.

*Question: A registered nurse has administered a dose of naloxone intravenously to a client with intravenous opioid overdose. The licensed practical nurse assigned to assist in monitoring the client ensures that which equipment is available in the immediate vicinity of the client?*

*Answer: Resuscitation equipment* Rationale: Naloxone is used to treat respiratory depression. The client who receives naloxone for suspected opioid overdose should have resuscitation equipment readily available to support naloxone therapy if it is needed. Other items that may be needed include oxygen, a mechanical ventilator, and medications such as vasopressors.

*Question: A client diagnosed with rheumatoid arthritis (RA) has been started on medication therapy with hydroxychloroquine. The nurse reinforces teaching with this client regarding the most serious adverse effect of this medication?*

*Answer: Retinal damage* Rationale: The most serious adverse effect of hydroxychloroquine is retinal damage. This drug slows the progression of mild rheumatoid disease before it worsens. The nurse needs to teach the client to report blurred vision or headache. Remind clients to have an eye examination before taking the drug and every 6 months to detect changes in the cornea, lens, or retina. If this rare complication occurs, the primary health care provider discontinues the drug.

*Question: The nurse is attempting to inspect the lacrimal apparatus of a client's eye. Because of its anatomical location, the nurse would do which action?*

*Answer: Retract the upper eyelid and ask the client to look down.* Rationale: The lacrimal apparatus consists of the lacrimal gland (in the upper lid over the outer canthus) and the secretory ducts that direct tears to the lacrimal sac in the inner canthus. The nurse examines part of this apparatus by retracting the upper eyelid and asking the client to look down. Abnormal findings would include edema and tenderness. The other options are incorrect.

*Question: The nurse is assisting in preparing a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to care for the client to improve communication. Which action would be appropriate for the nurse to suggest including in the plan of care?*

*Answer: Reward the client when a desired behavior is performed.* Rationale: The action that would be appropriate for the nurse to suggest including in the plan of care is rewarding the client when a desired behavior is performed. Operant conditioning entails rewarding a client for desired behaviors, and it is the basis for behavior modification. It uses a positive reinforcement approach. The other actions are not characteristics or appropriate components of the plan of care for this form of therapy.

*Question: A client has sustained multiple fractures in the left leg and is in skeletal traction. The nurse has obtained an overhead trapeze for the client's use to aid in bed mobility. The nurse would monitor for which high-risk area for pressure and breakdown?*

*Answer: Right heel* Rationale: The client's right heel is at high risk for pressure and breakdown. There are specific areas that are under pressure and are at risk for breakdown in the client who has skeletal traction. These include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the good leg (which is used as a brace when pushing up in bed). Other pressure points caused by the traction include the ischial tuberosity, popliteal space, and Achilles tendon.

*Question: A client has undergone a right pneumonectomy. The nurse positioning this client following admission from the postanesthesia care unit avoids placing the client in which harmful position?*

*Answer: Right lateral* Rationale: The client who has a pneumonectomy should not be positioned in the extreme lateral position. This could cause mediastinal shift and compression of remaining lung tissue. The other positions do not pose this risk for the client.

*Question: The nurse has assisted the primary health care provider with a liver biopsy, which was done at the bedside. Upon completion of the procedure, the nurse would assist the client into which position?*

*Answer: Right side-lying with a small pillow or towel under the puncture site* Rationale: Following a liver biopsy the client is assisted to assume a right side-lying position with a small pillow or folded towel under the puncture site for at least 3 hours. This helps immobilize the area and provides pressure to minimize bleeding in this vascular organ. The other options are incorrect.

*Question: A client diagnosed with an infected leg wound that is draining purulent material has a prescription for sodium hypochlorite to be used in the care of the wound. The nurse would perform which priority action while using this solution?*

*Answer: Rinse off the solution immediately following irrigation.* Rationale: Sodium hypochlorite is a chloride solution used for irrigating and cleaning either necrotic or purulent wounds. It cannot be used to pack purulent wounds because the solution is inactivated by copious pus. (It can be used to pack necrotic wounds, however.) It should not come into contact with healing or normal tissue, and it should be rinsed off immediately if used for irrigation. The solution is unstable and must be prepared on a regular basis (per agency and pharmacy procedures).

*Question: The nurse is caring for a client in the oncology unit who has developed stomatitis during chemotherapy. The nurse would plan which measure to treat this complication?*

*Answer: Rinse the mouth with dilute baking soda or saline solution.* Rationale: Stomatitis, or mouth ulcerations, occurs with the administration of many antineoplastic medications and altered oral flora due to immunosuppression. The client's mouth should be examined daily for signs of ulceration. If stomatitis occurs, the client should be instructed to rinse the mouth with dilute baking soda or saline solution. Food and fluids are important and should not be restricted. If chewing and swallowing are painful, the client may switch to a liquid diet. The client is instructed to avoid spicy foods and foods with hard crusts or edges. The client should avoid tooth brushing and flossing when stomatitis is severe because of the risk of bleeding. Lemon and glycerin swabs may cause pain and further irritation.

*Question: The nurse is administering gentamicin sulfate ophthalmic ointment to a client. After instilling the ointment, the nurse reinforces instructions to the client to close the eye and perform which action?*

*Answer: Roll the eyeball in all directions.* Rationale: Gentamicin sulfate is an anti-infective of the aminoglycoside type. After the ophthalmic ointment preparation has been applied, the client should close the eye and roll the eyeball in all directions. This helps distribute the medication properly. Options 2 and 3 are of no value. Option 4 is a possibility if systemic absorption is a concern, but this would be done for 1 to 2 minutes, not 10 minutes.

*Question: A client who has been newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. Which teaching information would the nurse reinforce upon discharge?*

*Answer: Rotate the insulin injection sites systematically.* Rationale: Insulin dosages should not be adjusted or increased before unusual exercise. If acetone is found in the urine, it may possibly indicate the need for additional insulin. To minimize the discomfort associated with insulin injections, the insulin should be administered at room temperature. Injection sites should be systematically rotated from one area to another. The client should be instructed to give injections in one area, about 1 inch apart, until the whole area has been used and then to change to another site. This prevents dramatic changes in daily insulin absorption.

*Question: The nurse working in the day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and assists in planning activities that will meet the child's needs. The nurse understands that the priority consideration in planning activities for the child is to ensure which need is met?*

*Answer: Safety with activities* Rationale: Safety with all activities is a priority in planning activities with the child. The child with autism is unable to anticipate danger, has a tendency for self-mutilation, and has sensory-perceptual deficits. Although providing social interactions, verbal communications, and familiarity and orientation are also appropriate interventions, the priority is safety.

*Question: The nurse is providing dietary instructions to a client with gout. The nurse would tell the client to avoid which food item?*

*Answer: Scallops* Rationale: Scallops should be omitted from the diet of a client who has gout because of the high purine content. The food items identified in the remaining options have negligible purine content and may be consumed by the client with gout.

*Question: A client arrives at the health care clinic and tells the nurse that they have been doubling their daily dosage of bupropion hydrochloride to help them get better faster. The nurse understands that the client is now at risk for which problem?*

*Answer: Seizure activity* Rationale: Bupropion is an atypical antidepressant and does not cause significant orthostatic blood pressure changes. Seizure activity is common in dosages greater than 450 mg daily. Bupropion frequently causes a drop in body weight. Insomnia is a side effect, but seizure activity causes a greater client risk.

*Question: The nurse is caring for a client following craniotomy who has a supratentorial incision. The nurse reviews the client's plan of care, expecting to note that the client would be maintained in which position?*

*Answer: Semi-Fowler's position* Rationale: In supratentorial surgery (surgery above the brain's tentorium), the client's head usually is elevated 30 degrees to promote venous outflow through the jugular veins. The client's head or the head of the bed is not lowered in the acute phase of care after supratentorial surgery. An exception to this position is the client who has undergone evacuation of a chronic subdural hematoma, but a primary health care provider's prescription is required for positions other than those involving head elevation.

*Question: The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria?*

*Answer: Separates into concentric rings and tests positive for glucose* Rationale: Leakage of CSF from the ears or nose may accompany basilar skull fracture. It can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, which is known as the halo sign. It also tests positive for glucose. Options 1, 2, and 3 are not characteristics of CSF.

*Question: A client with type 1 diabetes mellitus has had a left above-the-knee amputation. The nurse carefully inspects the residual limb for which complication because of the history of diabetes?*

*Answer: Separation of wound edges* Rationale: Clients with diabetes mellitus are at greater risk of wound infection and separation of wound edges leading to delayed wound healing. Postoperative residual limb edema and hemorrhage are complications in the immediate postoperative periods that apply to any client with an amputation. Pain is also considered normal, although the nurse carefully administers analgesia to minimize it.

*Question: The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding?*

*Answer: Serous drainage* Rationale: A small amount of serous drainage is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported.

*Question: The nurse is reviewing the results of serum laboratory studies drawn on a client diagnosed with acquired immunodeficiency syndrome (AIDS) who is receiving didanosine. The nurse determines that the client may have the medication discontinued by the primary health care provider (PHCP) if which significantly elevated result is noted?*

*Answer: Serum amylase* Rationale: Didanosine can cause pancreatitis. A serum amylase level that is increased 1.5 to 2 times the normal may signify pancreatitis in the client with acquired immunodeficiency syndrome and is potentially fatal. The medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure.

*Question: The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted?*

*Answer: Severe, throbbing headache* Rationale: The client with spinal cord injury above the level of T7 is at risk for autonomic dysreflexia. It is characterized by a severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. It is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury.

*Question: The nurse reinforces teaching to a client with diabetes mellitus regarding differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that glucose will be taken if which symptom develops?*

*Answer: Shakiness* Rationale: Shakiness is a sign of hypoglycemia, and it would indicate the need for food or glucose. Fruity breath odor, blurred vision, and polyuria are signs of hyperglycemia.

*Question: The nurse is collecting data from a client who is suspected of having mittelschmerz. Which finding, on data collection, is most closely associated with this disorder?*

*Answer: Sharp pain located on the right side of the pelvis* Rationale: Mittelschmerz (middle pain) refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain is due to growth of the dominant follicle within the ovary or rupture of the follicle and subsequent spillage of follicular fluid and blood into the peritoneal space. The pain is fairly sharp and is felt on the right or left side of the pelvis. It lasts generally a few hours to 2 days, and slight vaginal bleeding may accompany the discomfort.

*Question: The nurse is reinforcing discharge instructions to the client with pulmonary sarcoidosis. The nurse knows that the client understands the information if the client verbalizes which early sign of exacerbation?*

*Answer: Shortness of breath* Rationale: Shortness of breath is an early sign of exacerbation of pulmonary sarcoidosis. Others include chest pain, hemoptysis, and pneumothorax. Systemic signs and symptoms that occur later include weakness and fatigue, malaise, fever, and weight loss.

*Question: The nurse is assisting in admitting to the hospital a 4-month-old infant with a diagnosis of vomiting and dehydration. The nurse assists in developing a plan of care for the infant and suggests which position for the infant?*

*Answer: Side-lying position* Rationale: The vomiting infant or child should be placed in an upright or side-lying position to prevent aspiration. The positions identified in options 1, 3, and 4 will increase the risk of aspiration if vomiting occurs.

*Question: A client is about to undergo a lumbar puncture (LP). The nurse tells the client that which position will be used during the procedure?*

*Answer: Side-lying with the legs pulled up and the head bent down onto the chest* Rationale: The client undergoing LP is positioned lying on the side, with the legs pulled up to the abdomen, and with the head bent down onto the chest. This position helps open the spaces between the vertebrae and allows for easier needle insertion by the primary health care provider. All of the other options are incorrect.

*Question: The client is having a lumbar puncture (LP) performed. The nurse would place the client in which position for the procedure?*

*Answer: Side-lying, with legs pulled up and chin to the chest* Rationale: The client undergoing a lumbar puncture (LP) is positioned lying on the side, with the knees bent and drawn up to the abdomen and the chin tucked into the chest. This position helps open the spaces between the vertebrae.

*Question: The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding would the nurse note if this disorder is present?*

*Answer: Silvery-white scaly lesions* Rationale: Psoriatic patches are covered with silvery white scales. There is no patchy hair loss or round, red macules with scales. The skin is dry, and there is no presence of wheal patches scattered about the trunk.

*Question: The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. Which is the appropriate nursing intervention?*

*Answer: Sit beside the client in silence and verbalize occasional open-ended questions.* Rationale: Clients with catatonic stupor may be immobile and mute and may require consistent, repeated approaches. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond. The nurse would not leave the client alone. Fortunately, with pharmacotherapy and improved individual management, severe catatonic symptoms rarely occur. Option 4 relies on other clients to care for this one, which is an inappropriate expectation. Asking direct questions of this client is not therapeutic. Option 3 is the best action because it provides for client supervision and communication as appropriate.

*Question: A client is diagnosed with catatonic stupor. The client is lying on the bed, hidden under the sheets, with her body pulled into a fetal position. The nurse would take which appropriate action?*

*Answer: Sit beside the client in silence with occasional open-ended questions.* Rationale: The nurse facilitates communication with the client by sitting in silence and asking open-ended questions, with pauses to provide opportunities for the client to respond. Clients who are withdrawn may also be immobile and mute (catatonic stupor). These clients require consistent, repeated approaches to establish interpersonal contact. The other actions are not appropriate nursing interventions.

*Question: The nurse is reinforcing instructions to a hospitalized client with a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic episodes. Which position would the nurse instruct the client to assume?*

*Answer: Sitting on the side of the bed leaning on an overbed table* Rationale: Positions that will assist the client with breathing include sitting up and leaning on an overbed table, sitting up and resting with the elbows on the knees, or standing or leaning against the wall. The positions in options 1, 2, and 3 will not enhance the effectiveness of breathing.

*Question: The nurse is caring for a client who has been prescribed gabapentin and is monitoring for adverse effects of the medication. Which finding indicates a potential adverse effect?*

*Answer: Slurred speech* Rationale: Gabapentin is classified as an anticonvulsant and antineuralgic and works by reducing seizure activity and neuropathic pain. Adverse effects include overdosage, which manifests as slurred speech, drowsiness, lethargy, and diarrhea. Tremors, dysarthria (difficulty speaking), and weight gain are side effects of this medication.

*Question: A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. Next, the nurse would check the client's medical history for which item?*

*Answer: Smoking history* Rationale: The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger's disease). This is a relatively uncommon disorder characterized by inflammation and thrombosis of smaller arteries and veins. This disorder is typically found in young men who smoke. The cause is unknown but is suspected to have an autoimmune component.

*Question: A client diagnosed with hyperthyroidism will be taking propylthiouracil. The nurse reinforces medication instructions and determines that the client understands the information if the client states that it is most important to report which symptoms to the primary health care provider?*

*Answer: Sore throat* Rationale: An adverse effect of propylthiouracil is agranulocytosis. The client should be alert for this effect by noting the presence of fever or sore throat, which should be reported immediately. Muscle aches, weight loss, and excitability are neither side effects nor adverse effects of this medication.

*Question: The nurse is caring for a client who is hearing-impaired. Which approach would the nurse take to facilitate communication?*

*Answer: Speak in a normal tone.* Rationale: It is important to speak in a normal tone to the client with impaired hearing and avoid shouting. The nurse should talk directly to the client while facing the client and should speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but it is important to avoid talking directly into the impaired ear.

*Question: A client admitted with depression 3 days ago could hardly get out of bed without coaxing and needed constant encouragement to get dressed and participate in unit activities. Today the client appears in the dayroom dressed and well groomed, without any guidance from the staff. The client appears to be calm and relaxed, yet more energetic than before. The nurse would take which initial action after noting this client's behavior?*

*Answer: Speak to the client personally about the nurse's observations and ask if the client is thinking about suicide.* Rationale: The nurse's initial action after noting this client's behavior is to speak to the client personally about the nurse's observations and ask if the client is thinking about suicide. A sudden improvement in a depressed client's mood may indicate that the client has decided to commit suicide. The most direct way to validate the nurse's impression is to ask the client directly about suicidal ideation or plans. The other actions are not appropriate initially.

*Question: The nurse is gathering data on a client with a diagnosis of tuberculosis. The nurse would review the results of which diagnostic test to confirm this diagnosis?*

*Answer: Sputum culture* Rationale: A definitive diagnosis of tuberculosis is confirmed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made on the basis of a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.

*Question: A client who attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. The nurse, being most concerned with the client's safety, would take which action?*

*Answer: Stay with the client at all times.* Rationale: The nurse, being most concerned with the client's safety, would stay with the client at all times. The plan of care for a client with a suicide attempt must reflect action that will promote the client's safety. Constant observation status (one on one) is the immediate intervention. Options 3 and 4 do not provide constant observation of the client. Option 2 places an unfair burden on the friend of the client, which is inappropriate.

*Question: The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse would plan to perform which action?*

*Answer: Stay with the person and encourage the person to remain still.* Rationale: With a suspected fracture, the client is not moved unless it is dangerous to remain in that spot. The nurse should remain with the client and have someone else call for emergency help. A fracture is not reduced at the scene. Before moving the client, the site of the fracture is immobilized to prevent further injury.

*Question: The nurse is suctioning a client through a tracheal tube. During the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which would be the nurse's next action?*

*Answer: Stop the procedure and oxygenate the client.* Rationale: During suctioning the nurse should monitor the client closely for complications including hypoxemia, drop in heart rate due to vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If complications develop, especially cardiac irregularities, the nurse should stop the procedure and oxygenate the client.

*Question: The nurse is assisting in caring for a client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which sign experienced by the client would be reported immediately to the registered nurse (RN)?*

*Answer: Stridor* Rationale: The nurse reports the presence of stridor to the RN immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. It indicates airway edema and places the client at risk for airway obstruction. A respiratory rate of 26 breaths per minute and congestion are abnormal, but additional data are needed to determine if these pose a serious problem at this time. Occasional pink-tinged sputum may be expected at this time.

*Question: A nursing student is assisting the clinic nurse with the administration of immunizations in the well-baby clinic. The student is asked to administer a measles, mumps, and rubella (MMR) vaccine to a child and prepares to administer the vaccine in which way?*

*Answer: Subcutaneously in the upper arm* Rationale: MMR is administered subcutaneously into the outer aspect of the upper arm. Each child should receive two vaccinations, the first between 12 and 15 months of age and the second between 4 and 6 years or 11 and 12 years. Options 1, 3, and 4 are incorrect.

*Question: A client is receiving acetylcysteine, 20% solution diluted in 0.9% normal saline by nebulizer. The nurse would have which item available for a possible adverse event after giving this medication?*

*Answer: Suction equipment* Rationale: Acetylcysteine can be given orally or by nasogastric tube to treat acetaminophen overdose, or it may be given by inhalation for use as a mucolytic. The nurse administering this medication as a mucolytic should have suction equipment available in case the client cannot manage to clear the increased volume of liquefied secretions.

*Question: A client with respiratory congestion is scheduled to receive acetylcysteine 20% solution diluted in 0.9% normal saline by nebulizer. The nurse checks the client's room to ensure that which equipment is available for use following administration of this medication?*

*Answer: Suction equipment* Rationale: Acetylcysteine can be given orally or by nasogastric tube to treat acetaminophen overdose, or it may be given by inhalation for use as a mucolytic. The nurse administering this medication as a mucolytic should have suction equipment available in case the client cannot manage to clear the increased volume of liquefied secretions. The items in options 1, 2, and 3 are not necessary.

*Question: The nurse is caring for a postoperative client who has been NPO, and the primary health care provider (PHCP) has prescribed a clear liquid diet. When planning to initiate this diet, which priority item would the nurse place at the client's bedside?*

*Answer: Suction equipment* Rationale: In a postoperative client, a concern related to initiating a diet is aspiration. Initiating postoperative oral fluids may lead to distention and vomiting. Suction equipment must be available. A blood pressure cuff may be necessary but is not the priority from the options provided. A code cart is unnecessary. A straw may help the client sip fluids but is not necessary.

*Question: A camp nurse is reinforcing instructions to the parents of the children who are attending a daytime camp for the summer. The nurse instructs the parents to check their child daily for the presence of tick bites and tells the parents that if a tick is found to do which action first?*

*Answer: Suffocate the tick with a substance such as nail polish.* Rationale: The method to remove ticks includes suffocating the tick with nail polish, petroleum jelly, or oil, and waiting 30 minutes. The tick is then removed with tweezers, taking care to remove the head. If mouth parts remain, they are removed with a sterile needle. The area is then washed with soap and water. It is premature to instruct the parents to take the child to the emergency department.

*Question: The nurse has a prescription to give a first dose of hydrochlorothiazide to an assigned client. The nurse would question the prescription if the client had a history of allergy to which item?*

*Answer: Sulfa drugs* Rationale: Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. A sulfa allergy must be communicated to the pharmacist, primary health care provider, nurse, and other health care providers. The other options are incorrect.

*Question: The nurse is assigned to care for a client with a diagnosis of toxoplasmosis. The primary health care provider has prescribed sulfasalazine. The nurse preparing to administer the medication would determine that this medication is in which drug category?*

*Answer: Sulfonamide* Rationale: Sulfasalazine is a sulfonamide and produces anti-inflammatory and antibacterial effects. It is not an antibiotic, opioid analgesic, or nonsteroidal anti-inflammatory.

*Question: The nurse is assisting in caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy (DIC). Which finding is least likely associated with DIC?*

*Answer: Swelling of the calf of one leg* Rationale: DIC is a state of diffuse clotting in which clotting factors are consumed. This leads to widespread bleeding. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and are thus prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. Petechiae, oozing from injection sites and hematuria are associated with the presence of DIC. Swelling and pain in the calf of one leg more likely are associated with thrombophlebitis.

*Question: A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is reinforcing instructions to the client regarding the program. Which instruction would the nurse include?*

*Answer: Take a blood glucose test before exercising.* Rationale: A blood glucose test performed before exercising provides information to the client regarding the need to eat a snack first. Exercising during the peak times of insulin effect or before mealtime places the client at risk for hypoglycemia. Insulin should be administered as prescribed.

*Question: A licensed practical nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the AP as being an appropriate method, indicates the need for further teaching?*

*Answer: Taking an oral temperature for a client with a cough and nasal congestion* Rationale: An oral temperature should be avoided if the client has nasal congestion. One of the other methods of measuring the temperature should be used according to the equipment available. Taking a rectal temperature for a client who has undergone nasal surgery is appropriate. Other less invasive measures should be used if available; if they are not available, a rectal temperature is acceptable. Taking an axillary temperature on a client who just consumed coffee is also acceptable; however, the axillary method of measurement is the least reliable, and other methods should be used if available. If temporal equipment is available and the client is diaphoretic, it is acceptable to measure the temperature on the neck behind the ear, avoiding the forehead.

*Question: The nurse is assisting in conducting a group therapy session. During the session a client threatens to act out physically and states that he will punch another member of the group. Which is the appropriate nursing action?*

*Answer: Tell the client that he may talk about his anger but cannot act on it during the group session.* Rationale: If a client threatens to act out physically during a group session, the appropriate nursing action is to tell the client that he may talk about his anger but cannot act on it during the group session. The other nursing actions are inappropriate. Because the client's action was a threat, it is best for the nurse to deal with the behavior. Option 2 is a premature action. Telling the client that he must leave immediately or that if he hits another client he will be restrained and placed in seclusion violates the client's rights based on the information provided in the question.

*Question: A client who exhibits fatigue, lack of energy, constipation, and depression is diagnosed with hypothyroidism. The primary health care provider prescribes levothyroxine. To increase the likelihood of medication compliance in the early course of treatment, the nurse plans to reinforce which information?*

*Answer: The full therapeutic effect may take 1 to 3 weeks.* Rationale: The full therapeutic effect of this medication may not be seen for 1 to 3 weeks. Clients should be aware of this so that they do not discontinue the medication on their own due to lack of perceived effect. Diarrhea and weight gain are not side effects of this medication.

*Question: The nurse in the psychiatric unit is reviewing the records of the clients admitted to the nursing unit. A client with a history of violent behavior approaches the nurse and demands immediate discharge from the hospital. The nurse notes that the client was voluntarily admitted to the psychiatric unit. Which is the appropriate nursing action?*

*Answer: Tell the client that the primary health care provider will be contacted regarding discharge.* Rationale: The appropriate nursing action is to tell the client that the primary health care provider will be contacted regarding discharge. False imprisonment is an act with the intent to confine a person to a specific area. The nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital, if the client was voluntarily admitted, and if there are no agency or legal policies for detaining the client. The nurse would not allow the client to leave without first contacting the primary health care provider. An attempt to persuade the client to stay or contacting security may arouse violent feelings in the client. It is not appropriate to restrain the client.

*Question: Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal?*

*Answer: The client gives away a DVD and a cherished autographed picture of the performer.* Rationale: A depressed, suicidal client often gives away that which is of value as a way of saying "goodbye" and wanting to be remembered. Options 2, 3, and 4 identify acting-out behaviors.

*Question: A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, which would the nurse expect to note?*

*Answer: The client presents a harm to self.* Rationale: Involuntary admission is made without the client's consent. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment or physical care. Options 2, 3, and 4 describe the process of voluntary admission.

*Question: The nurse is assisting in the care of a client diagnosed with rheumatic heart disease. The nurse would reinforce instructions to the client to notify the dentist before dental procedures for which reason?*

*Answer: The client requires prophylactic antibiotics before treatment.* Rationale: The client with a history of rheumatic fever is at risk for developing infective endocarditis. The client should tell all health care providers and dentists about this problem so that prophylactic antibiotic therapy can be given before any procedure that is invasive or carries a risk of bleeding. Low-speed drills, epinephrine, and stressful events are unrelated to rheumatic heart disease.

*Question: A client with a phobia will be treated for the condition using a behavior modification technique known as systematic desensitization. The nurse describes the components of this form of therapy to the client and reinforces which client instruction?*

*Answer: The client will be introduced to short periods of exposure to the phobic object while in a relaxed state.* Rationale: Systematic desensitization is a form of therapy in which the client is introduced to short periods of exposure to the phobic object while in a relaxed state. Gradually, over a period of time, exposure is increased until the anxiety about or fear of the object or situation has ceased. Option 1 is not a specific component of systematic desensitization and describes pharmacological therapy. Option 2 describes self-control therapy, and option 3 describes self-help groups.

*Question: The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. During review of the client's record, the nurse notes that the admission was a voluntary one. Based on this type of admission, which would the nurse expect to note?*

*Answer: The client will participate in the treatment plan.* Rationale: Generally, voluntary admission is sought by the client or client's guardian. If the client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program. Options 1 and 3 are not likely for a client seeking voluntary admission. Option 4 is not centered on the individual client.

*Question: The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L (130 mmol/L). The nurse expects that this sodium level would be noted in a client with which condition?*

*Answer: The client with the syndrome of inappropriate secretion of antidiuretic hormone* Rationale: Hyponatremia is a serum sodium level less than 135 mEq/L (135 mmol/L). Hyponatremia can occur secondary to syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The client with an inadequate daily water intake, watery diarrhea, or diabetes insipidus is at risk for hypernatremia.

*Question: The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse would identify which as a priority concern?*

*Answer: The client's report of self-destructive thoughts* Rationale: The client's thoughts are extremely important when verbalized. Self-destructive thoughts are the highest priority. Options 1, 2, and 4 will all affect the treatment of the client but are not of greatest importance at this time.

*Question: The nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse would determine that this type of crisis could be caused by which event?*

*Answer: The death of a loved one* Rationale: A situational crisis is associated with a life event. External situations that could precipitate a situational crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis relates to a crisis, disaster, or event that is not a part of everyday life, is unplanned, and is accidental.

*Question: The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse recognizes that these types of delusions are characteristic of which thoughts?*

*Answer: The false belief that one is being singled out for harm by others* Rationale: A delusion is a false belief held to be true even when there is evidence to the contrary. A delusion of persecution is the thought that one is being singled out for harm by others. A delusion of grandeur is the false belief that he or she is a very powerful and important person. A delusion of jealousy is the false belief that one's partner is being unfaithful.

*Question: The primary health care provider (PHCP) prescribes exenatide for a client with type 1 diabetes mellitus who takes insulin. The nurse knows that which is the most appropriate intervention?*

*Answer: The medication is withheld, and the PHCP is called to question the prescription for the client.* Rationale: Exenatide is an incretin mimetic used for type 2 diabetes mellitus only. It is not recommended for clients taking insulin. Hence, the nurse should hold the medication and question the PHCP regarding this prescription. Although options 1 and 3 are correct statements about the medication, in this situation it should not be administered. The medication is packaged in prefilled pens ready for injection without the need for drawing it up into another syringe.

*Question: A postpartum nurse has reinforced instructions to a new mother on how to bathe her newborn. The nurse demonstrates the procedure to the mother and on the following day asks the mother to perform the procedure. Which observation made by the nurse indicates that the mother is performing the procedure correctly?*

*Answer: The mother begins to wash the newborn by starting with the eyes and face.* Rationale: Bathing should start at the eyes and face and with the cleanest area first. Next the external ears and behind the ears are cleaned. The newborn's neck should be washed because formula, lint, or breast milk often accumulates in the folds. Hands and arms are next, then the legs, with the diaper area washed last.

*Question: A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress during discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." While helping the mother prepare for her daughter's discharge, the nurse would make which suggestion?*

*Answer: The mother should restrict the amount of chocolate and caffeine products in the home.* Rationale: Clients with anxiety disorder should abstain from or limit their intake of caffeine, chocolate, and alcohol. These products have the potential of increasing anxiety. Options 1 and 3 are unreasonable and are an unhealthy approach. It may not be realistic for a family member to take time away from work.

*Question: The nurse is discussing foot care with a diabetic client and the spouse. The nurse includes which instruction during this informational session?*

*Answer: The toenails should be cut straight across.* Rationale: The client should be instructed to cut the toenails straight across. The client should not soak the feet in hot water to prevent burns. The client should be instructed to wash the feet daily using a mild soap. Moisturizing lotion can be applied to the feet but should not be placed between the toes.

*Question: Vancomycin has been prescribed for the client. The nurse would plan to monitor which item associated with effectiveness of this medication?*

*Answer: Therapeutic serum levels* Rationale: Vancomycin is classified as a tricyclic glycopeptide antibiotic and acts by producing a bactericidal effect. Therapeutic serum levels are drawn on a regular basis to ensure effectiveness of this medication. The nurse should monitor hearing acuity, kidney function studies, and heart rate and blood pressure because this medication can be ototoxic, nephrotoxic, and cardiotoxic; however, these findings are not associated specifically with the effectiveness of this medication.

*Question: A client with ulcerative colitis had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse?*

*Answer: This is a normal, expected event.* Rationale: As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy. Options 2, 3, and 4 are incorrect interpretations.

*Question: The primary health care provider has prescribed butenafine for a client. The nurse recognizes that this has been prescribed to treat which disorder?*

*Answer: Tinea pedis* Rationale: Butenafine is used for tinea pedis, tinea corporis, tinea cruris, and tinea versicolor. Oral candidiasis is treated with clotrimazole troches, nystatin mouthwash or lozenges, or oral amphotericin B. Candidiasis of the vulva and vagina may be treated with topical azoles (e.g., clotrimazole, miconazole, tioconazole) or oral fluconazole. Systemic fungal infections require intravenous amphotericin B, an effective but very toxic drug.

*Question: Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication?*

*Answer: Tinnitus* Rationale: Salicylic acid is absorbed readily through the skin and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism.

*Question: A parent calls the clinic nurse to schedule an appointment for her child's diphtheria, tetanus, and pertussis (DTaP) vaccination. The parent tells the nurse that her child had a swelling at the injection site and low-grade fever after the last DTaP vaccination. Which instructions would the nurse give to the parent to lessen this type of reaction to the upcoming vaccination?*

*Answer: To administer an appropriate dose of Tylenol 45 minutes before the appointment* Rationale: Nurses can involve the parent in minimizing the potential adverse effects of the vaccine by recommending administration of an appropriate dose of acetaminophen 45 minutes before the appointment time. A sugary drink will not be effective to lessen the pain of the injection. Needle length (appropriate to deliver into the muscle) is an important factor, and fewer reactions to immunizations are observed when the vaccine is given deep into the muscle rather than into subcutaneous tissue. A shorter needle may place the vaccination into subcutaneous tissue. Giving the Tylenol after the injection can be advised, but the dose before the injection is more effective.

*Question: The mother of a newborn calls the clinic and reports to the nurse that when she was cleansing the newborn's umbilical cord, the cord was moist and discharge was noted. Which nursing instruction to the mother is appropriate?*

*Answer: To bring the infant to the clinic* Rationale: Signs of infection are moistness, oozing, discharge, and a reddened base around the cord. If signs of infection occur, the mother should be instructed to notify a primary health care provider. If these signs occur, antibiotics are necessary. Options 2, 3, and 4 are inappropriate nursing interventions.

*Question: A client who is postoperative with incisional pain complains to the nurse about completing respiratory exercises. The client is willing to do the deep breathing exercises but states that it hurts to cough. The nurse provides gentle encouragement and appropriate pain management to the client, knowing that coughing is needed for which reason?*

*Answer: To expel mucus from the airways* Rationale: Coughing is one of the protective reflexes. Its purpose is to move mucus that is in the airways upward toward the mouth and nose. Coughing is needed in the postoperative client to mobilize secretions and expel them from the airways. The other options do not accurately address the purpose of coughing in the postoperative client.

*Question: The nurse has a routine prescription to instill erythromycin ointment into the eyes of the newborn. The nurse would explain to the parents that this medication is used for which primary purpose?*

*Answer: To protect the newborn from contracting an eye infection from the birth process* Rationale: The use of eye prophylaxis with an agent such as erythromycin protects the newborn from contracting a conjunctival infection during birth. This infection, called ophthalmia neonatorum, results from maternal vaginal infection with chlamydia or gonorrhea. This prophylaxis is mandatory in the United States.

*Question: Cycloserine is added to the medication regimen for a client with tuberculosis. Which instruction would the nurse reinforce in the client-teaching plan regarding this medication?*

*Answer: To return to the clinic weekly for serum drug-level testing* Rationale: Cycloserine is an antitubercular medication that requires weekly serum drug level determinations to monitor for the potential of neurotoxicity. Serum drug levels lower than 30 mcg/mL reduce the incidence of neurotoxicity. The medication must be taken after meals to prevent GI irritation. The client must be instructed to notify the PHCP if a skin rash or signs of central nervous system (CNS) toxicity are noted. Alcohol must be avoided because it increases the risk of seizure activity.

*Question: The licensed practical nurse (LPN) in the emergency department is caring for a client who was assaulted and sustained blunt force injuries to the chest and abdomen. Which priority client data would the LPN immediately report to the registered nurse (RN)?*

*Answer: Tracheal deviation to the left* Rationale: A tension pneumothorax is a life-threatening emergency that results when air enters the pleural space but cannot escape. The intrapleural pressures increasingly elevate, which results in compression of the lung on the affected side and pressure on the heart and great vessels, which decreases cardiac output. The mediastinum also shifts toward the unaffected side, which further compromises oxygenation by compressing the unaffected lung. The trachea deviates towards the unaffected side. Option 2 is an abnormal assessment finding that indicates the client is suffering from a tension pneumothorax and needs to be immediately reported to the registered nurse, who will then notify the primary health care provider. Options 1 and 3 are normal assessment findings. Option 4 is an expected assessment finding for a client who suffered blunt trauma to those areas and is not the priority over option 2.

*Question: The nurse is caring for a client after a thyroidectomy and notes that calcium gluconate is prescribed. The nurse determines that this medication has been prescribed for which reason?*

*Answer: Treat hypocalcemic tetany.* Rationale: Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed or injured during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips, or toes, or muscle spasms or twitching, the PHCP is notified immediately. Calcium gluconate should be accessible for the client who underwent thyroidectomy.

*Question: Which electrocardiogram changes would the nurse note on the cardiac monitor with a client whose potassium (K+) level is 2.7 mEq/L (2.7 mmol/L)?*

*Answer: U waves* Rationale: A serum potassium level less than 3.5 mEq/L (3.5 mmol/L) is indicative of hypokalemia. Potassium deficit is the most common electrolyte imbalance and is potentially life-threatening. Cardiac changes with hypokalemia may include peaked P waves, flattened T waves, depressed ST segment, and the presence of U waves.

*Question: A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. The nurse assists with performing Allen's test before drawing the blood to determine the adequacy of which?*

*Answer: Ulnar circulation* Rationale: Before performing a radial puncture to obtain an arterial specimen for ABG values, Allen's test should be performed to determine adequate ulnar circulation. Failure to assess collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. The remaining options are not associated with this test.

*Question: A primary health care provider is about to perform a paracentesis on a client diagnosed with abdominal ascites. The nurse would assist the client to assume which position?*

*Answer: Upright* Rationale: An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion. Ideally, the client sits upright in a chair, with feet flat on the floor, and with the bladder emptied before the procedure. Therefore, the supine, left side-lying, and right side-lying positions are incorrect.

*Question: A client with ascites is scheduled for a paracentesis. The nurse is assisting the primary health care provider (PHCP) with performing the procedure. Which position would the nurse assist the client into for this procedure?*

*Answer: Upright* Rationale: An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion. Options 1, 3, and 4 are incorrect positions.

*Question: The client with acute myelocytic leukemia is being treated with busulfan. Which laboratory value would the nurse specifically monitor during treatment with this medication?*

*Answer: Uric acid level* Rationale: Busulfan can cause an increase in the uric acid level because of massive cell death of malignant cells. Hyperuricemia can produce uric acid nephropathy, renal stones, and acute kidney injury. Clotting time, potassium, and glucose blood levels are not specifically related to this medication.

*Question: Bethanechol chloride is prescribed for a client with urinary retention. Which disorder should be a contraindication to the administration of this medication?*

*Answer: Urinary strictures* Rationale: Bethanechol chloride can be harmful to clients with urinary tract obstruction or weakness of the bladder wall. The medication has the ability to contract the bladder and thereby increase pressure within the urinary tract. Elevation of pressure within the urinary tract could rupture the bladder in clients with these conditions.

*Question: The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of the fluid resuscitation?*

*Answer: Urine output* Rationale: Successful or adequate fluid resuscitation in the adult is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and a clear sensorium. The most reliable indicator for determining the adequacy of fluid resuscitation is the urine output. For an adult, the hourly urine volume should be 30 mL to 50 mL.

*Question: During data collection on a postoperative client who has undergone hypophysectomy, the client complains of thirst and frequent urination. Knowing the expected complication of this surgery, the nurse would check which parameter next?*

*Answer: Urine specific gravity* Rationale: Following hypophysectomy, diabetes insipidus can occur temporarily because of antidiuretic hormone (ADH) deficiency. This deficiency is related to surgical manipulation. The nurse should assess specific gravity and notify the registered nurse if the results are less than 1.005. Although serum glucose, blood pressure, and respiratory rate may be components of the assessment, the nurse would next check urine specific gravity.

*Question: The nurse is reinforcing instructions to the client with a below-the-knee amputation (BKA) with regard to measures to protect the residual limb. The nurse would be sure to include which point in discussions with the client?*

*Answer: Use a mirror to inspect all areas of the residual limb.* Rationale: The client would use a mirror to visualize all areas of the residual limb after BKA. This will be most effective in helping the client detect any areas of redness or breakdown early. The client would not apply oils, creams, or lotions because they soften the skin too much for safe prosthesis use. The client would wear a clean woolen (not nylon) sock on the residual limb each day. The client would avoid using alcohol because it could cause drying or cracking of the skin.

*Question: The nurse is providing general information to a group of high school students about preventing human immunodeficiency virus (HIV) transmission. The nurse would inform the students that which behavior is most unsafe?*

*Answer: Use of natural skin condoms* Rationale: The use of natural skin condoms is not considered safe because the pores in the condom are large enough for the virus to pass through. Abstinence is the safest way to avoid HIV infection. The next most reliable method is participation in a mutually monogamous relationship. The use of latex condoms is considered safe because the latex prevents the transmission of the HIV virus as long as the condom is used properly and remains in place and intact.

*Question: The nurse is assisting in developing a plan of care for a client with a psychotic disorder who is experiencing altered thought processes. On review of the client's record, the nurse notes documentation that the client believes that the food is being poisoned. The nurse plans to use which communication technique when developing strategies that will promote adequate nutrition and encourage the client to discuss feelings?*

*Answer: Use open-ended questions and silence.* Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss their feelings. Options 2 and 4 are not helpful to the client because they do not encourage the client to express feelings. Option 3 will block the nurse-client relationship.

*Question: A client with prostatitis resulting from kidney infection has received instructions on management of the condition at home and prevention of recurrence. Which statement indicates that the client understood the instructions?*

*Answer: Use warm sitz baths and analgesics to increase comfort.* Rationale: Treatment of prostatitis includes medication with antibiotics, analgesics, and stool softeners. The client is also taught to rest, increase fluid intake, and use sitz baths for comfort. Antimicrobial therapy is always continued until the prescription is completely finished.

*Question: The client asks the nurse about various herbal therapies available for the treatment of insomnia. The nurse would encourage the client to discuss the use of which product with the primary health care provider?*

*Answer: Valerian* Rationale: Valerian has been used to treat insomnia, hyperactivity, and stress. It has also been used to treat nervous disorders such as anxiety and restlessness. Garlic is used as an antioxidant and to lower cholesterol levels. Lavender is used as an antiseptic and fragrance for a mild sedative effect. Glucosamine is an amino acid that assists with the synthesis of cartilage.

*Question: The low-pressure alarm sounds on the ventilator. The nurse checks the client and then attempts to determine the cause of the alarm but is unsuccessful. Which initial action would the nurse take?*

*Answer: Ventilate the client manually.* Rationale: If an alarm is sounding at any time and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and a manual resuscitation device is used to support respirations until the problem can be corrected. Although oxygen is helpful, it will not provide ventilation to the client. Checking vital signs is not the initial action. There is no reason to begin CPR.

*Question: A client with severe acne is seen in the clinic and the primary health care provider (PHCP) prescribes isotretinoin. The nurse reviews the client's medication record and would contact the PHCP if the client is also taking which medication?*

*Answer: Vitamin A* Rationale: Isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin toxicity. Because of the potential for increased toxicity, vitamin A supplements should be discontinued before isotretinoin therapy. There are no contraindications associated with digoxin, phenytoin, or furosemide.

*Question: A client undergoing renal dialysis is prescribed calcitriol to treat hypocalcemia. The nurse reinforces instructions and informs the client that this medication is also known as which nutrient?*

*Answer: Vitamin D* Rationale: Calcitriol is a natural form of vitamin D and is an important regulator for calcium and phosphorus homeostasis. This vitamin improves calcium absorption from the intestine. Few foods are naturally rich in vitamin D except for oily fish such as salmon. Many foods are enriched with vitamin D such as milk. Vitamin D can be obtained by the body with exposure to sunlight.

*Question: The nurse is collecting data from a pregnant client with a history of cardiac disease. The nurse is checking for venous congestion. The nurse inspects which area, knowing that venous congestion is most commonly noted where?*

*Answer: Vulva* Rationale: Assessment of the cardiovascular system includes observation for venous congestion that can develop into varicosities. Venous congestion most commonly is noted in the legs, vulva, or rectum. It would be difficult to assess for edema in the abdominal area of a client who is pregnant. Although edema may be noted in the fingers and around the eyes, edema in these areas would not be associated directly with venous congestion.

*Question: A client with osteoarthritis is receiving diclofenac sodium. The licensed practical nurse (LPN) reviewing the client's medication prescription sheet would verify the prescription with the registered nurse (RN) if which other medication is listed?*

*Answer: Warfarin* Rationale: Diclofenac sodium is a nonsteroidal anti-inflammatory drug (NSAID). Interactions may occur with anticoagulants such as warfarin, resulting in increased risk for bleeding. The LPN should consult with the RN regarding a potential medication interaction. The other medications do not interact with diclofenac sodium. Mysoline is an anticonvulsant, calcium carbonate is an antacid, and vitamin C is a nutritional supplement. These medications are not contraindicated when diclofenac sodium is administered.

*Question: The nurse assists with preparing the client for ear irrigation as prescribed by the primary health care provider (PHCP). Which action would the nurse plan to take?*

*Answer: Warm the irrigating solution to 98°F (36.6°C).* Rationale: Irrigation solutions that are not close to the client's body temperature can be uncomfortable and may cause injury, nausea, and vertigo. The client is positioned so that the ear to be irrigated is facing downward, because this allows gravity to assist with the removal of the ear wax and solution. After the irrigation, the client is to lie on the affected side to finish draining the irrigating solution. A slow, steady stream of solution should be directed toward the upper wall of the ear canal and not toward the eardrum. Too much force could cause the tympanic membrane to rupture.

*Question: The nurse in the delivery room is assisting with the delivery of a newborn. The nurse prepares to prevent heat loss in the newborn due to conduction by initiating which action?*

*Answer: Warming the crib pad before placing the newborn in the crib* Rationale: Hypothermia caused by conduction occurs when the newborn is on a cold surface such as a pad or mattress and heat from the newborn's body is transferred to the colder object. Warming the crib pad will assist in preventing hypothermia by conduction. Evaporation of moisture from a wet body dissipates heat along with the moisture. Drying the wet newborn at birth will prevent hypothermia via evaporation. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface.

*Question: A client with diabetes mellitus is scheduled to have a fasting blood glucose level determined in the morning. The nurse tells the client not to eat or drink after midnight. When the client asks for further information, the nurse clarifies by stating that which would be acceptable to take before the test?*

*Answer: Water* Rationale: When a client is scheduled for a fasting blood glucose level, the client should not eat or drink anything except water after midnight. This is needed to ensure accurate test results, which form the basis for adjustments or continuance of treatment. Tea without sugar, coffee without milk, and clear liquids such as apple juice are inaccurate, and the client should not consume these items before the test.

*Question: The nurse is collecting data from a client who is being seen in the health care clinic. The client is complaining of unrelieved back pain that has persisted over the past 3 months. The nurse determines that which harmful effect can occur as a result of uncontrolled muscle pain?*

*Answer: Weakness* Rationale: Uncontrolled musculoskeletal pain can result in harmful effects, resulting in certain assessment findings, such as weakness, fatigue, and immobility. Anorexia is associated with the gastrointestinal system; weight loss is associated with the endocrine system; and hypertension is associated with the cardiovascular system in terms of uncontrolled pain.

*Question: The nurse prepares to give a bath and change the bed linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate in the plan during the bathing of this client?*

*Answer: Wearing a gown and gloves* Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items, such as wound drainage, or while caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.

*Question: The nurse is assisting a client admitted to the hospital with pulmonary edema to prepare for discharge. The nurse would reinforce with the client the importance of complying with which measure to prevent a recurrence?*

*Answer: Weigh self every morning before breakfast.* Rationale: A long-range approach to the prevention of pulmonary edema is to minimize any pulmonary congestion. The client should weigh himself or herself daily as a means of determining fluid balance and possible overload. The client should sleep with the head elevated as high as needed to prevent pulmonary congestion during sleep. The client should not self-adjust any medication dosages.

*Question: A nursing student is assigned to care for an infant with a diagnosis of heart failure (HF). The student develops a plan of care for the child that is focused on monitoring for fluid overload. The student plans to best assess the urine output of the infant by taking which action?*

*Answer: Weighing the diapers* Rationale: The best method to assess urine output in an infant is to weigh the diapers. Comparing intake with output would not provide an accurate measure of urine output. Measuring the intake is not directly related to the subject of the question. Although Foley catheter drainage is most accurate in determining output, it is not the most appropriate method in an infant. In addition, insertion of a Foley catheter places the infant at risk for infection.

*Question: Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for monitoring by the nurse?*

*Answer: White blood cell count of 3000 mm3* Rationale: Silver sulfadiazine is used for the treatment of burn injuries. Adverse effects of this medication include rash and itching, blue-green or gray skin discoloration, leukopenia, and interstitial nephritis. The nurse should monitor a complete blood count, particularly the white blood cells, frequently for the client taking this medication. If leukopenia develops, the PHCP is notified and the medication is usually discontinued. The white blood cell count noted in option 4 is indicative of leukopenia. The other laboratory values are not specific to this medication, and are also within normal limits.

*Question: A hospitalized client is taking clozapine for the treatment of a schizophrenic disorder. Which laboratory study prescribed for the client would the nurse specifically review to monitor for an adverse effect associated with the use of this medication?*

*Answer: White blood cell count* Rationale: Hematological reactions can occur in the client taking clozapine and include agranulocytosis and mild leukopenia. The white blood cell count should be checked before initiating treatment and should be monitored closely during the use of this medication. The client should also be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. Options 1, 2, and 4 are unrelated to this medication.

*Question: The client with trigeminal neuralgia is being treated with carbamazepine. Which laboratory result indicates that the client is experiencing an adverse effect of the medication?*

*Answer: White blood cell count, 3000 mm3* Rationale: Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, leukopenia, cardiovascular disturbance, thrombophlebitis, dysrhythmia, and dermatological effects. Options 1, 2, and 4 identify normal laboratory values.

*Question: The client with recurrent constipation has begun using psyllium. The nurse would instruct the client that this medication would be taken in which manner?*

*Answer: With a full glass of liquid, followed by a second glass of liquid* Rationale: Metamucil is a bulk-forming laxative. It should be taken with a full glass of water or juice, followed by another glass of liquid. This will help prevent impaction of the medication in the stomach or small intestine. Therefore, the other options are incorrect.

*Question: Ketoconazole is prescribed for an assigned client. The nurse would prepare to administer the medication in which manner?*

*Answer: With food* Rationale: Ketoconazole is an antifungal medication. It should be administered with food to minimize gastrointestinal irritation. Administering the medication with an antacid, with 8 ounces of water, or on an empty stomach is incorrect. The medication requires acidity and should be administered at least 2 hours apart from an antacid.

*Question: The nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. The nurse places the infant in which position?*

*Answer: With the head and chest at a 30-degree angle, with the neck slightly extended* Rationale: The nurse should position the infant with the head and the chest at a 30- to 40-degree angle with the neck slightly extended to maintain an open airway and to decrease pressure on the diaphragm. Options 1, 2, and 3 do not achieve these goals.

*Question: The nurse is reinforcing teaching for a client regarding how to mix regular insulin and NPH insulin in the same syringe. Which action performed by the client indicates the need for further teaching?*

*Answer: Withdraws the NPH insulin first* Rationale: When preparing a mixture of regular insulin with another insulin preparation, the regular insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of regular insulin with insulin of another type. Options 2, 3, and 4 identify the correct actions for preparing NPH and regular insulin.

*Question: The nurse is assisting in the care of a client who has a serum sodium level of 128 mEq/L (128 mmol/L). The nurse relates which of the client's signs and symptoms to this electrolyte imbalance? Select all that apply.*

** Rationale: The normal serum sodium level for an adult is 135 to 145 mEq/L (135 to 145 mmol/L). Thus the client is experiencing low sodium, or hyponatremia, as evidenced by the weakness in extremities, confusion, and diarrhea with abdominal cramping. Signs of hyponatremia include rapid and thready pulse, postural blood pressure changes, weakness, abdominal cramping, poor skin turgor, muscle twitching and seizures, mental confusion, and apprehension. The neurological functioning of the client relates to the swollen brain cells that impair functioning. The gastrointestinal system is stimulated and hyperactive bowel sounds often occur. Dry skin and bleeding gums are not related to the low sodium level.

*Question: The nurse is performing a neurovascular check on a hospitalized child who had a cast applied to the lower leg. The child complains of tingling in the toes distal to the fracture site. Which action would the nurse take?*

*Answer: Notify the registered nurse (RN).* Rationale: Reduced sensation to touch or complaints of numbness or tingling at a site distal to the fracture may indicate poor tissue perfusion. This finding should be reported to the registered nurse or primary health care practitioner. Options 1, 2, and 4 are inappropriate and would delay the required and immediate interventions.

*Question: A client is scheduled for insertion of a peripherally inserted central catheter (PICC), and the nurse explains the advantages of this catheter. Which statement by the client indicates a lack of understanding about this type of catheter?*

*Answer: It is specifically designed for short-term use.* Rationale: PICC catheters are intended to be used for clients who need long-term catheter placement. It is reasonable in cost because the catheter does not need routine replacement, as do traditional peripheral IV catheters. The catheter is more comfortable for the client because there is no repeated venipuncture with catheter change. The catheter is also very reliable. It is less likely to infiltrate and can be used for administration of a number of different types of medications.