NCLEX #801-865
NO.863 Which of the following serum laboratory values would the nurse monitor during gentamicin therapy? A. Creatinine B. Sodium C. Calcium D. Potassium
Answer: A Explanation: (A) A common side effect of gentamicin is nephrotoxicity. The serum laboratory test that best reflects kidney function is serum creatinine. (B) Serum sodium has no relationship to gentamicin. (C) Serum calcium has no relationship to gentamicin. (D) Serum potassium has no relationship to gentamicin. If a client has impaired renal function secondary to gentamicin administration, he or she may also have hyperkalemia as a secondary disorder.
NO.812 When a client is receiving vasoactive therapy IV, such as dopamine (Intropin), and extravasation occurs, the nurse should be prepared to administer which of the following medications directly into the site? A. Phentolamine (Regitine) B. Epinephrine C. Phenylephrine (Neo-Synephrine) D. Sodium bicarbonate
Answer: A Explanation: (A) Phentolamine is given to counteract the-adrenergic effects that cause ischemia and necrosis of local tissue. (B) Epinephrine is an endogenous catecholamine that produces vasoconstriction and increases heart rate and contractility. (C) Phenylephrine causes constriction of arterioles of skin, mucous membranes, and viscera, which in turn can cause ischemia and necrosis. (D) Sodium bicarbonate is an alkalinizing agent that is incompatible with dopamine.
NO.835 A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best auscultated just: A. Below the umbilicus toward left side of mother's abdomen B. Below the umbilicus toward right side of mother's abdomen C. At the umbilicus D. Above the umbilicus to the left side of mother's abdomen
Answer: A Explanation: (A) LOA identifies a fetus whose back is on its mother's left side, whose head is the presenting part, and whose back is toward its mother's anterior. It is easiest to auscultate fetal heart tones (FHTs) through the fetus's back. (B) The identified fetus's back is on its mother's left side, not right side. It is easiest to auscultate FHTs through the fetus's back. (C) In an LOA position, the fetus's head is presenting with the back to the left anterior side of the mother. The umbilicus is too high of a landmark for auscultating the fetus's heart rate through its back. (D) This is the correct auscultation point for a fetus in the left sacroanterior position, where the sacrum is presenting, not LOA.
NO.852 A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from: A. Crying B. Falling asleep C. Rolling from his back to his tummy D. Sucking his thumb
Answer: A Explanation: (A) A child with a subdural hematoma has increased ICP. Crying may significantly increase this pressure. (B) Adequate sleep is essential, but it is important that the child can be aroused from sleep after head injury. (C) This child is free to roll from his back to his abdomen. (D) Thumb-sucking serves to reduce anxiety and should not be prevented at this time.
NO.804 Two weeks after a client's admission for depression, the physician orders a consult for electroconvulsive therapy (ECT). Which of the following conditions, if present, would be a contraindication for ECT? A. Brain tumor or other space-occupying lesion B. History of mitral valve prolapse C. Surgically repaired herniated lumbar disk D. History of frequent urinary tract infections
Answer: A Explanation: (A) A contraindication for ECT is a space-occupying lesion such as a brain tumor. During ECT, intracranial pressure increases. Therefore, ECT would not be prescribed for a client whose intracranial pressure is already elevated. (B) Any cardiac dysrhythmias or complications that arise during ECT are usually attributed to the IV anesthetics used, not to preexisting cardiac structural conditions. (C) Musculoskeletal injuries during ECT are extremely rare because of the IV use of centrally acting muscle relaxers. (D) A history of any kind of infection would not contraindicate the use of ECT. In fact, concurrent treatment of infections with ECT is not uncommon.
NO.807 After the fetal activity test (nonstress test) is completed, the RN is looking at the test results on the monitor strip. The RN observes that the fetal heart accelerated 5 beats/min with each fetal movement. The accelerations lasted 15 seconds and occurred 3 times during the 20- minute test. The RN knows that these test results will be interpreted as: A. A reactive test B. A nonreactive test C. An unsatisfactory test D. A negative test
Answer: A Explanation: (A) A nonstress test that shows at least two accelerations of the fetal heart rate of 15 bpm with fetal activity, lasting 15 seconds over a 20-minute period. (B) Reactive criteria are not met. The accelerations of the fetal heart rate are not at least 15 bpm and do not last 15 seconds. This could mean fetal well-being is compromised. Usually a contraction stress test is ordered if the nonstress test results are negative. (C) An unsatisfactory test means the data cannot be interpreted, or there was inadequate fetal activity. If this happens, usually the test is ordered to be done at a later date. (D) A negative test is a term used to describe the results of a contraction stress test.
NO.817 Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis? A. Urine output 22 mL/hr for 2 hours B. Serum potassium level of 3.7 C. Small T wave of ECG D. Serum glucose level of 180
Answer: A Explanation: (A) Adequate renal flow of 30 mL/hr is a necessity with potassium infusions because potassium is excreted renally. (B) Because potassium level will decrease during correction of diabetic ketoacidosis, potassium will be infused even if plasma levels of potassium are normal. (C) A small T wave is normal and desired on the electrocardiogram. A tall, peaked T-wave could indicate overinfusion of potassium and hyperkalemia. (D) Glucose levels of <200 are desirable.
NO.834 A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected. By 2 weeks' postinjury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is: A. Autonomic dysreflexia B. Bradycardia C. Central cord syndrome D. Spinal shock
Answer: A Explanation: (A) Autonomic dysreflexia is the exaggerated sympathetic nervous system response to various stimuli in the anesthetized area. Sympathetic stimulation results in severe, uncontrolled hypertension, which may result in myocardial infarction or cerebral hemorrhage. (B) Bradycardia occurs as a result of sympathetic blockade in the immediate postinjury period. After spinal shock recedes, cardiovascular stability returns, but the client will be bradycardiac for life. (C) Central cord syndrome is a specific type of spinal cord injury that occurs as a result of either hyperextension injuries or disrupted blood flow to the spinal cord. (D) Spinal shock occurs in the immediate postinjury phase and usually resolves in approximately 72 hours.
NO.802 Hematotympanum and otorrhea are associated with which of the following head injuries? A. Basilar skull fracture B. Subdural hematoma C. Epidural hematoma D. Frontal lobe fracture
Answer: A Explanation: (A) Basilar skull fractures are fractures of the base of the skull. Blood behind the eardrum or blood or cerebrospinal fluid (CSF) leaking from the ear are indicative of a dural laceration. Basilar skull fractures are the only type with these symptoms. (B, C, D) These do not typically cause dural lacerations and CSF leakage.
NO.850 A client was prescribed a major tranquilizer 2 months ago. One month ago she was placed on benztropine (Cogentin). What would indicate that benztropine therapy is effective? A. Smooth, coordinated voluntary movement B. Tremors C. Rigidity D. Muscle weakness
Answer: A Explanation: (A) Benztropine is prescribed to decrease or alleviate extrapyramidal side effects of major tranquilizers. Smooth, coordinated voluntary movement indicates minimal extrapyramidal side effects. (B) Tremors are an extrapyramidal side effect. (C) Rigidity is an extrapyramidal side effect. (D) Muscle weakness is an extrapyramidal side effect.
NO.824 Chorioamnionitis is a maternal infection that is usually associated with: A. Prolonged rupture of membranes B. Postterm deliveries C. Maternal pyelonephritis D. Maternal dehydration
Answer: A Explanation: (A) Chorioamnionitis is an inflammation of the chorion and amnion that is generally associated with premature or prolonged rupture of membranes. (B) Postterm deliveries have not been shown to increase the risk of chorioamnionitis unless there has been prolonged rupture of membranes. (C) Pyelonephritis is a kidney infection that develops in 20%-40% of untreated maternal UTIs. (D) Maternal dehydration, though of great concern, is not related to chorioamnionitis.
NO.821 The nurse recognizes that a client with the diagnosis of cholecystitis and cholelithiasis would expect to have stools that are: A. Clay or gray colored B. Watery and loose C. Bright-red streaked D. Black
Answer: A Explanation: (A) Clients who have obstruction in the biliary tract so that bile is not released into the duodenum experience a change in stools from brown to gray or clay colored. (B) This type of stool can occur with other GI problems, such as bacterial or viral infections, and other disease problems, and is not a common finding with biliary obstructions such as cholecystitis and cholelithiasis. (C) This type of stool is usually associated with a GI or bowel problem, such as lower GI bleeding, rather than with biliary obstructions. (D) This type of stool is usually associated with a GI or bowel problem, such as upper GI bleeding, rather than with biliary obstructions.
NO.833 The nurse assesses a postoperative mastectomy client and notes that breath sounds are diminished in both posterior bases. The nurse's action should be to: A. Encourage coughing and deep breathing each hour B. Obtain arterial blood gases C. Increase O2 from 2-3 L/min D. Remove the postoperative dressing to check for bleeding
Answer: A Explanation: (A) Decreased or absent breath sounds are frequently indicators of postoperative atelectasis. (B) Arterial blood gases are not indicated because there is no other information indicating impendingdanger. (C) Increasing O2 rate is not indicated without additional information. (D) Removing the dressing is not indicated without additional information.
NO.844 A client's physician has prescribed theophylline (Theo- Dur) to help control the bronchospasm associated with the client's COPD. Instructions that should be given to the client include: A. "Call your physician if you develop palpitations, dizziness, or restlessness.'' B. "Cigarette smoking may significantly increase the risk for theophylline toxicity.'' C. "Take this medication on an empty stomach.'' D. "Do not take your medicine if your pulse is less than 60 beats per minute.''
Answer: A Explanation: (A) Indications of theophylline toxicity include palpitations, dizziness, restlessness, nausea, vomiting, shakiness, and anorexia. (B) Cigarette smoking significantly lowers theophylline plasma levels. (C) Theophylline should be taken with food to decrease stomach upset. (D) These instructions are appropriate for someone taking digoxin.
NO.806 A client is to have a coronary artery bypass graft performed in the morning using a saphenous vein. He wants to know why the physician does not use the internal mammary artery for his bypass graft because his friend's physician uses this artery. The nurse tells the client that the internal mammary artery: A. Takes more time to remove B. Has a greater risk of becoming reoccluded C. Is smaller in diameter D. Has too many valves
Answer: A Explanation: (A) It does take more time to remove the internal mammary artery, and this is one reason why some physicians do not use it. (B) There is not a greater risk of reocclusion. In fact, it may actually stay patent longer. (C) The internal mammary artery is actually larger in diameter than the saphenous vein. (D) The internal mammary artery does not have too many valves.
NO.810 Which of the following should the nurse anticipate receiving as an as-needed order for a postoperative carotid endarterectomy client? A. Nifedipine 10 mg SL for B/P 140/90 B. Furosemide 20 mg/PO for decreased urine output C. Magnesium salicylate to decrease inflammation D. Nitroglycerin gr 1/150 for chest pain
Answer: A Explanation: (A) It is important to maintain a normal to slightly lower pressure to prevent the graft from blowing and excessive pressure to surgical vascular areas. (B, C, D) None of these drugs is related to managing the problem at hand. Also, none of the problems for which these drugs would be indicated is expected with this type of surgery, except if there is a prior history.
NO.855 Forty-eight hours after a thyroidectomy, a female client complains of numbness and tingling of the toes and fingers. The nurse notes upper arm and facial twitching. The nurse needs to: A. Report the findings to the physician B. Assist the client to do range of motion exercises C. Check the client's potassium level D. Administer the as-needed dose of phenytoin (Dilantin)
Answer: A Explanation: (A) Muscular hyperactivity and parasthesias may indicate hypocalcemic tetany and require immediate administration of calcium gluconate. Tetany can occur if the parathyroid glands were erroneously excised during surgery. (B) Range of motion exercises are not appropriate topresenting symptoms. (C) These characteristics are not usual signs of potassium imbalance, but of calcium imbalance. (D) Phenytoin is indicated for seizure activity mainly of neurological origin.
NO.839 A client takes warfarin (Coumadin) 15 mg po daily. To evaluate the medication's effectiveness, the nurse should monitor the: A. prothrombin time (PT) B. partial thromboplastin time (PTT) C. PTT-C D. Fibrin split products
Answer: A Explanation: (A) PT evaluates adequacy of extrinsic clotting pathway. Adequacy of warfarin therapy is monitored by PT. (B) PTT evaluates adequacy of intrinsic clotting pathway. Adequacy of heparin therapy is monitored by PTT. (C) There is no such laboratory test. (D) Fibrin split products indicate fibrinolysis. This is a screening test for disseminated intravascular coagulation. Heparin therapy may increase fibrin split products.
NO.849 A laboratory technique specific for diagnosing Lyme disease is: A. Polymerase chain reaction B. Heterophil antibody test C. Decreased serum calcium level D. Increased serum potassium level
Answer: A Explanation: (A) Polymerase chain reaction is the laboratory technique specific for Lyme disease. (B) Heterophil antibody test is used to diagnose mononucleosis. (C) Lyme disease does not decrease the serum calcium level. (D) Lyme disease does not increase the serum potassium level.
NO.857 A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because: A. Ischial spines are the narrowest diameter of the pelvis B. Ischial spines are the widest diameter of the pelvis C. They represent the inlet of birth canal D. They measure pelvic floor
Answer: A Explanation: (A) The fetal descent, or station, is determined by the relationship of the presenting part to the spine. (B) Ischial spines are the narrowest measurement. (C) Ischial spines measure the pelvic outlet. (D) Pelvic floor measurement is not related to fetal descent.
NO.827 A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time? A. Small, frequent feedings of foods that can be carried B. Tube feedings with nutritional supplements C. Allowing him to eat when and what he wants D. Giving him a quiet place where he can sit down to eat meals
Answer: A Explanation: (A) The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with finger foods allow him to eat during periods of activity. (B) This type of therapy should be implemented when other methods have been exhausted. (C) The manic client should not be in control of his treatment plan. This type of client may forget to eat. (D) The manic client is unable to sit down to eat full meals.
NO.862 A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate? A. Emphasize those aspects of the procedure that require cooperation. B. Tell the child not to cry or yell. C. Tell the child that he will get a "stick" in his back. D. Use medical terminology when explaining the procedure to the client.
Answer: A Explanation: (A) The nurse should emphasize what is required to elicit cooperation and help to develop a sense of autonomy. (B) The child may express discomfort verbally and should be encouraged to express his feelings. (C) Selecting nonthreatening words to explain a procedure will prevent misinterpretation. (D) When explaining the procedure to the parent with the child present, the nurse should use words that the child can understand to avoid misunderstanding.
NO.859 The physician has ordered that ampicillin 250 mg IV be given over 30 minutes. The medication is diluted as recommended in 10 mL in the volume control chamber of a set that has a tubing of 12 mL. Which nursing measure is most accurate considering these facts? A. Infuse volume at 44 mL/hr. B. Infuse volume at 22 mL/hr. C. Infuse volume at 10 mL/hr. D. Infuse volume at 30 mL/hr.
Answer: A Explanation: (A) The volume to be infused should be diluted medication volume added to the volume control chamber (10 mL) plus the tubing volume (12 mL). The general formula for calculating IV medications for children is: Rate = Volume to Be Infused X Administration Set Drop Factor (microdrop: 60 gtts/min)Desired Time to Infuse in Minutes Rate = (10 + 12)22 X 60 30 = 44 mL/hr. (B, C, D) These values are incorrect.
NO.831 A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse: A. Must use the least restrictive measure possible to control the behavior B. Should put the client in seclusion until he promises to behave appropriately C. Should apply full restraints until the behavior is under control D. Should allow other clients to observe the acting out so that they can learn from the experience
Answer: A Explanation: (A) This answer is correct. Least restrictive measures should always be attempted before a client is placed in seclusion or restraints. The nurse should first try a calm verbal approach, suggest a quiet room, or request that the client take "time-out" before placing the client in seclusion, givingmedication as necessary, or restraining. (B) This answer is incorrect. A calm verbal approach or requesting that a client go to his room should be attempted before restraining. (C) This answer is incorrect. Restraints should be applied only after all other measures fail to control the behavior. (D) This answer is incorrect. Other clients should be removed from the area. It is often very anxiety producing for other clients to see a peer out of control. It could also lead to mass acting- out behaviors.
NO.848 A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, "This is too much trouble. I would rather just have a Foley.'' An appropriate response for the RN teaching him would be: A. "I know. It is a lot to learn. In the long run, though, you will be able to reduce infections if you do an intermittent catheterization program.'' B. "It is not too much trouble. This is the best way to manage urination.'' C. "OK. I'll ask your physician if we can replace the Foley.'' D. "You need to learn this because your doctor ordered it.''
Answer: A Explanation: (A) This response acknowledges the client's feelings, gives him factual information, and acknowledges that the final decision is his. (B) This response is judgmental and discourages the client from expressing his feelings about the procedure. (C) Catheterization is a procedure thattakes time to learn, but which, for the spinal cord-injured client, can significantly reduce the incidence of urinary tract infections. A young client with a T-4 injury has the hand function to learn this procedure fairly easily. (D) The final decision about bladder elimination management ultimately rests with the client and not the physician.
NO.820 When assessing the client 6 hours postpartum, the fundus is found to be U +3, displaced to the right of midline, and slightly boggy. The nurse would first: A. Increase the IV oxytocin drip rate B. Give methergine IM C. Assess for a full bladder D. Grasp the uterus and massage vigorously
Answer: A Explanation: (A)Oxytocin may not be necessary if the bladder is emptied and if the uterus remains firm, midline, and at about U11 after massage. (B) The same rationale as for answer "A" applies. (C)A full bladder is the most common cause of uterine atony. If the bladder is full, it should be emptied and the uterus reassessed before further intervention. (D) If the bladder is full, the uteruswill not stay contracted or return to a normal position. Overly vigorous massage also encourages uterine atony.
NO.853 Goal setting for a client with Meniere's disease should include which of the following? A. Frequent ambulation B. Prevention of a fall injury C. Consumption of three meals per day D. Prevention of infection
Answer: B Explanation: (A) Although not contraindicated, initially ambulation may be difficult because of vertigo and is recommended only with assistance. (B) Vertigo resulting in balance problems is one of the most common manifestations of Meniere's disease. (C) Adequate nutrition is important, but the emphasis in Meniere's disease is not the number of meals per day but a decrease in intake of sodium. (D) Infection is not an anticipated problem.
NO.830 A female client admitted to the labor and delivery unit thinks her bag of water "broke" approximately 2 hours ago. She is having mild contractions 5 minutes apart. The most immediate nursing intervention would be to: A. Note the color and amount of fluid on her clothes. B. Assess the FHR. C. Notify the physician. D. Place the nitrazine test paper at the cervical os and note the color change.
Answer: B Explanation: (A) Amniotic fluid is generally pale and straw colored. Meconium- stained amniotic fluid would indicate a previous hypoxic episode. This intervention, though appropriate, is not the immediate priority. (B) With rupture of the membranes, the umbilical cord may prolapse if the presenting part does not fill the pelvis. Assessing FHR ascertains fetal well-being. (C) More information regarding fetal status and assessing for membrane rupture is needed prior to contacting the physician. (D) Nitrazine test paper differentiates amniotic fluid from urine. Amniotic fluid is normally alkaline in contrast to urine, which is acidic. This intervention, though appropriate, is not the immediate priority.
NO.805 A female client at 10 weeks' gestation complains to her physician of slight vaginal bleeding and mild cramps. On examination, her physician determines that her cervix is closed. The client is exhibiting signs of: A. An inevitable abortion B. A threatened abortion C. An incomplete abortion D. A missed abortion
Answer: B Explanation: (A) An inevitable abortion includes the signs of cervical dilation and effacement as well as pain and bleeding. (B) A threatened abortion is a condition in which intrauterine bleeding occurs early in pregnancy, the cervix remains undilated, and the uterine contents are not necessarily expelled. (C) An incomplete abortion occurs when some portions of the products of conception are expelled from the uterus. (D) A missed abortion occurs when the embryo dies in utero and is retained in the uterus.
NO.801 A 24-year-old male client is admitted with a diagnosis of sickle cell anemia. The nurse discusses his disease with him and emphasizes the following information: A. He should monitor his sputum, stools, and urine for signs of bleeding. B. His daily diet should include a large amount of fluid. C. He should not be concerned about having to fly on a commuter airplane on a weekly basis. D. He should not worry about having children because this disease is passed on only by female carriers.
Answer: B Explanation: (A) Bleeding is not a symptom of sickle cell anemia or sickle cell crisis. (B) Decreased blood viscosity leads to sickling of red blood cells. Increased fluid intake maintains adequate circulating blood volume and decreases the chance of sickling. (C) Hypoxia leads to sickling of cells. Flying in nonpressurized planes places the client in a situation of low O2 tension, which can lead to sickling. (D) Male and female clients with sickle cell disease can pass the trait on to their offspring. Therefore, this client should receive genetic counseling prior to having children.
NO.803 A client with emphysema is placed on diuretics. In order to avoid potassium depletion as a side effect of the drug therapy, which of the following foods should be included in his diet? A. Celery B. Potatoes C. Tomatoes D. Liver
Answer: B Explanation: (A) Celery is high in sodium. (B) Potatoes are high in potassium. (C) Tomatoes are high in sodium. (D) Liver is high in iron.
NO.840 In assessing the nature of the stool of a client who has cystic fibrosis, what would the nurse expect to see? A. Clay-colored stools B. Steatorrhea stools C. Dark brown stools D. Blood-tinged stools
Answer: B Explanation: (A) Clay-colored stools indicate dysfunction of the liver or biliary tract. (B) In the early stages of cystic fibrosis, fat absorption is primarily affected resulting in fat, foul, frothy, bulky stools. (C) Dark brown stools indicate normal passage through the colon. (D) Blood-tinged stools indicate dysfunction of the gastrointestinal (GI) tract.
NO.826 A schizophrenic client has made sexual overtures toward her physician on numerous occasions. During lunch, the client tells the nurse, "My doctor is in love with me and wants to marry me." This client is using which of the following defense mechanisms? A. Displacement B. Projection C. Reaction formation D. Suppression
Answer: B Explanation: (A) Displacement involves transferring feelings to a more acceptable object. (B) Projection involves attributing one's thoughts or feelings to another person. (C) Reaction formation involves transforming an unacceptable impulse into the opposite behavior. (D) Suppression involves the intentional exclusion of unpleasant thoughts or experiences.
NO.828 When teaching a class of nursing students, the nurse asks why the embryonic period (weeks 4-8) of pregnancy is so critical. A. Duplication of genetic information takes place. B. Organogenesis occurs. C. Subcutaneous fat builds up steadily. D. Kidneys begin to secrete urine.
Answer: B Explanation: (A) Duplication of genetic material occurs during the preembryonic period (weeks 1-3) following conception. The exact duplication of genetic material is essential for cell differentiation, growth, and biological maintenance of the organism. (B) Weeks 4-8, known as the embryonic period, are the time organogenesis occurs and pose the greatest potential for major congenital malformations. All major internal and external organs and systems are formed. (C) Subcutaneous fat does not develop until the latter weeks of gestation. (D) Kidneys begin to secrete urine during the 13th-16th week.
NO.841 A client is started on prednisone 2.5 mg po bid. Which of the following instructions should be included in her discharge teaching specific to this medication? A. Increase your oral intake of fluids to at least 4000 mL every day. B. Avoid contact with people who have contagious illnesses. C. Brush your teeth at least 4 times a day with a firm toothbrush. D. Immediately stop taking the prednisone if you feel depressed.
Answer: B Explanation: (A) Fluid retention is a side effect of prednisone. The nurse should teach clients to weigh themselves daily and to observe for signs of edema. If these signs of fluid retention occur, they should notify the physician. (B) Prednisone, a glucocorticoid, suppresses the normal immune response making the client more susceptible to infections. (C) An increase in bleeding tendencies is a side effect of prednisone therapy. The nurse should teach clients to use preventive measures (i.e., electric razors and soft toothbrushes). (D) Depression and personality changes are side effects of prednisone therapy. Prednisone should never be discontinued abruptly.
NO.811 A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardia. What first nursing actions would be essential in this situation? A. Hold the child's discharge for 1 hour. B. Notify the physician immediately. C. Discharge the child as the physician ordered. D. Administer an antiemetic as necessary.
Answer: B Explanation: (A) Holding the child's discharge alone does not address the client's problem. (B) Nausea, tachycardia, and irritability are all symptoms of theophylline toxicity. The physician should benotified immediately so that a serum theophylline level can be ordered. Theophylline dose should be withheld until the physician is notified. (C) The child must be evaluated for theophylline toxicity before any discharge. (D) Cause of the nausea should be investigated before the administration of an antiemetic.
NO.860 A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of: A. Loss of ability to speak and communicate effectively B. Aspiration and weight loss C. Secondary infection resulting from poor oral hygiene D. Drooling
Answer: B Explanation: (A) Loss of ability to speak is not dysphasia. Although the client may have difficulty communicating, alternative measures can be developed to enhance communication. This goal, while important, is of a lesser priority. (B) Dysphasia is difficulty swallowing, which could result in aspiration of food and inability to eat, causing weight loss. (C) A secondary infection could result from poor oral hygiene, which could enhance the client's inability to eat, but this goal is of a lesser priority. (D) Drooling normally occurs in clients with amyotrophic lateral sclerosis and may require suctioning. Drooling, while aggravating for the client, does not pose an immediate danger.
NO.836 A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation? A. Responsive to touch, wants to be held B. Uncomforted by touch, refuses bottle C. Maintains eye-to-eye contact D. Finicky eater, easily pacified, cuddly
Answer: B Explanation: (A) Normal infant attachment behaviors include responding to touch and wanting to be held. (B) Maternal deprivation behaviors include poor feeding, stiffening and refusal to eat, and inconsistencies in responsiveness. (C) Attachment behavior includes maintaining eye contact. (D) Maternal deprivation behaviors include displeasure with touch and physical contact.
NO.814 The nurse will be alert to the most potentially lifethreatening side effect associated with the administration of monoamine oxidase (MAO) inhibitor. This is: A. Oculogyric crisis B. Hypertensive crisis C. Orthostatic hypotension D. Tardive dyskinesia
Answer: B Explanation: (A) Oculogyric crisis, involuntary upward deviation and fixation of the eyeballs, is usually associated with either postencephalitic parkinsonian or drug-induced extrapyramidal symptoms (EPS). (B) Hypertensive crisis is a potentially life-threatening side effect. This may occur if the client ingests foods, beverages, or medications containing tyramine. (C) Orthostatic hypotension, a drop in blood pressure resulting from a rapid change of body position, can occur with the administration of antidepressants. (D) Tardive dyskinesia, characterized by slow, rhythmical, automatic or stereotyped muscular movements, usually is associated with the administration of certain antipsychotic medications.
NO.829 Two hours after the second injection of haloperidol, a client complains to the nurse of a stiff neck and inability to sit still. He is experiencing symptoms consistent with: A. Parkinsonism and dystonia B. Dystonia and akathisia C. Akathisia and parkinsonism D. Neuroleptic malignant syndrome
Answer: B Explanation: (A) Stiff neck is consistent with a dystonic reaction, but the client has no symptoms of drooling, shuffling gait, or pill-rolling movements characteristic of parkinsonism. (B) Stiff neck is consistent with a dystonic reaction, and inability to sit still with varying degrees of psychomotor agitation is characteristic of akathisia. (C) The client has symptoms of dystonia but not of parkinsonism. (D) The client has none of the characteristic symptoms of neuroleptic malignant syndrome: hyperpyrexia, generalized muscle rigidity, mutism, obtundation, agitation, sweating, increased blood pressure and pulse.
NO.851 After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis? A. One centimeter below the ischial spines B. One centimeter above the ischial spines C. Has not entered the pelvic inlet yet D. Located in the pelvic outlet
Answer: B Explanation: (A) The ischial spines are located on both sides of the midpelvis. These spines mark the diameter of the narrowest part of the pelvis that the fetus will encounter. They are not sharp protrusions that will harm the fetus. Station refers to the relationship between the ischial spines in the pelvis and the fetus. The ischial spines are designated at 0 station. If the presenting part of the fetus is located above the ischial spines, a negative number is assigned, noting the number of centimeters above the ischial spines. Therefore, 1 centimeter below the ischial spines is designated as +1 station. (B) See explanation in A. One centimeter above the ischial spines is designated as +1 station. (C) The pelvic inlet is the first part of the pelvis that the fetus enters in routine delivery. The midpelvis is the second part of the pelvis to be entered by the fetus. The ischial spines are located on both sides of the midpelvis. (D) The pelvic outlet is the last part of the pelvis that the fetus will enter. When the fetus reaches this part of the pelvis, birth is near.
NO.816 A female client at 36 weeks' gestation is experiencing preterm labor. Her physician has prescribed two doses of betamethasone 12 mg IM q24h. The nurse explains that she is receiving this drug to: A. Treat fetal respiratory distress syndrome B. Prevent uterine infection C. Promote fetal lung maturation D. Increase uteroplacental circulation
Answer: C Explanation: (A) Respiratory distress syndrome occurs in the newborn, not the fetus. It may be treated postnatally with surfactant therapy. (B) Betamethasone is a corticosteroid, not an anti-infective drug; therefore, its use would not prevent uterine infection. (C) Betamethasone binds with glucocorticoid receptors in alveolar cells to increase production of surfactant, thus increasing lung maturity in the preterm fetus. (D) Betamethasone does not affect uteroplacental circulatory exchange.
NO.808 A postoperative TURP client is ordered continuous bladder irrigations. Later in the evening on the first postoperative day, he complains of increasing suprapubic pain. When assessing the client, the nurse notes diminished flow of bloody urine and several large blood clots in the drainage tubing. Which one of the following should be the initial nursing intervention? A. Call the physician about the problem. B. Irrigate the Foley catheter. C. Change the Foley catheter. D. Administer a prescribed narcotic analgesic.
Answer: B Explanation: (A) The physician should be notified as problems arise, but in this case, the nurse can attempt to irrigate the Foley catheter first and call the physician if irrigation is unsuccessful. Notifying the physician of problems is a subsequent nursing intervention. (B) This answer is correct. Assessing catheter patency and irrigating as prescribed are the initial priorities to maintain continuous bladder irrigation. Manual irrigation will dislodge blood clots that have blocked the catheter and prevent problems of bladder distention, pain, and possibly fresh bleeding. (C) The Foley catheter would not be changed as an initial nursing intervention, but irrigation of the catheter should be done as ordered to dislodge clots that interfere with patency. (D) Even though the client complains of increasing suprapubic pain, administration of a prescribed narcotic analgesic is not the initial priority. The effect of the medication may mask the symptoms of a distended bladder and lead to more serious complications.
NO.847 A 45-year-old client diagnosed with major depression is scheduled for electroconvulsive therapy (ECT) in the morning. Which of the following medications are routinely administered either before or during ECT? A. Thioridazine (Mellaril), lithium, and benztropine B. Atropine, sodium brevitol, and succinylcholine chloride (Anectine) C. Sodium, potassium, and magnesium D. Carbamazepine (Tegretol), haloperidol, and trihexyphenidyl (Artane)
Answer: B Explanation: (A) Thioridazine (an antipsychotic drug), lithium (an antimanic drug), and benztropine (an antiparkinsonism agent) are generally administered to treat schizophrenic and bipolar disorders. (B) Atropine (a cholinergic blocker), sodium brevitol (a shortacting anesthetic), and succinylcholine (a neuromuscular blocker) are administered either before or during ECT to coun teract bradycardia and to provide anesthesia and total muscle relaxation. (C) These are electrolyte substances administered to correct fluid and electrolyte imbalances in the body. (D) Carbamazepine (an anticonvulsant), haldoperidol (an antipsychotic), and trihexyphenydyl (an antiparkinsonism agent) are usually administered in psychiatric settings to control problems associated with psychotic behavior.
NO.845 A nurse is taking a maternal history for a client at her first prenatal visit. Her pregnancy test was positive, she has two living children, she had one spontaneous abortion, and one infant died at the age of 3 months. Which of the following best describes the client at the present? A. Gravida 4, para 2, ab 1 B. Gravida 5, para 3, ab 1 C. Gravida 5, para 4, ab 0 D. Gravida 4, para 3, ab 0
Answer: B Explanation: (A) This individual has been pregnant four times, delivered two children, and had one abortion. (B) Your client has been pregnant five times, delivered three children, and had one abortion. (C) This individual has been pregnant five times, delivered four children, and has not had an abortion. (D) This individual has been pregnant four times, delivered three children, and has not had an abortion.
NO.865 The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks' gestation. An appropriate response by the nurse would be: A. "It must be God's will and probably is for the best." B. "This must be a difficult time for you. Would you like to talk about it?" C. "I'm sure your other children will be a comfort for you." D. "Don't worry, you're still young. If I were you I'd just try again."
Answer: B Explanation: (A) This response is nontherapeutic because it belittles the client's response and gives a meaningless rationalization. (B) This response acknowledges the client's feelings and demonstrates the therapeutic offering of self by the nurse. (C) This response is nontherapeutic because it does not focus on the client's feelings and offers false reassurance. (D) This response is nontherapeutic because it belittles the client's feelings and offers her advice.
NO.846 A 75-year-old client is hospitalized with pneumonia caused by gram-positive bacteria. Which one of the following best describes a gram-positive bacterial pneumonia? A. Klebsiellapneumonia B. Pneumococcal pneumonia C. Legionella pneumophilapneumonia D. Escherichia colipneumonia
Answer: B Explanation: (A)Klebsiellapneumonia is caused by gram-negative bacteria. (B) Pneumococcal pneumonia is caused by gram-positive bacteria. (C)Legionella pneumophilapneumonia is a nonbacterial pneumonia. (D)E. colipneumonia is caused by gram-negative bacteria.
NO.815 The predominant purpose of the first Apgar scoring of a newborn is to: A. Determine gross abnormal motor function B. Obtain a baseline for comparison with the infant's future adaptation to the environment C. Evaluate the infant's vital functions D. Determine the extent of congenital malformations
Answer: C Explanation: (A) Apgar scores are not related to the infant's care, but to the infant's physical condition. (B) Apgar scores assess the current physical condition of the infant and are not related to future environmental adaptation. (C) The purpose of the Apgar system is to evaluate the physical condition of the newborn at birth and to determine if there is an immediate need for resuscitation. (D) Congenital malformations are not one of the areas assessed with Apgar scores.
NO.856 A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, his family describes him as being "on the move," sleeping 3-4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment with the client, the nurse would expect him to exhibit which of the following? A. Short, polite responses to interview questions B. Introspection related to his present situation C. Exaggerated self-importance D. Feelings of helplessness and hopelessness
Answer: C Explanation: (A) During the manic phase of bipolar disorder, clients have short attention spans and may be abusive toward authority figures. (B) Introspection requires focusing and concentration; clients with mania experience flight of ideas, which prevents concentration. (C) Grandiosity and an inflated sense of self-worth are characteristic of this disorder. (D) Feelings of helplessness and hopelessness are symptoms of the depressive stage of bipolar disorder.
NO.838 A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention? A. Increased pulse rate B. Increased expectorate of secretions C. Decreased inspiratory difficulty D. Increased respiratory rate
Answer: C Explanation: (A) A side effect of epinephrine is fatal ventricular fibrillation owing to its effects on cardiac stimulation. (B) Medications used to treat asthma are designed to decrease bronchospasm, not to increase expectorate of secretions. (C) Epinephrine decreased inspiratory difficulty by stimulating -, 1, and 2-receptors causing sympathomimetic stimulation (e.g., bronchodilation). (D) The person with asthma fights to inspire sufficient air thus increasing respiratory rate.
NO.854 A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately: A. 10 weeks B. 16 weeks C. 20 weeks D. 30 weeks
Answer: C Explanation: (A) At 10 weeks, the fundus is located slightly above the symphysis pubis. (B) At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus. (C) At 20 weeks, the fundus is located approximately at the umbilicus. (D) At 30 weeks, the fundal height is about 30 cm, or 10 cm above the umbilicus.
NO.832 A client who has been diagnosed with anorexia nervosa reluctantly agrees to eat all prescribed meals. The most important intervention in monitoring her dietary compliance would be to: A. Allow her privacy at mealtimes B. Praise her for eating everything C. Observe behavior for 1-2 hours after meals to prevent vomiting D. Encourage her to eat in moderation, choose foods that she likes, and avoid foods that she dislikes
Answer: C Explanation: (A) Eating alone is not recommended for anorexic clients because they tend to hoard food instead of eating it. (B) The client should be praised for whatever she eats, which is usually a small portion or percentage of what is served. Praise should not be withheld until she eats everything. (C) The client should be observed eyeto- eye for at least 1 hour following meals to prevent discarding food stashed in her clothing at mealtime or engaging in selfinduced vomiting. (D) If offered these choices, the client would choose low-caloric foods, not a nutritious diet.
NO.809 A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin. The nurse's first intervention should be to: A. Check FHT B. Notify the attending physician C. Turn off the IV oxytocin D. Prepare for the delivery because the client is probably in transition
Answer: C Explanation: (A) FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. (B) The physician should be notified, but this is not the first intervention the nurse should do. (C) The standard of care for an induction according to the Association of Women's Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. (D) Contractions lasting 60-90 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.
NO.864 Azulfidine (Sulfasalazine) may be ordered for a client who has ulcerative colitis. Which of the following is a nursing implication for this drug? A. Limit fluids to 500 mL/day. B. Administer 2 hours before meals. C. Observe for skin rash and diarrhea. D. Monitor blood pressure, pulse.
Answer: C Explanation: (A) Fluids up to 2500-3000 mL/day are needed to prevent kidney stones. (B) The client should be instructed to take oral preparations with meals or snacks to lessen gastric irritation. (C) Sulfasalazine causes skin rash and diarrhea. (D) Blood pressure and pulse are not altered by sulfasalazine.
NO.813 A diagnosis of hepatitis C is confirmed by a male client's physician. The nurse should be knowledgeable of the differences between hepatitis A, B, and C. Which of the following are characteristics of hepatitis C? A. The potential for chronic liver disease is minimal. B. The onset of symptoms is abrupt. C. The incubation period is 2-26 weeks. D. There is an effective vaccine for hepatitis B, but not for hepatitis C.
Answer: C Explanation: (A) Hepatitis C and B may result in chronic liver disease. Hepatitis A has a low potential for chronic liver disease. (B) Hepatitis C and B have insidious onsets. Hepatitis A has an abrupt onset. (C) Incubation periods are as follows: hepatitis C is 2-26 weeks, hepatitis B is 6-20 weeks, and hepatitis A is 2-6 weeks. (D) Only hepatitis B has an effective vaccine.
NO.858 A burn victim's immunization history is assessed by the nurse. Which immunization is of priority concern? A. Oral poliovirus vaccine B. Inactivated poliovirus vaccine C. Tetanus toxoid D. Hepatitis B vaccine
Answer: C Explanation: (A) Oral poliovirus vaccine is given to prevent polio. Polio is transmitted by direct contact with an infected person. (B) Inactivated poliovirus vaccine is given to adults and immunosuppressed individuals. Polio is transmitted by direct contact with an infected person. (C) Tetanus toxoid prevents tetanus. Tetanus is transmitted through contaminated wounds. (D) Hepatitis B vaccine prevents hepatitis B infection. Hepatitis B is transmitted through contact with infected blood or body fluids.
NO.842 In teaching the client about proper umbilical cord care, the nurse recommends that: A. Petrolatum be placed around the cord after the sponge bath B. A belly binder be applied to prevent umbilical hernia C. The area be cleansed at diaper changes with alcohol and inspected for redness or drainage D. The cord clamp be left on until the cord stump separates
Answer: C Explanation: (A) Petrolatum does not allow the cord to dry and will encourage infection. (B) Belly binders do not facilitate drying of the cord and will encourage abdominal relaxation. (C) Frequent applications of alcohol will facilitate drying and discourage infection. (D) The cord clamp can be removed in 24 hours. Leaving it on is cumbersome and could pull on the cord unnecessarily.
NO.818 A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station 12 means that the: A. Presenting part is 2 cm above the level of the ischial spines B. Biparietal diameter is at the level of the ischial spines C. Presenting part is 2 cm below the level of the ischial spines D. Biparietal diameter is 5 cm above the ischial spines
Answer: C Explanation: (A) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is above the ischial spines, the station is negative. (B) When the biparietal diameter is at the level of the ischial spines, the presenting part is generally at a +4 or +5 station. (C) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is below the ischial spines, the station is positive. Thus, 2 cm below the ischial spines is the station +2. (D) When the biparietal diameter is above the ischial spines by 5 cm, the presenting part is usually engaged or at station 0.
NO.843 Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding? A. She uses the bulb syringe to help clear her baby's nose when milk is regurgitated. B. She places her infant on her right side after feeding her. C. She props the bottle in the crib to feed her baby,which allows her to write birth announcements and feed her baby at the same time. D. She burps her baby by placing her in a sitting position, supporting her head and neck and gently massaging her back.
Answer: C Explanation: (A) This practice is the proper use of the bulb syringe to clear the infant's airway in case of regurgitation. (B) Placing the infant on either side or on the stomach prevents aspiration of regurgitated milk. (C) "Bottle propping" is an unsafe practice because it increases the likelihood of aspiration. (D) This practice is one correct way of burping an infant.
NO.825 A postpartum client complains of rectal pressure and severe pain in her perineum; this may be indicative of: A. Afterbirth pains B. Constipation C. Cystitis D. A hematoma of the vagina or vulva
Answer: D Explanation: (A) Afterbirth pains are a common complaint in the postpartum client, but they are located in the uterus. (B) Constipation may cause rectal pressure but is not usually associated with "severe pain." (C) Cystitis may cause pain, but the location is different. (D) Hematomas are frequently associated with severe pain and pressure. Further assessments are indicated for this client.
NO.822 A female client has been treated since childhood for mitral valve prolapse. The antibiotic of choice for her during pregnancy would be: A. Sulfa B. Tetracycline C. Hydralazine D. Erythromycin
Answer: D Explanation: (A) Sulfa is a teratogen and will cause kernicterus. (B) Tetracycline is a teratogen and will effect tooth development. (C) Hydralazine is not an antibiotic but a calcium channel blocker. (D) Erythromycin is safe during pregnancy and can be used when the client is allergic to penicillin.
NO.837 A dose of theophylline may need to be altered if a client with COPD: A. Is allergic to morphine B. Has a history of arthritis C. Operates machinery D. Is concurrently on cimetidine for ulcers
Answer: D Explanation: (A) The effects of morphine or an allergic response to the drug will not affect theophylline clearance. (B) Xanthines are used cautiously in clients with severe cardiac disease, liver disease, cor pulmonale, hypertension, or hyperthyroidism. Arthritis does not influence the dosage of theophylline. (C) Theophylline does not cause sedation or drowsiness. Conversely, its side effects may be exhibited by central nervous system stimulation. (D) Cimetidine decreases theophylline clearance from the system and increases theophylline levels in the blood, thus increasing the risk of toxicity.
NO.823 A client's record from the ED indicates that she overdosed on phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor. Which diet would be the most appropriate at this time? A. High carbohydrate, low cholesterol B. High protein, high carbohydrate C. 1 g sodium D. Tyramine-free
Answer: D Explanation: (A) There are no data to support the need for increased carbohydrates or decreased cholesterol in the diet. (B) There is no data to support the need for increased protein or increased carbohydrates in the diet. (C) There is no assessment or laboratory data indicating that sodium should be restricted in the diet. (D) Tyramine is an amino acid activated by MAO in the liver and intestinal wall. It is released as proteins are hydrolyzed through aging, pickling, smoking, or spoilage of foods. When MAO is inhibited, tyramine levels rise, stimulating the adrenergic system to release large amounts of norepinephrine, which can produce a hypertensive crisis.
NO.819 A client who is gravida 1 para 1 vaginally delivered a 7- lb girl. She received a midline episiotomy at delivery. When assessing the level of her uterus immediately following delivery, the nurse would expect the fundus to be located: A. At the umbilicus B. At the symphysis pubis C. Midway between the umbilicus and the xiphoid process D. Midway between the umbilicus and the symphysis pubis
Answer: D Explanation: (A) Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. (B) The uterus descends into the pelvic cavity at approximately 10-12 postpartal days and can no longer be palpated abdominally. (C) Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. An enlarged uterus may indicate subinvolution or postpartal hemorrhage. (D) Immediately following delivery, the uterus lies midline, about midway between the umbilicus and the symphysis pubis.
NO.861 The nurse enters the room of a client on which a "do not resuscitate" order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, "please save her!" The nurse's action would be: A. Call the physician and inform him that the client has expired. B. Remind the husband that the physician wrote an order not to resuscitate. C. Discuss with the husband that these orders are written only on clients who are not likely to recover with resuscitative efforts. D. Call a code and proceed with cardiopulmonary resuscitation.
Answer: D Explanation: (A, B, C) The last request from the husband overrides the decision not to initiate resuscitation efforts. (D) The nurse should begin cardiopulmonary resuscitation unless a living will and durable power of attorney are in force. In the meantime, the nurse should talk with the husband and notify the doctor.
