Mary Ann Hogan RN Questions and rationals

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4 MCMA The clinic nurse is conducting health screenings. Which of the following client assessment findings indicates that client teaching is needed about the risk for stroke? Select all that apply. 1. Weight 205 lbs and height 5 feet 4 inches 2. Blood pressure 164/92 mmHg 3. Eats bran for breakfast daily 4. Smokes 1/2 pack cigarettes per day 5. Serum cholesterol level is 172 mg/dL

1, 2, 4 Obesity, hypertension, and smoking are modifiable risk factors for stroke. Hypercholesterolemia (cholesterol level greater than 200 mg) would also be a risk factor, but this client's level is less than 200 mg/dL. Eating a diet containing fiber helps keep cholesterol levels low and is not a risk factor for stroke. Analysis Health Promotion and Maintenance Nursing Process: Assessment Adult Health: Cardiovascular The core issue of the question is knowledge of risk factors for stroke. Recall that these are similar to the risk factors for cardiac disease to help make your selections.

30 MCSA Which of the following care measures should the nurse include in the discussion when teaching home care measures to the parents of a child who has bilateral bacterial conjunctivitis? 1. Use of warm, moist, disposable compresses to remove crusting 2. Use of oral antihistamine medication to relieve eye itching 3. Use of ophthalmic corticosteroids to decrease inflammatory response 4. Use of topical anesthetics applied to relieve discomfort

1 Crusting of dried exudate is common with bacterial conjunctivitis and it is important for the child's vision and safety that the crusts are removed. Warm, moist wipes aid in comfort and they need to be disposable to reduce the risk of transmitting the infection to others in the home. Oral antihistamines, ophthalmic corticosteroids, and topical anesthetics are not indicated in the management of bacterial conjunctivitis. Application Physiological Integrity: Physiological Adaptation Teaching and Learning Child Health Note the critical word conjunctivitis in the stem of the question. Recall that this infection is highly contagious. Then determine the correct option by associating the word disposable in the correct option with the concept of infection in the stem of the question.

79 MCSA The client is scheduled for a barium enema and is expressing concern that the barium will not be evacuated and a bowel obstruction will occur. What would be the best response for the nurse to make to the client? 1. "Don't worry. The physicians will make sure that all of the barium is out of your bowel before you return to the unit." 2. "You will be given extra fluids, laxatives, and an enema if you have not expelled the barium within 24 hours." 3. "The barium they are using will not cause an obstruction." 4. "Should I have the test rescheduled for when you are less concerned about it?"

2 The client will, in most cases, return to the unit with barium still present in the bowel. The physician will order laxatives or enemas if the client is potentially not able to expel the barium on his or her own. The nurse should encourage the client to increase fluid intake if possible as well. This is a common concern for many clients undergoing this procedure, and their feelings should not be ignored or belittled. Analysis Physiological Integrity: Reduction of Risk Potential Communication and Documentation Adult Health: Gastrointestinal Note the critical words best response in the stem of the question. This tells you that the correct response is a true statement of fact. Recall that this test can cause constipation from residual barium to aid in selecting the correct option.

69 MCSA A client presents to the Emergency Department with a complaint of chest pain. Which serum laboratory test does the nurse check off on the laboratory slip as part of a protocol order to rule out an acute myocardial infarction? 1. LDH4 2. Troponin 3. Amylase 4. CK-MM

Troponin is a sensitive test that indicates damage to the myocardial cells. A CK-MM isoenzyme elevation would indicate skeletal muscle damage. The LDH4 isoenzyme is utilized to determine hepatic function and amylase is a digestive enzyme. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Assessment Adult Health: Cardiovascular Specific knowledge is needed to answer this question. Recall that troponin is a newer enzyme that can be measured very early during myocardial damage and is an indicator of myocardial damage and thus myocardial infarction. 1

32 MCSA After correctly positioning a client for a wound dressing change, the nurse sets up a sterile field, placing the wound supplies in the field. The nurse hears a page to respond to another client who has fallen in the hallway. Which of the following is the most appropriate nursing action for the nurse to take? 1. Ensure the client's safety, cover the field with a sterile towel, and respond to the other client. 2. Continue quickly with the procedure, and then assist the other client, checking back with the first client as soon as possible. 3. Ensure the client's safety, discard the sterile equipment, and respond to the other client. 4. Explain the situation to the client needing wound dressing change, leave the sterile supplies in place, and attend to the other client.

1 A client fall is a potential medical emergency; however, the nurse's responsibility is ensuring the safety of the client being attended to. Option 2 ignores the safety of the potentially injured client. Option 3 wastes supplies. Option 4 could lead to a contaminated sterile field. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management Options 1 and 4 are incorrect, sterile equipment is considered contaminated if left unattended and therefore must be thrown away. Option 2 is incorrect; the nurse needs to prioritize care appropriately. Thus the nurse needs to respond to the client who fell rather than continue with the wound dressing change.

56 MCSA The nurse would be most careful to assess for stomatitis in a client receiving which of the following chemotherapeutic agents? 1. Fluorouracil (5-FU) 2. Cisplatin (Platinol) 3. Bleomycin (Blenoxane) 4. Vincristine (Oncovin)

1 Although many chemotherapy agents can cause stomatitis, the antimetabolites are commonly known for causing this side effect. Fluorouracil is the only drug listed in this class. Cisplatin is an alkylating agent; bleomycin is an antitumor antibiotic; and vincristine is a plant (vinca) alkaloid. Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Analysis Pharmacology The core issue of the question is knowledge of which antineoplastic agents cause stomatitis as an adverse effect. Use nursing knowledge and the process of elimination to answer the question.

53 MCSA The nurse is admitting a client with thermal burns to both arms and anterior trunk. The client asks for a drink of water. What is the most appropriate response for the nurse to make? 1. "I'm sorry, you cannot drink anything right now; let me moisten your mouth instead." 2. "I can only give you juice to drink, not water." 3. "I'll get you a drink as soon as I'm finished." 4. "Would you also like me to order you a meal tray?"

1 Clients should remain NPO upon admission to the clinical setting with a major burn. Initial fluid replacement is started via the parenteral route. NPO status is maintained because the client may be in shock with blood flow directed away from the digestive organs to more vital tissues. In addition it is possible that the client suffered burn injuries that could cause internal damage to body structures, and aspiration is also a risk initially. Options 2, 3, and 4 are incorrect—fluids and food via the mouth would be restricted at this time. Application Physiological Integrity: Basic Care and Comfort Nursing Process: Implementation Foundational Sciences: Nutrition The core issue of the question is knowledge that the client who has experienced burn injury is under severe physiological stress, and as such, blood flow is directed away from the digestive tract. Focus on the need to stabilize the client physiologically and provide fluids by the IV route to help you choose correctly.

27 MCSA The nurse would place highest priority on which of the following nursing interventions when planning to prevent atelectasis in the newly admitted postoperative client? 1. Hourly coughing and deep breathing 2. Assisting the client out of bed 3. Administration of bronchodilators 4. Supplemental oxygen

1 Frequent coughing and deep breathing is an easy maneuver that has great benefit to optimize ventilation in the postoperative client. Good pain management facilitates effective coughing and deep breathing. Getting the client out of bed and administering oxygen and bronchodilators are all appropriate interventions for preventing or treating atelectasis, but clearly the best option is to prevent its occurrence by simple maneuvers such as coughing and deep breathing. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Planning Adult Health: Respiratory Note the client in the question has newly arrived to the nursing unit following surgery. The critical words "nursing interventions" help you to eliminate options 3 and 4, which require a medical order. Choose option 1 over 2 because of the word "hourly" and because there is not enough information in the stem to determine whether the client can safely get out of bed at this time.

8 MCSA The nurse places highest priority on taking which of the following actions to reduce the spread of microorganisms when caring for a client at risk for infection? 1. Wash hands before and after client care. 2. Use clean gloves when implementing client care. 3. Institute transmission-based precautions. 4. Place the client in a private room.

1 Hand hygiene is a core principle of standard precautions. Using gloves is appropriate when there is a risk of exposure to blood, body fluids, secretions, and excretions. However, handwashing should be done after removal of gloves. Not all clients require transmission-based precautions (option 3) or a private room (option 4). Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Fundamentals Use the process of elimination based on nursing knowledge of standard precautions. Elements of transmission-based precautions are not initiated with all clients.

20 MCSA The nurse concludes that a child is in Piaget's concrete operations stage after observing which of the following traits in the child? 1. Conservation. 2. Egocentrism. 3. Animism. 4. Preconventional thought

1 In Piaget's theory on development the conservation is a hallmark sign in the concrete operational stage. Options 2, 3, and 4 are not characteristic of this stage. Application Psychosocial Integrity Nursing Process: Analysis Mental Health The core issue of the question is knowledge of characteristics of various cognitive developmental levels according to Piaget. Use this knowledge and the process of elimination to make a selection

57 MCSA The nurse will be working with an unlicensed assistive person (UAP) for the work shift. Prior to delegating care to the UAP, the nurse places high priority on which of the following? 1. Determining that the UAP is competent to perform the required task 2. Providing written directions to the UAP 3. Making sure all the necessary supplies are available at the client's bedside 4. Informing clients that an unlicensed staff member will be assigned to them

1 Safe and effective delegation is based on knowledge of the laws governing nursing practice and knowledge about job duties and responsibilities. Nurses must understand the competencies and training of unlicensed assistive personnel. Application Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management Option 2 is incorrect; it is not necessary to provide written directions when delegating tasks to UAPs as long as verbal directions are clear and expectations are understood. Option 3 is incorrect; your responsibility is not preparing the supplies for a delegated task but rather to ensure the delegated task is completed safely and correctly. Option 4 is incorrect; it is not necessary to inform the client about the tasks or assignments delegated to non-staff members. It is however, the responsibility of the staff member to inform the client prior to the assigned task what will be accomplished. 0

12 MCSA The Emergency Department has recently experienced a significant increase in client visits. The year-to-date census reveals a 20% increase in admission from the same period last year. In an effort to reduce staff stress and burnout by empowering the staff, the nurse manager uses which of the following approaches to demonstrate shared leadership? 1. Encourages the formation of self-directed work teams. 2. Encourages the group to try out nursing approaches that are evidence-based. 3. Suggests that staff who have demonstrated charting excellence be given opportunities for professional development activities. 4. Provides constructive criticism and facilitates the group to meet their goals.

1 Shared leadership recognizes that there are many leaders within a group so the leader encourages the formation of self-directed work teams. In transformational leadership, the leader encourages risk taking such as trying out nursing approaches that are evidence-based or research-based. A transactional leader uses incentives to promote productivity such as giving rewards for excellent performance. A democratic leader provides constructive criticism and facilitates the group to meet their goals. Application Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management The core issue of the question is knowledge of various leadership styles. Use this knowledge and the process of elimination to make a selection.

80 MCSA The nurse is conducting an educational group on an inpatient unit. One of the clients has not spoken during the group. An effective therapeutic response by the nurse would include: 1. Allowing the client to remain present but nonparticipative. 2. Explaining to the client that everyone in the group needs to participate. 3. Asking the rest of the group members how they feel about this member not sharing. 4. Stopping the group and asking the client to leave.

1 The only respectful therapeutic response here is option 1. The others are contraindicated for any group process. Everyone does not need to participate in every session (option 2). It is inappropriate to focus the group's attention on one individual because of level of participation (option 3). The client should be allowed to remain part of the group until the client is ready to participate (option 4). Application Psychosocial Integrity Communication and Documentation Mental Health The core issue of the question is knowledge of group process and conduct of a group meeting. Use knowledge of this treatment modality and the process of elimination to make a selection.

49 MCSA A client has a potassium level of 6.8 mEq/L. Which sign or symptom would the nurse expect to find when assessing this client? 1. Peaking of T wave on the telemetry monitor 2. The absence of bowel sounds, such as in an ileus 3. Muscle cramping of the lower extremities 4. Somnolence with early changes

1 The potassium level is abnormally high (normal 3.5-5.1 mEq/L). Since potassium is an intracellular ion, higher levels will alter the electrical pattern of the EKG. "Peaking of a T wave" is an indication that potassium is too high. With hyperkalemia (higher than normal potassium levels), muscle weakness, flaccidity of muscles, diarrhea, abdominal cramping, cerebral irritability/restlessness are present. Therefore, bowel sounds would be hyperactive and not silent, such as with an ileus. Muscles are weak and flaccid, not in a cramping state. Cerebral functions are stimulated and somnolence (sleeping, sluggishness) is not present. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Assessment Adult Health: Cardiovascular The core issue of the question is accurate interpretation of the potassium level and its significance. From there, associate the symptoms of hyperkalemia to make a selection.

37 MCSA A 4-year-old child has been exposed to chickenpox. After the nurse has provided information about chickenpox, the nurse asks the mother to repeat the information. Which statement by the mother indicates a need for additional information? 1. "During the prodomal period, my child will have pox all over his body." 2. "Chickenpox is a viral infection that can be spread to other children." 3. "I should monitor my child for Reye syndrome, which is a complication of chickenpox." 4. "My child should not visit my pregnant sister at this time."

1 The prodomal period refers to the period of time between the initial symptoms and the presence of the full-blown disease. The rash would not be apparent during this time. All the other statements are correct. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Evaluation Child Health The critical words in the stem of the question are need for additional information. This tells you that the correct option is an incorrect statement. Use knowledge of this communicable viral infection and the process of elimination to make a selection.

58 MCSA The nurse believes a client has slight one-sided weakness and further tests the client's muscle strength. The nurse asks the client to hold the arms up with hands supinated, as if holding a tray, and then asks the client to close the eyes. The client's right hand moves downward slightly and turns. The nurse documents and reports that the client has which of the following findings on assessment? 1. Pronator drift 2. Nystagmus 3. Hyperreflexia 4. Ataxia

1 This assessment may be done to detect small changes in muscle strength that might not otherwise be noted. Pronator drift occurs when a client cannot maintain the hands in a supinated position with the arms extended and eyes closed. Nystagmus is the presence of fine, involuntary eye movements. Hyperreflexia is an excessive reflex action. Ataxia is a disturbance in gait. Application Physiological Integrity: Physiological Adaptation Communication and Documentation Adult Health: Neurological Specific knowledge of physical assessment techniques is needed to answer the question. Note the association between the terms supinated in the question and pronator in the correct answer, in response to the client's change in hand position.

1 MCSA A client exposed to Mycobacterium tuberculosis starts on chemoprophylaxis. The nurse provides what instruction to the client? 1. "You will take a single drug such as isoniazid (INH) by mouth every day for 6 to 12 months." 2. "You will be on at least two drugs effective against the tubercle bacillus for three months." 3. "You will be on combination therapy in order to prevent development of drug resistance." 4. "You will need to learn to give yourself subcutaneous injections."

1 To prevent active tuberculosis after exposure, the client is initiated on a single agent regimen, usually isoniazid (INH). For newly diagnosed active disease (option 2), a combination of antitubercular agents is used for at least the first several weeks: isoniazid (INH), rifampin (Rifadin), and pyrazinamide (Tebrazid). The combination therapy lessens the risk of drug resistance (option 3). Except for streptomycin, which is for IM use, the antitubercular agents are administered orally (option 4). Application Physiological Integrity: Pharmacological and Parenteral Therapies Teaching and Learning Pharmacology The critical words in the stem of the question are exposed and chemoprophylaxis. Differentiate exposure from infection as the key concept being tested. Recall that if active infection requires multi-drug therapy, exposure can be managed with a single agent alone.

48 MCSA Which of the following actions would the nurse institute that is specific to the care of the assigned client who has tuberculosis? 1. Wearing a particulate respirator mask when taking vital signs. 2. Instructing the client to cover the mouth with the sheet from the stretcher when transported to other hospital departments. 3. Wearing sterile gloves when collecting a sputum specimen. 4. Keeping the client's door open to promote ventilation.

1 Tuberculosis is a respiratory infection, transmitted via airborne droplet nuclei less than 5 microns in size. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Planning Fundamentals Specific knowledge of the mode of transmission of Mycobacterium tuberculosis and the types of transmission-based precautions is needed to select the correct answer. Eliminate 2 and 3 as tuberculosis is transmitted via air currents. Choose option 1 over option 4 because tuberculosis is transmitted via airborne droplet nuclei less than 5 microns in size. 0

47 MCMA The nurse has admitted to the surgical unit a client who just underwent open reduction and internal fixation of a severely fractured right radius and ulna. Which nursing care activities would be appropriate for the nurse to delegate to the Licensed Practical/Vocational Nurse (LPN/LVN)? Select all that apply. 1. Measure vital signs every 30 minutes. 2. Report drainage on the cast if it appears. 3. Assess neurovascular status of the fingers of the casted arm hourly. 4. Elevate the casted arm above heart level. 5. Administer the prescribed intramuscular analgesic as ordered.

1, 2, 4, 5 The LPN/LVN is trained to collect data that is then reported to the registered nurse (RN). However, assessment remains the responsibility of the RN. For these reasons, the LPN/LVN can be expected to take vital signs, report drainage, administer medication, and elevate the casted limb. The RN should retain the responsibility for assessing neurovascular status to the casted extremity in the immediate postoperative period. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management Recall that procedures and simple data collection can be delegated to the LPN/LVN. With this in mind, eliminate each of the incorrect options systematically

5 MCMA Which of the following actions would the nurse take to maintain medical asepsis when caring for a client with diabetes mellitus on the medical nursing unit who requires irrigation of a leg ulcer and insulin injections? Select all that apply. 1. Wash hands before and after client care. 2. Wear personal protective equipment during the dressing change. 3. Recap a needle after administering insulin. 4. Change the dressing for a diabetic ulcer using sterile gloves. 5. Wipe the rubber stopper on the insulin vial before withdrawing dose.

1, 2, 5 Options 1, 2, and 5 are core principles of medical asepsis. Option 3 violates principles of medical asepsis. Option 4 uses principles of surgical asepsis. Option 6 is unrelated to the needs of this client. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Fundamentals Use knowledge of medical versus surgical asepsis as essential core concepts. Eliminate options that utilize surgical asepsis or are unrelated to the needs of the client.

34 MCMA The nurse is teaching a group of adults about health screenings for cancer. The nurse would include in the discussion which of the following points? Select all that apply. 1. Genetic screening is helpful in identification of cancer risks. 2. Annual medical exams uncover most tumors. 3. Men need to perform breast and testicle exams monthly. 4. Annual mammograms are recommended after a total mastectomy. 5. Inspection of the skin for cancer becomes less important as one ages.

1, 3 Genetic screening can identify markers for several types of cancer. One method to remind men to perform self-checks for cancer is to mark a calendar to monthly check for changes. Self exams as well as regular medical tests and exams uncover tumors. After a total mastectomy, women do not need mammograms. Skin cancer risk increases with age. Application Health Promotion and Maintenance Teaching and Learning Adult Health: Oncology Elimination of number 4 and looking suspiciously at the phrase most tumors will help to discriminate between the options. When in doubt, identify alternatives with most or all in the answer as false.

9 MCMA The nurse would report to the physician which of the following abnormal laboratory values for a 58-year-old client newly admitted to the nursing unit with fever and diarrhea? Select all that apply. 1. White blood cell count 12,260/mm3 2. Sodium 142 mEq/L 3. Potassium 3.9 mEq/L 4. Blood urea nitrogen 38 mg/dL 5. Serum creatinine 0.9 mg/dL

1, 4 The white blood cell count is elevated (normal 5,000-10,000/mm3), as is the BUN (0.8-22 mg/dL). These changes would be expected with infection (noted by fever) and possibly accompanying dehydration from diarrhea. The sodium (135-145 mEq/L), potassium (3.5-5.1 mEq/L), and serum creatinine (0.8-1.6 mg/dL) are all within normal limits. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Analysis Adult Health: Immunological The core issue of the question is the ability to discriminate between normal and abnormal laboratory values. Note the critical symptoms fever and diarrhea, which could lead you to select elevated white count for infection and elevated BUN with fluid loss from diarrhea.

38 MCSA The school health nurse is interested in promoting safety in the high school population. In planning safety education for this age group and their parents, the nurse would recognize that which of the following is a developmental risk factor for adolescents? 1. Substance abuse as a lifestyle means of dealing with stress 2. Feelings of immortality related to perception of being invulnerable to risks that affect others 3. Sports-related injuries that are usually related to not obeying rules and/or intense competition 4. Polypharmacy, which results in mixing of multiple medications

2 Adolescents tend to feel that they are invulnerable and that if anything bad will happen, it will affect others but not themselves. They also tend to feel immortal, as it is difficult for them to comprehend their own death. Option 1 is a factor related to the adult, option 3 is related to school-age children, and option 4 is related to the elderly. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Analysis Fundamentals Focus on the developmental level of the client. To answer this question correctly, it is necessary to understand growth and development and apply this knowledge to the needs of the adolescent for safety. 0

31 MCSA After a client has experienced a seizure, what is the most appropriate position in which the nurse should place the client? 1. On back with head raised 15 degrees 2. On the side 3. On abdomen 4. Upright in chair

2 After the seizure, the client will be postictal, which is a deep sleeping state. She/he could aspirate secretions unless side-lying to promote drainage from the upper airway. Positioning the client on the back (option 1) increases risk of aspiration. Positioning the client on the abdomen (option 3) or upright in chair (option 4) is unrealistic given the client's postictal state. Application Safe Effective Care Environment: Safety and Infection Control Nursing Process: Implementation Adult Health: Neurological The core issue of the question is knowledge of a position that will reduce the risk of aspiration following seizure activity. Use nursing knowledge and the process of elimination to make a selection. Recall that the side-lying position is commonly used in any situation in which aspiration is a risk.

40. MCSA The nurse is conducting an initial interview with a 10-year-old boy who has been brought to the mental health clinic by his parents. The nurse can establish rapport and credibility with the child by asking the child about his: 1. Behavioral symptoms. 2. Interests and hobbies. 3. Relationships with friends and family members. 4. Medical problems in the past.

2 Children at 10 years of age are egocentric and concerned with themselves. Asking about interests and hobbies is likely to foster establishment of rapport. Focusing on behavioral symptoms (option 1) could lead to an adversarial relationship. Children often are uncomfortable talking about friends and family (option 3) until they get to know a person better. Most children are unconcerned about past medical problems (option 4); they are focused on the here-and-now. Application Psychosocial Integrity Nursing Process: Assessment Mental Health The core issue of the question is knowledge of communication strategies that are likely to be effective in developing a therapeutic relationship. Focus on the age of the child and cognitive developmental level to make a selection.

60 MCSA The nurse knows that a client in the long-term care unit suffers from dysthymia. The most important nursing intervention to include in the nursing care plan is: 1. Provide at least 2 hours of quiet time every morning for the client. 2. Encourage the client to eat in the main dining room with other clients. 3. Include at least three regular meals per day and no snacks. 4. Include at least 2 liters of clear liquids per day in the diet regime.

2 For clients with dysthymia, a major concern is social isolation. Option 1 is contraindicated, as is option 3. If the client has a poor appetite, assigning 2 liters of liquid intake (option 4) is not therapeutic, nor is planning three regular meals per day (option 3). Analysis Psychosocial Integrity Nursing Process: Planning Mental Health The core issue of the question is knowledge of strategies to reduce the risk of isolation in a client with dysthymia. Use nursing knowledge and the process of elimination to make a selection.

13 MCSA A 56-year-old client reports to the nurse that his sleep patterns are different than when he was younger. The nurse anticipates that this client is likely to be experiencing which normal developmental pattern? 1. 6 to 8 hours of sleep per night with about 20 to 25% of rapid eye movement (REM) sleep and a marked decrease in Stage IV non-REM (NREM) sleep. 2. 6 to 8 hours of sleep per night with about 20% REM sleep and a decrease in Stage IV NREM sleep. 3. Erratic sleep because of work schedule with about 30% of REM sleep and no marked decrease in Stage IV NREM sleep. 4. Light sleep with equal amounts of REM sleep and NREM sleep.

2 Middle-aged adults have a decrease in deep sleep, stage IV NREM. Option 1 is an expected pattern in older adults; option 3 is expected in young adults, and option 4 is expected in neonates. Analysis Physiological Integrity: Basic Care and Comfort Nursing Process: Assessment Fundamentals The core issue of the question is knowledge of age-related changes in sleep pattern. Use this knowledge and the process of elimination to make a selection.

6 MCSA Laboratory test results indicate a client is in the nadir period that follows administration of a chemotherapy drug. Which drug should the nurse avoid administering to this client at this time? 1. Acetaminophen (Tylenol) 2. Ibuprofen (Motrin) 3. Diphenhydramine (Benadryl) 4. Guanefesin (Robitussin)

2 Red blood cells, white blood cells, and platelet counts may be decreased during the nadir period following administration of chemotherapy that has hematological toxicity. Medications that inhibit platelet aggregation should be avoided during the nadir period following antineoplastic therapy. Aspirin, ibuprofen, and indomethacin are examples of some of these agents. Tylenol is the drug of choice for mild pain and fever. Benadryl is often used for sinus drainage or as an antihistamine and Robitussin is used to manage cough. Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology The core issue of the question is the ability to determine which drugs could increase the risk of bleeding when a client's blood counts may be low. Use the process of elimination and knowledge of drug actions and adverse effects to make a selection.

29 MCSA A client's hemoglobin level is 14 grams/dL. Which interpretation of the laboratory value by the nurse is most accurate? 1. Client has a low value and is malnourished. 2. Client has a normal laboratory value and has no nutritional risk. 3. Client has a low to normal value indicative of a nutritional risk. 4. Client has an elevated value indicative of polycythemia.

2 The laboratory value given is within normal limits (12-16.5 grams/dL). All the other statements are inaccurate. The client is not malnourished (option 1), at nutritional risk (option 3), and does not have polycythemia (high level) as indicated by option 4. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Analysis Adult Health: Hematological The core issue of the question is knowledge of normal and abnormal hematological laboratory values. Use specific nursing knowledge and the process of elimination to make a selection. Note that options 1 and 3 are somewhat similar so you may eliminate both of those initially.

24 MCSA The fetal head is determined to be presenting in a position of complete extension. After learning of this, the nurse anticipates which of the following? 1. Precipitous labor and delivery 2. Prolonged labor and possible cesarean delivery 3. Normal labor and spontaneous vaginal delivery 4. Forceps-assisted vaginal delivery

2 The normal attitude of the fetal head is one of moderate flexion. Changes in fetal attitude, particularly the position of the head, present larger diameters to the maternal pelvis, which contributes to a prolonged and difficult labor and increases the likelihood of cesarean delivery. Analysis Health Promotion and Maintenance Nursing Process: Analysis Maternal-Newborn The core issue of the question is the significance of moderate flexion of the fetal head. Recognize that changes in the position of the fetal head affect delivery to choose the correct option.

2 MCSA The nurse delegates an unlicensed assistive person (UAP) to assist a client with a clean urinary catheterization procedure. The client had formerly been able to do the procedure but because of arthritis, he has been unable to perform the catheterization. Although the UAP has done this procedure before, which of the following must the nurse emphasize to the UAP? 1. Let the client do most of the procedure and report the expected output. 2. Report immediately any unusual observations, such as bleeding. 3. Complete in proper order the steps of the procedure. 4. Perform health teaching while performing the procedure.

2 The nurse ensures that the UAP understands the importance of reporting immediately any difficulties during the procedure such as bleeding. This provides for safe and effective care. Option 1 is incorrect because the client cannot do the procedure because of arthritis. Option 3 is unnecessary if the UAP is qualified to do the procedure. Option 4 is a function of the nurse, not the UAP. Application Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management The core issue of the question is the appropriate procedure for the nurse to use when delegating care to a UAP. Eliminate option 4 first because it is the role of the nurse. Eliminate options 1 and 3 next, because they are not indicated or unnecessary, respectively.

35 MCSA During a coffee break, the nurse notices two coworkers arguing about how to handle a difficult client. Their voices are raised and body postures are tense and defensive. Which would be the most appropriate approach for the nurse to use to address this conflict between staff members? 1. Let it pass because the coworkers probably did not intend to be critical. 2. Speak privately to the coworkers, telling them about personal reactions to this public encounter. 3. Confront and reprimand the coworkers publicly. 4. Inform each coworker privately that it would be most helpful not to display this behavior again.

2 The nurse should speak privately to the coworkers about their behavior and the impact on the nurse overhearing them. It does not help the climate of the unit to let it pass (option 1). The nurse is not in a position to confront and reprimand coworkers (option 3). Option 4 is somewhat plausible but option 2 personalizes the discussion between the nurse and the coworkers, and thus is best to diffuse the situation. Application Safe Effective Care Environment: Management of Care Communication and Documentation Leadership/Management Options 1, 3, and 4 are incorrect. To effectively manage conflict between staff members, address the conflict within an appropriate timeframe; do not let it pass unattended. Do not openly and publicly reprimand staff in front of other staff members or clients. Finally, address staff members privately but keep in mind what behavior is acceptable on the unit.

36 MCSA The school nurse is assessing a muscular 17-year-old female who is coming to the high school health service for complaints of edema, voice changes, and hair loss. The nurse's primary analysis based on the subjective and objective data is that the student: 1. Is going through a stage of puberty. 2. May be using steroids. 3. May be abusing barbiturates. 4. Is using marijuana regularly.

2 The student's age, along with symptoms of hair loss and edema indicate that this is not a stage of puberty. The symptoms are not indicated in abuse of barbiturates or marijuana use. By the process of elimination, the correct answer is option 2. In order to answer this correctly you need to have noted the muscular build of the student and know the signs and symptoms of illegal steroid use. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Analysis Pharmacology The core issue of the question is knowledge of adverse effects of steroid use. Use this information and the process of elimination to make a selection.

46 MCSA The nurse is assessing a 30-year-old client with a prior history of smoking who takes theophylline (Theo-Dur) for chronic obstructive pulmonary disease. Additional diagnoses include liver disease and congestive heart failure. The client is experiencing tremors, dizziness, tachycardia, and nausea. The nurse explains to the client that these symptoms may be the result of: 1. A history of smoking cigarettes. 2. Liver disease. 3. The client's age. 4. The client's weight.

2 Theophylline is a xanthine that causes bronchial dilation due to smooth muscle relaxation. Increased levels of theophylline occur with liver disease and congestive heart failure. Option 3 is incorrect because the client is young and therefore the age is insignificant. The smoking history (option 1) is not an issue; in fact, smokers metabolize theophylline more quickly and may need increased doses. There is no data about the client's weight (option 4) in the stem. Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Analysis Pharmacology The core issue of the question is knowledge that adverse effects of xanthine medication such as theophylline are increased in liver disease. Use specific knowledge of drug adverse effects and the process of elimination to make a selection.

18 MCSA A client with metabolic acidosis is admitted. Which of the following laboratory values would the nurse expect to find in this client? 1. pH 7.40; serum potassium 3.8 mEq/L 2. pH 7.36; serum potassium 3.1 mEq/ L 3. pH 7.2; serum potassium 6.2 mEq/ L 4. pH 7.0; serum potassium 5.5 mEq/ L

3 A client in metabolic acidosis may also be hyperkalemic. As the hydrogen ions shift from the ECF to the ICF, potassium enters the ECF, leading to an increased serum potassium. pH values of < 7.35 are associated with acidosis (option 2). Options 3 and 4 have K+ levels above 5.5 mEq/ L that are associated with acidosis, but option 3 contains the higher value. Option 1 has a normal pH and serum potassium level. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Endocrine and Metabolic Note the critical word acidosis in the question. Use this to eliminate options 1 and 2 because the pH is not low in either option. Focus on the critical word metabolic to pick the option that contains a cation with the highest value since hydrogen ions can enter the cell, which in this case is option 3. 1

39. MCSA When giving directions to a 24-year-old female with possible appendicitis who is about to undergo a pelvic sonogram, which statement should the nurse make to the client? 1. "Drink nothing for several hours prior to the exam." 2. "You will be given an enema to cleanse the bowel." 3. "Drink plenty of liquids so you will have a full bladder." 4. Do not take any medications prior to the exam."

3 A full bladder is necessary to bounce the sound waves off to compare other tissues or structures are being assessed. If done during pregnancy, the fetus must be over 26 weeks to not have the restriction for the full bladder, since the amniotic fluid would be used at that point. It would not be helpful to be NPO, because this would deprive the client of fluids. Enemas and refraining from medications are unnecessary. Application Physiological Integrity: Reduction of Risk Potential Teaching and Learning Adult Health: Gastrointestinal Fluids are needed to fill the bladder and are not withheld prior to testing. Bowel structures do not interfere with the assessment of structures and an enema is not required. Medications do not impact on sound waves and holding medications is not necessary for any reason.

10 MCSA The mental health nurse working with children anticipates that unrealistic expectations or a sense of failure to meet standards would cause a 10-year-old child to develop a sense of which of the following? 1. Shame 2. Guilt 3. Inferiority 4. Role confusion

3 According to Erikson's stages of development, a 10-year-old child is experiencing industry vs. inferiority. Shame (option 1), guilt (option 2), and role confusion (option 4) occur at other developmental levels. Application Psychosocial Integrity Nursing Process: Analysis Mental Health The core issue of the question is the ability to anticipate levels of growth and development in a 10-year-old child. Use knowledge of Erikson's theory to make a selection.

23 MCSA The nurse is working with a client suffering from chronic diarrhea. In teaching ways to reduce diarrhea, the nurse would encourage the client to avoid which of the following that contribute to the development of diarrhea? 1. Excessive intake of cheese and eggs 2. Habitually ignoring the urge to defecate 3. Anxiety or anger 4. Lack of exercise

3 Anxiety or anger increases peristalsis leading to subsequent diarrhea. Excessive intake of cheese or eggs, ignoring the urge to defecate, and lack of exercise can lead to the development of constipation. Application Physiological Integrity: Basic Care and Comfort Nursing Process: Implementation Fundamentals The core issue of the question is knowledge of ordinary factors that can contribute to diarrhea. Evaluate each of the options in turn and determine whether it is likely to aggravate diarrhea. Note that anxiety and anger stimulate the sympathetic nervous system, which then increases peristalsis; this will help you to choose correctly.

44 MCSA After reviewing the client's health history, the nurse concludes that which of the following is the most significant factor related to the development of bronchogenic carcinoma for this client? 1. Asthma 2. Smokeless tobacco 3. Cigarette smoking 4. Air pollution

3 Cigarette smoking is the leading cause of lung cancer. Smokeless tobacco is more often associated with oral cancer. Air pollution may also be a contributing factor to development of lung cancer. History of asthma is not associated with greater risk of lung cancer. Analysis Health Promotion and Maintenance Nursing Process: Assessment Adult Health: Respiratory Eliminate option 1 first because it is a health problem, not a risk factor. From there, choose cigarette smoking over the other options because it is highly associated with lung cancer.

42 MCSA As the nursing unit representative member serving on the hospital quality management committee, the nurse has been asked to evaluate the quality of nursing services on the unit. What would be an appropriate quality improvement activity for the nurse to ask team members to participate in? 1. Tracking the number of accidents or incidents on the unit 2. Documenting nursing time and activities spent on direct client care 3. Administering a client and family satisfaction survey 4. Assessing clients and report acuity to shift managers daily

3 Client and family satisfaction surveys are a formal set of activities that can be used to remedy deficiencies identified in the quality of direct patient care, administrative, and support services. Incident reports (option 1) serve as an indicator of risk. Documentation of time and activities related to direct care may be done as part of time and motion studies. Acuity relates to the need for nursing staff on the unit. Application Safe Effective Care Environment: Management of Care Nursing Process: Planning Leadership/Management Note the critical word services in the stem of the question. With this in mind, the correct option is one that gathers data from the recipients of services. Options 1, 2, and 4 are not quality service measures.

14 MCSA The nurse concludes that teaching has been effective when the laboring client's partner shouts, "She's crowning!" as: 1. The nurse first starts to see a little of the baby's head. 2. The baby's head recedes upward between pushing contractions. 3. The perineum is thin and stretching around the occiput. 4. The mouth and nose are being suctioned.

3 Crowning is the point in time when the perineum is thin and stretching around the fetal head both between and during contractions. Delivery is imminent when crowning occurs. Crowning occurs later than the first sight of the infant's head. A head that recedes upward between contractions is not crowning. The mouth and nose cannot be suctioned during crowning because they are not accessible, nor is it timely. Analysis Health Promotion and Maintenance Nursing Process: Evaluation Maternal-Newborn The critical word in the stem of the question is crowning. Use knowledge of what occurs during crowning and the process of elimination to make a selection. Visualize the word crown and select the answer that matches the part of the head that a crown would sit on.

45 MCSA The nurse is setting up the breakfast tray for a client with gastroesophageal reflux disease (GERD) and notices one food that the client should not eat. Which food should the nurse remove from the meal tray? 1. Poached egg 2. Dry toast 3. Coffee with cream 4. Skim milk

3 Foods that reduce lower esophageal sphincter (LES) pressure will increase reflux symptoms. These include coffee, fatty foods, alcohol, and chocolate. All the other items can be given to the client. Analysis Physiological Integrity: Basic Care and Comfort Nursing Process: Analysis Foundational Sciences: Nutrition The core issue of the question is knowing that certain types of foods lower LES pressure, and then being able to take it a step further and identify what types of foods those are. Eliminate each option systematically by reasoning that any foods high in fat (such as the cream in the coffee) can have this effect.

16 MCSA After three defibrillation attempts, the client continues to be in a pulseless ventricular tachycardia. A lidocaine bolus of 100 mg IV is administered. The nurse would expect to see which of the following as a therapeutic response to lidocaine? 1. Conversion from a ventricular tachycardia to a ventricular fibrillation 2. Slowing of heart rate to 80 beats per minute 3. A reduction in ventricular irritability 4. An increase in the level of consciousness

3 Lidocaine is the primary medication used to treat ventricular dysrhythmias. Lidocaine suppresses automaticity in the HIS-Purkinje system by elevating electrical stimulation threshold of the ventricle during diastole, thus decreasing ventricular irritability. Ventricular fibrillation (option 1) is a worsening dysrhythmia. Slowing the heart rate (option 2) without converting the rhythm to an atrial or sinus rhythm is not therapeutic. An increase in level of consciousness (option 4) would only occur once the ventricular rhythm is terminated. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Evaluation Pharmacology The core issue of the question is knowledge that Lidocaine is an antidysrhythmic that should reduce the irritability of the ventricle, thus making it more amenable to shock therapy. The reduction in ventricular irritability could manifest as a conversion to a supraventricular rhythm.

25 MCSA The nurse notices that an elderly nursing home resident has not been eating or drinking as much as usual. Which assessment finding would best indicate the presence of fluid volume deficit? 1. Clear lung fields with unlabored respirations 2. Tenting and dry, flaky skin 3. Increased drowsiness, mild confusion, and concentrated urine 4. Hand veins that fill within 3 to 5 seconds of being lowered below the heart

3 Mental status changes and concentrated urine are common signs of dehydration in the elderly. Tenting and dry, flaky skin are consistent changes seen with normal aging. Hand veins that fill within 3 to 5 seconds and clear lungs sounds with unlabored breathing are normal findings. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Cardiovascular Note the critical words in the question are not eating or drinking and deficit. With this in mind, look for a physical assessment finding that is consistent with dehydration. Eliminate options 1 and 2 first because of the words clear and dry respectively. Choose option 3 over 4 recalling that neurological symptoms are often present with altered fluid balance because sodium imbalance may occur simultaneously. 0

21 MCSA A 60-year-old client has been prescribed rabeprazole (Aciphex) for symptoms of gastroesophageal reflux disease (GERD). He has trouble swallowing pills. What alternate medication should the nurse plan to request for this client? 1. Omeprazole (Prilosec) 2. Pantoprazole (Protonix) 3. Lansoprazole (Prevacid) 4. There is no substitute for Aciphex

3 Omeprazole, pantoprazole, and rabeprazole must be swallowed whole. Lansoprazole and esomeprazole capsules may be opened and sprinkled on applesauce or dissolved in 40 mL of juice. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Planning Pharmacology The core issue of the question is knowledge of which medications used for GERD can be opened because they come in capsule form. Use knowledge of pharmacology to answer this question, which tests specific nursing knowledge of drug forms.

43 MCSA When a female client preparing for surgery suddenly bursts into tears, the preoperative holding unit nurse should take which of the following actions? 1. Pull the curtain closed and leave the area to provide privacy. 2. Be silent as a sign of compassion. 3. Ask the client to share what she is feeling. 4. Continue with the physical preparation of the client.

3 Option 3 is best because it represents a communication with the client and is open-ended. Options 1 and 2 are not the most appropriate initial approaches since the client is not encouraged to share her concerns, although later on in the interaction these may be appropriate. Option 4 ignores the client and does not address the client's concerns. Application Physiological Integrity: Reduction of Risk Potential Communication and Documentation Fundamentals The core issue of the question is the ability of the nurse to care for the emotional needs of a perioperative client. Since this is potentially an anxiety-producing time for clients, choose the option in which the nurse provides a therapeutic response to the client.

41 MCSA The nurse is providing medication instructions to a client. The nurse informs the client that persistent gynecomastia can result from taking which of the following newly prescribed diuretics? 1. Hydrochlorothiazide (HCTZ) 2. Furosemide (Lasix) 3. Spironolactone (Aldactone) 4. Indapamide (Lozol)

3 Spironolactone is a potassium-sparing diuretic used to treat hypertension. Gynecomastia is one of its adverse reactions. Adverse reactions usually disappear after the drug is discontinued; however, gynecomastia may persist after discontinuing spironolactone. Application Physiological Integrity: Pharmacological and Parenteral Therapies Teaching and Learning Pharmacology The core issue of the question is knowledge of adverse drug effects of spironolactone. Use specific drug knowledge and the process of elimination to make a selection.

50 MCSA The nurse is preparing to take a client to the electroconvulsive therapy (ECT) treatment suite. The nurse must ensure that which of the following pretreatment processes has been completed? 1. The client's husband has signed the consent form. 2. The client is wearing snug-fitting clothing. 3. The client is NPO. 4. The client has been given ample liquids before the procedure.

3 The client should be NPO before the procedure in order to be given anesthesia for the procedure (options 3 and 4). The client, not the husband, should sign the consent form (option 1). The client should be wearing loose-fitting clothing (option 2). Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Implementation Mental Health The core issue of the question is knowledge that ECT requires anesthesia, which leads to loss of airway protective reflexes. Use this knowledge to reason that the client must be NPO to prevent the risk of aspiration during the procedure.

61 MCSA A client who is receiving intravenous heparin by protocol orders has an activated partial thromboplastin time (APTT) level of 140 seconds (control time is 36 seconds). What is the priority action that the nurse should institute? 1. Increase the heparin dose as the APTT level is not therapeutic. Obtain a repeat APTT in 6 hours. 2. Stop the heparin therapy for 6 hours, then restart the therapy at the same unit dose and obtain a repeat APTT in 6 hours. 3. Stop the heparin therapy for 1 hour. Decrease the rate of infusion per protocol and restart the medication in 1 hour. Obtain a repeat APTT in 2 to 3 hours from the restart of the infusion. 4. Obtain an additional APTT in 1 hour and continue to monitor the client.

3 The effectiveness of a heparin protocol is monitored by trending APTT results to achieve a therapeutic level. An APTT of 140 is above the therapeutic level of anticoagulation and therefore the infusion should be stopped per protocol, and resumed at a decreased dose in one hour's time with a repeat APTT ordered in 2-3 hours per protocol. The dose should not be increased, as this would cause serious consequence to the client. Stopping the medication for a total 6 hours would undermine the anticoagulation control that the physician is trying to achieve. Ordering another APTT and continuing to run the infusion could also cause serious consequences to the client. Analysis Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology The core issue of the question is recognition that this is a critically high value for the APTT and that the action that will maintain client safety is to turn off the heparin for a period of time. Use the process of elimination and knowledge of the effects of heparin on APTT times to answer the question. 0

7 MCSA The newborn nursery has recently formed a unit policy and procedure committee. The nurse, while attending and participating in the meetings, determines that which nurse exemplifies a situational leader? 1. The nurse who offers suggestions, asks questions, and guides the group toward achieving group goals. 2. The nurse who recognizes the group's need for autonomy and abdicates responsibility. 3. The nurse who relies on the organization's rules, policies, and procedures to direct the group's work. 4. The nurse who recognizes that leadership style depends on the readiness and willingness of the group or the individuals to perform the assigned tasks.

4 A situational leader recognizes that leadership style depends on the readiness and willingness of the group or the individuals to perform the assigned tasks. The democratic or participative leader offers suggestions, asks questions, and guides the group toward achieving the group goals. The laissez-faire leader recognizes the group's need for autonomy and abdicates responsibility. A bureaucratic leader relies on the organization's rules, policies, and procedures to direct the group's work. Application Safe Effective Care Environment: Management of Care Nursing Process: Analysis Leadership/Management The core issue of the question is knowledge of various leadership styles. Use this knowledge and the process of elimination to make a selection

51 MCSA To minimize the pain related to intramuscular injection of 2 mL of penicillin G benzathine (Bicillin LA) in an adult client, the nurse would take which of the following actions? 1. Apply cold compress to site after injection. 2. Divide the dose and inject half into each deltoid. 3. Limit prolonging the time taken to administer the drug by not aspirating. 4. Administer the drug deep IM slowly into a large muscle such as the gluteus.

4 Administering very thick preparations such as penicillin G with benzathine (Bicillin LA) can be painful. To lessen the pain, intramuscular injection into a larger gluteal muscle should be administered over 12 to 15 seconds to separate the muscle fibers more gradually. Cold compresses to the injection site would delay absorption of the drug (option 1). Aspiration for blood return with all IM injections is necessary for safety since muscles contain larger blood vessels (option 3). Injection into the deltoid may also result in prolonged discomfort resulting in limited motion of the upper extremities (option 2). Rotating sites, light massage, and warm compress to site may also be employed to limit discomfort. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Implementation Pharmacology The core issue of the question is knowledge of proper administration technique for thick liquid parenteral medications. Use knowledge of intramuscular injection techniques and knowledge of drug absorption principles to make a selection.

28 MCSA A 14-year-old client has been diagnosed with bipolar disorder. The nurse would expect to see which of the following problems? 1. Intense mood swings lasting only 1 to 2 hours 2. Inflated self-esteem 3. Spending sprees 4. Fire-setting and gang behavior

4 Children with bipolar disorders are often misdiagnosed as having conduct disorder or ADHD. Intense mood swings (option 1), inflated self-esteem (option 2), and spending sprees (option 3) occur more often in adults. Analysis Psychosocial Integrity Nursing Process: Assessment Mental Health The core issue of the question is knowledge of how bipolar disorders may present in a child that is in early adolescence. Use nursing knowledge and the process of elimination to make a selection.

54 MCSA A mother brings a 3-year-old child to the clinic for a well-child checkup. The child has not been to the clinic since 6 months of age. The nurse determines that which of the following is the priority of care for this child? 1. Assess growth and development. 2. Begin dental care. 3. Complete hearing screening. 4. Update vaccinations.

4 Every time a child enters the healthcare system, the immunization status should be checked. Some children have uncertain history of immunization because of parental noncompliance or special circumstances such as being refugees. Once immunization status has been determined, the nurse can go on to assess growth and development and hearing, and to teach the parents about dental care as necessary. Application Health Promotion and Maintenance Nursing Process: Planning Child Health The critical word in the stem of the question is priority. This tells you that more than one option is likely to be a correct nursing action, but that one is more important than the others. Note the age of the child to help you choose immunizations as the priority, especially noting that the child has not received healthcare for 2.5 years, during a time when vaccinations should be kept up to date.

22 MCSA At the start of the shift there were only three newborns in the nursery, so staffing consisted of one RN and one LPN. Within two hours, three more newborns were admitted to the nursery, one requiring Level II care, and the parents of two newborns needed discharge teaching so they could go home. The RN was needed full time in the Level II nursery as the newborn was stabilized. What staffing is needed to provide appropriate care in this situation? 1. The LPN can complete the admission assessments and discharge teaching for the five Level 1 newborns. 2. An UAP from the postpartum unit can be reassigned to the nursery to do the discharge teaching. 3. The RN can complete the admission assessments while continuing to stabilize the Level II newborn. 4. Another RN needs to be assigned to the nursery to implement the admission assessments and discharge teaching.

4 It is an RN's responsibility to do assessments, analyze the data, plan and implement care and teaching, and evaluate the outcomes. A second RN needs to be assigned to the nursery to safely manage the care of the Level I newborns. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management Recognize that assessment and client education are part of the professional scope of practice. The correct answer would be the option that safely retains these functions for the RN given the change in unit census.

26 MCSA Following a liver transplant the client is taking prednisone among other medications to prevent organ rejection. The nurse should instruct the client to make it a priority to report which of the following signs and symptoms to the health care provider? 1. Moon face 2. Diminished pigmentation 3. Dysphagia 4. Bleeding

4 Liver function includes the regulation of blood clotting and corticosteroids can impair wound healing and irritate the GI tract. Thus, the client should be instructed to report signs and symptoms of bleeding. Option 1 is a side effect of corticosteroids but is not the priority from a physiological basis. Options 2 and 3 do not reflect the associated risk of bleeding with corticosteroid medications. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Immunological The core issue of the question is knowledge that the liver is a vascular organ and that some medications used to suppress the immune system to prevent rejection, such as corticosteroids, can lead to bleeding.

11 MCSA A postoperative client who has an order for 5,000 units of heparin SubQ for three doses wants to know why this drug is being ordered. What information would the nurse provide to the client to best answer the question? 1. "Heparin is used as a common medication in many clients who have surgery." 2. "Heparin is essential during the postoperative period to maintain adequate blood clotting levels." 3. "The injections will be given in the abdomen and are not usually associated with discomfort." 4. "Heparin is being used to prevent blood clots from forming as a result of surgery or decreased mobility."

4 Low-dose heparin therapy is indicated in many postoperative clients to prevent the development of thromboembolic episodes. It is not used in every postoperative situation (option 1), but it is usually used for clients who have orthopedic surgery or are anticipated to be immobilized for a time following surgery. Short-term therapy is not given to maintain adequate blood clotting levels (option 2) but merely to intervene as a preventative measure. While the statement that heparin is given SC into the abdomen and is not usually painful is factual, it is not the reason for the medication being given to the client (option 3). Application Physiological Integrity: Pharmacological and Parenteral Therapies Communication and Documentation Pharmacology The critical words in the stem of the question are best answer the question. This tells you that the correct answer is one that responds to the client's concern, rather than just reciting a fact about the medication. Use nursing knowledge and the process of elimination to answer the question.

3 MCSA The client is in the operating room for a surgical procedure. The nurse in the operating room is monitoring the physiological integrity of the client. Which of the following activities is most appropriate? 1. Determine client satisfaction with care received. 2. Assess client's emotional status. 3. Monitor asepsis in the environment. 4. Calculate fluid loss and its effects.

4 Only option 4 relates to the client's physiological integrity. Options 1 and 2 pertain to the psychological aspects of client care, while option 3 relates to the safety in the environment. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Assessment Fundamentals The core issue of the question is knowledge of physiological assessment priorities in the perioperative client. Fluid loss directly relates to cardiovascular status, which is one of the ABCs (airway, breathing, and circulation). Use nursing knowledge and the process of elimination to make a selection.

15 MCSA A client questions the surgical nurse about the personnel in the operating room. Which of the following initial responses by a nurse to the client's concern is most therapeutic? 1. "The nurses are well-qualified for the job they do." 2. "Have you had a bad experience in the OR?" 3. "You're concerned about the personnel, but you have no need to worry." 4. "Can you tell me about why you are interested in the personnel?"

4 Option 4 gives the client an opportunity to explain to the nurse the reason for asking the question. This helps the nurse understand the client's frame of reference and allows the nurse to best address the client's concern. Options 1 and 3 offer false reassurance and can give the impression that the nurse did not listen to or address the client's concerns. Option 2 is a close-ended question and may not help the nurse explore the client's concerns. Analysis Physiological Integrity: Reduction of Risk Potential Communication and Documentation Fundamentals The core issue of the question is knowledge of communication techniques that are effective when working with a client who will undergo surgery. Use knowledge of communication theory and the process of elimination to make a selection.

19 MCSA A client has a BUN of 68 mg/dL and a creatinine level of 6.0 mg/dL. The IV fluid is 5% dextrose in 0.9% sodium chloride with 40 mEq KCL @ 100 mL/hour. Which action would be most appropriate for the nurse to take? 1. Encourage more protein in the diet. 2. Ambulate the client more to increase circulation. 3. Take vital signs every hour. 4. Question the use of potassium in the IV fluids. \

4 Potassium (KCL) is contraindicated in clients with renal dysfunctions. It can not be filtered out if there is decreased renal filtration. With increased damage in tissues additional potassium is released, causing an even greater level of potassium that can be life-threatening. Encouraging protein, ambulation, and taking vital signs do not safeguard the client from the danger of this potential electrolyte imbalance. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Implementation Adult Health: Renal and Genitourinary Protein creates more potassium in the body and the lab shows that the kidneys are not filtering as they should. Additional potassium from protein metabolism may cause death. Activities, such as ambulation, will not change the BUN or creatinine since they reflect filtration of the renal system and not the rate of circulation of the blood. Taking the vital signs every hour only tells you information about the circulatory status and does not explain or improve the renal functions. Action needs to be taken immediately to discontinue the IV with the potassium to minimize the buildup of potassium to toxic levels that could be life-threatening.

52 MCSA The nurse is assigned to the care of an obese client who has gastroesophageal reflux disease (GERD). Which of the following activities could the nurse appropriately delegate to the unlicensed assistant person (UAP)? 1. Teach the client about the need for weight loss. 2. Explore any concerns about the prescribed regimen for managing GERD. 3. Explain why it is important to eat several small meals per day. 4. Instruct the client to remain upright for at least 2 hours after eating.

4 Teaching and assessment are within the domain of the registered nurse (RN) and cannot be delegated to a UAP. The UAP is also not trained in therapeutic communication or counseling techniques. These ancillary caregivers can complete tasks under the supervision and direction of the nurse, and report simple data when asked to do so. With this in mind, the only activity that can be delegated is the simple direction to the client to remain upright after eating. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Adult Health: Gastrointestinal The core issue of the question is knowledge of the appropriate tasks to delegate to a UAP. Recalling that teaching, counseling, and assessment remain the RN's responsibility assists in eliminating each of the incorrect options.

33 MCSA A client recently diagnosed with type 1 diabetes mellitus is learning to use the American Diabetes Association exchange lists. The nurse determines that the teaching has been effective if the client chooses which of the following as an appropriate exchange for white rice? 1. Egg 2. Tomato 3. Orange 4. Bread

4 The American Diabetes Association Exchange Lists divide food into groups with similar content (milk, vegetables, fruit, starch/bread, meat, and fat). All foods within a list are similar in calories, protein, fat, and carbohydrates if eaten in a certain size portion. Foods may be exchanged within the same list. Rice and bread are starches, egg is meat, tomato is vegetable, and orange is fruit. Analysis Physiological Integrity: Basic Care and Comfort Nursing Process: Evaluation Foundational Sciences: Nutrition First recall the basic food groups that are part of the American Diabetes Association Exchange Lists. Then compare each food choice identified with the list. Eliminate options 2 and 3 first as vegetables and fruits, then pick option 4 over 1 because it is a starch/bread.

17 MCSA The nurse is assigned to a client diagnosed with head and neck cancer who is receiving enteral feedings via gastrostomy tube. When the nurse is called away to care for another client, which task for this client could most appropriately be delegated to the unlicensed assistive person (UAP)? 1. Determining the amount of residual for the tube feeding 2. Giving mouth care and assessing the oral cavity 3. Exploring how the client is currently coping with the diagnosis 4. Administering a bath and changing bed linens

4 The UAP is qualified to complete simple procedures, such as bathing a client and changing bed linens. While the UAP could possibly administer mouth care to this client, the nurse must assess the oral cavity (option 2) and should be the one to assess tube feeding residual (option 1). UAPs are not trained in therapeutic communication skills and techniques (option 3). Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management The core issue of the question is an appropriate activity to delegate to an unlicensed assistant. Keep in mind that any activity that involves assessment is retained by the RN, so eliminate options 1 and 2. Choose option 4 over 3 because it is procedural in nature.

55 MCSA A client who has pancreatitis is experiencing pain. After administering an analgesic, the nurse should place the client in which of the following positions to promote comfort? 1. Supine 2. Prone 3. Left lateral decubitus 4. Sitting up and leaning forward

4 The pain in pancreatitis is usually aggravated by lying in a recumbent position, but improved by sitting up and leaning forward or in the fetal position with the knees pulled up to the chest. This position reduces pressure caused by contact of the inflamed pancreas with the posterior abdominal wall. Application Physiological Integrity: Physiological Adaptation Nursing Process: Implementation Adult Health: Gastrointestinal The core issue of the question is knowledge of proper positioning techniques to reduce the pain of inflammation that can be aggravated by movement. Use the process of elimination to select the position in which the pancreas is not as likely to be compressed against other body structures.

73 MCSA Which of the following would be an appropriate intervention for the nurse to include in a plan of care for a client with clinical diagnosis of bulimia? 1. Assess for laxative and diuretic possession. 2. Supervise mealtimes to ensure eating. 3. Observe for ritualistic eating patterns. 4. Reward nonpurging behavior with a favorite snack.

Answer: 1 Abuse of laxatives and diuretics is a frequent purging behavior for bulimic clients. Options 2 and 3 pertain to anorexia nervosa clients. In regard to option 4, food should never be used as a reward. Application Physiological Integrity: Basic Care and Comfort Nursing Process: Planning Foundational Sciences: Nutrition The critical word in the question is bulimia. Recall that this disorder has the classic features of binging and purging to guide you to the correct answer, which in this question is one that signifies agents that help one to purge.

64 MCSA The pregnant client is 7 centimeters, 100% effaced, and at a +1 station. The fetus is in a face presentation. The nurse concludes that teaching has been effective when the client's husband states: 1. "Our baby will come out face first." 2. "Our baby will come out facing one hip." 3. "Our baby will come out buttocks first." 4. "Our baby will come out with the back of the head first."

Answer: 1 Presentation refers to the part of the fetus that is coming through the cervix and birth canal first. Thus a face presentation occurs when the face is coming through first. Analysis Health Promotion and Maintenance Teaching and Learning Maternal-Newborn Associate the word face in the question with the word face in the correct response. The word presentation helps you to choose option 1 over option 2, which also contains the word face, but in an inappropriate context to this question. 0

77 MCSA The registered nurse (RN) is assigned to the postpartum unit. Which task could the RN safely delegate to a beginning student nurse? 1. Ambulate a client who delivered by cesarean 2 days ago. 2. Complete the admission assessment on a newly delivered client. 3. Call the physician to report a low hemoglobin level. 4. Verify a unit of blood prior to transfusion.

Answer: 1 The RN is responsible for delegating tasks appropriately and is responsible for the actions of unlicensed personnel. Ambulating a postoperative client is the only task from those listed that the RN could delegate to a novice student. The other tasks require higher level assessment and critical thinking skills and should be performed by the RN. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management Note the critical word beginning to describe the student nurse. With this in mind, select the delegation assignment that is simple and procedural in nature, and does not require assessment, teaching, or advanced knowledge in nursing.

62 MCMA The nurse has admitted to the intermediate care unit a client who sustained a spinal cord injury at T1 in a motor vehicle accident. Which of the following nursing care activities can the nurse delegate to the unlicensed assistive person (UAP) when working with this client? Select all that apply. 1. Measure oxygen saturation level every hour. 2. Listen to breath sounds. 3. Provide mouth care. 4. Teach use of incentive spirometer. 5. Assess for Homan's sign while bathing client.

Answer: 1, 3 The UAP can perform tasks or nursing care activities under the direct supervision of the registered nurse (RN). The nurse retains responsibility for assessment (options 2 and 5) and teaching (option 4). Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management The core issue of the question is the ability to discriminate between what the RN may delegate and what he or she may not. Evaluate each option and either choose it because it is a simple procedure or task, or choose not to select it because it involves assessment or teaching. 0

66 MCSA A child diagnosed with deficiency of growth hormone who needs replacement drug therapy comes to the clinic for treatment. Which one of the following nursing diagnoses would be most appropriate for this client? 1. Imbalanced nutrition: More than body requirements 2. Disturbed body image 3. Diversional activity deficit 4. Decreased cardiac output

Answer: 2 Children with growth hormone deficiency are smaller than their peers and frequently experience problems with self-esteem and body image. Option 1 would be the opposite problem of what the client is experiencing. The nursing diagnoses in options 3 and 4 are unrelated to the client in this question. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Analysis Adult Health: Endocrine and Metabolic The core issue of the question is knowledge that deficiency of growth hormone leads to short stature and often disturbed body image in the child. Use nursing knowledge and the process of elimination to make a selection. 0

68 MCSA The nurse would conclude that hypomagnesemia has not resolved if which of the following neuromuscular signs is still present after treatment? 1. Paralysis 2. Tetany 3. Flaccidity 4. Decreased reflexes

Answer: 2 Effects of hypomagnesemia are mainly due to increased neuromuscular responses. Paralysis, flaccidity, and decreased reflexes may be present with hypermagnesemia. Application Physiological Integrity: Physiological Adaptation Nursing Process: Evaluation Adult Health: Neurological Recall that options that have similarities are not likely to be correct. Examine the options from the viewpoint of neurological stimulation. Eliminate each of the incorrect responses because they reflect abnormally low activity of the nervous system.

70 MCSA The nurse is planning for a multidisciplinary team meeting concerning a client with bipolar disorder. In discussing the client's safety needs, the nurse would be sure to include: 1. Placement of the client in a four-bed room. 2. The client's risk level for self-harm. 3. Unrestricted visitors. 4. The need of the client to participate daily in many concentrated activities.

Answer: 2 The client's level of risk for self-harm is a major concern. The client may need a private room (option 1) and restricted visitors (option 3) if in a manic state. The client should not be overstimulated (option 4). Application Psychosocial Integrity Nursing Process: Planning Mental Health Critical words in the stem of the question are safety and bipolar disorder. Use nursing knowledge to associate depression as part of bipolar disorder with the threat to safety with suicide as a form of self-harm. This will lead you to the correct answer. 0

78 MCSA A client presents to the Emergency Department with a stab wound to the right upper abdominal quadrant. The client's vital signs are BP 85/60, pulse 125, and respiratory rate of 28 breaths/minute. The nurse should immediately suspect damage to what organ? 1. Stomach 2. Liver 3. Large intestine 4. Kidney

Answer: 2 The primary organ in the right upper quadrant of the abdominal cavity is the liver. Because of the early shock symptoms, which are presented, it would be expected that this organ has possibly been lacerated, causing extensive uncontrolled internal bleeding. The other organ systems would not be located in this area. Analysis Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Gastrointestinal First analyze the client's vital signs to determine that the client's status is consistent with a shock state. Then determine which organs are located in the right upper quadrant. Associate the liver, which is a vascular organ, and the location to determine the correct option. 0

72 MCSA The nurse admitting a client with a history of trigeminal neuralgia (tic Douloureux) would question the client about which of the following manifestations? 1. Facial droop accompanied by numbness and tingling 2. Stabbing pain that occurs with twitching of part of the face 3. Aching pain and ptosis of the eyelid 4. Burning pain and intermittent facial paralysis

Answer: 2 Trigeminal neuralgia is manifested by spasms of pain that begin suddenly and last anywhere from seconds to minutes. Clients often describe the pain as stabbing or similar to an electric shock. It is accompanied by spasms of facial muscles, which cause closure of the eye and/or twitching of parts of the face or mouth. Application Physiological Integrity: Physiological Adaptation Nursing Process: Assessment Adult Health: Neurological Note the critical word neuralgia in the question, which tells you the pain is of nervous system origin. Recalling that this type of pain is usually sharp, stabbing, and possibly burning may help you to eliminate some incorrect options. Distinguish between spasm associated with this disorder and paralysis (an opposite finding) to discriminate between options 2 and 4.

59 MCSA When a client has arterial blood gases drawn from the radial artery, the nurse should plan to do which of the following? 1. Hold the site for up to 1 minute. 2. Transfer the blood sample to a heparinized test tube. 3. Pack the sample in ice for transporting to the laboratory. 4. Obtain a second specimen after 10 minutes for comparison.

Answer: 3 Packing the sample in ice will minimize the changes in gas levels during the transportation of the specimen to the lab. The arterial site should be held for 5 minutes or longer if the client is receiving anticoagulant therapy. The blood is drawn originally in a heparinized syringe and does not need to be transferred to one. A second specimen is not necessary. Application Physiological Integrity: Reduction of Risk Potential Nursing Process: Implementation Adult Health: Respiratory The wording of the question tells you that the correct answer is also a true statement of fact. Eliminate option 1 first as being factually incorrect. Next, eliminate option 2 because the syringe is heparinized and the blood is not transferred to a test tube. Finally, eliminate option 4 because it is unnecessary.

76 MCSA A 3-month-old infant is diagnosed with leukemia. Which of the following does the nurse anticipate will be part of the plan of care for this infant? 1. The baby will be placed in isolation. 2. Leukemia is familial and other children should be assessed. 3. All immunizations will be withheld during exacerbations. 4. The baby will be NPO during chemotherapy

Answer: 3 Immunizations should be withheld during leukemia exacerbations because the immune system is compromised and the client cannot manage an appropriate response to the immunization. There is no need to place the client in isolation without added evidence of immunosuppression (option 1). Options 2 and 4 are irrelevant to the issue of the question. Application Physiological Integrity: Physiological Adaptation Nursing Process: Planning Child Health The core issue of the question is knowledge that leukemia adversely affects the immune system. With this in mind, the nurse needs to be mindful that immunizations will need to be withheld during an exacerbation. Use nursing knowledge and the process of elimination to make a selection. 0

74 MCSA A client has a strong family tendency toward hypertension. He denies that he will get hypertension because he watches what he eats, gets plenty of exercise, and keeps his weight within normal range. When implementing the plan of care, the nurse would do which of the following? 1. Praise the client and reassure him that these actions will prevent him from becoming hypertensive. 2. Emphasize that no matter what he does, the client will eventually develop hypertension because of his family history. 3. Recognize the client's efforts towards a healthy lifestyle and emphasis that early detection is essential to prevent complications. 4. Recommend that the client request antihypertensive medications prophylactically because of his family history.

Answer: 3 Lifestyle modifications and recognition of risk factors are important parts of prevention of long-term complications. Family history is a very strong risk factor but encouraging the client to maintain his current lifestyle and following up with health screening would be the best plan of action. False reassurance that he will never be hypertensive and prophylactic antihypertensive medications are inappropriate. Analysis Health Promotion and Maintenance Communication and Documentation Adult Health: Cardiovascular The core issue of the question is lifestyle management to reduce the risk of developing hypertension. Select the option that focuses on prevention while addressing the continued risk that the client faces.

67 MCMA The nursing unit is understaffed and a nurse from the surgical intermediate care unit has been floated to the unit for the day shift. Which of the following two clients should the nurse assign to this RN float nurse? Select all that apply. 1. A client newly admitted with exacerbation of heart failure 2. A client newly diagnosed with type 2 diabetes mellitus 3. A client who underwent emergency appendectomy during the night 4. A client with nephrolithiasis scheduled for lithotripsy later in the morning 5. A client admitted with thyrotoxicosis

Answer: 3, 4 The intermediate care surgical nurse should be most comfortable assuming the care of surgical clients. Heart failure, diabetes, and thyrotoxicosis are medical problems, and the client with diabetes will also require extensive teaching. The client with nephrolithiasis may also require teaching about the procedure, but since the client will undergo moderate sedation, the nurse would be completing typical preoperative care. Analysis Safe Effective Care Environment: Management of Care Nursing Process: Implementation Leadership/Management Note the critical word surgical in the description of the work setting of the float nurse. With this in mind, choose the two clients that have procedures that are surgical in nature

71 MCSA A nurse is teaching a female client newly diagnosed with Helicobacter pylori infection. The nurse anticipates that which of the following medications will not be used after learning the client is pregnant? 1. Metronizadole 2. Amoxicillin 3. Clarithromycin 4. Ciprofloxacin

Answer: 4 Ciprofloxacin is not recommended for Helicobacter pylori infection during pregnancy. The other medications can be used after consulting with the physician. Application Physiological Integrity: Pharmacological and Parenteral Therapies Nursing Process: Planning Pharmacology The core issue of the question is knowledge of the pregnancy categories of the specific drugs listed. Use the process of elimination to make a selection, realizing that specific drug knowledge is needed to answer the question.

63 MCSA The nurse has been instructed to have a surgical consent form signed by a client who will be undergoing a surgical procedure. What is the most essential information to include in the discussion prior to the client signing the permission? 1. The client's diagnosis 2. Treatment proposed and the cost 3. The technical aspects of the procedure 4. Right to withdraw consent

Answer: 4 The client's right to withdraw consent is necessary to be part of the consent and it means that coercion was not utilized in obtaining the signature. It is the physician's responsibility, not the nurse's, to explain the diagnosis (option 1) and the need for the surgical procedure (option 2). Cost (option 2) is not an important aspect for informed consent. The technical aspects of the procedure are not needed by the client, although an overview of the procedure should be included (option 3), but again this is the role of the physician. All preparation for the procedure should include information about what the client will see, feel, and hear. Analysis Physiological Integrity: Reduction of Risk Potential Nursing Process: Implementation Fundamentals The core issue of the question is knowledge of the nurse's role in obtaining informed consent. Keep in mind that the nurse reinforces explanations already given by the physician and use the process of elimination to make a selection. 0

75 MCSA A parent asks the nurse what to do with rough edges of her child's cast, which are beginning to cause excoriation on the child's skin. Which of the following responses by the nurse describes the appropriate action to take? 1. "Perform good skin care to the skin around the cast edges, with a protective barrier like Vaseline." 2. "Call the physician to have the rough edges of the cast cut away." 3. "Tape a soft towel to the edge of the cast to provide some protection from the rough edges." 4. "Petal the cast edges with strips of adhesive tape, placing the tape from just inside the cast over the edge to outside the cast."

Answer: 4 When a cast is dry, edges that are not smooth or covered by a piece of stockinette should be covered to prevent skin irritation. This can be done by petaling the cast edges with strips of adhesive tape, beginning each strip on the inside of the cast, and folding over the edge to the outside of the cast. Application Physiological Integrity: Physiological Adaptation Communication and Documentation Child Health The wording of the question indicates that the correct response is a true statement. Eliminate options 1 and 3 first as least plausible after visualizing these options, then discard option 2 as unrealistic, since the procedure would be completed at the time of application. 0

Mary Ann Hogan RN Questions and rationals

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