NURS366 Final Exam

53. The nurse is caring for a 12-year-old receiving peritoneal dialysis. The nurse notes the return to be cloudy, and the child is complaining of abdominal pain. The child's parents ask what the next step will likely be. Which is the nurse's best response? 1. "We will probably place antibiotics in the dialysis fluid before the next dwell time." 2. "Many children experience cloudy returns. We do not usually worry about it." 3. "We will probably give your child some oral antibiotics just to make sure nothing else develops." 4. "The abdominal pain is likely due to the fluid going in too slowly. We will increase the rate of administration with the next fill."

1. "We will probably place antibiotics in the dialysis fluid before the next dwell time." *Cloudy returns and abdominal pain are signs of peritonitis and are usually treated with the administration of antibiotics in the dialysis fluid.

4. The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent shoulder adduction. 2. Turn and reposition the client every shift. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises three (3) times a day. 5. Instruct the client to hold the fingers in a fist.

1. Position the client to prevent shoulder adduction. 3. Encourage the client to move the affected side.

37. The nurse is caring for an infant with a myelomeningocele. The parents ask the nurse why the nurse keeps measuring the baby's head circumference. Select the nurse's best response: 1. "Babies' heads are measured to ensure growth is on track." 2. "Babies with a myelomeningocele are at risk for hydrocephalus, which shows up as an increase in head size." 3. "Because your baby has an opening on the spinal cord, your infant is at risk for meningitis, which can show up as an increase in head size." 4. "Many infants with myelomeningocele have microcephaly, which can show up as a decrease in head size."

2. "Babies with a myelomeningocele are at risk for hydrocephalus, which shows up as an increase in head size."

23. The nurse is providing discharge teaching to the parents of a toddler who experienced a febrile seizure. The nurse knows clarification is needed when the mother says: 1. "My child will likely have another seizure." 2. "My child's 7-year-old brother is also at high risk for a febrile seizure." 3. "I'll give my child acetaminophen when ill to prevent the fever from rising too high too rapidly." 4. "Most children with febrile seizures do not require seizure medicine."

2. "My child's 7-year-old brother is also at high risk for a febrile seizure." Most children over the age of 5 years do not have febrile seizures.

19. The male client diagnosed with CKD secondary to diabetes has been receiving dialysis for 12 years. The client is notified he will not be placed on the kidney transplant list. The client tells the nurse he will not be back for any more dialysis treatments. Which response by the nurse is most therapeutic? 1. "You cannot just quit your dialysis. This is not an option." 2. "You're angry at not being on the list, and you want to quit dialysis?" 3. "I will call your nephrologist right now so you can talk to the HCP." 4. "Make your funeral arrangements because you are going to die."

2. "You're angry at not being on the list, and you want to quit dialysis?" Reflecting the client's feelings and restating them are therapeutic responses the nurse should use when addressing the client's issues.

37. Which protrusion into the groin of a female most likely causes inguinal hernias? 1. Bowel. 2. Fallopian tube. 3. Large thrombus formation. 4. Muscle tissue.

2. Fallopian tube. *Fallopian tube or an ovary is the most common tissue to protrude into the groin in females.

20. Which nursing task could be delegated to the unlicensed assistive personnel (UAP) for the client who had a total vaginal hysterectomy? 1. Observe the color and amount of drainage on the client's perineal pad. 2. Maintain a current intake and output for the client each shift. 3. Provide the client with a plan of pharmacological pain management. 4. Prepare the client for her discharge scheduled for the next day.

2. Maintain a current intake and output for the client each shift. *This nursing task can be delegated, but evaluation is the responsibility of the nurse.

60. Family discharge teaching has been effective when the parent of a toddler diagnosed with Kawasaki disease (KD) states: 1. "The arthritis in her knees is permanent. She will need knee replacements." 2. "I will give her diphenhydramine (Benadryl) for her peeling palms and soles of her feet." 3. "I know she will be irritable for 2 months after her symptoms started." 4. "I will continue with high doses of Tylenol for her inflammation."

3. "I know she will be irritable for 2 months after her symptoms started."

67. The female client is diagnosed with rheumatic fever and prescribed penicillin, an antibiotic. Which statement indicates the client needs more teaching concerning the discharge teaching? 1. "I must take all the prescribed antibiotics." 2. "I may get a vaginal yeast infection with penicillin." 3. "I will have no problems as long as I take my medication." 4. "My throat culture was positive for a streptococcal infection."

3. "I will have no problems as long as I take my medication." Even with antibiotic treatment for rheumatic fever, the client may experience bacterial endocarditis in later years and should know this may occur.

52. The parent of a child diagnosed with acute renal failure (ARF) asks the nurse why peritoneal dialysis was selected instead of hemodialysis. Which is the nurse's best response? 1. "Hemodialysis is not used in the pediatric population." 2. "Peritoneal dialysis has no complications, so it is a treatment used without hesitation." 3. "Peritoneal dialysis removes fluid at a slower rate than hemodialysis, so many complications are avoided." 4. "Peritoneal dialysis is much more efficient than hemodialysis."

3. "Peritoneal dialysis removes fluid at a slower rate than hemodialysis, so many complications are avoided."

31. Which plan would be appropriate in helping to control congestive heart failure (CHF) in an infant? 1. Promoting fluid restriction. 2. Feeding a low-salt formula. 3. Feeding in semi-Fowler position. 4. Encouraging breast milk.

3. Feeding in semi-Fowler position. The infant has a great deal of difficulty feeding with CHF, so even getting the maintenance fluids is a challenge. The infant is fed in the more upright position so fluid in the lungs can go to the base of the lungs, allowing better expansion.

15. The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? 1. Administer sublingual nitroglycerin. 2. Obtain a STAT electrocardiogram. 3. Have the client sit down immediately. 4. Assess the client's vital signs.

3. Have the client sit down immediately. Stopping all activity will decrease the need of the myocardium for oxygen and may help decrease the chest pain.

41. The most common cardiac dysrhythmia in pediatrics is: 1. Ventricular tachycardia. 2. Sinus bradycardia. 3. Supraventricular tachycardia. 4. First-degree heart block.

3. Supraventricular tachycardia.

6. The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The assistant places a gait belt around the client's waist prior to ambulating. 2. The assistant places the client on the back with the client's head to the side. 3. The assistant places a hand under the client's right axilla to move up in bed. 4. The assistant praises the client for attempting to perform ADLs independently.

3. The assistant places a hand under the client's right axilla to move up in bed. This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the back or using a lift sheet.

53. Which would the school nurse expect in a student who has an insulin-to-carbohydrate ratio of 1:10? 1. The student administers 10 U of regular insulin for every gram of carbohydrate consumed. 2. The student is trying to limit carbohydrate intake to 10 g per insulin dose. 3. The student administers 1 U of regular insulin for every 10 grams of carbohydrate consumed. 4. The student plans to eat 10 g of carbohydrate for every dose of insulin.

3. The student administers 1 U of regular insulin for every 10 grams of carbohydrate consumed. An insulin-to-carbohydrate ratio refers to the amount of insulin given per gram of carbohydrate. A ratio of 1:10 means 1 U regular insulin for every 10 g carbohydrates.

46. A 13-year-old with type 2 diabetes mellitus asks the nurse, "Why do I need to have this hemoglobin A1c test?" The nurse's response is based on which of the following? 1. To determine how balanced the child's diet has been. 2. To make sure the child is not anemic. 3. To determine how controlled the child's blood sugar has been. 4. To make sure the child's blood ketone level is normal.

3. To determine how controlled the child's blood sugar has been. Hemoglobin A1c, or glycosylated hemoglobin, reflects average blood glucose levels over 2 to 3 months. Frequent high blood glucose levels would result in a higher hemoglobin A1c, suggesting that blood glucose needs to be in better control.

13. Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction? 1. Creatine kinase (CK-MB). 2. Lactate dehydrogenase (LDH). 3. Troponin. 4. White blood cells (WBCs).

3. Troponin. Troponin is the enzyme that elevates within 1 to 2 hours.

47. The parents of a 7-year-old tell the nurse they do not understand the difference between chronic renal failure (CRF) and acute renal failure (ARF). Which is the nurse's best response? 1. "There really is not much difference because the terms are used interchangeably." 2. "Most children experience ARF. It is highly unusual for a child to experience CRF." 3. "CRF tends to occur suddenly and is irreversible." 4. "ARF is often reversible, whereas CRF results in permanent deterioration of kidney function."

4. "ARF is often reversible, whereas CRF results in permanent deterioration of kidney function."

7. A child with a ventriculoperitoneal (VP) shunt complains of headache and blurry vision and now experiences irritability and sleeping more than usual. The parents ask the nurse what they should do. Select the nurse's best response. 1. "Give her some acetaminophen, and see if her symptoms improve. If they do not improve, bring her to the pediatrician's office." 2. "It is common for girls to have these symptoms, especially prior to beginning their menstrual cycle. Give her a few days, and see if she improves." 3. "You are probably worried that she is having a problem with her shunt. This is very unlikely as it has been working well for 9 years." 4. "You should immediately take her to the emergency room as these may be symptoms of a shunt malfunction."

4. "You should immediately take her to the emergency room as these may be symptoms of a shunt malfunction."

A client with chronic renal failure has completed a hemodialysis treatment. Which standard indicators would the nurse initially use to evaluate the client's status after dialysis? 1. Vital signs and BUN 2. Potassium level and weight 3. BUN and creatinine levels 4. Vital signs and weight

4. Vital signs and weight

23. Which arterial blood gas results should the nurse expect in the client diagnosed with diabetic ketoacidosis? 1. pH 7.34, PaO2 99, PaCO2 48, HCO3 24. 2. pH 7.38, PaO2 95, PaCO2 40, HCO3 22. 3. pH 7.46, PaO2 85, PaCO2 30, HCO3 26. 4. pH 7.30, PaO2 90, PaCO2 30, HCO3 18.

4. pH 7.30, PaO2 90, PaCO2 30, HCO3 18. This ABG indicates metabolic acidosis, which is expected in a client diagnosed with diabetic ketoacidosis.

49. Which is the American Cancer Society's recommendation for the early detection of cancer of the prostate? 1. A yearly PSA level and DRE beginning at age 50. 2. A biannual rectal examination beginning at age 40. 3. A semiannual alkaline phosphatase level beginning at age 45. 4. A yearly urinalysis to determine the presence of prostatic fluid.

1. A yearly PSA level and DRE beginning at age 50. *The American Cancer Society recommends all men have a yearly prostate-specific antigen (PSA) blood level, followed by a digital rectal examination (DRE) beginning at age 50. Men in the high-risk group, including all African American men, should begin at age 45.

7. Which child is at risk for developing glomerulonephritis? 1. A 3-year-old who had impetigo 1 week ago. 2. A 5-year-old with a history of five UTIs in the previous year. 3. A 6-year-old with new-onset type 1 diabetes. 4. A 10-year-old recovering from viral pneumonia.

1. A 3-year-old who had impetigo 1 week ago. *Impetigo is a skin infection caused by the streptococcal organism that is commonly associated with glomerulonephritis.

3. Which client would the nurse identify as being most at risk for experiencing a CVA? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female.

1. A 55-year-old African American male. African Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women; African Americans suffer more extensive damage from a CVA than do people of other cultural groups.

2. The nurse is caring for a client diagnosed with ARF. Which laboratory values are most significant for diagnosing ARF? 1. BUN and creatinine. 2. WBC and hemoglobin. 3. Potassium and sodium. 4. Bilirubin and ammonia level.

1. BUN and creatinine. Blood urea nitrogen (BUN) levels reflect the balance between the production and excretion of urea from the kidneys. Creatinine is a by-product of the metabolism of the muscles and is excreted by the kidneys. Creatinine is the ideal substance for determining renal clearance because it is relatively constant in the body and is the laboratory value most significant in diagnosing renal failure.

3. The nurse administered 28 units of Humulin N, an intermediate-acting insulin, to a client diagnosed with type 1 diabetes at 1600. Which intervention should the nurse implement? 1. Ensure the client eats the bedtime snack. 2. Determine how much food the client ate at lunch. 3. Perform a glucometer reading at 0700. 4. Offer the client protein after administering insulin.

1. Ensure the client eats the bedtime snack. Humulin N peaks in 6 to 8 hours, making the client at risk for hypoglycemia around midnight, which is why the client should receive a bedtime snack. This snack will prevent nighttime hypoglycemia.

8. Which position initially is most beneficial for an infant who has just returned from having a ventriculoperitoneal (VP) shunt placed? 1. Semi-Fowler in an infant seat. 2. Flat in the crib. 3. Trendelenburg. 4. In the crib with the head elevated to 90 degrees.

2. Flat in the crib. Flat in the crib is the position usually used initially, with the angle gradually increasing as the child tolerates.

9. The nurse is aware that cloudy cerebrospinal fluid (CSF) most likely indicates: 1. Viral meningitis. 2. Bacterial meningitis. 3. No infection, as CSF is usually cloudy. 4. Sepsis.

2. Bacterial meningitis.

68. Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve? 1. Pulmonary embolus. 2. Cerebrovascular accident. 3. Hemoptysis. 4. Deep vein thrombosis.

2. Cerebrovascular accident. Bacteria enter the bloodstream from invasive procedures, and sterile platelet-fibrin vegetation forms on heart valves. The mitral valve is on the left side of the heart and, if the vegetation breaks off, it will go through the left ventricle into the systemic circulation and may lodge in the brain, kidneys, or peripheral tissues.

2. The client is experiencing urinary incontinence. Which intervention should the nurse implement? 1. Teach the client to drink prune juice weekly. 2. Encourage the client to eat a high-fiber diet. 3. Discuss the need to urinate every six (6) hours. 4. Explain the importance of wearing cotton underwear.

2. Encourage the client to eat a high-fiber diet. Clients experiencing incontinence should eat a high-fiber diet to avoid constipation, which increases pressure on the bladder, which may increase incontinence.

22. Which laboratory results besides hematuria are most consistent with hemolytic uremic syndrome (HUS)? 1. Massive proteinuria, elevated blood urea nitrogen, and creatinine. 2. Mild proteinuria, decreased blood urea nitrogen, and creatinine. 3. Mild proteinuria, increased blood urea nitrogen, and creatinine. 4. Massive proteinuria, decreased blood urea nitrogen, and creatinine.

3. Mild proteinuria, increased blood urea nitrogen, and creatinine.

34. Which statement by the mother of a child with rheumatic fever (RF) shows she has good understanding of the care of her child? 1. "I will apply heat to his swollen joints to promote circulation." 2. "I will have him do gentle stretching exercises to prevent contractures." 3. "I will give him the aspirin that is ordered for pain and inflammation." 4. "I will apply cold packs to his swollen joints to reduce pain."

3. "I will give him the aspirin that is ordered for pain and inflammation."

31. The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching? 1. "Do you have a daily bowel movement?" 2. "Do you get yearly chest x-rays?" 3. "Are you sexually active?" 4. "Have you had any weight change?"

3. "Are you sexually active?" Sexual activity is a risk factor for angina resulting from coronary artery disease. The client's being elderly should not affect the nurse's assessment of the client's concerns about sexual activity.

4. Which intervention should the nurse implement first for the client who has had an incontinent episode? 1. Palpate the client's bladder to assess for urinary retention. 2. Obtain a bedside commode for the client. 3. Assist the client with changing the wet clothes. 4. Request the UAP to change the client's linens.

3. Assist the client with changing the wet clothes. The nurse should first assist the client in getting out of the wet clothes prior to any other action. Wet clothes are embarrassing to the client and can lead to skin breakdown.

42. Which would the nurse expect to find on assessment in a child with Wilms tumor? 1. Decreased blood pressure, increased temperature, and a firm mass located in one flank area. 2. Increased blood pressure, normal temperature, and a firm mass located in one flank area. 3. Increased blood pressure, normal temperature, and a firm mass located on one side of the midline of the abdomen. 4. Decreased blood pressure, normal temperature, and a firm mass located on one side or the other of the midline of the abdomen.

3. Increased blood pressure, normal temperature, and a firm mass located on one side of the midline of the abdomen. *The blood pressure may be increased if there is renal damage. The mass will be located on one side or the other of the midline of the abdomen. There is no reason for the child's temperature to be affected.

8. Which combination of signs is commonly associated with glomerulonephritis? 1. Massive proteinuria, hematuria, decreased urinary output, and lethargy. 2. Mild proteinuria, increased urinary output, and lethargy. 3. Mild proteinuria, hematuria, decreased urinary output, and lethargy. 4. Massive proteinuria, decreased urinary output, and hypotension.

3. Mild proteinuria, hematuria, decreased urinary output, and lethargy.

17. Congenital heart defects (CHDs) are classified by which of the following? Select all that apply. 1. Cyanotic defect. 2. Acyanotic defect. 3. Defects with increased pulmonary blood flow. 4. Defects with decreased pulmonary blood flow. 5. Mixed defects. 6. Obstructive defects. 7. Pansystolic murmurs.

3. Defects with increased pulmonary blood flow. 4. Defects with decreased pulmonary blood flow. 5. Mixed defects. 6. Obstructive defects.

25. The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching? 1. "I should keep the tablets in the dark-colored bottle they came in." 2. "If the tablets do not burn under my tongue, they are not effective." 3. "I should keep the bottle with me in my pocket at all times." 4. "If my chest pain is not gone with one tablet, I will go to the ER."

4. "If my chest pain is not gone with one tablet, I will go to the ER." The client should take one tablet every five (5) minutes and, if no relief occurs after the third tablet, have someone drive him to the emergency department or call 911.

59. One week after kidney transplant, a child complains about abdominal pain, and the parents note that the child has been very irritable. The nurse notes a 10% weight gain as well as elevated BUN and creatinine levels. Which of the following medications would the child most likely be taking? 1. Codeine tablets. 2. Furosemide. 3. MiraLAX powder. 4. Corticosteroids.

4. Corticosteroids. *Corticosteroids are considered to be part of the antirejection regimen that is essential after a kidney transplant.

54. Which statement indicates discharge teaching has been effective for the client who is postoperative TURP? 1. "I will call the surgeon if I experience any difficulty urinating." 2. "I will take my Proscar daily, the same as before my surgery." 3. "I will continue restricting my oral fluid intake." 4. "I will take my pain medication routinely even if I do not hurt."

1. "I will call the surgeon if I experience any difficulty urinating."

1. What can an electrocardiogram (ECG) detect? Select all that apply. 1. Ischemia. 2. Injury. 3. Cardiac output (CO). 4. Dysrhythmias. 5. Systemic vascular resistance (SVR). 6. Occlusion pressure. 7. Conduction delay.

1. Ischemia. 2. Injury. 4. Dysrhythmias. 7. Conduction delay.

3. Tetralogy of Fallot (TOF) involves which defects? Select all that apply. 1. Ventricular septal defect (VSD). 2. Right ventricular hypertrophy. 3. Left ventricular hypertrophy. 4. Pulmonic stenosis (PS). 5. Pulmonic atresia. 6. Overriding aorta. 7. Patent ductus arteriosus (PDA).

1. Ventricular septal defect (VSD). 2. Right ventricular hypertrophy. 4. Pulmonic stenosis (PS). 6. Overriding aorta.

36. Which is the nurse's best response to the parents of a neonate with a meningocele who ask what can they expect? 1. "After initial surgery to close the defect, most children experience no neurological dysfunction." 2. "Surgery to close the sac will be postponed until the infant has grown and has enough skin to form a graft." 3. "After the initial surgery to close the defect, the child will likely have motor and sensory deficits." 4. "After the initial surgery to close the defect, the child will likely have future problems with urinary and bowel continence."

1. "After initial surgery to close the defect, most children experience no neurological dysfunction." Because a meningocele does not con- tain any nerve endings, most children experience no neurological problems after surgical correction.

26. The client with coronary artery disease asks the nurse, "Why do I get chest pain?" Which statement would be the most appropriate response by the nurse? 1. "Chest pain is caused by decreased oxygen to the heart muscle." 2. "There is ischemia to the myocardium as a result of hypoxemia." 3. "The heart muscle is unable to pump effectively to perfuse the body." 4. "Chest pain occurs when the lungs cannot adequately oxygenate the blood."

1. "Chest pain is caused by decreased oxygen to the heart muscle." This is a correct statement presented in layman's terms. When the coronary arteries cannot supply adequate oxygen to the heart muscle, there is chest pain.

13. Which question is most important for the nurse to ask the client with a cystocele who is scheduled to have a pessary inserted? 1. "Do you know if you are allergic to latex?" 2. "When did you start having incontinence?" 3. "When was your last bowel movement?" 4. "Are you experiencing any pelvic pressure?"

1. "Do you know if you are allergic to latex?" *The client should be assessed for allergies to latex as a result of the composition of the pessary.

61. The parents of a 3-year-old are concerned that the child is having "more accidents" during the day. Which question would be appropriate for the nurse to ask to obtain more information? Select all that apply. 1. "Has there been a stressful event in the child's life, such as the birth of a sibling?" 2. "Has anyone else in the family had problems with accidents?" 3. "Does your child seem to be drinking more than usual?" 4. "Is your child more irritable, and does your child seem to be in pain when urinating?" 5. "Is your child having difficulties at preschool?"

1. "Has there been a stressful event in the child's life, such as the birth of a sibling?" 2. "Has anyone else in the family had problems with accidents?" 3. "Does your child seem to be drinking more than usual?" 4. "Is your child more irritable, and does your child seem to be in pain when urinating?"

20. A preschooler has been having periods during which he suddenly falls and appears to be weak for a short time after the event. The preschool teacher asks what she should do. Select the nurse's best response. 1. "Have the parents follow up with his pediatrician as this is likely an atonic seizure." 2. "Find out if there have been any new stressors in his life, as it could be attention-seeking behavior." 3. "Have the parents follow up with his pediatrician as this is likely an absence seizure." 4. "The preschool years are a time of rapid growth, and many children appear clumsy. It would be best to watch him, and see if it continues."

1. "Have the parents follow up with his pediatrician as this is likely an atonic seizure." An atonic seizure is characterized by a loss of muscular tone, whereby the child may fall to the ground.

19. A 13-month-old is discharged following repair of his epispadias. Which statement made by the parents indicates they understand the discharge teaching? 1. "If a mucous plug forms in the urinary drainage tube, we will irrigate it gently to prevent a blockage." 2. "If a mucous plug forms in the urinary drainage tube, we will allow it to pass on its own because this is a sign of healing." 3. "We will make sure the dressing is loosely applied to increase the toddler's comfort." 4. "If we notice any yellow drainage, we will know that everything is healing well."

1. "If a mucous plug forms in the urinary drainage tube, we will irrigate it gently to prevent a blockage." *Any mucous plugs should be removed by irrigation to prevent blockage of the urinary drainage system.

56. The school nurse is talking to a 14-year-old about managing type 1 diabetes mellitus. Which statement indicates the student's understanding of the disease? 1. "It really does not matter what type of carbohydrate I eat as long as I take the right amount of insulin." 2. "I should probably have a snack right after gym class." 3. "I need to cut back on my carbohydrate intake and increase my lean protein intake." 4. "Losing weight will probably help me decrease my need for insulin."

1. "It really does not matter what type of carbohydrate I eat as long as I take the right amount of insulin." A carbohydrate is a carbohydrate, and insulin dosing is based on blood sugar level and carbohydrates to be eaten.

12. Which statement by a parent is most consistent with minimal change nephrotic syndrome (MCNS)? 1. "My child missed 2 days of school last week because of a really bad cold." 2. "After camping last week, my child's legs were covered in bug bites." 3. "My child came home from school a week ago due to vomiting and stomach cramps." 4. "We have a pet turtle but no one washes their hands after playing with the turtle."

1. "My child missed 2 days of school last week because of a really bad cold." *An upper respiratory infection often precedes MCNS by a few days.

26. The client in the gynecology clinic asks the nurse, "What are the risk factors for developing cancer of the cervix?" Which statement is the nurse's best response? 1. "The earlier the age of sexual activity and the more partners, the greater the risk." 2. "Eating fast foods high in fat and taking birth control pills are risk factors." 3. "A Chlamydia trachomatis infection can cause cancer of the cervix." 4. "Having yearly Pap smears will protect you from developing cancer."

1. "The earlier the age of sexual activity and the more partners, the greater the risk." *Risk factors for cancer of the cervix include sexual activity before the age of 20 years; multiple sexual partners; early childbearing; exposure to the human papillomavirus; HIV infection; smoking; and nutritional deficits of folates, beta carotene, and vitamin C.

11. The client who has had a mastectomy tells the nurse, "My husband will leave me now since I am not a whole woman anymore." Which response by the nurse is most therapeutic? 1. "You're afraid your husband will not find you sexually appealing?" 2. "Your husband should be grateful you will be able to live and be with him." 3. "Maybe your husband would like to attend a support group for spouses." 4. "You don't know that is true. You need to give him a chance."

1. "You're afraid your husband will not find you sexually appealing?"

11. The parents of a child with glomerulonephritis ask how they will know their child is improving after they go home. Which is the nurse's best response? 1. "Your child's urine output will increase, and the urine will become less tea-colored." 2. "Your child will rest more comfortably as lab tests become more normal." 3. "Your child's appetite will decrease as urine output increases." 4. "Your child's laboratory values will become more normal."

1. "Your child's urine output will increase, and the urine will become less tea-colored."

29. Which causes the clinical manifestations of hydronephrosis? 1. A structural abnormality in the urinary system causes urine to back up and can cause pressure and cell death. 2. A structural abnormality causes urine to flow too freely through the urinary system, leading to fluid and electrolyte imbalances. 3. Decreased production of urine in one or both kidneys results in an electrolyte imbalance. 4. Urine with an abnormal electrolyte balance and concentration leads to increased blood pressure and subsequent increased glomerular filtration rate.

1. A structural abnormality in the urinary system causes urine to back up and can cause pressure and cell death.

19. A child with a seizure disorder has been having episodes during which she drops her pencil and simply appears to be daydreaming. This is most likely a/an: 1. Absence seizure. 2. Akinetic seizure. 3. Non-epileptic seizure. 4. Simple spasm seizure.

1. Absence seizure. Absence seizures occur frequently and last less than 30 seconds. The child experiences a brief loss of consciousness during which she may have a change in activity. These children rarely fall, but they may drop an object. The condition is often confused with daydreaming.

17. The client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first? 1. Administer 50% dextrose IVP. 2. Notify the health-care provider. 3. Move the client to the ICU. 4. Check the serum glucose level.

1. Administer 50% dextrose IVP. The nurse should assume the client is hypoglycemic and administer IVP dextrose, which will rouse the client immediately. If the collapse is the result of hyperglycemia, this additional dextrose will not further injure the client.

12. A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? 1. Administer a stool softener b.i.d. 2. Encourage the client to cough hourly. 3. Monitor neurological status every shift. 4. Maintain the dopamine drip to keep BP at 160/90.

1. Administer a stool softener b.i.d. The client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when straining during defecation. Therefore, stool softeners would be appropriate.

18. A child diagnosed with meningitis is having a generalized tonic-clonic seizure. Which should the nurse do first? 1. Administer blow-by oxygen and call for additional help. 2. Reassure the parents that seizures are common in children with meningitis. 3. Call a code and ask the parents to leave the room. 4. Assess the child's temperature and blood pressure.

1. Administer blow-by oxygen and call for additional help. The child experiencing a seizure usually requires more oxygen as the seizure increases the body's metabolic rate and demand for oxygen. The seizure may also affect the child's airway, causing the child to be hypoxic. It is always appropriate to give the child blow-by oxygen immediately. The nurse should remain with the child and call for additional help.

10. The client is admitted to the emergency department after a gunshot wound to the abdomen. Which nursing intervention should the nurse implement first to prevent ARF? 1. Administer normal saline IV. 2. Take vital signs. 3. Place client on telemetry. 4. Assess abdominal dressing.

1. Administer normal saline IV. Preventing and treating shock with blood and fluid replacement will prevent acute renal failure from hypoperfusion of the kidneys. Significant blood loss is expected in the client with a gunshot wound.

9. Which interventions decrease cardiac demands in an infant with congestive heart failure (CHF)? Select all that apply. 1. Allow parents to hold and rock their child. 2. Feed only when the infant is crying. 3. Keep the child uncovered to promote low body temperature. 4. Make frequent position changes. 5. Feed the child when sucking the fists. 6. Change bed linens only when necessary. 7. Organize nursing activities.

1. Allow parents to hold and rock their child. 4. Make frequent position changes. 5. Feed the child when sucking the fists. 6. Change bed linens only when necessary. 7. Organize nursing activities.

6. The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure? 1. An elevated B-type natriuretic peptide (BNP). 2. An elevated creatine kinase (CK-MB). 3. A positive D-dimer. 4. A positive ventilation/perfusion (V/Q) scan.

1. An elevated B-type natriuretic peptide (BNP). BNP is a specific diagnostic test. Levels higher than normal indicate congestive heart failure, with the higher the number, the more severe the CHF.

58. The client asks, "What does an elevated PSA test mean?" On which scientific rationale should the nurse base the response? 1. An elevated PSA can result from several different causes. 2. An elevated PSA can be only from prostate cancer. 3. An elevated PSA can be diagnostic for testicular cancer. 4. An elevated PSA is the only test used to diagnose BPH.

1. An elevated PSA can result from several different causes. An elevated PSA can be from urinary retention, BPH, prostate cancer, or prostate infarct.

7. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication.

1. An oral anticoagulant medication. The nurse would anticipate an oral anticoagulant, warfarin (Coumadin), to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA (stroke).

1. The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4+ pitting edema of feet. 2. Thick white sputum and crackles that clear with cough. 3. The client sleeping with no pillow and eupnea. 4. Radial pulse rate of 90 and capillary refill time <3 seconds.

1. Apical pulse rate of 110 and 4+ pitting edema of feet. The client with CHF would exhibit tachycardia (apical pulse rate of 110), dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status.

7. The home health nurse is completing the admission assessment for a 76-year-old client diagnosed with type 2 diabetes controlled with 70/30 insulin. Which intervention should be included in the plan of care? 1. Assess the client's ability to read small print. 2. Monitor the client's serum PT level. 3. Teach the client how to perform a hemoglobin A1c test daily. 4. Instruct the client to check the feet weekly.

1. Assess the client's ability to read small print. Age-related visual changes and diabetic retinopathy could cause the client to have difficulty in reading and drawing up insulin dosage accurately.

59. The client returned from surgery after having a TURP and has a P 110, R 24, BP 90/40, and cool and clammy skin. Which interventions should the nurse implement? Select all that apply. 1. Assess the urine in the continuous irrigation drainage bag. 2. Decrease the irrigation fluid in the continuous irrigation catheter. 3. Lower the head of the bed while raising the foot of the bed. 4. Contact the surgeon to give an update on the client's condition. 5. Check the client's postoperative creatinine and BUN.

1. Assess the urine in the continuous irrigation drainage bag. 3. Lower the head of the bed while raising the foot of the bed. 4. Contact the surgeon to give an update on the client's condition.

13. The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client's significant other? 1. Awaken the client every two (2) hours. 2. Monitor for increased intracranial pressure. 3. Observe frequently for hypervigilance. 4. Offer the client food every three (3) to four (4) hours.

1. Awaken the client every two (2) hours. Awakening the client every two (2) hours allows the identification of headache, dizziness, lethargy, irritability, and anxiety—all signs of postconcussion syndrome—that would warrant the significant other's taking the client back to the emergency department.

11. The nurse is caring for a 6-month-old infant diagnosed with meningitis. When the child is placed in the supine position and flexes his neck, the nurse notes he flexes his knees and hips. This is referred to as: 1. Brudzinski sign. 2. Cushing triad. 3. Kernig sign. 4. Nuchal rigidity.

1. Brudzinski sign. Brudzinski sign occurs when the child responds to a flexed neck with an involuntary flexion of the hips and/or knees.

29. The nurse is caring for an unconscious 6-year-old who has had a severe closed-head injury and notes the following changes: heart rate has dropped from 120 to 55, blood pressure has increased from 110/44 to 195/62, and respirations are becoming more irregular. Which should the nurse do first after calling the physician? 1. Call for additional help, and prepare to administer mannitol. 2. Continue to monitor the patient's vital signs, and prepare to administer a bolus of isotonic fluids. 3. Call for additional help, and prepare to administer an antihypertensive. 4. Continue to monitor the patient, and administer supplemental oxygen.

1. Call for additional help, and prepare to administer mannitol. Cushing triad is characterized by a decrease in heart rate, an increase in blood pressure, and changes in respirations. The triad is associated with severely increased ICP. Mannitol is an osmotic diuretic that helps decrease the increased ICP.

26. Which is a care priority for a newborn diagnosed with bladder exstrophy and a malformed pelvis? 1. Change the diaper frequently and assess for skin breakdown. 2. Keep the exposed bladder open in a warm and dry environment to avoid any heat loss. 3. Offer formula for infant growth and fluid management. 4. Cluster all care to allow the child to sleep, grow, and gain strength for the upcoming surgical repair.

1. Change the diaper frequently and assess for skin breakdown. *Preventing infection from stool contamination and skin breakdown is the top priority of care.

33. A 2-month-old infant is brought to the emergency room after experiencing a seizure. The infant appears lethargic with very irregular respirations and periods of apnea. The parents report the baby is no longer interested in feeding and before the seizure, rolled off the couch. What additional testing should the nurse immediately prepare for? 1. Computed tomography (CT) scan of the head and dilation of the eyes. 2. Computed tomography (CT) scan of the head and electroencephalogram (EEG). 3. X-rays of the head. 4. X-rays of all long bones.

1. Computed tomography (CT) scan of the head and dilation of the eyes. A computed tomography scan of the head will reveal trauma. Dilating the eyes is performed to check for retinal hemorrhages that are seen in an infant who has experienced SBS.

36. A child born with Down syndrome should be evaluated for which associated cardiac manifestation? 1. Congenital heart defect (CHD). 2. Systemic hypertension. 3. Hyperlipidemia. 4. Cardiomyopathy.

1. Congenital heart defect (CHD).

14. Which are the most serious complications for a child with Kawasaki disease (KD)? Select all that apply. 1. Coronary thrombosis. 2. Coronary stenosis. 3. Coronary artery aneurysm. 4. Hypocoagulability. 5. Decreased sedimentation rate. 6. Hypoplastic left heart syndrome.

1. Coronary thrombosis. 2. Coronary stenosis. 3. Coronary artery aneurysm.

59. The client's telemetry reading shows a P wave before each QRS complex and the rate is 78. Which action should the nurse implement? 1. Document this as normal sinus rhythm. 2. Request a 12-lead electrocardiogram. 3. Prepare to administer the cardiotonic digoxin PO. 4. Assess the client's cardiac enzymes.

1. Document this as normal sinus rhythm. The P wave represents atrial contraction, and the QRS complex represents ventricular contraction—a normal telemetry reading. A rate between 60 and 100 indicates normal sinus rhythm. Therefore, the nurse should document this as normal sinus rhythm and not take any action.

30. Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply. 1. Encourage a low-fat, low-cholesterol diet. 2. Instruct client to walk 30 minutes a day. 3. Decrease the salt intake to two (2) g a day. 4. Refer to counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet.

1. Encourage a low-fat, low-cholesterol diet. 2. Instruct client to walk 30 minutes a day. 4. Refer to counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet.

42. A nursing action that promotes ideal nutrition in an infant with congestive heart failure (CHF) is: 1. Feeding formula that is supplemented with additional calories. 2. Allowing the infant to nurse at each breast for 20 minutes. 3. Providing large feedings every 5 hours. 4. Using firm nipples with small openings to slow feedings.

1. Feeding formula that is supplemented with additional calories. Formula can be supplemented with extra calories, either from a commercial supplement, such as Polycose, or from corn syrup. Calories in formula could increase from 20 kcal/oz to 30 kcal/oz or more.

49. The telemetry nurse is unable to read the telemetry monitor at the nurse's station. Which intervention should the telemetry nurse implement first? 1. Go to the client's room to check the client. 2. Instruct the primary nurse to assess the client. 3. Contact the client on the client call system. 4. Request the nursing assistant to take the crash cart to the client's room.

1. Go to the client's room to check the client.

21. The diet that produces anticonvulsant effects from ketosis consists of: 1. High-fat and low-carbohydrate foods. 2. High-fat and high-carbohydrate foods. 3. Low-fat and low-carbohydrate foods. 4. Low-fat and high-carbohydrate foods.

1. High-fat and low-carbohydrate foods. High fat and low carbohydrates are the components of the ketogenic diet.

16. The nurse is caring for a child with Kawasaki disease (KD). A student nurse who is on the unit asks if there are medications to treat this disease. The nurse's response to the student nurse is: 1. Immunoglobulin G and aspirin. 2. Immunoglobulin G and ACE inhibitors. 3. Immunoglobulin E and heparin. 4. Immunoglobulin E and ibuprofen.

1. Immunoglobulin G and aspirin.

54. A child receiving peritoneal dialysis has not been having adequate volume in the return. The child is currently edematous and hypertensive. Which would the nurse anticipate the physician to do? 1. Increase the glucose concentration of the dialysate. 2. Decrease the glucose concentration of the dialysate. 3. Administer antihypertensives and diuretics but not change the dialysate concentration. 4. Decrease the dwell time of the dialysate.

1. Increase the glucose concentration of the dialysate. *Increasing the concentration of glucose will pull more fluid into the return.

4. The client is diagnosed with ARF. Which signs/symptoms indicate to the nurse the client is in the recovery period? Select all that apply. 1. Increased alertness and no seizure activity. 2. Increase in hemoglobin and hematocrit. 3. Denial of nausea and vomiting. 4. Decreased urine-specific gravity. 5. Increased serum creatinine level.

1. Increased alertness and no seizure activity. 2. Increase in hemoglobin and hematocrit. 3. Denial of nausea and vomiting.

29. The following are examples of acquired heart disease. Select all that apply. 1. Infective endocarditis. 2. Hypoplastic left heart syndrome. 3. Rheumatic fever (RF). 4. Cardiomyopathy. 5. Kawasaki disease (KD). 6. Transposition of the great vessels.

1. Infective endocarditis. 3. Rheumatic fever (RF). 4. Cardiomyopathy. 5. Kawasaki disease (KD).

14. The elderly client is admitted to the intensive care department diagnosed with severe HHNS. Which collaborative intervention should the nurse include in the plan of care? 1. Infuse 0.9% normal saline intravenously. 2. Administer intermediate-acting insulin. 3. Perform blood glucometer checks daily. 4. Monitor arterial blood gas results.

1. Infuse 0.9% normal saline intravenously. The initial fluid replacement is 0.9% normal saline (an isotonic solution) intravenously, followed by 0.45% saline. The rate depends on the client's fluid volume status and physical health, especially of the heart.

23. A child with hemolytic uremic syndrome (HUS) is very pale and lethargic. Stools have progressed from watery to bloody diarrhea. Blood work indicates low hemoglobin and hematocrit levels. The child has not had any urine output in 24 hours. The nurse expects administration of blood products and what else to be added to the plan of care? 1. Initiation of dialysis. 2. Close observation of the child's hemodynamic status. 3. Diuretic therapy to force urinary output. 4. Monitoring of urinary output.

1. Initiation of dialysis. *Because the child is symptomatic, dialysis is the treatment of choice.

34. The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement? 1. Instruct client to keep a diary of activity, especially when having chest pain. 2. Discuss the need to remove the Holter monitor during a.m. care and showering. 3. Explain that all medications should be withheld while wearing a Holter monitor. 4. Teach the client the importance of decreasing activity while wearing the monitor.

1. Instruct client to keep a diary of activity, especially when having chest pain. The Holter monitor is a 24-hour electrocardiogram, and the client must keep an accurate record of activity so that the health-care provider can compare the ECG recordings with different levels of activity.

54. The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client? 1. Instruct the client to use a soft-bristle toothbrush. 2. Discuss the importance of getting a monthly partial thromboplastin time (PTT). 3. Teach the client about signs of pacemaker malfunction. 4. Explain to the client the procedure for synchronized cardioversion.

1. Instruct the client to use a soft-bristle toothbrush. A client with chronic atrial fibrillation will be taking an anticoagulant to help prevent clot formation. Therefore, the client is at risk for bleeding and should be instructed to use a soft-bristle toothbrush.

31. Which should be included in the plan of care for a child diagnosed with hydronephrosis? 1. Intake and output as well as vital signs should be strictly monitored. 2. Fluids and sodium in the diet should be limited. 3. Steroids should be administered as ordered. 4. Limited contact with other people to avoid infection.

1. Intake and output as well as vital signs should be strictly monitored. *Fluid status is monitored to ensure adequate urinary output. Assessing blood pressure monitors kidney function.

24. The client is admitted to the ICU diagnosed with DKA. Which interventions should the nurse implement? Select all that apply. 1. Maintain adequate ventilation. 2. Assess fluid volume status. 3. Administer intravenous potassium. 4. Check for urinary ketones. 5. Monitor intake and output.

1. Maintain adequate ventilation. 2. Assess fluid volume status. 3. Administer intravenous potassium. 4. Check for urinary ketones. 5. Monitor intake and output.

45. The nurse is caring for a child due for surgery on a Wilms tumor. The child's procedure will consist of which of the following? 1. Only the affected kidney will be removed. 2. Both the affected kidney and the other kidney will be removed in case of recurrence. 3. The mass will be removed from the affected kidney. 4. The mass will be removed from the affected kidney, and a biopsy of the tissue of the unaffected kidney will be done.

1. Only the affected kidney will be removed.

31. The nurse is caring for a child with a skull fracture who is unconscious and has severely increased intracranial pressure (ICP). The nurse notes the child's temperature to be 104°F (40°C). Which should the nurse do first? 1. Place a cooling blanket on the child. 2. Administer Tylenol (acetaminophen) via nasogastric tube. 3. Administer Tylenol (acetaminophen) rectally. 4. Place ice packs in the child's axillary areas.

1. Place a cooling blanket on the child.

21. The client receiving dialysis is complaining of being dizzy and light-headed. Which action should the nurse implement first? 1. Place the client in the Trendelenburg position. 2. Turn off the dialysis machine immediately. 3. Bolus the client with 500 mL of normal saline. 4. Notify the health-care provider as soon as possible.

1. Place the client in the Trendelenburg position. The nurse should place the client's chair with the head lower than the body, which will shunt blood to the brain; this is the Trendelenburg position.

54. Which physiological changes occur as a result of hypoxemia in congestive heart failure (CHF)? 1. Polycythemia and clubbing. 2. Anemia and barrel chest. 3. Increased white blood cells and low platelets. 4. Elevated erythrocyte sedimentation rate and peripheral edema.

1. Polycythemia and clubbing. The hypoxemia stimulates erythropoiesis, which causes polycythemia, in an attempt to increase oxygen by having more red blood cells carry oxygen. Clubbing of the fingers is a result of the polycythemia and hypoxemia.

19. The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving? 1. Purposeless movement in response to painful stimuli. 2. Flaccid paralysis in all four extremities. 3. Decerebrate posturing when painful stimuli are applied. 4. Pupils that are 6 mm in size and nonreactive on painful stimuli.

1. Purposeless movement in response to painful stimuli. Purposeless movement indicates that the client's cerebral edema is decreasing. The best motor response is purposeful movement, but purposeless movement indicates an improvement over decorticate movement, which, in turn, is an improvement over decerebrate movement or flaccidity.

15. The nurse is assessing the client diagnosed with a rectocele. Which signs and symptoms should the nurse expect? Select all that apply. 1. Rectal pressure. 2. Flatus. 3. Fecal incontinence. 4. Constipation. 5. Urinary frequency.

1. Rectal pressure. 2. Flatus. 3. Fecal incontinence. 4. Constipation.

56. Chronic hypertension in the child who has chronic renal failure (CRF) is due to which of the following? 1. Retention of sodium and water. 2. Obstruction of the urinary system. 3. Accumulation of waste products in the body. 4. Generalized metabolic alkalosis.

1. Retention of sodium and water.

41. The most appropriate nursing diagnosis for a child with type 1 diabetes mellitus is which of the following? 1. Risk for infection related to reduced body defenses. 2. Impaired urinary elimination (enuresis). 3. Risk for injury related to medical treatment. 4. Anticipatory grieving.

1. Risk for infection related to reduced body defenses. Risk for infection is a correct nursing diagnosis. Understanding DM is understanding the effect it has on peripheral circulation and impairment of defense mechanisms.

55. During hemodialysis, the nurse notes that a 10-year-old becomes confused and restless. The child complains of a headache and nausea and has generalized muscle twitching. This can be prevented by which of the following? 1. Slowing the rate of solute removal during dialysis. 2. Ensuring the patient is warm during dialysis. 3. Administering antibiotics before dialysis. 4. Obtaining an accurate weight the night before dialysis.

1. Slowing the rate of solute removal during dialysis. *The child is experiencing signs of disequilibrium syndrome, which is caused by free water shifting from intravascular spaces and can be prevented by slowing the rate of dialysis.

A patient is admitted with a dx of acute renal failure. Which explanation is the most accurate? 1. Sudden loss of kidney function due to failure of the renal circulation or tubular damage 2. Progressive deterioration in renal function that ends fatally when uremia develops 3. An inflammation of the renal pelvis, tubules, or interstitial tissue of 1 or both kidneys 4. An inflammation process precipitated by chemical changes in the renal glomeruli of both kidneys

1. Sudden loss of kidney function due to failure of the renal circulation or tubular damage

9. The diabetic educator is teaching a class on diabetes type 1 and is discussing sick-day rules. Which interventions should the diabetes educator include in the discussion? Select all that apply. 1. Take diabetic medication even if unable to eat the client's normal diabetic diet. 2. If unable to eat, drink liquids equal to the client's normal caloric intake. 3. It is not necessary to notify the health-care provider if ketones are in the urine. 4. Test blood glucose levels and test urine ketones once a day and keep a record. 5. Call the health-care provider if glucose levels are higher than 180 mg/dL.

1. Take diabetic medication even if unable to eat the client's normal diabetic diet. 2. If unable to eat, drink liquids equal to the client's normal caloric intake. 5. Call the health-care provider if glucose levels are higher than 180 mg/dL. The most important issue to teach clients is to take insulin even if they are unable to eat. Glucose levels are increased with illness and stress. The client should drink liquids such as regular cola or orange juice, or eat regular gelatin, which provide enough glucose to prevent hypoglycemia when receiving insulin. The HCP should be notified if the blood glucose level is this high. Regular insulin may need to be prescribed to keep the blood glucose level within acceptable range.

18. The client diagnosed with CKD has a new arteriovenous fistula in the left forearm. Which intervention should the nurse implement? 1. Teach the client to carry heavy objects with the right arm. 2. Perform all laboratory blood tests on the left arm. 3. Instruct the client to lie on the left arm during the night. 4. Discuss the importance of not performing any hand exercises.

1. Teach the client to carry heavy objects with the right arm. Carrying heavy objects in the left arm could cause the fistula to clot by putting undue stress on the site, so the client should carry objects with the right arm.

3. Which information indicates to the nurse the client teaching about treatment of urinary incontinence has been effective? 1. The client prepares a scheduled voiding plan. 2. The client verbalizes the need to increase fluid intake. 3. The client explains how to perform pelvic floor exercises. 4. The client attempts to retain the vaginal cone in place the entire day.

1. The client prepares a scheduled voiding plan. Scheduled voiding allows the client to void every two (2) to three (3) hours apart, and when the client has remained consistently dry, the interval is increased by about 15 minutes.

19. Which information should the nurse include in the discharge teaching for the client recovering from an abdominal hysterectomy? 1. The client should report any vaginal bleeding or cramping to the surgeon. 2. The client should start a vigorous exercise routine to restore her muscle tone. 3. The client should continue sitting in the bedside chair at least six (6) hours daily. 4. The client should soak in a warm tub bath each night for one (1) hour.

1. The client should report any vaginal bleeding or cramping to the surgeon. *The client should report any vaginal bleeding or gastrointestinal changes such as distention, cramping, or changes in bowel habits.

12. The nurse is developing a care plan for the client diagnosed with type 1 diabetes. The nurse identifies the problem "high risk for hyperglycemia related to noncompliance with the medication regimen." Which statement is an appropriate short-term goal for the client? 1. The client will have a blood glucose level between 90 and 140 mg/dL. 2. The client will demonstrate appropriate insulin injection technique. 3. The nurse will monitor the client's blood glucose levels four (4) times a day. 4. The client will maintain normal kidney function with 30-mL/hr urine output.

1. The client will have a blood glucose level between 90 and 140 mg/dL. The short-term goal must address the response part of the nursing diagnosis, which is "high risk for hyperglycemia," and this blood glucose level is within acceptable ranges for a client who is noncompliant.

21. The manifestations of hemolytic uremic syndrome (HUS) are due primarily to which event? 1. The swollen lining of the small blood vessels damages the red blood cells, which are then removed by the spleen, leading to anemia. 2. There is a disturbance of the glomerular basement membrane, allowing large proteins to pass through. 3. The red blood cell changes shape, causing it to obstruct microcirculation. 4. There is a depression in the production of all formed elements of the blood.

1. The swollen lining of the small blood vessels damages the red blood cells, which are then removed by the spleen, leading to anemia.

3. A child had a urinary tract infection (UTI) 3 months ago and was treated with an oral antibiotic. A follow-up urinalysis revealed normal results. The child has had no other problems until this visit when the child was diagnosed with another UTI. Which is the most appropriate plan? 1. Urinalysis, urine culture, and VCUG. 2. Evaluate for renal failure. 3. Admit to the pediatric unit. 4. Discharge home on an antibiotic.

1. Urinalysis, urine culture, and VCUG. *Urinalysis and urine culture are routinely used to diagnose UTIs. VCUG is used to determine the extent of urinary tract involvement when a child has a second UTI within 1 year.

28. The nurse is providing discharge instructions to the parents of an infant born with bladder exstrophy who had a continent urinary reservoir placed. Which statement should be included? 1. "Allow your child to sleep on the abdomen to provide comfort during the immediate post-operative period." 2. "As your child grows, be cautious around playgrounds because the surface could be a health hazard." 3. "As your child grows, be sure to encourage many different foods because it is not likely that food allergies will develop." 4. "Encourage your child's development, by having brightly colored objects around, such as balloons."

2. "As your child grows, be cautious around playgrounds because the surface could be a health hazard." *Many children with urological malformations are prone to latex allergies. The surfaces of playgrounds are often made of rubber, which contains latex.

33. The client is diagnosed with benign uterine fibroid tumors. Which question should the nurse ask to determine if the client is experiencing a complication? 1. "How many periods have you missed?" 2. "Do you get short of breath easily?" 3. "How many times have you been pregnant?" 4. "Where is the location of the pain you are having?"

2. "Do you get short of breath easily?" *Many women delay surgery until anemia has occurred from the heavy menstrual flow. A symptom of anemia is shortness of breath.

35. Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet? 1. "I will not eat more than six (6) eggs a week." 2. "I should bake or grill any meats I eat." 3. "I will drink eight (8) ounces of whole milk a day." 4. "I should not eat any type of pork products."

2. "I should bake or grill any meats I eat." The American Heart Association recommends a low-fat, low-cholesterol diet for a client with coronary artery disease. The client should avoid any fried foods, especially meats, and bake, broil, or grill any meat.

42. A 6-month-old infant was just diagnosed with craniosynostosis. The infant's father asks the nurse for more information about reconstructive surgery. Select the nurse's best response. 1. "The surgery is done for cosmetic reasons and is without many complications." 2. "The surgery is important to allow the brain to grow properly. Although most children do well, serious complications can occur, so your child will be closely observed in the intensive care unit." 3. "The surgery is important to allow the brain to grow properly. Most surgeons wait until the child is 3 years old to minimize potential complications." 4. "The surgery is mainly done for cosmetic reasons, and most surgeons wait until the child is 3 years old as the head has finished growing at that time."

2. "The surgery is important to allow the brain to grow properly. Although most children do well, serious complications can occur, so your child will be closely observed in the intensive care unit."

38. The parents of a 6-week-old male ask the nurse if there is a difference between an inguinal hernia and a hydrocele. Which is the nurse's best response? 1. "The terms are used interchangeably and mean the same thing." 2. "The symptoms are similar, but an inguinal hernia occurs when tissue protrudes into the groin, whereas a hydrocele is a fluid-filled mass in the scrotum." 3. "A hydrocele is the term used when an inguinal hernia occurs in females." 4. "A hydrocele presents in a manner similar to that of an inguinal hernia but causes increased concern because it is often malignant."

2. "The symptoms are similar, but an inguinal hernia occurs when tissue protrudes into the groin, whereas a hydrocele is a fluid-filled mass in the scrotum."

9. The parent of a child with glomerulonephritis asks the nurse why the urine is such a funny color. Which is the nurse's best response? 1. "It is not uncommon for the urine to be discolored when children are receiving steroids and blood pressure medications." 2. "There is blood in your child's urine that causes it to be tea-colored." 3. "Your child's urine is very concentrated, so it appears to be discolored." 4. "A ketogenic diet often causes the urine to be tea-colored."

2. "There is blood in your child's urine that causes it to be tea-colored."

50. A 10-kg toddler is diagnosed with acute renal failure (ARF), is afebrile, and has a 24-hour urine output of 110 mL. After calculating daily fluid maintenance, which would the nurse expect the toddler's daily allotment of fluids to be? 1. Sips of clear fluids and ice chips only. 2. 350 mL of oral and intravenous fluids. 3. 1000 mL of oral and intravenous fluids. 4. 2000 mL of oral and intravenous fluids.

2. 350 mL of oral and intravenous fluids. *350 mL is approximately a third of the daily fluid requirement and is recommended for the child in the oliguric phase of ARF. If the child were febrile, the fluid intake would be increased.

8. The client who is four (4) months pregnant finds a lump in her breast and the biopsy is positive for Stage II cancer of the breast. Which treatment should the nurse anticipate the HCP recommending to the client? 1. A lumpectomy to be performed after the baby is born. 2. A modified radical mastectomy. 3. Radiation therapy to the chest wall only. 4. Chemotherapy only until the baby is born.

2. A modified radical mastectomy. *A modified radical mastectomy is recommended for this client because the client is not able to begin radiation or chemotherapy, which are part of the regimen for a lumpectomy or wedge resection. Many breast cancers developed during pregnancy are hormone sensitive and have the ideal grounds for growth. The tumor should be removed as soon as possible.

14. The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with Steri-Strips. Which signs/ symptoms would warrant transferring the resident to the emergency department? 1. A 4-cm area of bright red drainage on the dressing. 2. A weak pulse, shallow respirations, and cool pale skin. 3. Pupils that are equal, react to light, and accommodate. 4. Complaints of a headache that resolves with medication.

2. A weak pulse, shallow respirations, and cool pale skin. These signs/symptoms—weak pulse, shallow respirations, cool pale skin—indicate increased intracranial pressure from cerebral edema secondary to the fall, and they require immediate attention.

16. The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply. 1. Administer morphine intramuscularly. 2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula. 4. Place the client in a supine position. 5. Administer nitroglycerin subcutaneously.

2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula.

22. Which medication should the nurse anticipate administering first to a child in status epilepticus? 1. Establish an intravenous line, and administer intravenous lorazepam. 2. Administer rectal diazepam. 3. Administer an oral glucose gel to the side of the child's mouth. 4. Administer oral diazepam.

2. Administer rectal diazepam. Rectal diazepam is first administered in an attempt to stop the seizure long enough to establish an IV, and then IV medication is administered.

20. The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. 1. Maintain the head of the bed at 60 degrees of elevation. 2. Administer stool softeners daily. 3. Ensure that pulse oximeter reading is higher than 93%. 4. Perform deep nasal suction every two (2) hours. 5. Administer mild sedatives.

2. Administer stool softeners daily. 3. Ensure that pulse oximeter reading is higher than 93%. 5. Administer mild sedatives. Stool softeners are initiated to prevent the Valsalva maneuver, which increases intracranial pressure. Oxygen saturation higher than 93% ensures oxygenation of the brain tissues; decreasing oxygen levels increase cerebral edema. Mild sedatives will reduce the client's agitation; strong narcotics would not be administered because they decrease the client's level of consciousness.

11. The nurse at a freestanding health care clinic is caring for a 56-year-old male client who is homeless and is a type 2 diabetic controlled with insulin. Which action is an example of client advocacy? 1. Ask the client if he has somewhere he can go and live. 2. Arrange for someone to give him insulin at a local homeless shelter. 3. Notify Adult Protective Services about the client's situation. 4. Ask the HCP to take the client off insulin because he is homeless.

2. Arrange for someone to give him insulin at a local homeless shelter. Client advocacy focuses support on the client's autonomy. Even if the nurse disagrees with his living on the street, it is the client's right. Arranging for someone to give him his insulin provides for his needs and allows his choices.

18. The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? 1. Medicate the client with intravenous morphine. 2. Assess the client's chest dressing and vital signs. 3. Encourage the client to turn from side to side. 4. Check the client's telemetry monitor.

2. Assess the client's chest dressing and vital signs. The nurse must always assess the client to determine if the chest pain that is occurring is expected postoperatively or if it is a complication of the surgery.

27. The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure? 1. Perform passive range-of-motion exercises. 2. Assess the client's neurovascular status. 3. Keep the client in high Fowler's position. 4. Assess the gag reflex prior to feeding the client.

2. Assess the client's neurovascular status. The nurse must make sure that blood is circulating to the right leg, so the client should be assessed for pulses, paresthesia, paralysis, coldness, and pallor.

29. Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease? 1. Assess the client's radial pulse. 2. Assess the client's serum potassium level. 3. Assess the client's glucometer reading. 4. Assess the client's pulse oximeter reading.

2. Assess the client's serum potassium level. Loop diuretics cause potassium to be lost in the urine output. Therefore, the nurse should assess the client's potassium level, and if the client is hypokalemic, the nurse should question administering this medication.

8. The client diagnosed with ARF is placed on bedrest. The client asks the nurse, "Why do I have to stay in bed? I don't feel bad." Which scientific rationale supports the nurse's response? 1. Bedrest helps increase the blood return to the renal circulation. 2. Bedrest reduces the metabolic rate during the acute stage. 3. Bedrest decreases the workload of the left side of the heart. 4. Bedrest aids in reduction of peripheral and sacral edema.

2. Bedrest reduces the metabolic rate during the acute stage. Bedrest reduces exertion and the metabolic rate, thereby reducing catabolism and subsequent release of potassium and accumulation of endogenous waste products (urea and creatinine).

25. Which activity should an adolescent just diagnosed with epilepsy avoid? 1. Swimming, even with a friend. 2. Being in a car at night. 3. Participating in any strenuous activities. 4. Returning to school right away.

2. Being in a car at night. The rhythmic reflection of other car lights can trigger a seizure in some children.

24. Which needs to be present to diagnose hemolytic uremic syndrome (HUS)? 1. Increased red blood cells with a low reticulocyte count, increased platelet count, and renal failure. 2. Decreased red blood cells with a high reticulocyte count, decreased platelet count, and renal failure. 3. Increased red blood cells with a high reticulocyte count, increased platelet count, and renal failure. 4. Decreased red blood cells with a low reticulocyte count, decreased platelet count, and renal failure.

2. Decreased red blood cells with a high reticulocyte count, decreased platelet count, and renal failure. *The triad in HUS includes decreased red blood cells (with a high reticulocyte count as the body attempts to produce more red blood cells), decreased platelet count, and renal failure.

57. Which best describes the electrolyte imbalance that occurs in chronic renal failure (CRF)? 1. Decreased serum phosphorus and calcium levels. 2. Depletion of phosphorus and calcium stores from the bones. 3. Change in the structure of the bones, causing calcium to remain in the bones. 4. Nutritional needs are poorly met, leading to a decrease in many electrolytes such as calcium and phosphorus.

2. Depletion of phosphorus and calcium stores from the bones. *The calcium and phosphorus levels are drawn from the bones in response to low calcium levels.

2. The client is diagnosed with breast cancer and is considering whether to have a lumpectomy or a more invasive procedure, a modified radical mastectomy. Which information should the nurse discuss with the client? 1. Ask if the client is afraid of having general anesthesia. 2. Determine how the client feels about radiation and chemotherapy. 3. Tell the client she will need reconstruction with either procedure. 4. Find out if the client has any history of breast cancer in her family.

2. Determine how the client feels about radiation and chemotherapy. *The client should understand the treatment regimen for follow-up care. A lumpectomy requires follow-up with radiation therapy to the breast and then systemic chemotherapy. If the cancer is in its early stages, this regimen has results equal to those with a modified radical mastectomy.

14. Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? 1. Midepigastric pain and pyrosis. 2. Diaphoresis and cool clammy skin. 3. Intermittent claudication and pallor. 4. Jugular vein distention and dependent edema.

2. Diaphoresis and cool clammy skin. Diaphoresis (sweating) is a systemic reaction to the MI. The body vasoconstricts to shunt blood from the periphery to the trunk of the body; this, in turn, leads to cold, clammy skin.

A nurse is performing an admission assessment on a 2 year old child who has been diagnosed with nephrotic syndrome. The nurse knows that the most common characteristic associated with nephrotic syndrome is: 1. Frank bright red blood in the urine 2. Generalized edema 3. Increased urinary output 4. Hypotension

2. Generalized edema *Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, hyperlipemia, and edema

A nurse is performing an admission assessment on a 2 year old child who has been diagnosed with nephrotic syndrome. The nurse knows that the most common characteristic associated with nephrotic syndrome is: 1. Frank bright red blood in the urine 2. Generalized edema 3. Increased urinary output 4. Hypotension

2. Generalized edema Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, hyperlipemia, and edema

2. The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump effectively" is written. Which short-term goal would be best for the client? The client will: 1. Be able to ambulate in the hall by date of discharge. 2. Have an audible S1 and S2 with no S3 heard by end of shift. 3. Turn, cough, and deep breathe every two (2) hours. 4. Have a pulse oximeter reading of 98% by day two (2) of care.

2. Have an audible S1 and S2 with no S3 heard by end of shift. Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular failure which could be life threatening.

8. The client with type 2 diabetes controlled with biguanide oral diabetic medication is scheduled for a computed tomography (CT) scan with contrast of the abdomen to evaluate pancreatic function. Which intervention should the nurse implement? 1. Provide a high-fat diet 24 hours prior to test. 2. Hold the biguanide medication for 48 hours prior to test. 3. Obtain an informed consent form for the test. 4. Administer pancreatic enzymes prior to the test.

2. Hold the biguanide medication for 48 hours prior to test. Biguanide medication must be held for a test with contrast medium because it increases the risk of lactic acidosis, which leads to renal problems.

37. The Norwood procedure is used to correct: 1. Transposition of the great vessels. 2. Hypoplastic left heart syndrome. 3. Tetralogy of Fallot (TOF). 4. Patent ductus arteriosus (PDA).

2. Hypoplastic left heart syndrome.

3. The nurse is caring for a client diagnosed with rule-out ARF. Which condition predisposes the client to developing prerenal failure? 1. Diabetes mellitus. 2. Hypotension. 3. Aminoglycosides. 4. Benign prostatic hypertrophy.

2. Hypotension. Hypotension, which causes a decreased blood supply to the kidney, is one of the most common causes of prerenal failure (before the kidney).

13. The clinical manifestations of minimal change nephrotic syndrome (MCNS) are due to which of the following? 1. Chemical changes in the composition of albumin. 2. Increased permeability of the glomeruli. 3. Obstruction of the capillaries of the glomeruli. 4. Loss of the kidney's ability to excrete waste and concentrate urine.

2. Increased permeability of the glomeruli. *Increased permeability of the glomeruli in MCNS allows large substances such as protein to pass through and be excreted in the urine.

A nurse is reviewing the components of the peritoneal dialysis solution with a client. The client asks the nurse about the purpose of the glucose contained in the solution. The nurse bases the response on the knowledge that glucose: 1. Prevents excess glucose from being removed from the client 2. Increases osmotic pressure to produce ultrafiltration 3. Decreases the risk of peritonitis 4. Prevents disequilibrium syndrome

2. Increases osmotic pressure to produce ultrafiltration

11. The UAP tells the nurse the client with ARF has a white crystal-like layer on top of the skin. Which intervention should the nurse implement? 1. Have the assistant apply a moisture barrier cream to the skin. 2. Instruct the UAP to bathe the client in cool water. 3. Tell the UAP not to turn the client in this condition. 4. Explain this is normal and do not do anything for the client.

2. Instruct the UAP to bathe the client in cool water. These crystals are uremic frost resulting from irritating toxins deposited in the client's tissues. Bathing in cool water will remove the crystals, promote client comfort, and decrease the itching resulting from uremic frost.

13. Which order would the nurse question for a child just admitted with the diagnosis of bacterial meningitis? 1. Maintain isolation precautions until 24 hours after receiving intravenous antibiotics. 2. Intravenous fluids at 1 1/2 times regular maintenance. 3. Neurological checks every hour. 4. Administer acetaminophen for temperatures higher than 38°C (100.4°F).

2. Intravenous fluids at 1 1/2 times regular maintenance. Intravenous fluids at 1 1/2 times regular maintenance could cause fluid overload and lead to increased ICP.

62. Which is true of a Wilms tumor? Select all that apply. 1. It is also referred to as neuroblastoma. 2. It can occur at any age but is seen most often between the ages of 2 and 5 years. 3. It can occur on its own or can be associated with many congenital anomalies. 4. It is a slow-growing tumor. 5. It is associated with a very poor prognosis.

2. It can occur at any age but is seen most often between the ages of 2 and 5 years. 3. It can occur on its own or can be associated with many congenital anomalies.

26. Which is the best action for the nurse to take during a child's seizure? 1. Administer the child's rescue dose of oral Valium (diazepam). 2. Loosen the child's clothing, and call for help. 3. Place a tongue blade in the child's mouth to prevent aspiration. 4. Carry the child to the infirmary to call 911 and start an intravenous line.

2. Loosen the child's clothing, and call for help. The nurse should remain with the child and observe the seizure. The child should be protected from his environment, and clothing should be loosened.

55. Which is the most likely reason an adolescent with diabetes has problems with low self-esteem? 1. Managing diabetes decreases independence. 2. Managing diabetes complicates perceived ability to "fit in." 3. Obesity complicates perceived ability to "fit in." 4. Hormonal changes are exacerbated by fluctuations in insulin levels.

2. Managing diabetes complicates perceived ability to "fit in." Because the desire to fit in is so strong in adolescence, the need to manage one's diabetes can compromise the patient's perception of ability to do so. For example, an adolescent with type 1 DM has to plan meals and snacks, test blood sugar, limit choices of when and what to eat, and always be concerned with the immediate health consequences of actions as simple as eating. The fact that these limitations can negatively affect self-esteem is an essential concept for the nurse caring for adolescents with diabetes to understand.

11. The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented? 1. Check the client for peripheral edema and make sure the client takes a diuretic early in the day. 2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. 3. Determine if the client has gained weight and instruct the client to keep the legs elevated. 4. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily.

2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. The most probable cause of the leg cramping is potassium excretion as a result of diuretic medication. Bananas and orange juice are foods that are high in potassium.

35. An infant is born with a sac protruding through the spine, containing cerebrospinal fluid (CSF), a portion of the meninges, and nerve roots. This condition is referred to as: 1. Meningocele. 2. Myelomeningocele. 3. Spina bifida occulta. 4. Anencephaly.

2. Myelomeningocele. A myelomeningocele is a sac that contains a portion of the meninges, the CSF, and the nerve roots.

19. The UAP on the medical floor tells the nurse the client diagnosed with DKA wants something else to eat for lunch. Which intervention should the nurse implement? 1. Instruct the UAP to get the client additional food. 2. Notify the dietitian about the client's request. 3. Request the HCP increase the client's caloric intake. 4. Tell the UAP the client cannot have anything else.

2. Notify the dietitian about the client's request. The client will not be compliant with the diet if he or she is still hungry. Therefore, the nurse should request the dietitian talk to the client to try to adjust the meals so the client will adhere to the diet.

72. The client with infective endocarditis is admitted to the medical department. Which health-care provider's order should be implemented first? 1. Administer intravenous antibiotic. 2. Obtain blood cultures times two (2). 3. Schedule an echocardiogram. 4. Encourage bedrest with bathroom privileges.

2. Obtain blood cultures times two (2). Blood cultures must be done before administering antibiotics so that an adequate number of organisms can be obtained to culture and identify.

38. An 8-year-old with type 1 diabetes mellitus is complaining of a headache and dizzi- ness and is visibly perspiring. Which of the following should the nurse do first? 1. Administer glucagon intramuscularly. 2. Offer the child 8 oz of milk. 3. Administer rapid-acting insulin lispro (Humalog). 4. Offer the child 8 oz of water or calorie-free liquid.

2. Offer the child 8 oz of milk. Milk is best to give for mild hypoglycemia, which would present with the symptoms described.

2. The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse document? 1. Hemiparesis of the client's left arm and apraxia. 2. Paralysis of the right side of the body and ataxia. 3. Homonymous hemianopsia and diplopia. 4. Impulsive behavior and hostility toward family.

2. Paralysis of the right side of the body and ataxia. The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement.

15. Which electrolyte replacement should the nurse anticipate being ordered by the health-care provider in the client diagnosed with DKA who has just been admitted to the ICU? 1. Glucose. 2. Potassium. 3. Calcium. 4. Sodium.

2. Potassium. The client in DKA loses potassium from increased urinary output, acidosis, catabolic state, and vomiting. Replacement is essential for preventing cardiac dysrhythmias secondary to hypokalemia.

9. The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? 1. Potential for injury. 2. Powerlessness. 3. Disturbed thought processes. 4. Sexual dysfunction.

2. Powerlessness. Expressive aphasia means that the client cannot communicate thoughts but understands what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize needs, which, in turn, causes the client to have a lack of control and feel powerless.

48. A child had a tonsillectomy 6 days ago and was seen in the emergency room 4 hours ago due to post-operative hemorrhage. The parent noted that her child was "swallowing a lot and finally began vomiting large amounts of blood." The child's vital signs are as follows: T 99.5°F (37.5°C), HR 124, BP 84/48, and RR 26. The nurse knows that this child is at risk for which type of renal failure? 1. CRF due to advanced disease process. 2. Prerenal failure due to dehydration. 3. Primary kidney damage due to a lack of urine flowing through the system. 4. Postrenal failure due to a hypotensive state.

2. Prerenal failure due to dehydration. Examples of causes of prerenal failure include dehydration and hemorrhage.

55. Aspirin has been ordered for the child with rheumatic fever (RF) in order to: 1. Keep the patent ductus arteriosus (PDA) open. 2. Reduce joint inflammation. 3. Decrease swelling of strawberry tongue. 4. Treat ventricular hypertrophy of endocarditis.

2. Reduce joint inflammation. Joint inflammation is experienced in RF; aspirin therapy helps with inflammation and pain.

32. The nurse in a diabetic clinic sees a 10-year-old who is a new diabetic and has had trouble maintaining blood glucose levels within normal limits. The child's parent states the child has had several daytime "accidents." The nurse knows that this is referred to as which of the following? 1. Primary enuresis. 2. Secondary enuresis. 3. Diurnal enuresis. 4. Nocturnal enuresis.

2. Secondary enuresis. *Secondary enuresis refers to urinary incontinence in a child who previously had bladder control.

33. The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina? 1. Put a nitroglycerin tablet under the tongue. 2. Stop the activity immediately and rest. 3. Document when and what activity caused angina. 4. Notify the health-care provider immediately.

2. Stop the activity immediately and rest. Stopping the activity decreases the heart's need for oxygen and may help decrease the angina (chest pain).

3. The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply. 1. Notify health-care provider of a weight gain of more than one (1) pound in a week. 2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct client to remove the saltshaker from the dinner table. 4. Encourage client to monitor urine output for change in color to become dark. 5. Discuss the importance of taking the loop diuretic furosemide at bedtime.

2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct client to remove the saltshaker from the dinner table. The client should not take digoxin if the radial pulse is less than 60. The client should be on a low-sodium diet to prevent water retention.

28. The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication? 1. The client has a BP of 110/70. 2. The client has an apical pulse of 56. 3. The client is complaining of a headache. 4. The client's potassium level is 4.5 mEq/L.

2. The client has an apical pulse of 56. A beta blocker decreases sympathetic stimulation to the heart, thereby decreasing the heart rate. An apical rate less than 60 indicates a lower-than-normal heart rate and should make the nurse question administering this medication because it will further decrease the heart rate.

18. Which assessment data indicate the client diagnosed with diabetic ketoacidosis is responding to the medical treatment? 1. The client has tented skin turgor and dry mucous membranes. 2. The client is alert and oriented to date, time, and place. 3. The client's ABG results are pH 7.29, PaCO2 44, HCO3 15. 4. The client's serum potassium level is 3.3 mEq/L.

2. The client is alert and oriented to date, time, and place. The client's level of consciousness can be altered because of dehydration and acidosis. If the client's sensorium is intact, the client is getting better and responding to the medical treatment.

23. The nurse is preparing the client for an insertion of a pessary. Which information should the nurse teach the client? 1. The pessary does not need to be changed. 2. The client should clean the pessary routinely. 3. The pessary must be inserted in surgery. 4. Estrogen cream is necessary for effective use of a pessary.

2. The client should clean the pessary routinely.

30. The client has had a total abdominal hysterectomy for cancer of the uterus. Which discharge instruction should the nurse teach? 1. The client should take HRT every day to prevent bone loss. 2. The client should practice pelvic rest until seen by the HCP. 3. The client can drive a car as soon as she is discharged from the hospital. 4. The client should expect some bleeding after this procedure.

2. The client should practice pelvic rest until seen by the HCP. *Pelvic rest means nothing is placed in the vagina. The client does not need a tampon at this time, but sexual intercourse should be avoided until the vaginal area has healed.

60. The nurse is caring for a client with a TURP. Which expected outcome indicates the client's condition is improving? 1. The client is using the maximum amount allowed by the PCA pump. 2. The client's bladder spasms are relieved by medication. 3. The client's scrotum is swollen and tender with movement. 4. The client has passed a large, hard, brown stool this morning.

2. The client's bladder spasms are relieved by medication. Bladder spasms are common, but being relieved with medication indicates the condition is improving.

5. The client had a mastectomy for cancer of the breast and asks the nurse about a TRAM flap procedure. Which information should the nurse explain to the client? 1. The surgeon will insert a saline-filled sac under the skin to simulate a breast. 2. The surgeon will pull the client's own tissue under the skin to create a breast. 3. The surgeon will use tissue from inside the mouth to make a nipple. 4. The surgeon can make the breast any size the client wants the breast to be.

2. The surgeon will pull the client's own tissue under the skin to create a breast. *The TRAM flap procedure is one in which the client's own tissue is used to form the new breast. Abdominal tissue and fat are pulled under the skin with one end left attached to the site of origin to provide circulation until the body builds collateral circulation in the area.

44. The parents overhear the health-care team refer to their child's disease as in stage III. The parents ask the nurse what this means. Which is the nurse's best response? 1. The tumor is confined to the abdomen, but it has spread to the lymph nodes or peritoneal area; the prognosis is poor. 2. The tumor is confined to the abdomen, but it has spread to the lymph nodes or peritoneal area; the prognosis is very good. 3. The tumor has been found in three other organs beyond the peritoneal area; the prognosis is good. 4. The tumor has spread to other organs beyond the peritoneal area; the prognosis is poor.

2. The tumor is confined to the abdomen, but it has spread to the lymph nodes or peritoneal area; the prognosis is very good.

34. The nurse knows that young infants are at risk for injury from shaken baby syndrome (SBS) because: 1. The anterior fontanel is open. 2. They have insufficient musculoskeletal support and a disproportionate head-to-body ratio. 3. They have an immature vascular system with veins and arteries that are more superficial. 4. The nurse knows there is immature myelination of the nervous system in a young infant.

2. They have insufficient musculoskeletal support and a disproportionate head-to-body ratio. Insufficient musculoskeletal support and a disproportionate head size place the infant at risk because the head cannot be supported during a shaking episode.

50. The nurse observes red urine and several large clots in the tubing of the normal saline continuous irrigation catheter for the client who is one (1) day postoperative TURP. Which intervention should the nurse implement? 1. Remove the indwelling catheter. 2. Titrate the NS irrigation to run faster. 3. Administer protamine sulfate IVP. 4. Administer vitamin K slowly.

2. Titrate the NS irrigation to run faster. Increasing the irrigation fluid will flush out the clots and blood.

1. An 18-year-old female client, 5′4′′ tall, weighing 113 kg, comes to the clinic for a nonhealing wound on her lower leg, which she has had for two (2) weeks. Which disease process should the nurse suspect the client has developed? 1. Type 1 diabetes. 2. Type 2 diabetes. 3. Gestational diabetes. 4. Acanthosis nigricans.

2. Type 2 diabetes. Type 2 diabetes is a disorder usually occurring around the age of 40, but it is now being detected in children and young adults as a result of obesity and sedentary lifestyles. Nonhealing wounds are a hallmark sign of type 2 diabetes. This client weighs 248.6 pounds and is short.

38. A parent of a newborn diagnosed with myelomeningocele asks what is a common long-term complication? The nurse's best response is: 1. Learning disabilities. 2. Urinary tract infections. 3. Hydrocephalus. 4. Decubitus ulcers and skin breakdown.

2. Urinary tract infections. Urinary tract infections are the most common complication of myelomeningocele. Nearly all children with myelomeningocele have a neurogenic bladder that leads to incomplete emptying of the bladder and subsequent urinary tract infections. Frequent catheterization also increases the risk of urinary tract infection.

20. Which would the nurse most likely find in the history of a child with hemolytic uremic syndrome (HUS)? 1. Frequent UTIs and possible vesicoureteral reflux (VUR). 2. Vomiting and diarrhea before admission. 3. Bee sting and localized edema of the site for 3 days. 4. Previously healthy and no signs of illness.

2. Vomiting and diarrhea before admission. *HUS is often preceded by diarrhea that may be caused by E. coli present in undercooked meat.

17. The nurse is caring for a newborn with hypospadias. His parents ask if circumcision is an option. Which is the nurse's best response? 1. "Circumcision is a fading practice and is now contraindicated in most children." 2. "Circumcision in children with hypospadias is recommended because it helps prevent infection." 3. "Circumcision is an option, but it cannot be done at this time." 4. "Circumcision can never be performed in a child with hypospadias."

3. "Circumcision is an option, but it cannot be done at this time." *It is usually recommended that circumcision be delayed in the child with hypospadias because the foreskin may be needed for repair of the defect.

28. A child fell off his bike and sustained a closed-head injury. The child is currently awake and alert, but his mother states that he "passed out" for approximately 2 minutes. The mother appears highly anxious and is very tearful. The child was not wearing a helmet. Which is a priority for the triage nurse to say at this time? 1. "Was anyone else injured in the accident?" 2. "Tell me more about the accident." 3. "Did he vomit, have a seizure, or display any other behavior that was unusual when he woke up?" 4. "Why was he not wearing a helmet?"

3. "Did he vomit, have a seizure, or display any other behavior that was unusual when he woke up?"

20. The emergency department nurse is caring for a client diagnosed with HHNS who has a blood glucose of 680 mg/dL. Which question should the nurse ask the client to determine the cause of this acute complication? 1. "When is the last time you took your insulin?" 2. "When did you have your last meal?" 3. "Have you had some type of infection lately?" 4. "How long have you had diabetes?"

3. "Have you had some type of infection lately?" The most common precipitating factor is infection. The manifestations may be slow to appear, with onset ranging from 24 hours to 2 weeks.

43. A 6-month-old male has been diagnosed with positional brachycephaly. The nurse is providing teaching about the use of a helmet for his therapy. Which statement indicates that the parents understand the education? 1. "We will keep the helmet on him when he is awake and remove it only for bathing and sleeping." 2. "He will start wearing the helmet when he is closer to 9 months, as he will be more upright and mobile." 3. "He will wear the helmet 23 hours every day." 4. "Most children need to wear the helmet for 6 to 12 months."

3. "He will wear the helmet 23 hours every day." The helmet is worn 23 hours every day and removed only for bathing.

33. The parent of a 7-year-old voices concern over the child's continued bed-wetting at night. The parent, on going to bed, has tried getting the child up at 11:30 p.m., but the child still wakes up wet. Which is the nurse's best response about what the parent should do next? 1. "There is a medication called DDAVP that decreases the volume of the urine. The physician thinks that will work for your child." 2. "When your child wakes up wet, be very firm, and indicate how displeased you are. Have your child change the sheets to see how much work is involved." 3. "Limit fluids in the evening, and start a reward system in which your child can choose a reward after a certain number of dry nights." 4. "Bed-wetting alarms are readily available, and most children do very well with them."

3. "Limit fluids in the evening, and start a reward system in which your child can choose a reward after a certain number of dry nights."

30. A child in the PICU with a head injury is comatose and unresponsive. The parent asks if he needs pain medication. Select the nurse's best response. 1. "Pain medication is not necessary as he is unresponsive and cannot feel pain." 2. "Pain medication may interfere with his ability to respond and may mask any signs of improvement." 3. "Pain medication is necessary to make him comfortable." 4. "Pain medication is necessary for comfort, but we use it cautiously as it increases the demand for oxygen."

3. "Pain medication is necessary to make him comfortable." Pain medication promotes comfort and ultimately decreases ICP.

57. The client who is postoperative TURP asks the nurse, "When will I know if I will be able to have sex after my TURP?" Which response is most appropriate by the nurse? 1. "You seem anxious about your surgery." 2. "Tell me about your fears of impotency." 3. "Potency can return in six (6) to eight (8) weeks." 4. "Did you ask your doctor about your concern?"

3. "Potency can return in six (6) to eight (8) weeks."

14. The parents of a child hospitalized with minimal change nephrotic syndrome (MCNS) ask why the last blood test revealed elevated lipids. Which is the nurse's best response? 1. "If your child had just eaten a fatty meal, the lipids may have been falsely elevated." 2. "It's not unusual to see elevated lipids in children because of the dietary habits of today." 3. "Since your child is losing so much protein, the liver is stimulated and makes more lipids." 4. "Your child's blood is very concentrated because of the edema, so the lipids are falsely elevated."

3. "Since your child is losing so much protein, the liver is stimulated and makes more lipids." *In MCNS, the lipids are truly elevated. Lipoprotein production is increased because of the increased stimulation of the liver hypoalbuminemia.

18. An infant is scheduled for a hypospadias and chordee repair. The parent tells the nurse, "I understand why the hypospadias repair is necessary, but do they have to fix the chordee as well?" Which is the nurse's best response? 1. "I understand your concern. Parents do not want their children to undergo extra surgery." 2. "The chordee repair is done strictly for cosmetic reasons that may affect your son as he ages." 3. "The repair is done to optimize sexual functioning when he is older." 4. "This is the best time to repair the chordee because he will be having surgery anyway."

3. "The repair is done to optimize sexual functioning when he is older." *Releasing the chordee surgically is necessary for future sexual function.

43. A child diagnosed with a Wilms tumor is scheduled for an MRI scan of the lungs. The parent asks the nurse the reason for this test as a Wilms tumor involves the kidney, not the lung. Which is the nurse's best response? 1. "I'm not sure why your child is going for this test. I will check and get back to you." 2. "It sounds like we made a mistake. I will check and get back to you." 3. "The test is done to check to see if the disease has spread to the lungs." 4. "We want to check the lungs to make sure your child is healthy enough to tolerate surgery."

3. "The test is done to check to see if the disease has spread to the lungs."

25. A 5-year-old is discharged from the hospital following the diagnosis of hemolytic uremic syndrome (HUS). The child has been free of diarrhea for 1 week, and renal function has returned. The parent asks the nurse when the child can return to school. Which is the nurse's best response? 1. "Immediately, as your child is no longer contagious." 2. "It would be best to keep your child home for a few more weeks because the immune system is weak, and there could be a relapse of HUS." 3. "Your child will be contagious for approximately another 10 days, so it is best to not allow a return just yet." 4. "It would be best to keep your child home to monitor urinary output."

3. "Your child will be contagious for approximately another 10 days, so it is best to not allow a return just yet." *Children with HUS are considered contagious for up to 17 days after the resolution of diarrhea and should be placed on contact isolation.

14. The nurse is caring for a 1-year-old who has just been diagnosed with viral encephalitis. The parents ask if their child will be admitted to the hospital. Select the nurse's best response. 1. "Your child will likely be sent home because encephalitis is usually caused by a virus and not bacteria." 2. "Your child will likely be admitted to the pediatric floor for intravenous antibiotics and observation." 3. "Your child will likely be admitted to the PICU for close monitoring and observation." 4. "Your child will likely be sent home because she is only 1 year old. We see fewer complications and a shorter disease process in the younger child."

3. "Your child will likely be admitted to the PICU for close monitoring and observation." The young child with encephalitis should be admitted to a PICU where close observation and monitoring are available. The child should be observed for signs of increased ICP and for cardiac and respiratory compromise.

10. Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dL. 2. A right-sided carotid bruit. 3. A blood pressure of 220/120 mm Hg. 4. The presence of bronchogenic carcinoma.

3. A blood pressure of 220/120 mm Hg. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium.

7. The client diagnosed with ARF is admitted to the intensive care unit and placed on a therapeutic diet. Which diet is most appropriate for the client? 1. A high-potassium and low-calcium diet. 2. A low-fat and low-cholesterol diet. 3. A high-carbohydrate and restricted-protein diet. 4. A regular diet with six (6) small feedings a day.

3. A high-carbohydrate and restricted-protein diet. Carbohydrates are increased to provide for the client's caloric intake and protein is restricted to minimize protein breakdown and to prevent accumulation of toxic waste products.

15. A child with minimal change nephrotic syndrome (MCNS) has generalized edema. The skin appears stretched, and areas of breakdown are noted over the bony prominences. The child has been receiving Lasix twice daily for several days. Which does the nurse expect to be included in the treatment plan to reduce edema? 1. An increase in the amount and frequency of Lasix. 2. Addition of a second diuretic, such as mannitol. 3. Administration of intravenous albumin. 4. Elimination of all fluids and sodium from the child's diet.

3. Administration of intravenous albumin. *In cases of severe edema, albumin is used to help return the fluid to the bloodstream from the subcutaneous tissue.

5. Which child does not need a urinalysis to evaluate for a urinary tract infection (UTI)? 1. A 4-month-old female presenting with a 2-day history of fussiness and poor appetite; current vital signs include axillary T 100.8°F (38.2°C), HR 120 beats per minute. 2. A 4-year-old female who states, "It hurts when I pee"; she has been urinating every 30 minutes; vital signs are within normal range. 3. An 8-year-old male presenting with a finger laceration; mother states he had surgical reimplantation of his ureters 2 years ago. 4. A 12-year-old female complaining of pain to her lower right back; she denies any burning or frequency at this time; oral temperature of 101.5°F (38.6°C).

3. An 8-year-old male presenting with a finger laceration; mother states he had surgical reimplantation of his ureters 2 years ago. *Although this child has had a history of urinary infections, the child is currently not displaying any signs and therefore does not need a urinalysis at this time.

25. The nurse is caring for a 30-year-old nulliparous client who is complaining of severe dysmenorrhea. Which diagnostic test should the nurse prepare the client to undergo to determine a diagnosis? 1. A bimanual vaginal exam. 2. A pregnancy test. 3. An exploratory laparoscopy. 4. An ovarian biopsy.

3. An exploratory laparoscopy. *There is a high incidence of endometriosis among women who have never had children (nulliparity) and those who have children later in life. The most common way to diagnose this condition is through an exploratory laparoscopy.

4. Which recommendation is the American Cancer Society's (ACS) guideline for the early detection of breast cancer? 1. Beginning at age 18, have a biannual clinical breast examination by an HCP. 2. Beginning at age 30, perform monthly breast self-exams. 3. Beginning at age 40, receive a yearly mammogram. 4. Beginning at age 50, have a breast sonogram every five (5) years.

3. Beginning at age 40, receive a yearly mammogram. *The ACS recommends a yearly mammogram for the early detection of breast cancer. A mammogram can detect disease that will not be large enough to feel.

49. A child diagnosed with acute renal failure (ARF) complains of "not feeling well," having "butterflies in the chest," and arms and legs "feeling like Jell-O." The cardiac monitor shows that the QRS complex is wider than before and that an occasional premature ventricular contraction (PVC) is seen. Which would the nurse expect to administer? 1. An isotonic saline solution with 20 mEq KCl/L. 2. Sodium bicarbonate via slow intravenous push. 3. Calcium gluconate via slow intravenous push. 4. Oral potassium supplements.

3. Calcium gluconate via slow intravenous push. *Calcium gluconate is the drug of choice for cardiac irritability secondary to hyperkalemia.

32. In which congenital heart defect (CHD) would the nurse need to take upper and lower extremity BPs? 1. Transposition of the great vessels. 2. Aortic stenosis (AS). 3. Coarctation of the aorta (COA). 4. Tetralogy of Fallot (TOF).

3. Coarctation of the aorta (COA). With COA there is narrowing of the aorta, which increases pressure proximal to the defect (upper extremities) and decreases pressure distal to the defect (lower extremities). There will be high BP and strong pulses in the upper extremities and lower-than-expected BP and weak pulses in the lower extremities.

10. Which finding requires immediate attention in a child with glomerulonephritis? 1. Sleeping most of the day and being very "cranky" when awake; blood pressure is 170/90. 2. Urine output is 190 mL in an 8-hour period and is the color of Coca-Cola. 3. Complaining of a severe headache and photophobia. 4. Refusing breakfast and lunch and stating he "just is not hungry."

3. Complaining of a severe headache and photophobia. A severe headache and photophobia can be signs of encephalopathy due to hypertension, and the child needs immediate attention.

32. The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement? 1. Perform isometric exercises daily. 2. Walk for 15 minutes three (3) times a week. 3. Do not walk outside if it is less than 40 ̊F. 4. Wear open-toed shoes when ambulating.

3. Do not walk outside if it is less than 40 ̊F. When it is cold outside, vasoconstriction occurs, and this will decrease oxygen to the heart muscle. Therefore, the client should not exercise when it is cold outside.

13. The client diagnosed with type 2 diabetes is admitted to the intensive care unit with hyperosmolar hyperglycemic nonketonic syndrome (HHNS) coma. Which assessment data should the nurse expect the client to exhibit? 1. Kussmaul's respirations. 2. Diarrhea and epigastric pain. 3. Dry mucous membranes. 4. Ketone breath odor.

3. Dry mucous membranes. Dry mucous membranes are a result of the hyperglycemia and occur with both HHNS and DKA.

6. The nurse is developing a plan of care for a client diagnosed with ARF. Which statement is an appropriate outcome for the client? 1. Monitor intake and output every shift. 2. Decrease of pain by 3 levels on a 1-10 scale. 3. Electrolytes are within normal limits. 4. Administer enemas to decrease hyperkalemia.

3. Electrolytes are within normal limits. Renal failure causes an imbalance of electrolytes (potassium, sodium, calcium, phosphorus). Therefore, the desired client outcome is electrolytes within normal limits.

10. The client received 10 units of Humulin R, a fast-acting insulin, at 0700. At 1030 the unlicensed assistive personnel (UAP) tells the nurse the client has a headache and is really acting "funny." Which intervention should the nurse implement first? 1. Instruct the UAP to obtain the blood glucose level. 2. Have the client drink eight (8) ounces of orange juice. 3. Go to the client's room and assess the client for hypoglycemia. 4. Prepare to administer one (1) ampule 50% dextrose intravenously.

3. Go to the client's room and assess the client for hypoglycemia. Regular insulin peaks in 2 to 4 hours. Therefore, the nurse should think about the possibility the client is having a hypoglycemic reaction and should assess the client. The nurse should not delegate nursing tasks to a UAP if the client is unstable.

58. The diet for a child with chronic renal failure (CRF) should be high in calories and include: 1. Low protein, and all minerals and electrolytes. 2. Low protein and minerals. 3. High protein and calcium and low potassium and phosphorus. 4. High protein, phosphorus, and calcium and low potassium and sodium.

3. High protein and calcium and low potassium and phosphorus.

5. Which signs best indicate increased intracranial pressure (ICP) in an infant? Select all that apply. 1. Sunken anterior fontanel. 2. Complaints of blurred vision. 3. High-pitched cry. 4. Increased appetite. 5. Sleeping more than usual.

3. High-pitched cry. 5. Sleeping more than usual.

59. A heart transplant may be indicated for a child with severe heart failure and: 1. Patent ductus arteriosus (PDA). 2. Ventricular septal defect (VSD). 3. Hypoplastic left heart syndrome. 4. Pulmonic stenosis (PS).

3. Hypoplastic left heart syndrome. Hypoplastic left heart syndrome is treated by the Norwood procedure, or heart transplant.

24. The client receiving hemodialysis is being discharged home from the dialysis center. Which instruction should the nurse teach the client? 1. Notify the HCP if oral temperature is 102 ̊F or greater. 2. Apply ice to the access site if it starts bleeding at home. 3. Keep fingernails short and try not to scratch the skin. 4. Encourage significant other to make decisions for the client.

3. Keep fingernails short and try not to scratch the skin. Uremic frost, which results when the skin attempts to take over the function of the kidneys, causes itching, which can lead to scratching possibly resulting in a break in the skin.

21. The nurse is formulating a care plan for a client post an abdominal hysterectomy. Which nursing diagnosis is appropriate for the client who has developed a complication? 1. Potential for urinary retention. 2. Potential for nerve damage. 3. Potential for intestinal obstruction. 4. Potential for fluid imbalance.

3. Potential for intestinal obstruction. *Clients who have had a total abdominal hysterectomy are at risk for intestinal obstruction.

52. A 12-year-old with type 2 diabetes mellitus presents with a fever and a 2-day history of vomiting. The nurse observes that the child's breath has a fruity odor and breathing is deep and rapid. Which should the nurse do first? 1. Offer the child 8 oz of clear non-caloric fluid. 2. Test the child's urine for ketones. 3. Prepare the child for an IV infusion. 4. Offer the child 25 g of carbohydrates.

3. Prepare the child for an IV infusion. This patient needs fluid and electrolyte therapy to restore tissue perfusion prior to beginning IV insulin therapy.

12. Select the best room assignment for a newly admitted child with bacterial meningitis. 1. Semiprivate room with a roommate who also has bacterial meningitis. 2. Semiprivate room with a roommate who has bacterial meningitis but has received intravenous antibiotics for more than 24 hours. 3. Private room that is dark and quiet with minimal stimulation. 4. Private room that is bright and colorful and has developmentally appropriate activities available.

3. Private room that is dark and quiet with minimal stimulation. A quiet private room with minimal stimulation is ideal as the child with meningitis should be in a quiet environment to avoid cerebral irritation.

2. The nurse is caring for a 4-year-old who weighs 15 kg. At the end of a 10-hour period, the nurse notes the urine output to be 150 mL. What action does the nurse take? 1. Notifies the physician because this urine output is too low. 2. Encourages the child to increase oral intake to increase urine output. 3. Records the child's urine output in the chart. 4. Administers isotonic fluid intravenously to help with rehydration.

3. Records the child's urine output in the chart. *Recording the child's urine output in the chart is the appropriate action because the urine output is within the expected range of 0.5-1 mL/kg/hr, or 75-150 mL for the 10-hour period.

12. The client diagnosed with ARF is experiencing hyperkalemia. Which medication should the nurse prepare to administer to help decrease the potassium level? 1. Erythropoietin. 2. Calcium gluconate. 3. Regular insulin. 4. Osmotic diuretic.

3. Regular insulin. *Regular insulin, along with glucose, will drive potassium into the cells, thereby lowering serum potassium levels temporarily.

21. The nurse is discussing ways to prevent diabetic ketoacidosis with the client diagnosed with type 1 diabetes. Which instruction is most important to discuss with the client? 1. Refer the client to the American Diabetes Association. 2. Do not take any over-the-counter medications. 3. Take the prescribed insulin even when unable to eat because of illness. 4. Explain the need to get the annual flu and pneumonia vaccines.

3. Take the prescribed insulin even when unable to eat because of illness. Illness increases blood glucose levels; therefore, the client must take insulin and consume high-carbohydrate foods such as regular Jell-O, regular popsicles, and orange juice.

21. The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? 1. Notify the health-care provider immediately. 2. Prepare to administer an antihistamine. 3. Test the drainage for presence of glucose. 4. Place 2 × 2 gauze under the nose to collect drainage.

3. Test the drainage for presence of glucose. The presence of glucose in drainage from the nose or ears indicates cerebrospinal fluid, and the HCP should be notified immediately once this is determined.

15. The nurse is caring for the following clients. Which client would the nurse assess first after receiving the shift report? 1. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours. 2. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan. 3. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale score of 6. 4. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.

3. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale score of 6. The Glasgow Coma Scale is used to determine a client's response to stimuli (eye-opening response, best verbal response, and best motor response) secondary to a neurological problem; scores range from 3 (deep coma) to 15 (intact neurological function). A client with a score of 6 should be assessed first by the nurse.

6. The nurse is assessing the feet of a client with long-term type 2 diabetes. Which assessment data warrant immediate intervention by the nurse? 1. The client has crumbling toenails. 2. The client has athlete's foot. 3. The client has a necrotic big toe. 4. The client has thickened toenails.

3. The client has a necrotic big toe. A necrotic big toe indicates "dead" tissue. The client does not feel pain, does not realize the injury, and does not seek treatment. Increased blood glucose levels decrease the oxygen supply needed to heal the wound and increase the risk for developing an infection.

5. The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective? 1. The client's peripheral pitting edema has gone from 3+ to 4+. 2. The client is able to take the radial pulse accurately. 3. The client is able to perform ADLs without dyspnea. 4. The client has minimal jugular vein distention.

3. The client is able to perform ADLs without dyspnea. Being able to perform activities of daily living (ADLs) without shortness of breath (dyspnea) would indicate the client's condition is improving. The client's heart is a more effective pump and can oxygenate the body better without increasing fluid in the lungs.

19. The client diagnosed with a myocardial infarction is six (6) hours post-right femoral percutaneous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse? 1. The client is keeping the affected extremity straight. 2. The pressure dressing to the right femoral area is intact. 3. The client is complaining of numbness in the right foot. 4. The client's right pedal pulse is 3+ and bounding.

3. The client is complaining of numbness in the right foot. Any neurovascular assessment data that are abnormal require intervention by the nurse; numbness may indicate decreased blood supply to the right foot.

24. The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse? 1. The client's BP is 110/70 and pulse is 90. 2. The client's groin dressing is dry and intact. 3. The client refuses to keep the leg straight. 4. The client denies any numbness and tingling.

3. The client refuses to keep the leg straight. If the client bends the leg, it could cause the insertion site to bleed. This is arterial blood and the client could bleed to death very quickly, so this requires immediate intervention.

15. The male client diagnosed with CKD has received the initial dose of erythropoietin, a biologic response modifier, 1 week ago. Which complaint by the client indicates the need to notify the health-care provider? 1. The client complains of flu-like symptoms. 2. The client complains of being tired all the time. 3. The client reports an elevation in his blood pressure. 4. The client reports discomfort in his legs and back.

3. The client reports an elevation in his blood pressure. After the initial administration of erythropoietin, a client's antihypertensive medications may need to be adjusted. Therefore, this complaint requires notification of the HCP. Erythropoietin therapy is contraindicated in clients with uncontrolled hypertension.

1. The client frequently finds lumps in her breasts, especially around her menstrual period. Which information should the nurse teach the client regarding breast self-care? 1. This is a benign process which does not require follow-up. 2. The client should eliminate chocolate and caffeine from the diet. 3. The client should practice breast self-examination monthly. 4. This is the way breast cancer begins and the client needs surgery.

3. The client should practice breast self-examination monthly. *The American Cancer Society no longer recommends breast self-examination (BSE) for all women, but it is advisable for women with known breast conditions to perform BSE monthly to detect potential cancer.

22. The charge nurse is making client assignments in the intensive care unit. Which client should be assigned to the most experienced nurse? 1. The client with type 2 diabetes who has a blood glucose level of 348 mg/dL. 2. The client diagnosed with type 1 diabetes who is experiencing hypoglycemia. 3. The client with DKA who has multifocal premature ventricular contractions. 4. The client with HHNS who has a plasma osmolarity of 290 mOsm/L.

3. The client with DKA who has multifocal premature ventricular contractions. Multifocal PVCs, which are secondary to hypokalemia and can occur in clients with DKA, are a potentially life-threatening emergency. This client needs an experienced nurse.

13. The nurse is caring for the client diagnosed with chronic kidney disease (CKD) who is experiencing metabolic acidosis. Which statement best describes the scientific rationale for metabolic acidosis in this client? 1. There is an increased excretion of phosphates and organic acids, which leads to an increase in arterial blood pH. 2. A shortened life span of red blood cells because of damage secondary to dialysis treatments in turn leads to metabolic acidosis. 3. The kidney cannot excrete increased levels of acid because they cannot excrete ammonia or cannot reabsorb sodium bicarbonate. 4. An increase in nausea and vomiting causes a loss of hydrochloric acid and the respiratory system cannot compensate adequately.

3. The kidney cannot excrete increased levels of acid because they cannot excrete ammonia or cannot reabsorb sodium bicarbonate.

2. The client diagnosed with type 1 diabetes has a glycosylated hemoglobin (A1c) of 8.1%. Which interpretation should the nurse make based on this result? 1. This result is below normal levels. 2. This result is within acceptable levels. 3. This result is above recommended levels. 4. This result is dangerously high.

3. This result is above recommended levels. This result parallels a serum blood glucose level of approximately 180 to 200 mg/dL. An A1c is a blood test reflecting average blood glucose levels over a period of three (3) months; clients with elevated blood glucose levels are at risk for developing long-term complications.

41. The parent of a 3-year-old is shocked to hear the diagnosis of Wilms tumor and says, "How could I have missed a lump this big?" Which is the nurse's best response? 1. "Do not be hard on yourself. It's easy to overlook something that has probably been growing for months when we see our children on a regular basis." 2. "I understand you must be very upset. Your child would have had a better prognosis had you caught it earlier." 3. "It really takes a trained professional to recognize something like this." 4. "Do not blame yourself. This mass grows so fast that it was probably not noticeable a few days ago."

4. "Do not blame yourself. This mass grows so fast that it was probably not noticeable a few days ago." *The tumor is fast-growing and could very easily not have been evident a few days earlier.

17. Which statement indicates further instruction is needed for the client with a cystocele? 1. "I need to have a sonogram to diagnose this problem." 2. "I need to practice Kegel exercises to help strengthen my muscles." 3. "I lose my urine when I sneeze because of my cystocele." 4. "I can never have sexual intercourse again."

4. "I can never have sexual intercourse again." *Clients with cystoceles may have sexual intercourse unless contraindicated by another medical reason.

39. The nurse evaluates the parents' understanding of the teaching about an inguinal hernia as successful when they say which of the following? 1. "There are no risks associated with waiting to have the hernia reduced; surgery is done for cosmetic reasons." 2. "It is normal to see the bulge in the baby's groin decrease with a bowel movement." 3. "We will wait for surgery until the baby is older because narcotics for pain control will be required for several days." 4. "It is normal for the bulge in the baby's groin to look smaller when the baby is asleep."

4. "It is normal for the bulge in the baby's groin to look smaller when the baby is asleep." *The hernia often appears smaller when the child is asleep.

35. A child has been diagnosed with valvular disease following rheumatic fever (RF). During patient teaching, the nurse discusses the child's long-term prophylactic therapy with antibiotics for dental procedures, surgery, and childbirth. The parents indicate they understand when they say: 1. "She will need to take the antibiotics until she is 18 years old." 2. "She will need to take the antibiotics for 5 years after the last attack." 3. "She will need to take the antibiotics for 10 years after the last attack." 4. "She will need to take the antibiotics for the rest of her life."

4. "She will need to take the antibiotics for the rest of her life." Valvular involvement indicates significant damage, so antibiotics would be taken for the rest of her life.

16. A parent asks the nurse how to prevent the child from having minimal change nephrotic syndrome (MCNS) again. Which is the nurse's best response? 1. "It is very rare for a child to have a relapse after having fully recovered." 2. "Unfortunately, many children have cycles of relapses, and there is very little that can be done to prevent it." 3. "Your child is much less likely to get sick again if sodium is decreased in the diet." 4. "Try to keep your child away from sick children because relapses have been associated with infectious illnesses."

4. "Try to keep your child away from sick children because relapses have been associated with infectious illnesses." *Exposure to infectious illness has been linked to the relapse of nephrotic syndrome.

1. The nurse is admitting a client diagnosed with acute renal failure (ARF). Which question is most important for the nurse to ask during the admission interview? 1. "Have you recently traveled outside the United States?" 2. "Did you recently begin a vigorous exercise program?" 3. "Is there a chance you have been exposed to a virus?" 4. "What over-the-counter medications do you take regularly?"

4. "What over-the-counter medications do you take regularly?" Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) and some herbal remedies are nephrotoxic; therefore, asking about medications is appropriate.

4. The mother of an unconscious child has been calling her name repeatedly and gently shaking her shoulders in an attempt to wake her up. The nurse notes that the child is flexing her arms and wrists while bringing her arms closer to the midline of her body. The child's mother asks, "What is going on?" Select the nurse's best response. 1. "I think your daughter hears you, and she is attempting to reach out to you." 2. "Your child is responding to you; please continue trying to stimulate her." 3. "It appears that your child is having a seizure." 4. "Your child is demonstrating a reflex that indicates she is overwhelmed with the stimulation she is receiving."

4. "Your child is demonstrating a reflex that indicates she is overwhelmed with the stimulation she is receiving." Posturing is a reflex that often indicates that the child is receiving too much stimulation.

1. The bladder capacity of a 3-year-old is approximately how much? 1. 1.5 fl. oz. 2. 3 fl. oz. 3. 4 fl. oz. 4. 5 fl. oz.

4. 5 fl. oz. *The capacity of the bladder in fluid ounces can be estimated by adding 2 to the child's age in years.

56. The client with a TURP who has a continuous irrigation catheter complains of the need to urinate. Which intervention should the nurse implement first? 1. Call the surgeon to inform the HCP of the client's complaint. 2. Administer the client a narcotic medication for pain. 3. Explain to the client this sensation happens frequently. 4. Assess the continuous irrigation catheter for patency.

4. Assess the continuous irrigation catheter for patency.

4. The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first? 1. Sponge the client's forehead. 2. Obtain a pulse oximetry reading. 3. Take the client's vital signs. 4. Assist the client to a sitting position.

4. Assist the client to a sitting position. The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. Then, the nurse could take vital signs and check the pulse oximeter and then sponge the client's forehead.

32. The nurse is caring for an adolescent who remains unconscious 24 hours after sustaining a closed-head injury in a motor vehicle accident (MVA). She responds to deep, painful stimulation with decorticate posturing and has an intracranial monitor that shows periodic increased ICP. All other vital signs remain stable. Select the most appropriate nursing action. 1. Encourage the teen's peers to visit and talk to her about school and other pertinent events. 2. Encourage the teen's parents to hold her hand and speak loudly to her in an attempt to help her regain consciousness. 3. Attempt to keep a normal day/night pattern by keeping the teen in a bright, lively environment during the day and dark quiet environment at night. 4. Attempt to keep the environment dark and quiet, and encourage minimal stimulation.

4. Attempt to keep the environment dark and quiet, and encourage minimal stimulation. A dark, quiet environment and minimal stimulation will decrease oxygen consumption and ICP.

40. The nurse is teaching the family about caring for their 7-year-old, who has been diagnosed with type 1 diabetes mellitus. What information should the nurse provide about this condition? 1. Best managed through diet, exercise, and oral medication. 2. Can be prevented by proper nutrition and monitoring blood glucose levels. 3. Characterized mainly by insulin resistance. 4. Characterized mainly by insulin deficiency.

4. Characterized mainly by insulin deficiency. Individuals with type 1 DM do not produce insulin. If one does not produce insulin, type 1 DM is the diagnosis.

11. The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? 1. Administer a nonnarcotic analgesic. 2. Prepare for STAT magnetic resonance imaging (MRI). 3. Start an intravenous infusion with D5W at 100 mL/hr. 4. Complete a neurological assessment.

4. Complete a neurological assessment. The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action.

27. Brain damage in a child who sustained a closed-head injury can be caused by which factor? 1. Increased perfusion to the brain and increased metabolic needs of the brain. 2. Decreased perfusion to the brain and decreased metabolic needs of the brain. 3. Increased perfusion to the brain and decreased metabolic needs of the brain. 4. Decreased perfusion of the brain and increased metabolic needs of the brain.

4. Decreased perfusion of the brain and increased metabolic needs of the brain.

22. The nurse is teaching the client diagnosed with uterine prolapse. Which information should the nurse include in the discussion? 1. Increase fluids and daily exercise to prevent constipation. 2. Explain there is only one acceptable treatment for uterine prolapse. 3. Instruct the client to visually check the uterine prolapse daily 4. Discuss limiting coughing and lifting heavy objects.

4. Discuss limiting coughing and lifting heavy objects. *Symptoms can be aggravated by coughing, sneezing, lifting heavy objects, standing for prolonged periods, and climbing stairs.

5. The elderly client recovering from a prostatectomy has been experiencing stress incontinence. Which independent nursing intervention should the nurse discuss with the client? 1. Establish a set voiding frequency of every two (2) hours while awake. 2. Encourage a family member to assist the client to the bathroom to void. 3. Apply a transurethral electrical stimulator to relieve symptoms of urinary urgency. 4. Discuss the use of a "bladder drill," including a timed voiding schedule.

4. Discuss the use of a "bladder drill," including a timed voiding schedule. Use of the bladder training drill is helpful in stress incontinence. The client is instructed to void at scheduled intervals. After consistently being dry, the interval is increased by 15 minutes until the client reaches an acceptable interval.

42. The nurse caring for a patient with type 1 diabetes mellitus is teaching how to self- administer insulin. Which is the proper injection technique? 1. Position the needle with the bevel facing downward before injection. 2. Spread the skin prior to intramuscular injection. 3. Aspirate for blood return prior to injection. 4. Elevate the subcutaneous tissue before injection.

4. Elevate the subcutaneous tissue before injection. Skin tissue is elevated to prevent injection into the muscle when giving a subcutaneous injection. Insulin is only given subcutaneously.

16. The nurse is developing a nursing care plan for the client diagnosed with CKD. Which nursing problem is priority for the client? 1. Low self-esteem. 2. Knowledge deficit. 3. Activity intolerance. 4. Excess fluid volume.

4. Excess fluid volume. Excess fluid volume is priority because of the stress placed on the heart and vessels, which could lead to heart failure, pulmonary edema, and death.

43. The nurse is caring for a child who complains of constant hunger, constant thirst, frequent urination, and recent weight loss without dieting. Which can the nurse expect to be included in care for this child? 1. Limiting daily fluid intake. 2. Weight management consulting. 3. Strict intake and output monitoring. 4. Frequent blood glucose testing.

4. Frequent blood glucose testing. Frequent blood glucose testing is included in the care of a child with type 1 DM. The symptoms described in the question are characteristic of a child just prior to the diagnosis of type 1 DM.

18. During a well-child checkup for an infant with tetralogy of Fallot (TOF), the child develops severe respiratory distress and becomes cyanotic. The nurse's first action should be to: 1. Lay the child flat to promote hemostasis. 2. Lay the child flat with legs elevated to increase blood flow to the heart. 3. Sit the child on the parent's lap, with legs dangling, to promote venous pooling. 4. Hold the child in knee-chest position to decrease venous blood return.

4. Hold the child in knee-chest position to decrease venous blood return. The increase in the SVR would increase afterload and increase blood return to the pulmonary artery.

4. Which should the nurse teach a group of girls and parents about the importance of preventing urinary tract infections (UTIs)? 1. Avoiding constipation has no effect on the occurrence of UTIs. 2. After urinating, always wipe from back to front to prevent fecal contamination. 3. Hygiene is an important preventive measure and can be accomplished with frequent tub baths. 4. Increasing fluids will help prevent and treat UTIs.

4. Increasing fluids will help prevent and treat UTIs. *Increasing fluids will help flush the bladder of any organism, encourage urination, and prevent stasis of urine.

17. The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? 1. Assess neurological status. 2. Monitor pulse, respiration, and blood pressure. 3. Initiate an intravenous access. 4. Maintain an adequate airway.

4. Maintain an adequate airway. The most important nursing goal in the management of a client with a head injury is to establish and maintain an adequate airway.

30. In addition to increased blood pressure, which findings would most likely be found in a child with hydronephrosis? 1. Metabolic alkalosis, polydipsia, and polyuria. 2. Metabolic acidosis, and bacterial growth in the urine. 3. Metabolic alkalosis, and bacterial growth in the urine. 4. Metabolic acidosis, polydipsia, and polyuria.

4. Metabolic acidosis, polydipsia, and polyuria. *The blood pressure is increased as the body attempts to compensate for the decreased glomerular filtration rate. Metabolic acidosis is caused by a reduction in hydrogen ion secretion from the distal nephron. Polydipsia and polyuria occur as the kidney's ability to concentrate urine decreases. There is bacterial growth in the urine due to the urinary stasis caused by the obstruction.

57. The client is eight (8) hours post-transurethral prostatectomy for cancer of the prostate. Which nursing intervention is priority at this time? 1. Control postoperative pain. 2. Assess abdominal dressing. 3. Encourage early ambulation to prevent DVT. 4. Monitor fluid and electrolyte balance.

4. Monitor fluid and electrolyte balance. *With irrigation of the surgical site through the indwelling three-way catheter to prevent blood clots, fluids may be absorbed through the open surgical site and retained. This can lead to fluid volume overload and electrolyte imbalance (hyponatremia).

16. The client diagnosed with HHNS was admitted yesterday with a blood glucose level of 780 mg/dL. The client's blood glucose level is now 300 mg/dL. Which intervention should the nurse implement? 1. Increase the regular insulin IV drip. 2. Check the client's urine for ketones. 3. Provide the client with a therapeutic diabetic meal. 4. Notify the HCP to obtain an order to decrease insulin.

4. Notify the HCP to obtain an order to decrease insulin. When the glucose level is decreased to around 300 mg/dL, the regular insulin infusion therapy is decreased. Subcutaneous insulin will be administered per sliding scale.

8. The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? 1. Obtain a rubber mat to place under the dinner plate. 2. Purchase a long-handled bath sponge for showering. 3. Purchase clothes with Velcro closure devices. 4. Obtain a raised toilet seat for the client's bathroom.

4. Obtain a raised toilet seat for the client's bathroom. Raising the toilet seat is modifying the home and addresses the client's weakness in being able to sit down and get up without straining muscles or requiring lifting assistance from the wife.

27. Which medication would most likely be included in the post-operative care of a child with repair of bladder exstrophy? 1. Lasix. 2. Mannitol. 3. Meperidine. 4. Oxybutynin.

4. Oxybutynin. *Oxybutynin is used to control bladder spasms.

5. The nurse is discussing the importance of exercising with a client diagnosed with type 2 diabetes whose diabetes is well controlled with diet and exercise. Which information should the nurse include in the teaching about diabetes? 1. Eat a simple carbohydrate snack before exercising. 2. Carry peanut butter crackers when exercising. 3. Encourage the client to walk 20 minutes three (3) times a week. 4. Perform warmup and cool-down exercises.

4. Perform warmup and cool-down exercises. All clients who exercise should perform warmup and cool-down exercises to help prevent muscle strain and injury.

39. Which is included in the plan of care for a newborn who has a myelomeningocele? 1. Place the child in the prone position with a sterile dry dressing over the defect. Slowly begin oral gastric feeds to prevent the development of necrotizing enterocolitis. 2. Place the child in the prone position with a sterile dry dressing over the defect. Begin intravenous fluids to prevent dehydration. 3. Place the child in the prone position with a sterile moist dressing over the defect. Slowly begin oral gastric feeds to prevent the development of necrotizing enterocolitis. 4. Place the child in the prone position with a sterile moist dressing over the defect. Begin intravenous fluids to prevent dehydration.

4. Place the child in the prone position with a sterile moist dressing over the defect. Begin intravenous fluids to prevent dehydration. The child is placed in the prone position to avoid any pressure on the defect. A sterile moist dressing is placed over the defect to keep it as clean as possible. Intravenous fluids are begun to prevent dehydration.

51. The nurse is caring for a 1-year-old diagnosed with acute renal failure (ARF). Edema is noted throughout the child's body, and the liver is enlarged. The child's urine out- put is less than 0.5 mL/kg/hr, and vital signs are as follows: HR 146, BP 176/92, and RR 42. The child is noted to have nasal flaring and retractions with inspiration. The lung sounds are coarse throughout. Despite receiving oral Kayexalate, the child's serum potassium continues to rise. Which treatment will provide the most benefit to the child? 1. Additional rectal Kayexalate. 2. Intravenous furosemide. 3. Endotracheal intubation and ventilatory assistance. 4. Placement of a Tenckhoff catheter for peritoneal dialysis.

4. Placement of a Tenckhoff catheter for peritoneal dialysis. *Placement of a Tenckhoff catheter for peritoneal dialysis is needed when the child's condition deteriorates despite medical treatment.

12. The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome? 1. Measure intake and output. 2. Provide two (2)-g sodium diet. 3. Weigh client daily. 4. Plan for frequent rest periods.

4. Plan for frequent rest periods. Scheduling activities and rest periods allows the client to participate in his or her own care and addresses the desired outcome.

53. Which nursing diagnosis is priority for the client who has undergone a TURP? 1. Potential for sexual dysfunction. 2. Potential for an altered body image. 3. Potential for chronic infection. 4. Potential for hemorrhage.

4. Potential for hemorrhage.

5. The client diagnosed with ARF has a serum potassium level of 6.8 mEq/L. Which collaborative treatment should the nurse anticipate for the client? 1. Administer a phosphate binder. 2. Type and crossmatch for whole blood. 3. Assess the client for leg cramps. 4. Prepare the client for dialysis.

4. Prepare the client for dialysis. Normal potassium level is 3.5 to 5.5 mEq/L. A level of 6.8 mEq/L is life threatening and could lead to cardiac dysrhythmias. Therefore, the client may be dialyzed to decrease the potassium level quickly. This requires a healthcare provider order, so it is a collaborative intervention.

5. The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care? 1. Observe the client swallowing for possible aspiration. 2. Position the client in a semi-Fowler's position when sleeping. 3. Place a suction setup at the client's bedside during meals. 4. Refer the client to an occupational therapist for evaluation.

4. Refer the client to an occupational therapist for evaluation.

10. A child is being admitted with the diagnosis of meningitis. Select the procedure the nurse should do first: 1. Administration of intravenous antibiotics. 2. Administration of maintenance intravenous fluids. 3. Placement of a Foley catheter. 4. Send the spinal fluid and blood samples to the laboratory for cultures.

4. Send the spinal fluid and blood samples to the laboratory for cultures. Cultures of spinal fluid and blood should be obtained, followed by administration of intravenous antibiotics.

14. Which intervention should the nurse include when teaching the client who is having an anterior colporrhaphy to repair a cystocele? 1. Discuss the need to perform perineal care every four (4) hours. 2. Discuss the care of an indwelling catheter for at least one (1) month. 3. Instruct the client how to care for the pessary inserted in surgery. 4. Teach the client how to perform Kegel exercises.

4. Teach the client how to perform Kegel exercises. *The client should be taught how to perform Kegel exercises to strengthen the muscles.

21. The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication? 1. The client's apical pulse is 64. 2. The client's calcium level is elevated. 3. The client's telemetry shows occasional PVCs. 4. The client's blood pressure is 90/62.

4. The client's blood pressure is 90/62. The client's blood pressure is low, and a calcium channel blocker could cause the blood pressure to bottom out.

23. The client diagnosed with CKD is receiving peritoneal dialysis. Which assessment data warrant immediate intervention by the nurse? 1. Inability to auscultate a bruit over the fistula. 2. The client's abdomen is soft, is nontender, and has bowel sounds. 3. The dialysate being removed from the client's abdomen is clear. 4. The dialysate instilled was 1,500 mL and removed was 1,500 mL.

4. The dialysate instilled was 1,500 mL and removed was 1,500 mL. Because the client is in ESRD, fluid must be removed from the body, so the output should be more than the amount instilled. These assessment data require intervention by the nurse.

6. The nurse is teaching a class on breast health to a group of ladies at a senior citizen's center. Which risk factor is the most important to emphasize to this group? 1. The clients should find out about their family history of breast cancer. 2. Men at this age can get breast cancer also and should be screened. 3. Monthly breast self-examination is the key to early detection. 4. The older a woman gets, the greater the chance of developing breast cancer.

4. The older a woman gets, the greater the chance of developing breast cancer. *The greatest risk factor for developing breast cancer is being female. The second greatest risk factor is being elderly. By age 80, one (1) in every eight (8) women develops breast cancer.

54. Which is the reason a student takes metformin (Glucophage) three times a day? 1. Type 1 diabetes mellitus. 2. Diabetes insipidus. 3. Inflammatory bowel disease. 4. Type 2 diabetes mellitus.

4. Type 2 diabetes mellitus. Metformin is commonly used to manage type 2 DM.

A patient POD #2 for a urostomy should be monitored for the following complication: 1. Urinary output for > 30 ml/hr 2. Stoma edema 3. Slight stoma bleeding 4. Urine crystals on the skin

4. Urine crystals on the skin *Urine/bag leaking

6. Which is the best way to obtain a urine sample in an 8-month-old being evaluated for a urinary tract infection (UTI)? 1. Carefully cleanse the perineum from front to back, and apply a self-adhesive urine collection bag to the perineum. 2. Insert an indwelling Foley catheter, obtain the sample, and wait for results. 3. Place a sterile cotton ball in the diaper, and immediately obtain the sample with a syringe after the first void. 4. Using a straight catheter, obtain the sample, and immediately remove the catheter without waiting for the results of the urine sample.

4. Using a straight catheter, obtain the sample, and immediately remove the catheter without waiting for the results of the urine sample. *An in-and-out catheterization is the best way to obtain a urine culture in a child who is not yet toilet-trained.

A child with periorbital edema, decreased urine output, pallor, and fatigue is admitted to the pediatric unit. The child is being examined for acute glomerular nephritis. Which of the following nursing measures should be considered? Select all that apply. A: On examination, there is usually mild to moderate elevation in BP compared with normal values for age, although severe HTN may be present B: Urinalysis during the acute phase characteristically shows hematuria, proteinuria, and increased specific gravity C: The primary objective is to reduce the excretion of urinary protein and maintain protein-free urine D: Assessment of the child's appearance for signs of cerebral complications is an important nursing function because the severity of the acute phase is variable and unpredictable E: Because these children are particularly vulnerable to URIs, protect them from contact with infected roommates, family, or visitors

A: On examination, there is usually mild to moderate elevation in BP compared with normal values for age, although severe HTN may be present B: Urinalysis during the acute phase characteristically shows hematuria, proteinuria, and increased specific gravity D: Assessment of the child's appearance for signs of cerebral complications is an important nursing function because the severity of the acute phase is variable and unpredictable

The nurse is caring for a 4-year-old girl with a history of frequent UTIs. What should the nurse be aware of before obtaining a urine sample? Select all that apply. A: To obtain a clean-catch urine specimen, have the child sit on the toilet facing backward toward the tank B: Because children who have a UTI will have painful urination, have the child drink a large amount of fluid before obtaining the sample C: The specimen must be fresh - less than 1 hour after voiding with storage at room temperature or less than 4 hours after voiding with refrigeration D: If a urinalysis obtained by bag specimen is negative, a specimen still needs to be obtained by catheterization or suprapubic aspiration E: The key to distinguishing a true UTI from asymptomatic bacteriuria is the presence of pyuria F: Because the child is febrile, the nurse should immediately start an antimicrobial and then obtain a urine culture

A: To obtain a clean-catch urine specimen, have the child sit on the toilet facing backward toward the tank C: The specimen must be fresh - less than 1 hour after voiding with storage at room temperature or less than 4 hours after voiding with refrigeration E: The key to distinguishing a true UTI from asymptomatic bacteriuria is the presence of pyuria