Saunders 4th Edition - Part 1

2421) A nurse develops a plan of care for a client with a spica cast that covers a lower extremity and documents a nursing diagnosis of risk for constipation. When planning for bowel elimination needs, the nurse includes which of the following in the plan of care? a. Use a fracture pan for bowel elimination. b. Use a regular bedpan to prevent spilling of contents in the bed. c. Use a bedside commode for all elimination needs. d. Administer an enema daily. Source: Saunders 4th

ANS: A Rationale: A fracture pan is designed to be used for clients with body or leg casts. A client with a spica cast (body cast) involving a lower extremity cannot bend at the hips to sit up. Therefore, a regular bedpan and a commode would be inappropriate. Daily enemas are not a part of routine care. Strategy: Focus on the strategic words lower extremity and visualize the mechanics of this type of traction. Noting the words fracture pan in option 1 will direct you to this option. Review care of the client with a spica cast if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 644). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1394-1395). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2626) A nurse notes a persistent dry cough in an adult client being seen in the ambulatory clinic. When questioned, the client states that the cough began approximately 2 months ago. On further assessment, the nurse learns that the client began taking quinapril (Accupril) shortly before the time that the cough began. The nurse should interpret that the cough is: a. An expected although bothersome side effect of therapy b. An early indication of heart failure c. Caused by a concurrent upper respiratory infection d. Due to neutropenia as a result of therapy Source: Saunders 4th

ANS: A Rationale: A frequent side effect of therapy with any angiotensin-converting enzyme (ACE) inhibitor, including quinapril, is a persistent, dry cough. In general, the cough does not resolve during the course of medication therapy, so clients should be advised to notify the physician if the cough becomes very troublesome. The other options are incorrect. Strategy: Use the process of elimination. Eliminate options 3 and 4 because they both relate to infection. To choose correctly between the remaining options, you must know the side effects of this medication. Review the side effects of ACE inhibitors if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 996). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2128) A nurse is teaching a client who is to have a gallium scan about the procedure. The nurse should include which of the following items as part of the instructions? a. The gallium will be injected intravenously 2 to 3 hours before the procedure. b. The procedure takes about 15 minutes to perform. c. The client must stand erect during the filming. d. The client should remain on bedrest for the remainder of the day after the scan. Source: Saunders 4th

ANS: A Rationale: A gallium scan is similar to a bone scan, but with injection of gallium isotope instead of technetium Tc 99m. Gallium is injected 2 to 3 hours before the procedure. The procedure takes 30 to 60 minutes to perform. The client must lie still during the procedure. There is no special aftercare. Strategy: Use the process of elimination. If you know that a gallium scan is similar to a bone scan, then you can begin by eliminating options 3 and 4. The time frame in option 2 is rather brief, which allows you to choose option 1 as the correct answer. Review this diagnostic test if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 577). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1464) The client is unwilling to go out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound, except when accompanied outside by the spouse. Based on this data, the nurse determines that the client is experiencing: a. Agoraphobia b. Social phobia c. Claustrophobia d. Hypochondriasis Source: Saunders 4th

ANS: A Rationale: Agoraphobia is a fear of open spaces and the fear of being trapped in a situation from which there may not be an escape. Agoraphobia includes the possibility of experiencing a sense of helplessness or embarrassment if an attack occurs. Avoidance of such situations usually results in reduction of social and professional interactions. Social phobia focuses more on specific situations, such as the fear of speaking, performing, or eating in public. Claustrophobia is a fear of closed places. Clients with hypochondriacal symptoms focus their anxiety on physical complaints and are preoccupied with their health. Strategy: Use the process of elimination. Focusing on the strategic words remains homebound will direct you to option 1. If you had difficulty with this question, review phobia types and associated client behaviors. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 178-179). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 271). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 234). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Mental Health Alternate Question Types -> Multiple Choice

147) The nurse is told by a physician that a client in hypovolemic shock will require plasma expansion. The nurse anticipates receiving an order to transfuse which product? a. Albumin b. Platelets c. Cryoprecipitate d. Packed red blood cells Source: Saunders 4th

ANS: A Rationale: Albumin may be used as a plasma expander. Platelets are used when the client's platelet count is low. Cryoprecipitate is useful in treating bleeding from hemophilia or disseminated intravascular coagulopathy because it is rich in clotting factors. Packed red blood cells replace erythrocytes and are not a plasma expander. Strategy: Use the process of elimination, noting the strategic words require plasma expansion. Recalling the composition of each of the blood components identified in the options will direct you to option 1. If you had difficulty with this question, review the various blood component therapies. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 870). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1092) A nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client's heart rhythm? a. Atrial fibrillation b. Sinus tachycardia c. Ventricular fibrillation d. Ventricular tachycardia Source: Saunders 4th

ANS: A Rationale: Atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS complex. The atria quiver, which can lead to thrombi formation. Strategy: Use the process of elimination. Noting the strategic words there are no P waves should direct you to option 1. Loss of P waves is characteristic of this dysrhythmia. Review the characteristics of atrial fibrillation if you had difficulty with this question. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., p. 680). St. Louis: Mosby. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 868). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2354) A client with multiple sclerosis is receiving baclofen (Lioresal). A nurse assessing the client monitors for which of the following as an indication of a primary therapeutic response to the medication? a. Decreased muscle spasms b. Increased range of motion of all extremities c. Increased muscle tone and strength d. Decreased nausea Source: Saunders 4th

ANS: A Rationale: Baclofen is a skeletal muscle relaxant and acts at the spinal cord level to decrease the frequency and amplitude of muscle spasms in clients with spinal cord injuries or diseases or with multiple sclerosis. Options 2 and 3 are not directly related to the effects of this medication. Option 4 is incorrect. Strategy: Note the strategic word primary. Recalling that this medication is a skeletal muscle relaxant will guide you to the correct option. Review the action of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 119). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

934) The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the appropriate nursing intervention? a. Notify the physician. b. Administer the prescribed pain medication. c. Call and ask the operating room team to perform the surgery as soon as possible. d. Reposition the client and apply a heating pad on warm setting to the client's abdomen. Source: Saunders 4th

ANS: A Rationale: Based on the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the physician. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the physician probably would perform the surgery earlier than the prescheduled time. Strategy: Use the process of elimination. Focus on the signs and symptoms in the question and consider the complications that can occur with appendicitis. Options 3 and 4 can be eliminated easily. Noting that the signs presented in the question indicate a complication will assist in directing you to option 1. Review care of the client with appendicitis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1339-1340). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1336) A nurse is caring for a client who is going to have arthrography with a contrast medium. Which assessment by the nurse would be of highest priority? a. Allergy to iodine or shellfish b. Ability of the client to remain still during the procedure c. Whether the client wishes to void before the procedure d. Whether the client has any remaining questions about the procedure Source: Saunders 4th

ANS: A Rationale: Because of the risk of allergy to contrast dye, the nurse places highest priority on assessing whether the client has an allergy to iodine or shellfish. The nurse also reinforces information about the test and tells the client about the need to remain still during the procedure. Strategy: Use the process of elimination. Note the strategic words highest priority. This tells you that more than one or all of the options are correct (in fact, they all are). Use Maslow's Hierarchy of Needs theory. Although options 2, 3, and 4 compete for priority, option 1 (allergy to iodine or shellfish) takes first preference. The consequence of possible anaphylactic shock (physiological risk) makes this the correct option. Review client preparation for arthrography if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1153). St. Louis: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1645). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

2376) A client being admitted to the nursing unit has been taking bethanechol chloride (Urecholine) at home. During the admission assessment, the nurse gives special attention to assessing the client for which of the following as a side effect of this medication? a. Bradycardia b. Decreased sweating or dry mouth, or both c. Constipation d. Hypertension Source: Saunders 4th

ANS: A Rationale: Bethanechol chloride is a direct-acting muscarinic agonist (cholinergic medication). It can cause hypotension secondary to vasodilation and bradycardia. It also can cause excessive salivation, increased secretion of gastric acid, abdominal cramps, and diarrhea. Higher doses can cause involuntary defecation. Strategy: Use the process of elimination and recall the classification of this medication. Knowing that the medication is a direct-acting muscarinic agonist will guide you to the correct option. If you are unfamiliar with the action and effects of this medication, review this content. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 99). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1903) A client who has had a prostatectomy is complaining of pain due to bladder spasm. The nurse checks the physician's order sheet to see if which of the following medications is ordered to treat the problem? a. Belladonna and opium (B&O) suppository b. Meperidine hydrochloride (Demerol) c. Morphine sulfate d. Hydromorphone (Dilaudid) Source: Saunders 4th

ANS: A Rationale: Bladder spasm following prostatectomy is treated with antispasmodic medications, such as B&O suppository or propantheline bromide (ProBanthine). Opioid analgesics such as meperidine hydrochloride, morphine sulfate, and hydromorphone usually are not effective in treating pain caused by spasm. Strategy: Use the process of elimination. Note that options 2, 3, and 4 are comparative or alike in that they are all opioid analgesics. Review the treatment for bladder spasms following prostatectomy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1025). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

157) The nurse is picking up a unit of packed red blood cells at the hospital blood bank. After putting the pen down, the nurse glances at the clock, which reads 1:00. The nurse calculates that the transfusion must be started by: a. 1:30 b. 2:00 c. 2:30 d. 3:00 Source: Saunders 4th

ANS: A Rationale: Blood must be hung as soon as possible (within 30 minutes) after obtaining it from the blood bank. After that time, the blood temperature will be higher than 50° F and could be unsafe for use. For this reason options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination. You should know that blood must be hung within 30 minutes after obtaining it from the blood bank to answer this question correctly. Review the standard procedures related to safe blood administration if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 914). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 747). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2124) A nurse is administering lidocaine hydrochloride (Xylocaine) by the intravenous (IV) route. Which of the following would indicate to the nurse that the client is experiencing toxicity? a. Client complaints of blurred vision and nausea b. Heart rate of 70 beats/min, blood pressure of 130/72 mm Hg c. Client complaints of a headache and a temperature of 100° F orally d. Urine output of 275 mL over the past 8 hours Source: Saunders 4th

ANS: A Rationale: Blurred vision and nausea are common indicators of lidocaine toxicity. The heart rate and blood pressure noted in option 2 are normal. A headache and elevated temperature are important assessment signs but are not related to the lidocaine. Urine output is greater than the minimum amount of 30 mL/hr and therefore is adequate. Strategy: Use the process of elimination, focusing on the strategic word toxicity. Note that options 2, 3, and 4 reveal normal findings or mild physiological alterations. Review the signs of toxicity if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 761). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1573) The breast-feeding mother of an infant with lactose intolerance asks the nurse about dietary measures. The nurse tells the mother to avoid: a. Hard cheeses b. Green leafy vegetables c. Dried beans d. Egg yolk Source: Saunders 4th

ANS: A Rationale: Breast-feeding mothers with lactose intolerance infants need to be encouraged to limit dairy products. Cheese is a dairy product. Alternative calcium sources that can be consumed by the mother include egg yolk, green leafy vegetables, dried beans, cauliflower, and molasses. Strategy: Use the process of elimination. Note the strategic word avoid in the question. Knowledge that lactose is the sugar found in dairy products will easily direct you to option 1. Review the dietary management for the infant with lactose intolerance if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 194). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Child Health Alternate Question Types -> Multiple Choice

2056) A nurse is preparing to care for a client with a diagnosis of metastatic cancer. The nurse notes documentation in the client's chart that the client is experiencing cachexia. Which of the following would the nurse expect to note on assessment of the client? a. Sunken eyes and a hollow cheek appearance b. Periorbital edema and swelling around the ears c. Generalized edema and the presence of weight gain d. Elevated blood pressure and ascites Source: Saunders 4th

ANS: A Rationale: Cachexia accompanies chronic wasting diseases and conditions such as cancer, dehydration, and starvation. Assessment findings in a client with cachexia include sunken eyes, hollow cheeks, and an exhausted, defeated expression. Options 2, 3, and 4 are not characteristics of a cachexia appearance. Strategy: Use the process of elimination, recalling that cachexia indicates a chronic wasting of the body. This will direct you to option 1. If you had difficulty with this question, review the characteristic findings in a client experiencing cachexia. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 485). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

2533) A nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit. The nurse notes that a cardiac troponin T level assay was performed while the client was in the intensive care unit. The nurse determines that this test was performed to assist in diagnosing which of the following conditions? a. Myocardial infarction b. Congestive heart failure c. Ventricular tachycardia d. Atrial fibrillation Source: Saunders 4th

ANS: A Rationale: Cardiac troponin T or cardiac troponin I has been found to be a protein marker in the detection of myocardial infarction, and assay for this protein is used in some institutions to aid in the diagnosis of a myocardial infarction. The test is not used to diagnose congestive heart failure, ventricular tachycardia, or atrial fibrillation. Strategy: Specific knowledge regarding the cardiac troponin test is needed to answer this question. Think about each condition identified in the options and the method of diagnosing the condition to direct you to option 1. Review the purpose of this laboratory test if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., pp. 1094-1095). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1068) A client is admitted to an emergency room with chest pain that is being ruled out for myocardial infarction. Vital signs are as follows: at 11 <sc>AM</sc>, pulse (P), 92 beats/min, respiratory rate (RR), 24 breaths/min, blood pressure (BP), 140/88 mm Hg; 11:15 <sc>AM</sc>, P, 96 beats/min, RR, 26 breaths/min, BP, 128/82 mm Hg; 11:30 <sc>AM</sc>, P, 104 beats/min, RR, 28 breaths/min, BP, 104/68 mm Hg; 11:45 <sc>AM</sc>, P, 118 beats/min, RR, 32 breaths/min, BP, 88/58 mm Hg. The nurse should alert the physician because these changes are most consistent with which of the following complications? a. Cardiogenic shock b. Cardiac tamponade c. Pulmonary embolism d. Dissecting thoracic aortic aneurysm Source: Saunders 4th

ANS: A Rationale: Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypotension, a rapid pulse that becomes weaker, decreased urine output, and cool, clammy skin. Respiratory rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with severe dyspnea accompanying the chest pain. Dissecting aortic aneurysms usually are accompanied by back pain. Strategy: Use the process of elimination. Recalling that the early serious complications of myocardial infarction include dysrhythmias, cardiogenic shock, and sudden death will direct you to option 1. No information in the question would guide you to select options 2, 3, or 4. Review the complications of myocardial infarction if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 854). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2668) A client has begun taking cascara sagrada. In monitoring the client for medication side effects, the nurse is likely to note which of the following? a. Abdominal cramps b. Partial bowel obstruction c. Gastrointestinal (GI) bleeding d. Peptic ulcer disease Source: Saunders 4th

ANS: A Rationale: Cascara sagrada is a laxative that causes nausea and abdominal cramps as the most frequent side effects. The incorrect options represent health problems that are not caused by this medication. Strategy: Recall that cascara is a laxative, and that a common adverse effect of laxatives is abdominal cramping. Also, use the process of elimination to rule out options 2, 3, and 4 because they are comparative or alike and identify medical disorders. Review the action and side effects of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 148). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

45) A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for deficient fluid volume? a. A client with a colostomy b. A client with congestive heart failure c. A client with decreased kidney function d. A client receiving frequent wound irrigations Source: Saunders 4th

ANS: A Rationale: Causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with congestive heart failure or decreased kidney function, or a client receiving frequent wound irrigations, is at risk for excess fluid volume. Strategy: Read the question carefully, noting that it asks for the client at risk for a deficit. Read each option and think about the fluid imbalance that can occur in each. The clients presented in options 2, 3, and 4 retain fluid. The only condition that can cause a deficit is the condition noted in option 1. If you had difficulty with this question, review the causes of deficient fluid volume. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 223, 2494). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1324). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2563) A nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note which of following documented in the assessment data section of the record? a. The client experienced paresthesias a few days before admission to the hospital. b. The client complained of a severe headache, which was followed by sudden onset of paralysis. c. Sudden loss of consciousness occurred. d. Signs and symptoms occurred suddenly. Source: Saunders 4th

ANS: A Rationale: Cerebral thrombosis does not occur suddenly. In the few hours or days preceding a thrombotic stroke, the client may experience a transient loss of speech, hemiplegia, or paresthesias on one side of the body. Signs and symptoms of thrombotic stroke vary but may include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage. Strategy: Use the process of elimination, focusing on the client's diagnosis, thrombotic stroke. Recalling that a cerebral thrombosis does not occur suddenly will direct you to option 1. Review the manifestations of this type of stroke if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1028, 1033). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2333) An ambulatory care nurse is providing instructions to a client scheduled for a myelogram regarding preparation for the procedure. Which statement by the client indicates a need for further instruction? a. "A light diet should be eaten on the day of the procedure." b. "My procedure will take approximately 45 minutes." c. "My jewelry will need to be removed." d. "An informed consent form will need to be signed." Source: Saunders 4th

ANS: A Rationale: Client preparation for a myelogram includes instructing the client to restrict food and fluids for 4 to 8 hours before the procedure. The client is told that the procedure takes about 45 minutes. An informed consent is required, and the client will need to remove jewelry and any metal objects. The client also is told that pretest medications may be administered for relaxation. Strategy: Use the process of elimination. Note the strategic words need for further instruction in the question. This phrasing indicates a negative event query and asks you to select an incorrect statement. Recalling the components of this procedure will direct you to option 1. If you had difficulty with this question, review the pre-procedure preparation of the client scheduled for a myelogram. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 804). Philadelphia: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 652). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1364) Allopurinol (Zyloprim) is prescribed for a client and the nurse provides medication instructions to the client. The nurse instructs the client: a. To drink 3000 mL of fluid a day b. To take the medication on an empty stomach c. That the effect of the medication will occur immediately d. That if swelling of the lips occurs, this is a normal expected response Source: Saunders 4th

ANS: A Rationale: Clients taking allopurinol are encouraged to drink 3000 mL of fluid a day. A full therapeutic effect may take 1 week or longer. Allopurinol is to be given with, or immediately after, meals or milk. A client who develops a rash, irritation of the eyes, or swelling of the lips or mouth should contact the physician because this may indicate hypersensitivity. Strategy: Use the process of elimination. Option 4 can be eliminated easily because it indicates hypersensitivity, which is not a normal expected response. From the remaining options, recalling that this medication is used to treat gout will direct you to option 1. If you had difficulty with this question, review the client instructions related to allopurinol. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 35). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2154) A client has just been admitted to the hospital with a fractured femur and pelvic fractures. The nurse plans to carefully monitor the client for which of the following signs and symptoms? a. Tachycardia, hypotension b. Bradycardia, hypertension c. Fever, bradycardia d. Fever, hypertension Source: Saunders 4th

ANS: A Rationale: Clients who experience fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and the thigh. This can occur with closed fractures as well as open fractures. Signs of hypovolemic shock include tachycardia and hypotension. Strategy: Use the process of elimination. First, recall that hypovolemic shock is a complication after these types of fractures. Second, recalling the signs and symptoms of hypovolemic shock will direct you to option 1. Review the complications that may follow this type of injury and the signs of hypovolemic shock if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2444-2446, 2473). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2033) A mental health nurse in a psychiatric unit is meeting with a client who has a long history of acting out and violent behavior. The client also is known to have abused drugs on numerous occasions. During the session the client says to the nurse, "I'm feeling much better now and I'm ready to go straight." Which response by the nurse would be therapeutic? a. "Tell me what makes you feel that you are ready." b. "You have said this many times before!" c. "I have not seen any changes in you to believe that you are ready to go straight." d. "I'm so glad to hear you talking this way. I will let your doctor know." Source: Saunders 4th

ANS: A Rationale: Clients with a long history of acting out and violent behavior and clients who have used drugs need to demonstrate motivation to change the behavior, not just verbalization of the behavior. The therapeutic response by the nurse would be directed at assisting the client to look at the behaviors that indicate the change. Option 1 is the only option that will provide this direction to the client. Strategy: Use the process of elimination and therapeutic communication techniques to assist in answering the question. Option 2 is not therapeutic because it is insensitive and sarcastic. Option 3 is not therapeutic because this statement disagrees with the client, rather than assisting the client to verbalize how things would be different. Option 4 jumps to a conclusion with no data gathering and provides a social response rather than a therapeutic one. Review therapeutic communication techniques if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed., pp. 30-34, 632). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1158) The client with chronic renal failure has an indwelling abdominal catheter for peritoneal dialysis. The client spills water on the catheter dressing while bathing. The nurse should immediately: a. Change the dressing. b. Reinforce the dressing. c. Flush the peritoneal dialysis catheter. d. Scrub the catheter with povidone-iodine. Source: Saunders 4th

ANS: A Rationale: Clients with peritoneal dialysis catheters are at high risk for infection. A wet dressing is a conduit for bacteria to reach the catheter insertion site. The nurse ensures that the dressing is kept dry at all times. Reinforcing the dressing is not a safe practice to prevent infection in this circumstance. Flushing the catheter is not indicated. Scrubbing the catheter with povidone-iodine is done at the time of connection or disconnection of peritoneal dialysis. Strategy: Use the process of elimination. Note the subject of the question, a wet dressing. Recalling that this client is at risk for infection and knowing that it is better to change a wet dressing than reinforce it will direct you to option 1. Review care to the client receiving peritoneal dialysis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1759). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2382) A hypertensive client has clonidine hydrochloride (Catapres-TTS), a transdermal patch, prescribed. The nurse provides written instructions to the client on the use of the patch. Which statement by the client indicates the need for further instruction? a. "I need to change the patch every 24 hours." b. "I need to apply the patch to skin areas that are not broken." c. "I need to apply the patch to a hairless body site." d. " I need to apply the patch to the skin on the upper arm or body." Source: Saunders 4th

ANS: A Rationale: Clonidine is an antihypertensive medication that is applied to a hairless intact skin area of the upper arm or torso every 7 days. Options 2, 3, and 4 are correct statements. Strategy: Use the process of elimination and note the strategic words need for further instruction. This phrasing indicates a negative event query and asks you to select an incorrect statement. Recalling that the patch is changed every 7 days will direct you to option 1. Review this medication administration method if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 273). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 177). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2146) A client with a herniated intervertebral lumbar disk complains of knife-like, stabbing pain in the lower back, as well as pain radiating into the right buttock. The nurse interprets that the sharp stabbing pain probably is a result of: a. Muscle spasm in the area of the herniated disk b. Pressure on the spinal cord c. Pressure on the spinal nerve root d. Excess cerebrospinal fluid production in the area Source: Saunders 4th

ANS: A Rationale: Compression of a nerve results in inflammation, which then irritates adjacent muscles, putting them into spasm. The pain of muscle spasm is continuous, knife-like, and localized in the affected area. Pressure on a spinal nerve root causes the symptoms of sciatica. Pressure on the spinal cord itself could result in a variety of manifestations, depending on the area involved. Strategy: Use the process of elimination. Focus on the client data in the question to direct you to option 1. Additionally, herniated disk is stated in the question and again in the correct option. Review the causes of pain in a client with a herniated disk if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2141). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 978). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1813) A nurse is performing an assessment on a client who has been receiving parenteral nutrition at 125 mL/hr. On assessment, the nurse notes the presence of bilateral crackles in the lungs and 2+ pedal edema. The nurse also notes that the client has gained 3 pounds in 5 days. Which of the following nursing actions would be the most appropriate for this client? a. Notify the physician of the assessment findings. b. Encourage the client to cough and deep breathe. c. Administer the prescribed daily diuretic and reassess the client in 2 hours. d. Slow the infusion rate to 100 mL/hr. Source: Saunders 4th

ANS: A Rationale: Crackles, edema, and weight gain signify fluid shifts from intravascular spaces to the interstitial spaces and indicate signs of fluid retention and possible excess fluid intake. The problem may or may not be related to the parenteral nutrition. Other possible causes of fluid retention are impaired respiratory and cardiovascular function and impaired kidney function. Option 2 will have little, if any, effect on peripheral edema and weight gain. Option 3 may delay necessary and immediate treatment and is incorrect. The nurse should not decrease the infusion rate without a physician's order. Additionally, it is not recommended to increase or decrease the rate of the infusion, because of the potential for hyperosmolar diuresis, hypoglycemia, or hyperglycemia. Strategy: Use the process of elimination, focusing on the client data provided in the question. Eliminate option 4 first because the nurse should not decrease the infusion rate without a physician's order. Eliminate option 2 next because this action will have little, if any, effect on peripheral edema and weight gain. Eliminate option 3 because this action may delay necessary and immediate treatment. Review the complications and associated nursing interventions of parenteral nutrition if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1432-1433). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1611). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2492) A nurse has provided discharge instructions to a client who has had cryosurgery to remove a malignant skin lesion. The nurse determines that the client understands the instructions if the client states which of the following? a. "I need to clean the site with hydrogen peroxide to prevent infection." b. "I need to apply ice to the site to prevent swelling." c. "I need to apply alcohol-soaked dressings twice a day." d. "I need to avoid showering for 7 to 10 days." Source: Saunders 4th

ANS: A Rationale: Cryosurgery involves the local application of liquid nitrogen to isolated lesions, causing cell death and tissue destruction. The nurse teaches the client to expect swelling and increased tenderness of the treated area when the skin thaws. Tissue freezing is followed in 1 to 2 days by hemorrhagic blister formation. The nurse instructs the client to clean the treatment site with hydrogen peroxide to prevent secondary infection. A topical antibiotic also may be prescribed. Intermittent application of a warm damp washcloth to the site will provide relief from any discomfort. Alcohol-soaked dressings will cause irritation. It is not necessary to avoid showering. Because cryosurgery involves tissue freezing, the application of ice is avoided following the procedure. Strategy: Use the process of elimination. Eliminate option 4 first because it is not necessary for the client to avoid showers. Eliminate option 3 (alcohol-soaked dressing) next. Regarding the remaining options, note that option 1 addresses the prevention of infection. This is the best option to select. If you had difficulty with this question, review client education for postprocedure care with cryosurgery. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1610). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

2345) A client experiencing spasticity as a result of spinal cord injury has a new order for dantrolene (Dantrium). Before administering the first dose, the nurse checks to see if which baseline study has been done? a. Liver function studies b. Otoscopic examination c. Blood glucose measurements d. Renal function studies Source: Saunders 4th

ANS: A Rationale: Dantrolene can cause liver damage; therefore, the nurse should monitor the results of liver function studies. They should be done before therapy starts and periodically throughout therapy. Dantrolene is discontinued if no relief of spasticity is achieved in 6 weeks. The incorrect options are not specifically related to the administration of this medication. Strategy: Recalling that this medication is hepatotoxic will direct you to the correct option. If you had difficulty with this question, review its adverse effects. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 314). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1414) A client who has just been sexually assaulted is quiet and calm. The nurse analyzes this behavior as indicating which defense mechanism? a. Denial b. Projection c. Rationalization d. Intellectualization Source: Saunders 4th

ANS: A Rationale: Denial is refusal to admit to a painful reality and may be a response by a victim of sexual abuse. Projection is transferring one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Rationalization is justifying the unacceptable attributes about oneself. Intellectualization is the excessive use of abstract thinking or generalizations to decrease painful thinking. Strategy: Use the process of elimination and note the strategic words calm and quiet. These behaviors indicate denial in a sexually abused victim. If you had difficulty with this question, review content related to the sexually abused victim and defense mechanisms. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 9). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 220, 553). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1422) A client is admitted to a mental health unit for treatment of psychotic behavior. The client is at the locked exit door and is shouting, "Let me out. There's nothing wrong with me. I don't belong here." The nurse analyzes this behavior as: a. Denial b. Projection c. Regression d. Rationalization Source: Saunders 4th

ANS: A Rationale: Denial is refusal to admit to a painful reality, which is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other persons, objects, or situations. In regression, the client returns to an earlier, more comforting, although less mature, way of behaving. Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller and the listener. Strategy: Use the process of elimination. The strategic words in the question that should direct you to the correct option are "There's nothing wrong with me." Select the option that recognizes the client's attempt to avoid looking at the reality of the situation. If you had difficulty with this question, review defense mechanisms. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 9). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 220-221). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1140) A client arrives in the emergency department after complaining of unrelieved chest pain for 2 days. The pain has subsided slightly but never disappeared. When the nurse approaches the client with a 0.4-mg nitroglycerin sublingual tablet, the client states, "I don't need that. My dad takes that for his heart. There's nothing wrong with my heart." The nurse interprets that the client is exhibiting which type of reaction? a. Denial b. Phobic c. Angry d. Obsessive-compulsive Source: Saunders 4th

ANS: A Rationale: Denial is the most common reaction when a client has a myocardial infarction or anginal pain. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination. Eliminate options 2 and 4 first because both are psychiatric diagnoses. From the remaining options, recalling that denial is the most common reaction when a client has chest pain will direct you to option 1. Review behavioral reactions of a client with chest pain if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M., (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 845, 852). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2269) A client with right leg hemiplegia has a nursing diagnosis of impaired physical mobility. The nurse determines a need for reinforcement of client/family teaching if the nurse observes which of the following being done by the family? a. Encouraging the client to stand unassisted on the leg b. Active range of motion to the affected leg c. Passive range of motion to the affected leg d. Applying a premolded splint Source: Saunders 4th

ANS: A Rationale: Depending on the client's functional ability, either passive or active range of motion is indicated to keep the joint moving freely. Application of a premolded splint also would keep the limb aligned and in good position. The client should not attempt to stand unsupported on a weak or paralyzed limb. The inability to bear weight will cause the client to fall. Strategy: Use the process of elimination. Note the strategic words need for reinforcement and note the client's diagnosis. Focusing on the subject of safety will direct you to option 1. Review care of the client with hemiplegia if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2111-2112, 2125-2126). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2111) A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. The nurse interprets that: a. Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable. b. Anorexia is a sign of clinical depression, and a referral to a psychologist is needed. c. The client has compulsive habits, which should be ignored so long as they are not harmful. d. The client probably has a naturally slow metabolism, and the decreased nutritional intake will not matter. Source: Saunders 4th

ANS: A Rationale: Depression frequently may be seen in the client with spinal cord injury and may be exhibited as a loss of appetite. However, the client should be allowed to choose the types of food eaten and when they are eaten as much as is feasible, because it is one of the few areas of control that the client has left. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination, focusing on the data presented in the question. Noting the strategic words client control in option 1 should direct you to this option. Review care of the client with a spinal cord injury if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2227). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1508) The nurse is preparing a hospitalized client with a diagnosis of depression for discharge. In evaluating the coping strategies learned during hospitalization, the nurse would recognize which of the following statements, if made by the client, as an indication that further teaching needs to occur? a. "I know that I won't become depressed again." b. "I know that I can't be all things to all people." c. "I need to take my medications just as prescribed." d. "I have learned ways to deal with the stresses in my life." Source: Saunders 4th

ANS: A Rationale: Depression may be a recurring illness for some persons. The client needs to understand the symptoms and recognize when treatment needs to begin again. Options 2, 3, and 4 indicate that the client has learned some coping skills, such as setting limits and taking medications. Option 1 is an unrealistic statement, indicating that further teaching is needed. Strategy: Use the process of elimination, noting the strategic words further teaching needs to occur. These words indicate a negative event query and ask you to select an option that is incorrect. Review expected outcomes for the client with depression if you had difficulty with this question. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 340). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Teaching and Learning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2176) A client with narcolepsy has been prescribed dextroamphetamine (Dexedrine). The client complains to the nurse that he cannot sleep well anymore at night and does not want to take the medication any longer. Before making any specific comment, the nurse plans to investigate whether the client takes the medication at which of the following proper time schedules? a. At least 6 hours before bedtime b. 2 hours before bedtime c. After supper each night d. Just before going to sleep Source: Saunders 4th

ANS: A Rationale: Dextroamphetamine is a central nervous system (CNS) stimulant that acts by releasing norepinephrine from nerve endings. The client should take the medication at least 6 hours before going to bed at night to prevent disturbances with sleep. Strategy: Use the process of elimination. Remember that this medication causes CNS stimulation and this medication effect interferes with sleep. Knowing this, evaluate each of the options in terms of how far removed the scheduled dose is from the client's bedtime. This will direct you to option 1. Review the proper administration schedule for this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 254). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2335) A client is scheduled for a digital subtraction angiography study. In providing instructions to the client regarding the test, the nurse explains that the test is performed to: a. Provide information about the blood vessels b. Inject medication into the bone c. Detect lesions in the brain d. Examine the cerebrospinal column Source: Saunders 4th

ANS: A Rationale: Digital subtraction angiography is a radiographic method to study the blood vessels. The nurse should explain to the client that the test provides information about the blood vessels. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they are comparative or alike in that they both relate to the neurological system. Regarding the remaining options, focus on the strategic word angiography to direct you to option 1. Review this content if you are unfamiliar with this test. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., pp. 474-475). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2602) A client has been given diphenhydramine (Benadryl) 1% as a topical agent for allergic dermatitis. The nurse instructs the client to observe for which intended medication effect? a. Decrease in urticaria b. Nighttime sedation c. Resolution of ecchymoses d. Healing of burned tissue Source: Saunders 4th

ANS: A Rationale: Diphenhydramine reduces the symptoms of allergic reaction, such as itching or urticaria, when used as a topical agent on the skin. When taken orally, it may provide mild nighttime sedation. It is not used to treat burns or ecchymoses. Strategy: Note the strategic words topical agent and intended medication effect. Recalling that diphenhydramine is an antihistamine will assist in directing you to the correct option. Review the intended effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 365). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1996) A client is receiving phenobarbital sodium (Luminal) for the treatment of a seizure disorder. Which of the following findings on the nursing assessment would indicate that the client is experiencing a common side effect of this medication? a. Drowsiness b. Blurred vision c. Seizure activity d. Hypocalcemia Source: Saunders 4th

ANS: A Rationale: Drowsiness is a common side effect of phenobarbital. Blurred vision is not an associated side effect of this medication. Seizure activity could occur from abrupt withdrawal of this medication therapy, or as a toxic reaction. Hypocalcemia is a rare toxic reaction. Strategy: Focus on the strategic word common in the question. Use the process of elimination and eliminate option 3, knowing that this medication is used to prevent and treat seizure disorders. Regarding the remaining options, recalling that this medication may cause drowsiness will direct you to option 1. Review the action and effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 923). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1705) A client is seen in the health care clinic and is diagnosed with mild anemia. The anemia is believed to be a result of the menstrual period. The woman asks the nurse how much blood is lost during a menstrual period. The nurse plans to respond by stating which of the following amounts of blood is lost during this time? a. 40 mL b. 60 mL c. 80 mL d. 100 mL Source: Saunders 4th

ANS: A Rationale: During a menstrual period, a woman loses about 40 mL of blood. Because of the recurrent loss of blood, many women become mildly anemic during their reproductive years, especially if their diets are low in iron. Strategy: Use the process of elimination. Knowledge regarding the menstrual phase of the menstrual cycle and the amount of blood lost during a menstrual period is required to answer this question. Remember that during a menstrual period, a woman loses about 40 mL of blood. If you are unfamiliar with the menstrual phase, review this content area. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 63). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1580) A pregnant client is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. The nurse plans to base the response on which of the following? a. The breast changes are because of the secretion of estrogen and progesterone. b. The breasts become stretched because of the weight gain. c. The increased metabolic rate causes the breasts to become larger. d. Cortisol secreted by the adrenal glands play a factor in increasing the size and appearance of the breasts. Source: Saunders 4th

ANS: A Rationale: During pregnancy, the breasts change in size and appearance. The increase in size is because of the effects of estrogen and progesterone. Estrogen stimulates the growth of mammary ductal tissue and progesterone promotes the growth of lobes, lobules, and alveoli. A delicate network of veins is often visible just beneath the surface of the skin. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination. Knowledge regarding the physiological changes that occur during pregnancy is required to answer this question. Remember the increase in size is because of the effects of estrogen and progesterone. If you are unfamiliar with the effects of hormones and the changes that occur, review this content. Reference: Lowdermilk, D., & Perry, A. (2004). Maternity and woman's health care (8th ed., p. 355). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1632) An 85-year-old client is hospitalized for a right fractured hip. During the postoperative period, the client's appetite is poor and the client refuses to get out of bed. Which nursing statement would be appropriate to make to the client? a. "It is important for you to get out of bed so that calcium will go back into the bone." b. "We need to increase your calcium intake because you are spending too much time in bed." c. "We need to give you iodine so that it will help in hemoglobin synthesis." d. "You need to remember to turn yourself in bed every 2 hours to keep from getting so stiff." Source: Saunders 4th

ANS: A Rationale: Early ambulation in the postoperative period is important because if a client does not increase activity, the bones will suffer from loss of calcium. Increasing calcium intake would cause elevated amounts of calcium in the blood, which could lead to kidney stones. Iron, not iodine, is recommended for hemoglobin synthesis because oxygen is necessary for wound healing. Clients who are not turned in bed will develop pressure ulcers. An 85-year-old client who is immobile needs to be turned every 2 hours by the nursing staff. The client should not be expected to turn himself or herself. Strategy: Use the process of elimination. Option 4 should be eliminated first because in this statement, the nurse is not accepting responsibility for the client's care. Next, eliminate option 3 because iodine is not useful in hemoglobin synthesis. From the remaining options, select option 1 over option 2 because of the importance of the client getting out of bed. Review the complications associated with immobility if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 311-312). Philadelphia: W.B. Saunders. Reference: Meiner, S., & Leuckenotte, A. (2006). Gerontologic nursing (3rd ed., p. 353). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

920) The client is admitted to the hospital for treatment of acute hepatitis B. Which activity order should the nurse expect to be prescribed? a. Bed rest b. Out of bed in a chair c. Encourage ambulation d. No activity restrictions Source: Saunders 4th

ANS: A Rationale: Fatigue is a normal response to hepatic cellular damage. During the acute stage, rest is an essential intervention to reduce the metabolic demands on the liver and increase its blood supply. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination and note the strategic word acute in the question. Knowing that the liver will need to rest to heal will direct you to option 1. If you are unfamiliar with the care of a client with hepatitis, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1386). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1678) A 13-year-old child is diagnosed with Ewing's sarcoma of the femur. Following a course of radiation and chemotherapy, it has been decided that leg amputation is necessary. Following the amputation, the child becomes very frightened because of aching and cramping felt in the missing limb. Which nursing statement would be appropriate to assist in alleviating the child's fear? a. "This aching and cramping is normal and temporary and will subside." b. "This normally occurs after the surgery and we will teach you ways to deal with it." c. "The pain medication that I give you will take these feelings away." d. "This pain is not real pain and relaxation exercises will help it go away." Source: Saunders 4th

ANS: A Rationale: Following amputation, phantom limb pain is a temporary condition that some children may experience. This sensation of burning, aching, or cramping in the missing limb is most distressing to the child. The child needs to be reassured that the condition is normal and only temporary. Options 2, 3 and 4 are not appropriate responses to the child. Strategy: Use therapeutic communication techniques. Note that the subject of the question relates to alleviating the child's fear. Option 1 is the only option that will alleviate fear. Options 2, 3, and 4 imply that this pain may be permanent. Review care to the child following amputation if you had difficulty with this question. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 1164). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Child Health Alternate Question Types -> Multiple Choice

1116) A nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous infusion with a rate of 150 mL/hr, unchanged for the last 10 hours. The client's urine output for the last 3 hours was 90, 50, and 28 mL (28 mL most recent). The client's blood urea nitrogen level is 35 mg/dL and serum creatinine level is 1.8 mg/dL, measured this morning. Which of the following actions should the nurse take next? a. Call the physician. b. Check the urine specific gravity. c. Check to see if the client had a sample for serum albumin level drawn. d. Put the intravenous line on a pump so that the infusion rate is sure to stay stable. Source: Saunders 4th

ANS: A Rationale: Following abdominal aortic aneurysm resection or repair, the nurse monitors the client for signs of renal failure. Renal failure can occur because often much blood is lost during the surgery and, depending on the aneurysm location, the renal arteries may be hypoperfused for a short period during surgery. The nurse monitors hourly intake and output and notes the results of daily blood urea nitrogen and creatinine levels. Urine output lower than 30 to 50 mL/hr is reported to the physician. Strategy: Focus on the information in the question and the abnormal assessment data. This question indicates elevations in blood urea nitrogen and creatinine levels and a significant drop in hourly urine output. These assessment findings should direct you to option 1. Review the complications associated with this surgical procedure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 807-808). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1559) The client has had surgery to repair a fractured left hip. The nurse obtains which of the following most important items from the unit storage area to use when repositioning the client from side to side in bed? a. Abductor splint b. Adductor splint c. Bed pillow d. Overhead trapeze Source: Saunders 4th

ANS: A Rationale: Following surgery to repair a fractured hip, an abductor splint is used to maintain the affected extremity in good alignment when the client is turned side to side. An overhead trapeze and bed pillow may also be used in the postoperative period, but they are not the priority items to be used in repositioning. Strategy: Use the process of elimination, noting the strategic words most important. Also, focus on the subject, repositioning the client from side to side in the postoperative period. Use principles of client safety and knowledge of this surgical procedure to direct you to option 1. Review care of the client with a fractured hip if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 642-643). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1214-1215). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2611) A physician has just ordered foscarnet (Foscavir) to be given intravenously for a client with acquired immunodeficiency syndrome (AIDS). The nurse obtains which of the following pieces of equipment to administer this medication? a. An infusion pump b. A glass bottle c. A microdrip tubing set d. Special manufacturer's tubing Source: Saunders 4th

ANS: A Rationale: Foscarnet, an antiviral medication used to treat cytomegalovirus (CMV) retinitis in clients with AIDS, should be administered with a controlled infusion device because of its potential toxicity. The items described in each of the other options are unnecessary. Strategy: Use the process of elimination. Noting the strategic word intravenously will assist in directing you to option 1. Review nursing considerations with the administration of this medication if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 580). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2194) A home health nurse visits an agoraphobic client who experiences panic attacks. Which of the following statements by the client would indicate that the client is responding to behavioral and pharmacological treatment? a. "I went to the movies with my family and stayed through the whole film by sitting in a seat along the aisle." b. "I took extra Xanax and got through the funeral fairly well." c. "Taking my Prozac and Xanax before I leave has helped me to cross the bridge and go to work every morning." d. "I have noticed that I'm becoming anxious and I worry that if I don't take my Xanax just before it's due, I'll go crazy, so I get it ready to take to calm down." Source: Saunders 4th

ANS: A Rationale: Generalizing fears to a specific place or situation is the hallmark of agoraphobia. Improvement is observed when the client is able to demonstrate appropriate coping behaviors for anxiety reduction. Options 2 and 3 would not indicate improvement because the client is identifying the need to take extra medication— alprazolam (Xanax) and fluoxetine (Prozac)—to cope. Option 4 is inappropriate because the client is demonstrating "clock-watching" with regard to the medication schedule. Strategy: Use the process of elimination, focusing on the subject, responding to treatment. Option 1 is the only option that demonstrates the client's use of an appropriate coping mechanism. Review content that relates to phobias and coping mechanisms if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 277, 280). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1978) Ferrous sulfate (iron) has been prescribed for the pregnant client. Before initiating the therapy, the nurse reviews which of the following laboratory values that reflects the need for this dietary supplement? a. Hemoglobin level b. Prothrombin time c. Bleeding time d. Clotting time Source: Saunders 4th

ANS: A Rationale: Generally, a healthy diet provides adequate sources of iron. Because of the expansion of maternal blood volume and the production of fetal red blood cells, iron requirements increase in pregnancy. Hemoglobin measures the amount of oxygen in the blood. Ferrous sulfate is a common iron supplement given to pregnant women to prevent anemia. Prothrombin time, bleeding time, and clotting time are tests performed for clients with bleeding disorders. Strategy: Focus on the subject of the question. Note the relationship between iron in the question and hemoglobin in the correct option. Review laboratory values that identify iron deficiency anemia and the need for ferrous sulfate if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 356). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1426) A nurse enters a client's room, and the client is demanding release from the hospital. The nurse reviews the client's record and notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that the admission was a voluntary admission. Which of the following actions will the nurse take? a. Contact the physician. b. Call the client's family. c. Persuade the client to stay a few more days. d. Tell the client that discharge is not possible at this time. Source: Saunders 4th

ANS: A Rationale: Generally, the client seeks voluntary admission. Voluntary clients have the right to demand and obtain release. If the client is a minor, the release may be contingent on the consent of the parent(s) or guardian. The nurse needs to be familiar with the state and facility policies and procedures. Many states require that the client submit a written release notice to the facility staff members, who reevaluate the client's condition for possible conversion to involuntary status, according to criteria established by laws. The best nursing action is to contact the physician. Strategy: Use the process of elimination. Noting the type of hospital admission will assist in eliminating option 4. To "persuade" a client to stay in the hospital is inappropriate. Option 2 should be eliminated simply based on the subjects of client rights and confidentiality. Review the various types of hospital admission and discharge processes if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 50). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 150). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 120-121). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1933) A client with acute glomerulonephritis has had a urinalysis sample sent to the laboratory. The report reveals the presence of hematuria and proteinuria. The nurse interprets that these results are: a. Consistent with glomerulonephritis b. Inconsistent with glomerulonephritis c. Unclear, and no conclusion can be drawn d. Indicative of impending renal failure Source: Saunders 4th

ANS: A Rationale: Gross hematuria and proteinuria are the cardinal signs of glomerulonephritis. The urine may be small in volume, dark or smoky in color from the hematuria, and foamy from the proteinuria. Concurrent serum studies would reveal an elevated blood urea nitrogen, creatinine, C-reactive protein levels, and antistreptolysin O titer. Strategy: Use the process of elimination. Option 4 can be eliminated first, because these results do not indicate impending renal failure. Option 3 is not a likely interpretation and can be eliminated next. Regarding the remaining options, noting the client's diagnosis will direct you to option 1. Review these signs if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1717). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1931) A nurse is performing an admission assessment on a client with a diagnosis of bladder cancer. The nurse would expect to note which of the following as the most likely assessment finding in this client? a. Hematuria b. Burning c. Urgency d. Frequency Source: Saunders 4th

ANS: A Rationale: Gross, painless hematuria most frequently is the first manifestation of bladder cancer. As the disease progresses, the client may experience dysuria, frequency, and urgency. Strategy: Use the process of elimination. The subject of the question relates specifically to bladder cancer. Focusing on this subject should easily direct you to option 1. Also note that options 2, 3, and 4 are most closely associated with urinary tract infections. Review the clinical manifestations of bladder cancer if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1702). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

946) A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which of the following? a. Malaise b. Dark stools c. Weight gain d. Left upper quadrant discomfort Source: Saunders 4th

ANS: A Rationale: Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts. Strategy: Use the process of elimination. Recalling the function of the liver will easily direct you to option 1. Remember that fatigue and malaise are common. If you had difficulty with this question, review the signs and symptoms of hepatitis. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1383). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1033) A client with acquired immunodeficiency syndrome has histoplasmosis. A nurse assesses the client for which of the following signs and symptoms? a. Dyspnea b. Headache c. Weight gain d. Hypothermia Source: Saunders 4th

ANS: A Rationale: Histoplasmosis is an opportunistic fungal infection that can occur in the client with acquired immunodeficiency syndrome (AIDS). The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. Enlargement of the client's lymph nodes, liver, and spleen may occur as well. Strategy: Use the process of elimination. Recalling that histoplasmosis is an infectious process will help you eliminate option 4. Because the client has AIDS and another infection, weight gain is an unlikely symptom and can be eliminated next. Knowing that histoplasmosis begins as a respiratory infection helps you choose dyspnea over headache as the correct option. Review the signs of histoplasmosis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 434). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1792) The nurse notes that the infant with the diagnosis of hydrocephalus has a head that is heavier than that of the average infant. The nurse determines that special safety precautions are needed when moving the infant with hydrocephalus. Which statement would the nurse plan to include in the discharge teaching with the parents to reflect this safety need? a. "When picking up your infant, support the infant's neck and head with the open palm of your hand." b. "Feed your infant in a side-lying position." c. "Place a helmet on your infant when in bed." d. "Hyperextend your infant's head with a rolled blanket under the neck area." Source: Saunders 4th

ANS: A Rationale: Hydrocephalus is a condition characterized by an enlargement of the cranium because of an abnormal accumulation of cerebrospinal fluid in the cerebral ventricular system. This characteristic causes the increase in the weight of the infant's head. The infant may experience significant head enlargement. Care must be exercised so that the head is well supported when the infant is fed or moved to prevent extra strain on the infant's neck, and measures must be taken to prevent the development of pressure areas. Supporting the infant's head and neck, when picking up him or her, will prevent the hyperextension of the neck area and the infant from falling backward. The infant should be fed with the head elevated for proper motility of food processing. A helmet could suffocate an unattended infant during rest and sleep times, and hyperextension of the infant's head could put pressure on the neck vertebrae, causing injury. Strategy: Use the process of elimination and focus on the subject of the question, moving the infant with an enlarged head size. Visualize each option to assist in directing you to option 1, the safe measure. If you had difficulty with this question, review care of the infant with hydrocephalus. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 1060). St. Louis: Mosby. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1508). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

1627) The nurse is caring for a client who is receiving growth hormone replacement therapy. The nurse monitors the client for which side effect of this therapy? a. Hyperglycemia b. Hyperthyroidism c. Hypoglycemia d. Hypocalciuria Source: Saunders 4th

ANS: A Rationale: Hyperglycemia can occur from the administration of growth hormone, particularly in a client with diabetes mellitus. Growth hormone therapy is associated with a decline in thyroid function. Hypercalciuria can occur, particularly during the first 2 to 3 months of therapy. Glucose and thyroid hormone levels should be monitored. Strategy: Knowledge regarding the side effects associated with growth hormone replacement therapy is required to answer the question. Remember that hyperglycemia can occur from the administration of growth hormone. Review these side effects if you are unfamiliar with them. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 761). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2229) A nurse is monitoring the respiratory status of a client after creation of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which of the following coexisting problems? a. Hypotension b. Fever c. Respiratory failure d. Epilepsy Source: Saunders 4th

ANS: A Rationale: Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse oximetry readings from impaired peripheral perfusion. Fever and epilepsy would not affect the accuracy of measurement. Respiratory failure also would not affect the accuracy of measurement, although the readings may be abnormally low. Strategy: Recall that pulse oximetry measures oxygen saturation in blood flowing through the blood vessels in the periphery of the body and that inaccurate measurement may result from any factor that impairs blood flow through the periphery. Evaluating each of the options from this standpoint will help you to select hypotension as the answer. Review the concepts related to pulse oximetry if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1783-1784). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1453) A woman comes into the emergency room in a severe state of anxiety following a car accident. The appropriate nursing intervention is to: a. Remain with the client. b. Put the client in a quiet room. c. Teach the client deep breathing. d. Encourage the client to talk about their feelings and concerns. Source: Saunders 4th

ANS: A Rationale: If a client with severe anxiety is left alone, the client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also important, but the nurse must stay with the client. Teaching the client deep breathing or relaxation is not possible until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased. Strategy: Use the process of elimination. Note the strategic words severe state. Eliminate options 3 and 4 first, knowing that these actions are not possible when the client is in a severe state of anxiety. From the remaining options, the appropriate action is to remain with the client. Review care of the client with severe anxiety if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 512-514). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 216). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1579) An adolescent is diagnosed with conjunctivitis and the nurse provides information to the adolescent about the use of contact lenses. Which statement by the client indicates the need for further information? a. "My contact lenses can be worn if they are cleaned as directed." b. "I should not wear my contact lenses." c. "New contact lenses should be obtained." d. "My old contact lenses should be discarded." Source: Saunders 4th

ANS: A Rationale: If the child wears contact lenses, he or she should be instructed to discontinue wearing them until the infection has cleared completely. Securing new contact lenses will eliminate the chance of reinfection from contaminated contact lenses and will also lessen the risk of a corneal ulceration. Strategy: Use the process of elimination. Note the strategic words need for further information in the question. These words indicate a negative event query and ask you to select an option that is incorrect. Options 2, 3, and 4 are comparative or alike in that they relate to avoiding the use of contact lenses during infection. If you had difficulty with this question, review treatment measures for conjunctivitis. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1588). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

1240) The nurse is caring for a client following enucleation. The nurse notes the presence of bright red drainage on the dressing. Which nursing action is appropriate? a. Notify the physician. b. Document the finding. c. Continue to monitor the drainage. d. Mark the drainage on the dressing and monitor for any increase in bleeding. Source: Saunders 4th

ANS: A Rationale: If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the physician, because this indicates hemorrhage. Options 2, 3, and 4 are inappropriate. Strategy: Use the process of elimination and note the strategic words bright red. Remember, bright red drainage indicates active bleeding. Review postoperative complications associated with an enucleation if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1106-1107). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1009) An unconscious client is admitted to an emergency room. Arterial blood gas measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, a normal oxygen level, and an elevated potassium level. These results indicate the presence of: a. Metabolic acidosis b. Respiratory acidosis c. Overcompensated respiratory acidosis d. Combined respiratory and metabolic acidosis Source: Saunders 4th

ANS: A Rationale: In an acidotic condition, the pH would be low, indicating the acidosis. In addition, a low bicarbonate level along with the low pH would indicate a metabolic state. Therefore, options 2, 3, and 4 are incorrect. Strategy: Use the Pyramid Steps for evaluating the results of a blood gas test. Remember to look at the pH first. This pH of 7.30 would indicate an acidosis. Next, look at the CO₂ level, which in this situation is normal; therefore, a respiratory condition does not exist. This will assist you in eliminating options 2, 3, and 4. Noting that the bicarbonate level is low, as is the pH, should assist in directing you to option 1, a metabolic condition. Review blood gas analysis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 286). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2535) A nurse is performing an assessment on a client who is unconscious after sustaining a head injury. The nurse should avoid performing the oculocephalic response (doll's eyes maneuver) if which condition is present in the client? a. A cervical cord injury b. Lumbar trauma c. Dilated pupils d. Altered level of consciousness Source: Saunders 4th

ANS: A Rationale: In an unconscious client, eye movements are an indication of brain stem activity and are tested by the oculocephalic response. When the doll's eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as that for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brain stem. Contraindications to performing this test include cervical-level spinal cord injuries and severely increased intracranial pressure. Strategy: Use the process of elimination, noting the strategic word avoid. Visualize the classic findings with this maneuver and recall that with a cervical injury, the head is not turned but maintained in a midline position. Review the contraindications associated with this test if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2055-2056). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2547) A nurse is developing a plan of care for a client at risk for acute respiratory distress syndrome (ARDS). The nurse includes in the plan of care to assess for early signs of this disorder by monitoring the client for: a. Dyspnea b. Frothy sputum c. Diminished breath sounds d. Edema Source: Saunders 4th

ANS: A Rationale: In most cases of ARDS, tachypnea and dyspnea are the first clinical manifestations. Blood-tinged frothy sputum would present as a later sign after the development of pulmonary edema. Breath sounds in the early stages of ARDS usually are clear. Edema is not directly associated with ARDS. Strategy: Use the process of elimination. Note the strategic word early in the question. Recall that in most respiratory disorders, tachypnea, dyspnea, and restlessness are often the initial presenting signs as the hypoxia develops. This will assist in directing you to option 1. Review the early signs of ARDS if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 657). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1541) The nurse is interviewing a 16-year-old client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement, if made by the client, indicates an immediate need for further investigation? a. "I don&#39;t like my face any more. I always look like I have been crying." b. "I don&#39;t like my breasts anymore. These silver lines are ugly." c. "I don&#39;t like my stomach anymore. That brown line is disgusting." d. "I don&#39;t like my figure anymore. My clothes are all too tight." Source: Saunders 4th

ANS: A Rationale: In option 1, there is an implication of periorbital and facial edema, which could be indicative of gestational hypertension. Because the question identifies an adolescent who has not sought early prenatal care, she is at higher risk for the development of gestational hypertension. Options 2, 3, and 4 also deal with body image and, although these comments should not be ignored, the need for follow-up is not urgent. Strategy: Use the process of elimination. Note the week of the first prenatal visit (week 18). Also, note the strategic words immediate need. Although all the options identify a potential alteration in body image, option 1 is the only option that identifies data that could indicate a complication of the pregnancy. Review assessment signs related to gestational hypertension if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 597). St. Louis: W.B. Saunders. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 643). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

995) A nurse reviews the arterial blood gas values of a client. The results indicate respiratory acidosis. Which of the following values would indicate that this acid-base imbalance exists? a. pH of 7.30 b. pH of 7.48 c. P<SC>CO</SC> ₂ of 32 mm Hg d. HCO₃ of 20 mEq/L Source: Saunders 4th

ANS: A Rationale: In respiratory acidosis, the pH will be lower than normal and the P<SC>CO</SC> ₂ will be elevated. The normal pH is 7.35 to 7.45. The normal P<SC>CO</SC> ₂ is 35 to 45 mm Hg. The only option that reflects these conditions is option 1. Strategy: Remember that when an acidotic condition exists, the pH will be low. Next, recall that in a respiratory acidotic condition, the P<SC>CO</SC> ₂ will move in the opposite direction from the pH. The only option that represents these conditions is option 1. Review the process of blood gas analysis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 286-287). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1002) Isoniazid (INH) and rifampin (Rifadin) have been prescribed for a client with tuberculosis and the nurse reviews the client's medical record. Which of the following, if noted in the client's history, would require physician notification? a. Hepatitis B b. Heart disease c. Rheumatic fever d. Allergy to penicillin Source: Saunders 4th

ANS: A Rationale: Isoniazid and rifampin are contraindicated in clients with acute liver disease or a history of hepatic injury. Option 1 is the only option that addresses hepatic dysfunction. The medications are not contraindicated in the disorders noted in options 2, 3, and 4. Strategy: Use the process of elimination. Eliminate options 2 and 3 first because they relate to cardiac disorders. From the remaining options, you must know that these medications may cause hepatotoxicity. Review the contraindications associated with the use of these medications if you had difficulty with this question. Reference: Kee, J. Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach. (5th ed., p. 463). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1601) The clinic nurse is assessing the status of jaundice in a child with hepatitis. Which anatomical area will provide the best data regarding the presence of jaundice? a. The nail beds b. The skin in the abdominal area c. The skin in the sacral area d. The membranes in the ear canal Source: Saunders 4th

ANS: A Rationale: Jaundice, if present, is best assessed in the sclera, nail beds, and mucous membranes. Generalized jaundice will appear in the skin throughout the body. Option 4 is not an appropriate area to assess for the presence of jaundice. Strategy: Use the process of elimination. Note the strategic word best in the question. Options 2 and 3 can be eliminated first because jaundice present in the skin is generalized. From the remaining options, recalling that skin discoloration can best be assessed in the nail beds will direct you to option 1. Review assessment findings related to jaundice if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., pp. 821, 1150). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Child Health Alternate Question Types -> Multiple Choice

2537) A nurse is reviewing the record of a client admitted to the nursing unit and notes that the client has a history of Laennec's cirrhosis. The plan of care developed by the nurse will reflect that this type of cirrhosis most commonly is caused by long-term: a. Alcohol abuse b. Cardiac disease c. Exposure to chemicals d. Obstruction to biliary ducts Source: Saunders 4th

ANS: A Rationale: Laennec's cirrhosis results from long-term alcohol abuse. Cardiac cirrhosis most commonly is caused by long-term right-sided congestive heart failure. Exposure to hepatotoxins, chemicals, or infections, or a metabolic disorder can cause postnecrotic cirrhosis. Biliary cirrhosis results from a decrease in bile flow and is most commonly caused by long-term obstruction of bile ducts. Strategy: Specific knowledge regarding the various types of cirrhosis is needed to answer this question. Remember that Laennec's cirrhosis results from long-term alcohol abuse. Review this content if you are unfamiliar with it. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1336-1337). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2028) A nurse is performing an assessment on a client with a diagnosis of Ménière&#39;s disease. The nurse anticipates that the client is most likely to report which of the following symptoms during an acute attack? a. Tinnitus b. Headache c. Fatigue d. Insomnia Source: Saunders 4th

ANS: A Rationale: Ménière's disease results in a disturbance of the fluid of the endolymphatic system. The cause of the disturbance is not known. Attacks may be preceded by feelings of fullness in the ear or by tinnitus. Headaches, fatigue, and insomnia are not associated with this disorder. Strategy: Use the process of elimination. Recalling that Ménière's disease results from a disturbance in the fluid of the endolymphatic system and that it is an ear disorder will direct you to option 1. If you had difficulty with this question, review the pathophysiology and manifestations of Ménière's disease. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1132). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

1408) The client who is human immunodeficiency virus seropositive has been taking Stavudine (d4t, Zerit). The nurse monitors which of the following most closely while the client is taking this medication? a. Gait b. Appetite c. Level of consciousness d. Gastrointestinal function Source: Saunders 4th

ANS: A Rationale: Stavudine (d4t, Zerit) is an antiretroviral used to manage human immunodeficiency virus infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy, and the nurse should monitor the client's gait closely and ask the client about paresthesia. Strategy: Focus on the name of the medication. Recalling that this medication causes peripheral neuropathy will direct you to option 1. If you are not familiar with this medication and the important assessment measures, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1077). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1389) The nurse is providing dietary instructions to the client with systemic lupus erythematosus. Which of the following dietary items would the nurse instruct the client to avoid? a. Steak b. Turkey c. Broccoli d. Cantaloupe Source: Saunders 4th

ANS: A Rationale: The client with systemic lupus erythematosus (SLE) is at risk for cardiovascular disorders such as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce salt, fat, and cholesterol intake. Strategy: Use the process of elimination and note the strategic word avoid in the question. Knowledge regarding the risks associated with SLE and knowledge regarding basic nutritional components of food items help direct you to option 1. If you had difficulty with this question, review therapeutic management of SLE. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1742). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

2464) A nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit and notes a pH of 7.38, PaCO₂ of 38 mm Hg, Pa O₂ of 86 mm Hg, and HCO₃⁻of 23 mEq/L. The nurse interprets that these values indicate which of the following? a. Normal results b. Metabolic alkalosis c. Metabolic acidosis d. Respiratory acidosis Source: Saunders 4th

ANS: A Rationale: The client's results fall in the normal range for pH (7.35 to 7.45), Pa<sc>CO</sc>₂ (35 to 45), and bicarbonate level (22 to 26 mEq/L). With acidosis, the pH would be less than 7.35; with alkalosis, the pH would be greater than 7.45. Carbon dioxide levels would be high with respiratory acidosis, whereas bicarbonate levels would be low if metabolic acidosis was present. Strategy: Knowledge related to arterial blood gas analysis is needed to answer this question. Recalling the normal range for each arterial blood gas level will direct you to option 1. Review these normal values if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 245). Philadelphia: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 117). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

97) The nurse instructs a client with renal failure who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu? a. Cream of wheat, blueberries, coffee b. Sausage and eggs, banana, orange juice c. Bacon, cantaloupe melon, tomato juice d. Cured pork, grits, strawberries, orange juice Source: Saunders 4th

ANS: A Rationale: The diet for a client with renal failure who is receiving hemodialysis should include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids. Options 2, 3, and 4 are high in sodium, phosphorus and potassium. Strategy: Use the process of elimination and focus on the client's diagnosis. Noting the items sausage (option 2), bacon (option 3), and cured pork (option 4) will assist in eliminating these options. Review dietary guidelines for the client with renal failure if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1215). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2060) A community health nurse is providing an educational session for community members regarding dietary measures that will assist in reducing the risk of osteoporosis. The nurse instructs the community members to increase dietary intake of which food known to be helpful in minimizing this risk? a. Yogurt b. Turkey c. Spaghetti d. Shellfish Source: Saunders 4th

ANS: A Rationale: The major dietary source of calcium is from dairy products including milk, yogurt, and a variety of cheeses. Calcium also can be added to certain products such as orange juice, which are then advertised as being fortified with calcium. Calcium supplements also are available and recommended for persons with typically low calcium intake. Options 2, 3, and 4 are not high-calcium products. Strategy: Use the process of elimination. Knowledge that in the client with osteoporosis, calcium intake should be increased will assist in directing you to option 1. If you had difficulty with this question or are unfamiliar with the dietary measures associated with osteoporosis or with the foods high in calcium, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 206, 1160). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

68) A nurse reviews the blood gas results of a client with Guillain-Barré syndrome. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which of the following validates the nurse's findings? a. pH 7.25, P<sc>CO</sc>₂ 50 mm Hg b. pH 7.35, P<sc>CO</sc>₂ 40 mm Hg c. pH 7.50, P<sc>CO</sc>₂ 52 mm Hg d. pH 7.52, P<sc>CO</sc>₂ 28 mm Hg Source: Saunders 4th

ANS: A Rationale: The normal pH is 7.35 to 7.45. The normal Pco₂ is 35 to 45 mm Hg. In respiratory acidosis, the pH is decreased and the Pco₂ is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition. Option 4 identifies respiratory alkalosis. Strategy: Use the process of elimination. Remember that in a respiratory imbalance you will find an opposite response between the pH and the Pco₂. Also, remember that the pH is decreased in an acidotic condition. Option 2 reflects a normal blood gas result. Options 3 and 4 reflect an elevated pH, which indicates an alkalotic condition. Option 1 is the only option that reflects an acidotic condition. Review blood gas analysis if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 245). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D. & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1009). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2466) A clinic nurse is reviewing the laboratory test results for an adult male client as part of a routine physical examination. The nurse interprets that the serum creatinine level is normal if which of the following values is noted? a. 0.6 mg/dL b. 1.9 mg/dL c. 2.4 mg/dL d. 3.5 mg/dL Source: Saunders 4th

ANS: A Rationale: The normal serum creatinine level for an adult male is 0.6 to 1.3 mg/dL. The normal value for females is 0.5 to 1.0 mg/dL. Options 2, 3, and 4 indicate elevated serum creatinine values. Strategy: Knowledge regarding the normal serum creatinine level is required to answer this question. Remember that this level ranges from 0.5 to 1.3 mg/dL. Review this normal value if you had difficulty with this question. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 326). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

95) The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which of the following? a. 2,000 cells/mm³ b. 5,800 cells/mm³ c. 8,400 cells/mm³ d. 11,500 cells/mm³ Source: Saunders 4th

ANS: A Rationale: The normal white blood cell count ranges from 4,500 to 11,000/mm³. The client who is immunosuppressed has a decrease in the number of circulating white blood cells. The nurse implements neutropenic precautions when the client's values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. Options 2, 3, and 4 are normal values. Strategy: Use the process of elimination. Recalling that the normal white blood cell count is 4,500 to 11,000/mm³ will direct you to option 1. Review this hematological test if you had difficulty with this question. Reference: Pagana, K., & Pagana, T. (2006). Mosby's manual of diagnostic and laboratory tests (3rd ed., p. 537). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

1507) The client in a severe major depressive episode is unable to address activities of daily living (ADLs). The appropriate nursing intervention is to: a. Feed, bathe, and dress the client as needed until the client can perform these activities independently. b. Offer the client choices and consequences for the failure to comply with the expectation of maintaining ADLs. c. Have the client's peers confront the client about how the noncompliance in addressing ADLs affects the milieu. d. Structure the client's day so that adequate time can be devoted to the client's assuming responsibility for the ADLs. Source: Saunders 4th

ANS: A Rationale: The symptoms of major depression includes depressed mood, loss of interest or pleasure, changes in appetite and sleep patterns, psychomotor agitation or retardation, fatigue, feelings of worthlessness and guilt, diminished ability to think or concentrate, and recurrent thoughts of death. Often, the client does not have the energy or interest to complete activities of daily living. Options 2 and 4 may lead to increased feelings of worthlessness if the client fails to meet expectations. Option 3 will increase the client's feelings of poor self-esteem and unworthiness. Strategy: Use the process of elimination and note the strategic words severe major depressive episode. Remember that severely depressed clients are unable to perform even the simplest of activities of daily living. Review care of the client with severe depression if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 351). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 336, 341). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1362) A nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Select all instructions that the nurse would include on the list. a. Keep the cast and extremity elevated. b. The cast needs to be kept clean and dry. c. Allow the wet cast 24 to 72 hours to dry. d. Tingling and numbness in the extremity are expected. e. Use a hair dryer set on a warm to hot setting to dry the cast. f. Use a soft padded object that will fit under the cast to scratch the skin under the cast. Source: Saunders 4th

ANS: A ANS: B ANS: C Rationale: A plaster cast takes 24 to 72 hours to dry (synthetic casts dry in 20 minutes). The cast and extremity may be elevated to reduce edema. However, some authors report that this may impede circulation to the affected limb. A wet cast is handled with the palms of the hand until it is dry, and the extremity is turned (unless contraindicated) so that all sides of the wet cast will dry. A cool setting on the hair dryer can be used to dry a plaster cast (heat cannot be used on a plaster cast because the cast heats up and burns the skin). The cast needs to be kept clean and dry, and the client is instructed not to stick anything under the cast because of the risk of breaking skin integrity. The client is instructed to monitor the extremity for circulatory impairment, such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. The physician is notified immediately if circulatory impairment occurs. Strategy: Focus on the issue, a plaster cast. Recalling that edema occurs following a fracture and recalling the complications associated with a cast will assist you in answering the question. Review cast care instructions if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1199). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Multiple

1044) The nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for tuberculosis. Of the following instructions, which will the nurse include on the list? Select all that apply. a. Activities should be resumed gradually. b. Avoid contact with other individuals, except family members, for at least 6 months. c. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. d. Respiratory isolation is not necessary because family members already have been exposed. e. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. f. When one sputum culture is negative, the client is no longer considered infectious and usually can return to former employment. Source: Saunders 4th

ANS: A ANS: C ANS: D ANS: E Rationale: The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. Instruct the client to follow the medication regimen exactly as prescribed and always to have a supply of the medication on hand. Advise the client of the side effects of the medication and ways of minimizing them to ensure compliance. Reassure the client that after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Inform the client that activities should be resumed gradually and about the need for adequate nutrition and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection. Inform the client and family that respiratory isolation is not necessary because family members already have been exposed. Instruct the client about thorough hand washing and to cover the mouth and nose when coughing or sneezing and to put used tissues into plastic bags. Inform the client that a sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of three sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment. Strategy: Knowledge regarding the pathophysiology, transmission, and treatment of tuberculosis is needed to answer this question. Read each option carefully to answer correctly. Review home care instructions for the client with tuberculosis if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1847-1850). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Multiple

1256) The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implantation. Which home care measures will the nurse include in the plan? Select all that apply. a. Avoid activities that require bending over. b. Contact the surgeon if eye scratchiness occurs. c. Place an eye shield on the surgical eye at bedtime. d. Episodes of sudden severe pain in the eye are expected. e. Contact the surgeon if a decrease in visual acuity occurs. f. Take acetaminophen (Tylenol) for minor eye discomfort. Source: Saunders 4th

ANS: A ANS: C ANS: E ANS: F Rationale: Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and usually is relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse also would instruct the client to notify the surgeon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure, such as bending over. Strategy: Note that the client has had eye surgery. Recalling that the eye needs to be protected and that a concern is increased intraocular pressure will assist in determining the home care measures to be included in the plan. Review these measures if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1951). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 452). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Multiple

2613) A nurse is caring for a client receiving haloperidol (Haldol). To assess whether the client is experiencing akathisia as a side effect of the medication, the nurse should observe the client for which of the following? a. Rapid tongue movements b. Restlessness or constant generalized movement c. Lip smacking d. Puffing of the cheeks Source: Saunders 4th

ANS: B Rationale: Akathisia is restlessness or a desire to keep moving. It may appear within 6 hours of administration of the first dose and may be difficult to distinguish from psychotic agitation. The other options describe tardive dyskinesia, which is manifested by uncontrolled rhythmic movements of the mouth, face, and extremities. These movements can include lip smacking or puckering, puffing of the cheeks, uncontrolled chewing, and the presence of rapid or undulating (worm-like) movements of the tongue. Strategy: Use the process of elimination, noting the similarity between options 1, 3, and 4 in that they all refer to the face and mouth. If you had difficulty with this question, review the difference between akathisia and tardive dyskinesia. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 412). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

13) An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that she would like to take an herbal substance to help lower her blood pressure. The nurse should take which appropriate action? a. Tell the client that herbal substances are not safe and should never be used. b. Advise the client to discuss the use of an herbal substance with the physician. c. Teach the client how to take her blood pressure so that it can be monitored closely. d. Tell the client that if she takes the herbal substance she will need to have her blood pressure checked frequently. Source: Saunders 4th

ANS: B Rationale: Although herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are being treated with conventional medication therapy should be advised to avoid herbal substances with similar pharmacological effects because the combination may lead to an excessive reaction or to unknown interaction effects. Therefore, the nurse would advise the client to discuss the use of the herbal substance with the physician. Options 1, 3, and 4 are inappropriate nursing actions. Strategy: Use the process of elimination. Eliminate option 1 first because of the close-ended word never. Next, eliminate options 3 and 4 because they are comparative or alike. Review the limitations associated with the use of herbal substances if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 922-923). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2255) A nurse instructs a client taking aluminum hydroxide (Amphojel) that a most common side effect associated with administration of this medication is: a. Diarrhea b. Constipation c. Muscle weakness d. Headache Source: Saunders 4th

ANS: B Rationale: Aluminum-containing antacids are constipating, so the client should be instructed to take a stool softener or additional bulk-type laxatives to relieve this uncomfortable side effect. Options 1, 3, and 4 are incorrect. Strategy: Remember that aluminum-containing antacids cause constipation. If you are unfamiliar with this medication, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 46). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2567) A client with a diagnosis of Parkinson's disease began taking amantadine (Symmetrel) approximately 2 weeks ago. The client reports to the clinic for a follow-up evaluation. The nurse will determine that the client is experiencing an adverse reaction related to the use of this medication if which of the following is noted? a. Decreased akinesia b. Client complaints of urinary retention c. Decreased rigidity d. A blood pressure of 136/84 mm Hg Source: Saunders 4th

ANS: B Rationale: Amantadine is an antiparkinson agent that potentiates the action of dopamine in the central nervous system. The expected effect of therapy is a decrease in akinesia and rigidity. Leukopenia, urinary retention, and hypotension all are adverse effects of the medication. Strategy: Use the process of elimination. Focus on the client's diagnosis and the subject, adverse reaction. Eliminate options 1 and 3 first because these findings would indicate a therapeutic response to the medication. Eliminate option 4 next because this finding indicates a normal blood pressure. Review the adverse effects of amantadine if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 47). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 961-962). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

940) The client with cirrhosis is beginning to show signs of hepatic encephalopathy. The nurse would plan a dietary consult to limit the amount of which ingredient in the client's diet? a. Fat b. Protein c. Minerals d. Carbohydrate Source: Saunders 4th

ANS: B Rationale: Ammonia is formed as a product of protein metabolism. Clients with hepatic encephalopathy have high serum ammonia levels, which are responsible for the symptoms of encephalopathy. Limiting protein intake will prevent further elevation in the serum ammonia level and prevent further deterioration of the client's mental status. Strategy: Recall the function of the liver and the pathophysiology associated with cirrhosis. This will direct you to option 2. Review this content if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1370). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1539) Propylthiouracil (PTU) is prescribed for the client with hyperthyroidism. The nurse provides instructions to the client regarding the medication and informs the client to notify the physician if which of the following signs occur? a. Drowsiness b. Sore throat c. Increased urination d. Dry mouth Source: Saunders 4th

ANS: B Rationale: An adverse effect of PTU is agranulocytosis. The client needs to be informed of the early signs of this adverse effect, which include fever and sore throat. Drowsiness is an occasional side effect of the medication. Increased urination and dry mouth are unrelated to this medication. Strategy: Use the process of elimination. Recalling that agranulocytosis is an adverse effect of PTU will direct you to option 2. Review the adverse effects of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 731). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2651) A client with bipolar mood disorder has been given a prescription for carbamazepine (Tegretol). The nurse teaching the client about medication side effects instructs the client to notify the physician if which of the following develops? a. Nausea b. Sore throat c. Drowsiness d. Dizziness Source: Saunders 4th

ANS: B Rationale: An adverse reaction to carbemazepine is blood dyscrasia. With development of a fever, sore throat, mouth ulcerations, unusual bleeding or bruising, or joint pain, the physician should be notified because these findings may indicate a blood dyscrasia. Drowsiness, dizziness, nausea, and vomiting are frequent side effects associated with the medication. Strategy: Use the process of elimination, noting the strategic words notify the physician. Recalling that blood dyscrasias can occur with the use of carbemazapine will assist in answering the question. Also, focusing on the strategic words and noting that a sore throat indicates a sign of infection will guide you to select option 2. If you are unfamiliar with the adverse reactions of carbemazepine, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 184). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1973) A client is admitted to the ambulatory care unit for elective surgery. The nurse asks the client if any food, fluid, or medication was taken today. Which of the following medications if taken by the client would indicate to the nurse the need to contact the physician? a. An antibiotic b. An anticoagulant c. A calcium channel blocker d. A β-blocker Source: Saunders 4th

ANS: B Rationale: An anticoagulant suppresses coagulation by inhibiting clotting factors. A client admitted for elective surgery should have been instructed to discontinue the anticoagulant 7 to 10 days preoperatively. Even if this were unscheduled surgery, the nurse should notify the physician. Vitamin K can be given for reversal of its action, but the client may still have an increased risk of bleeding. The other medications listed are commonly taken and do not constitute an increased risk for the client. Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they are comparative or alike (both are cardiac medications). From the remaining options, select option 2, knowing that bleeding poses a risk following surgery. Review preoperative care and the associated risks if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 298). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 606). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2294) A nurse is assessing a client's gait, which is characterized by unsteadiness and staggering steps. The nurse would interpret this gait as being: a. Spastic b. Ataxic c. Festinating d. Dystrophic or broad-based Source: Saunders 4th

ANS: B Rationale: An ataxic gait is characterized by unsteadiness and staggering. A spastic gait is characterized by stiff, short steps with legs held together, hip and knees flexed, and with toes that catch and drag. A festinating gait is best described as walking on the toes with an accelerating pace. A dystrophic or broad-based gait is seen as waddling, with weight shifting from side to side, and with legs far apart. Strategy: Use the process of elimination. Options 1 and 4 can be eliminated first because the names of those types of gait do not seem to coincide with the description in the question. Regarding the remaining options, it may help to remember that an ataxic gait is one of the more common gait alterations. Review the various types of gait if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2030). Philadelphia: W.B. Saunders. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., pp. 712-713). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2044) A nurse receives a telephone call from the hospital emergency department and is told that a client with a cerebral aneurysm will be transferred to the nursing unit. The client is to be placed on aneurysm precautions. The nurse prepares the room for the client and prepares a plan of care. Which of the following should be avoided in the care plan? a. Notify the dietary department to restrict coffee or other caffeine-containing products. b. Allow the client to ambulate four times a day through the hospital hallway. c. Place a blood pressure cuff at the client's bedside. d. Close the shades in the client's room and keep the lights turned down. Source: Saunders 4th

ANS: B Rationale: Aneurysm precautions include placing the client on bedrest in a quiet setting. Lights are kept to a minimum to prevent environmental stimulation. Any activity that increases the blood pressure or impedes venous return from the brain is prohibited, such as pushing, pulling, sneezing, or straining. The nurse provides all physical care, to minimize increases in blood pressure. Visitors, radio, television, and reading materials are prohibited or limited. Stimulants such as coffee and other caffeine-containing products and nicotine are prohibited. Decaffeinated coffee or tea may be used. Strategy: Use the process of elimination, noting the strategic word avoids in the question. This indicates a negative event query and directs you to select an incorrect intervention. Read each option in terms of whether it would increase intracranial pressure. Recalling that the client must remain on bedrest will assist in directing you to this option. Review the components of aneurysm precautions if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2095). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

986) A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client? a. Hypocapnia b. A hyperinflated chest noted on the chest x-ray c. Increased oxygen saturation with exercise d. A widened diaphragm noted on the chest x-ray Source: Saunders 4th

ANS: B Rationale: Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Strategy: Use the process of elimination. Eliminate option 1 because in the client with COPD, hypercapnia would be noted. Next, eliminate option 3 because oxygen desaturation rather than saturation would occur. From the remaining options, reading carefully will assist in directing you to option 2. If you are unfamiliar with the manifestations associated with COPD, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 559). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2086) A nurse is administering a dose of morphine sulfate to a client via an epidural catheter after nephrectomy. Before administering the medication, the nurse should plan to: a. Aspirate with a syringe to ensure presence of a cerebrospinal fluid (CSF) return. b. Ensure that naloxone (Narcan) is readily available. c. Place the head of the bed flat. d. Flush the catheter with 6 mL of sterile water. Source: Saunders 4th

ANS: B Rationale: Epidural analgesia is used for clients with expected high levels of postoperative pain. The nurse carefully checks the medication, notes the client's level of sedation, and makes sure that the head of bed is elevated 30 degrees, unless contraindicated. The nurse aspirates with a syringe to make sure that no CSF return occurs. If CSF returns with aspiration, the catheter has migrated from the epidural space into the subarachnoid space. The catheter is not flushed with 6 mL of sterile water. Narcan should be readily available for use if respiratory depression should occur. Strategy: Use the process of elimination. Begin to answer this question by eliminating option 4 first. Flushing 6 mL of sterile water through an epidural catheter is not appropriate. Option 1 is eliminated next, because CSF aspiration should not occur with an epidural catheter. Regarding the remaining options, recalling that naloxone is used to treat respiratory depression will direct you to option 2. Review the procedure for administering medication through an epidural catheter if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 925). Philadelphia: W.B. Saunders. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007. Philadelphia: W.B. Saunders, p. 796. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2543) An emergency department nurse is preparing a plan for initial care of a client with a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome (HHNS). The care plan will reflect that the hyperglycemia associated with this disorder results from: a. Increased utilization of glucose b. Increased production of glucose c. Overproduction of insulin d. Increased osmotic movement of water Source: Saunders 4th

ANS: B Rationale: Hyperglycemia results from decreased utilization and increased production of glucose. Increased utilization of glucose and overproduction of insulin would most likely cause hypoglycemia. Option 4 is incorrect. Strategy: Focus on the subject of the question, hyperglycemia. Use the process of elimination and think about the pathophysiologic changes associated with hyperglycemia to direct you to option 2. Review the pathophysiology of HHNS if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1545). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

55) A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level? a. The client with renal failure b. The client who is taking diuretics c. The client with hyperaldosteronism d. The client who is taking corticosteroids Source: Saunders 4th

ANS: B Rationale: Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with renal failure or hyperaldosteronism are at risk for hypernatremia. Strategy: Use the process of elimination. First, determine that the client is experiencing hyponatremia. Next, you must know the causes of hyponatremia to direct you to option 2. Review the normal serum sodium level and the causes of hyponatremia if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1141). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2532) A nurse is reviewing the medical record of a client transferred to the medical unit from the critical care unit. The nurse notes that the client received intra-aortic balloon pump (IABP) therapy while in the critical care unit. The nurse suspects that the client received this therapy for which of the following conditions? a. Congestive heart failure b. Cardiogenic shock c. Pulmonary edema d. Aortic insufficiency Source: Saunders 4th

ANS: B Rationale: IABP therapy most often is used in the treatment of cardiogenic shock and is most effective if instituted early in the course of treatment. Use of the IABP is contraindicated in clients with aortic insufficiency and thoracic and abdominal aneurysms. This therapy is not used in the treatment of congestive heart failure or pulmonary edema. Strategy: Use the process of elimination. Eliminate options 1 and 3 first because they are comparative or alike. Regarding the remaining options, consider the purpose of IABP. Recalling that IABP is contraindicated in clients with aortic insufficiency will direct you to option 2. Review the purpose and use of IABP if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 854). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

915) The nurse is performing a colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action? a. Notify the physician. b. Stop the irrigation temporarily. c. Increase the height of the irrigation. d. Medicate for pain and resume the irrigation. Source: Saunders 4th

ANS: B Rationale: If cramping occurs during a colostomy irrigation, the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from an infusion that is too rapid or is causing too much pressure. The physician does not need to be notified. Increasing the height of the irrigation will cause further discomfort. Medicating the client for pain is not the appropriate action in this situation. Strategy: Focus on the subject, abdominal cramping during irrigation. This will assist in eliminating options 1, 3, and 4. If you had difficulty answering this question, review the procedure for colostomy irrigation. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 838). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1092). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1831) A nurse is monitoring a client who has just returned from surgery after a transurethral resection of the prostate (TURP). The client has a three-way Foley catheter in place for ongoing bladder irrigation. The nurse is observing the color of the client's urine and should expect which of the following during the immediate postoperative period? a. Bright red blood with small clots in the urine b. A pale pink-colored urine c. Tea-colored urine d. A dark pink-colored urine Source: Saunders 4th

ANS: B Rationale: If the bladder irrigation is infusing at a sufficient rate, the urinary drainage through the Foley tubing should be pale pink. Bright red bleeding and clots could indicate a complication, and if this is noted, it should be reported to the physician. A dark pink-colored urine indicates that the rate of the irrigation solution should be increased. Tea-colored urine is not seen after a TURP but may be noted in a client with other renal disorders such as renal failure. Strategy: Use the process of elimination. Eliminate options 1 and 4, recalling that hemorrhage is a complication after this procedure. Regarding the remaining options, recall that the purpose of a bladder irrigation is to flush out blood and clots that would otherwise accumulate in the bladder. This will direct you to option 2. If you had difficulty with this question, review the expected findings after a TURP. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1024). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1863). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1858) A nurse is reviewing the record of a client who arrives at the health care clinic. The nurse notes that irbesartan (Avapro) has been prescribed for the client. The nurse would suspect that the client has which of the following conditions? a. Renal transplant rejection b. Hypertension c. Diabetes mellitus d. Hypothyroidism Source: Saunders 4th

ANS: B Rationale: Irbesartan (Avapro) is an angiotensin II type 1 (AT1) receptor antagonist. It is used to treat hypertension. This medication is not used to treat renal transplant rejection, diabetes mellitus, or hypothyroidism. Strategy: Use the process of elimination. Knowledge regarding the therapeutic use of irbesartan is required to answer this question. Remember that this medication is used to treat hypertension. If you are unfamiliar with this medication, review its use and action. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 636-637). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1654) A client is seen in the clinic for complaints of thirst, frequent urination, and headaches. Following diagnostic studies, diabetes insipidus in diagnosed. Lypressin is prescribed. The nurse instructs the client that the medication is prescribed to: a. Relieve the headaches. b. Increase water reabsorption. c. Decrease the production of the antidiuretic hormone. d. Stimulate the production of aldosterone. Source: Saunders 4th

ANS: B Rationale: Lypressin is an antidiuretic hormone used in the treatment of diabetes insipidus. It promotes renal conservation of water by acting on the collecting ducts of the kidney to increase the permeability to water, which results in increased water reabsorption. Options 1, 3, and 4 are not actions of the medication. Strategy: Note the diagnosis identified in the question. Recalling the pathophysiology associated with the disorder will assist in the process of elimination and in directing you to the correct option. Review the action of lypressin if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 759). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1557) The nurse recognizes that which of the following interventions is unlikely to facilitate effective communication between the dying client and family? a. The nurse encourages the client and family to identify and discuss feelings openly. b. The nurse makes decisions for the client and family to relieve them of unnecessary demands. c. The nurse assists the client and family in carrying out spiritually meaningful practices. d. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger. Source: Saunders 4th

ANS: B Rationale: Maintaining effective and open communication among family members affected by death and grief is of the greatest importance. Option 1 describes encouraging discussion of feelings and is likely to enhance communications. Option 3 is also an effective intervention, because spiritual practices give meaning to life and have an impact on how people react to crisis. Option 4 is also an effective technique, because the client and family need to know that someone will be there who is supportive and nonjudgmental. Option 2 describes the nurse removing autonomy and decision making from the client and family, who are already experiencing feelings of loss of control in that they cannot change the process of dying. This is an ineffective intervention, which could further impair communication. Strategy: Use the process of elimination, noting the strategic words unlikely to facilitate. Understanding that people in crisis usually feel helpless and unable to control their circumstances can assist in identifying option 2 as a response that further removes control. Review these therapeutic interventions if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 579). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 603). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1450) The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. The symptom presented by the client that requires the nurse's immediate intervention is the client's: a. Outlandish behaviors and inappropriate dress b. Nonstop physical activity and poor nutritional intake c. Grandiose delusions of being a royal descendent of King Arthur d. Constant, incessant talking that includes sexual innuendoes and teasing the staff Source: Saunders 4th

ANS: B Rationale: Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. Mania is a period when the mood is predominantly elevated, expansive, or irritable. All options reflect a client's possible symptomatology. Option 2, however, clearly presents a problem that compromises physiological integrity and needs to be addressed immediately. Strategy: Note the strategic word immediate and use Maslow's Hierarchy of Needs theory to assist you in answering the question. Option 2 is the only option that reflects a physiological need. Review care of the client with mania if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 210-211). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 364-365, 368). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

1565) The hospitalized client with diabetes mellitus received NPH insulin in the morning. The nurse monitors the client for hypoglycemia, knowing that the peak action occurs: a. 2 to 4 hours after administration. b. 4 to 12 hours after administration. c. 12 to 16 hours after administration. d. 18 to 24 hours after administration. Source: Saunders 4th

ANS: B Rationale: NPH insulin is an intermediate-acting insulin. Its onset of action is 3 to 4 hours, it peaks in 4 to 12 hours, and its duration of action is 16 to 20 hours. Strategy: Read the question carefully, noting that the question is asking about NPH insulin. Knowledge regarding the onset of action, peak, and duration of action is required to answer the question. Review these points regarding both NPH and Regular insulin if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1254). Philadelphia: W.B. Saunders. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 779-780). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1205) Nalidixic acid (NegGram) is prescribed for a client with a urinary tract infection. On review of the client's record, the nurse notes that the client is taking warfarin sodium (Coumadin) daily. Which prescription should the nurse anticipate for this client? a. Discontinuation of warfarin sodium (Coumadin) b. A decrease in the warfarin sodium (Coumadin) dosage c. An increase in the warfarin sodium (Coumadin) dosage d. A decrease in the usual dose of nalidixic acid (NegGram) Source: Saunders 4th

ANS: B Rationale: Nalidixic acid can intensify the effects of oral anticoagulants by displacing these agents from binding sites on plasma protein. When an oral anticoagulant is combined with nalidixic acid, a decrease in the anticoagulant dosage may be needed. Strategy: Knowledge about the medication interactions associated with the use of nalidixic acid is needed to answer this question. Remember that nalidixic acid can intensify the effects of oral anticoagulants. Review these interactions if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 488). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1819) A nurse is performing Apgar scoring for a newborn immediately after birth. The nurse notes that the respiratory rate is less than 100, that respiratory effort is irregular, and that muscle tone shows some extremity flexion. The newborn grimaces when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. The nurse should appropriately document which of the following Apgar scores for the newborn? a. 3 b. 5 c. 7 d. 10 Source: Saunders 4th

ANS: B Rationale: One of the earliest indicators of successful adaptation of the newborn is the Apgar score. Scores range from 0 to 10. Five criteria are used to measure the infant's adaptation. Heart rate: absent = 0; less than 100 = 1; greater than 100 = 2. Respiratory effort: absent = 0; slow or irregular weak cry = 1; good, crying lustily = 2. Muscle tone: limp or hypotonic = 0; some extremity flexion = 1; active, moving, and well flexed = 2. Irritability or reflexes (measured by bulb suctioning): no response = 0; grimace = 1; cough, sneeze, or vigorous cry = 2. Color: cyanotic or pale = 0; acrocyanotic, cyanosis of extremities = 1; pink = 2. Strategy: Knowledge of the Apgar scoring system is required to answer this question. First recall that the maximum score is 10. Note the following words: less than 100, irregular, some extremity flexion, grimaces, and cyanosis of extremities. Each of these items suggests that one point should be deducted from each area. If you had difficulty with this question, review Apgar scoring. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 298). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Communication and Documentation Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

2503) A postpartum client who received an epidural analgesic after giving birth by cesarean section is lethargic and has a respiratory rate of 8 breaths/min. The nurse obtains which of the following medications from the emergency cart after notifying the physician? a. Meperidine hydrochloride (Demerol) b. Naloxone (Narcan) c. Betamethasone d. Morphine sulfate Source: Saunders 4th

ANS: B Rationale: Opioids are used for epidural analgesia, which can lead to delayed respiratory depression. For this reason, respirations are monitored for 24 hours after administration of epidural analgesia. Naloxone is a narcotic antagonist, which reverses the effects of opioids and is given if the respiratory rate falls below 6 to 8 breaths/min. Morphine sulfate and meperidine hydrochloride are opioids and would further compromise the respiratory rate. Bethamethasone is a corticosteroid administered to enhance fetal lung maturity. Strategy: Use the process of elimination. Recalling that narcotics are used for epidural anesthesia will assist in eliminating options 1 and 4. From the remaining options, eliminate option 3 because it is a corticosteroid, whereas option 2 is the opioid antagonist. Review the purpose and actions of the medications presented in the options if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 813). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 600). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1528) The nurse is describing the medication side effects to a client who is taking oxazepam (Serax). The nurse incorporates in discussions with the client the need to: a. Consume a low-fiber diet. b. Increase fluids and bulk in the diet. c. Rest if the heart begins to beat rapidly. d. Take antidiarrheal agents if diarrhea occurs. Source: Saunders 4th

ANS: B Rationale: Oxazepam (Serax) causes constipation, and the client is instructed to increase fluid intake and bulk (high fiber) in the diet. If the heart begins to beat fast, the physician is notified, because this could indicate overdose. Additionally, diarrhea could indicate an incomplete intestinal obstruction and, if this occurs, the physician is notified. Strategy: Use the process of elimination. Recalling that constipation is a side effect of this medication will direct you to option 2. Review the side effects and adverse effects of oxazepam if you had difficulty with this question. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., p. 677). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2397) A client has an order to have blood drawn to measure peak and trough vancomycin (Vancocin) levels to determine the effectiveness of therapy with this medication. The nurse arranges with the laboratory to have the peak level specimen drawn: a. Immediately after administration of the scheduled dose b. 1.5 hours after completion of the scheduled infusion c. 1 hour before administration of the scheduled dose d. 30 minutes before administration of the scheduled dose Source: Saunders 4th

ANS: B Rationale: Peak serum drug levels should be monitored to ensure that the dosage is appropriate and should be drawn 1.5 to 2.5 hours after the IV infusion is completed. Peak levels of 30 to 40 mcg/mL generally are acceptable. Options 1, 3, and 4 are incorrect. Strategy: Use the process of elimination. Noting the subject, peak level, will assist in eliminating options 1, 3, and 4. Review nursing interventions related to determination of peak and trough levels if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 978). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1681) The client with type 1 diabetes mellitus is having trouble remembering the types, duration, and onset of the action of insulin. The client tells the nurse that the family members have not been supportive. The nurse's best response to the client is: a. "You can't always depend on your family to help." b. "Let me go over the types of insulin with you again." c. "It's not really necessary for you to remember this." d. "What is it that you don't understand?" Source: Saunders 4th

ANS: B Rationale: Reinforcement of knowledge and behaviors is vital to the success of the client's self-care. Options 1, 3, and 4 do not address the need for client instructions and are not therapeutic responses. Strategy: Use the process of elimination and therapeutic communication techniques. Option 1 devalues a client's family, option 3 places the client's issue on hold, and option 4 requests an explanation from the client. Option 2 validates and clarifies previous information. Review therapeutic communication techniques if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1290). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

2368) A pediatric nurse has obtained ribavirin (Virazole) in powder form from the pharmacy to administer to a child with respiratory syncytial virus (RSV) infection. After preparing the medication, the nurse administers it by which of the following routes? a. Intravenous b. Inhalation c. Oral, in formula d. Subcutaneous Source: Saunders 4th

ANS: B Rationale: Ribavirin is active against RSV, influenza virus types A and B, and herpes simplex virus. It is administered by oral inhalation. The medication is absorbed from the lungs and achieves high concentrations in respiratory tract secretions and erythrocytes. It is not administered by the routes identified in options 1, 3, and 4. Strategy: To answer this question correctly, you must know that this medication is administered by inhalation. If you are unfamiliar with this medication and its method or route of administration, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1017). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 754). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2699) A client with a respiratory tract infection is receiving intravenous tobramycin sulfate (Tobrex). The nurse should assess for which of the following adverse effects of this medication? a. Hypotension b. Vertigo c. Vomiting d. Nausea Source: Saunders 4th

ANS: B Rationale: Ringing in the ears and vertigo are two symptoms of ototoxicity that may indicate dysfunction of the eighth cranial nerve. This is a frequent adverse effect of therapy with the use of aminoglycosides and could result in permanent hearing loss. In clients with these symptoms, the nurse should withhold the dose of the medication and notify the physician. Nausea, vomiting, and hypotension are rare side effects of the medication. Strategy: Note the strategic words adverse effects. Recalling that tobramycin is an aminoglycoside and that ototoxicity is a frequent adverse effect of this medication will direct you to option 2. Review the adverse and side effects of this medication if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 1174). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2564) The clinic nurse is reviewing the assessment findings for a client who has been taking spironolactone (Aldactone) for treatment of hypertension. Which of the following, if noted in the client's record, would indicate that the client is experiencing a side effect related to the medication? a. A potassium level of 3.2 mEq/L b. A potassium level of 5.8 mEq/L c. Client complaint of constipation d. Client complaint of dry skin Source: Saunders 4th

ANS: B Rationale: Spironolactone is a potassium-sparing diuretic. Side effects include hyperkalemia, dehydration, hyponatremia, and lethargy. Although the concern with most diuretics is hypokalemia, this medication is potassium sparing, which means that the concern with this medication is hyperkalemia. Additional side effects include nausea, vomiting, cramping, diarrhea, headache, ataxia, drowsiness, confusion, and fever. Strategy: Use the process of elimination. Recalling that this medication is a potassium-sparing diuretic will direct you to option 2. Review the classification of spironolactone and its side effects if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 1074-1075). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1720). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1861) Tamsulosin hydrochloride (Flomax) is prescribed for a client. The nurse should suspect the medication is prescribed to relieve which of the following conditions? a. Respiratory congestion b. Urinary obstruction c. Constipation d. Muscle spasms Source: Saunders 4th

ANS: B Rationale: Tamsulosin hydrochloride is used to relieve mild-to-moderate manifestations that occur in benign prostatic hypertrophy. The medication also improves urinary flow rates. Options 1, 3, and 4 are incorrect. Strategy: Knowledge regarding the action of tamsulosin hydrochloride is required to answer this question. Recall that this medication is used to treat urinary obstruction. If you had difficulty with this question or are unfamiliar with this medication, review its action and use. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1096). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1561) The nurse has given activity guidelines to the client with chronic low back pain. The nurse determines that the client understands the instructions if the client states that he or she will avoid which of the following positions? a. Lying on the side, with knees and hips bent b. Lying prone c. Standing with one foot on a step or stool d. Sitting using a lumbar roll or pillow Source: Saunders 4th

ANS: B Rationale: The client should avoid positions or activities that place strain on the lower back. The client should not sleep on the abdomen (prone) or on the side if the hips and knees are straight. The client should not lean forward without bending the knees, stand in one position for lengthy amounts of time, or lift anything above elbow level. It may be helpful for the client to stand with a foot elevated on a stool, or to sit using a form of lumbar support. Strategy: Use the process of elimination, noting the strategic word avoid. Use knowledge of body mechanics and low back injury to answer the question. If you had difficulty with this question, review client teaching points related to low back pain. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 978-979). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 1700-1701). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1223) A nurse is instructing a client to administer epoetin alfa (Epogen, Procrit) by the subcutaneous route. The nurse tells the client to: a. Shake the vial before use. b. Refrigerate the medication. c. Freeze the medication before use. d. Obtain syringes with 1½-inch needles from the pharmacy. Source: Saunders 4th

ANS: B Rationale: The client should be instructed not to shake the bottle. The medication should be refrigerated at all times. The medication should not be frozen. Syringes with a ⅝-inch needle are used for subcutaneous injection. A 1½-inch needle may be used for intramuscular injection. Strategy: Use the process of elimination. Note that options 2 and 3 identify opposite actions. This should provide you with the clue that one of these options may be the correct one. Review the teaching points related to the administration of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 423). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

929) The client with a new colostomy is concerned about the odor from stool in the ostomy drainage bag. The nurse teaches the client to include which food in the diet to reduce odor? a. Eggs b. Yogurt c. Broccoli d. Cucumbers Source: Saunders 4th

ANS: B Rationale: The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor but is a gas-forming food as well. Broccoli, cucumbers, and eggs are gas-forming foods. Strategy: Use the process of elimination. Recalling the effect of various foods on the gastrointestinal tract of the client with an ostomy will direct you to option 2. If this question was difficult, review which foods cause odor or gas and those that have a deodorizing effect. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1325). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2634) A client who is taking chlorothiazide (Diuril) comes to the clinic for periodic evaluation. In monitoring the client's laboratory test results for medication side effects, the clinic nurse is most likely to note: a. Hypernatremia b. Hypokalemia c. Hyperphosphatemia d. Hypocalcemia Source: Saunders 4th

ANS: B Rationale: The client taking a potassium-wasting diuretic such as chlorothiazide should be monitored for decreased potassium levels. Other possible fluid and electrolyte imbalances that occur with use of this medication include hyponatremia, hypercalcemia, hypomagnesemia, and hypophosphatemia. Strategy: As a memory aid, the trade name of this medication, Diuril, can be correlated with the type of medication, diuretic. Recalling that this medication is potassium-wasting will direct you to option 2. If this question was difficult for you, review the side effects of this medication. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 179). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1099) A nurse is performing cardiopulmonary resuscitation on a client who has had a cardiac arrest. An automatic external defibrillator is available to treat the client. Which of the following activities will allow the nurse to assess the client's cardiac rhythm? a. Hold the defibrillator paddles firmly against the chest. b. Apply adhesive patch electrodes to the chest and move away from the client. c. Apply standard electrocardiographic monitoring leads to the client and observe the rhythm. d. Connect standard electrocardiographic electrodes to a transtelephonic monitoring device. Source: Saunders 4th

ANS: B Rationale: The nurse or rescuer puts two large adhesive patch electrodes on the client's chest in the usual defibrillator positions. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds. The machine then indicates if defibrillation is necessary. Strategy: Use the process of elimination. If you are not familiar with this piece of equipment, look first at the word automatic in the name. This implies that a person is not as involved in the process as with a conventional defibrillator and will help eliminate option 1. Because standard electrocardiogram monitoring leads do not play an active role once resuscitation is underway (options 3 and 4), you can eliminate these comparative or alike options. Review the procedure related to the use of an automatic external defibrillator if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 742). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1046) A client receiving oral theophylline is due to have a theophylline level drawn. A nurse questions the client to ensure that the client has not ingested which of the following substances before the blood sample is drawn? a. Glucose b. Caffeine c. Sedatives d. Opioids Source: Saunders 4th

ANS: B Rationale: Theophylline is a xanthine bronchodilator. Before drawing of a serum level of the medication, the client should avoid taking foods or beverages that contain xanthine, such as colas, coffee, or chocolate. Thus, the client is told to avoid caffeine intake before the test. Strategy: Use the process of elimination. Recalling that this medication is a xanthine bronchodilator will direct you to option 2. Review client teaching points related to this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 57). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2291) A home health nurse has been discussing interventions to prevent constipation with a client with multiple sclerosis. The nurse determines that the client is using the information most effectively if the client reports: a. Giving herself an enema every morning before breakfast b. Initiating a bowel movement every other day, 45 minutes after the largest meal of the day c. Drinking a total of 1500 mL/day d. Taking stool softeners daily, and a glycerin suppository once a week Source: Saunders 4th

ANS: B Rationale: To effectively manage constipation, the client should take in a high-fiber diet, bulk formers, and stool softeners. A fluid intake of 2000 mL/day is recommended. The client should initiate the bowel program on an every-other-day basis. This should be done approximately 45 minutes after the largest meal of the day, to take advantage of the gastrocolic reflex. A glycerin suppository, bisacodyl suppository, or digital stimulation may be used to initiate the process. Laxatives and enemas should be avoided whenever possible because they lead to dependence. Strategy: Use the process of elimination. Recalling the basic measures related to preventing constipation will direct you to option 2. Review these measures if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2179). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1652) A client is scheduled for a Papanicolaou (Pap) smear at the next scheduled clinic visit. The nurse provides instructions to the client regarding preparation for this test. The nurse tells the client that: a. The test can be performed during menstruation. b. Fluids are restricted on the day of the test. c. The test is painless. d. Vaginal douching is required 2 hours before the test. Source: Saunders 4th

ANS: C Rationale: A Pap smear is usually painless. The test cannot be performed during menstruation. The client needs to be instructed to avoid douching for at least 24 hours prior to the test. There is no reason to restrict fluids on the day of the test. Strategy: Use the process of elimination. Eliminate option 2 first as an unlikely preparation measure. Eliminate options 1 and 4 next because both menstruation and douching will affect the results of the test. Review client preparation for a Pap test if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1781-1782). Philadelphia: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., pp. 674-677). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

1512) The moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by: a. Suggesting a reduction of medication b. Allowing increased "in-room" activities c. Increasing the level of suicide precautions d. Allowing the client off-unit privileges as needed Source: Saunders 4th

ANS: C Rationale: A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm himself or herself. Suicide precautions are necessary to keep the client safe. Strategy: Use the process of elimination. Options 1 and 4 support the client's notion that a cure has occurred. Option 2 allows the client to increase isolation and would present a threat to the client's safety. Safety is of the utmost importance; therefore, option 3 is the correct option. Review care of the client with depression if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing. (3rd ed., pp. 216-217). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 335, 811). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2183) A client began taking amantadine (Symmetrel) approximately 2 weeks earlier. The nurse determines that the medication is having a therapeutic effect if the client exhibits decreased: a. White blood cell count b. Voiding c. Rigidity and akinesia d. Blood pressure Source: Saunders 4th

ANS: C Rationale: Amantadine is an antiparkinson agent that potentiates the action of dopamine in the central nervous system. The expected effect of therapy is a decrease in akinesia and rigidity. Leukopenia, urinary retention, and hypotension all are adverse effects of the medication. Strategy: Use the process of elimination. Recalling that this medication is used to treat Parkinson's disease will direct you to option 3. Review the purpose and use of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 47). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1100) A nurse employed in a cardiac unit determines that which of the following clients is the least likely to have implantation of an automatic internal cardioverter-defibrillator (AICD)? a. A client with syncopal episodes related to ventricular tachycardia b. A client with ventricular dysrhythmias despite medication therapy c. A client with an episode of cardiac arrest related to myocardial infarction d. A client with three episodes of cardiac arrest unrelated to myocardial infarction Source: Saunders 4th

ANS: C Rationale: An automatic internal cardioverter-defibrillator (AICD) detects and delivers an electrical shock to terminate life-threatening episodes of ventricular tachycardia and ventricular fibrillation. These devices are implanted in clients who are considered high risk, including those who have survived sudden cardiac death unrelated to myocardial infarction, those who are refractive to medication therapy, and those who have syncopal episodes related to ventricular tachycardia. Strategy: Use the process of elimination and note the strategic words least likely. Ventricular dysrhythmias that induce syncope or occur while the client is on medication are likely to be true indications for the AICD, so eliminate options 1 and 2 first. From the remaining options, the main difference is whether or not the cardiac arrest was related to myocardial infarction. Of these two, the one most likely to be responsive to AICD would be the client without myocardial infarction because those dysrhythmias are spontaneous. Review the indications for the use of an AICD, if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 743). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2130) A nurse in the hospital emergency department is caring for a client with a fractured arm and is preparing the client for a reduction of the fracture that will be done in the casting room. Which of the following is unnecessary? a. Explanation of the procedure to the client b. Administration of an analgesic c. Anesthesia consent d. Consent for the procedure Source: Saunders 4th

ANS: C Rationale: Before a fracture is reduced, the client is informed about the procedure, and an informed consent is obtained. An analgesic is given as prescribed, because the procedure is painful. Closed reductions may be done in the emergency department without anesthesia. If anesthesia is used, the procedure is done in the operating room. Strategy: Use the process of elimination. Note the strategic word unnecessary. Options 1 and 4 obviously are needed, so these options are eliminated first. The question specifically states that the procedure is going to be done in the casting room, which helps you to choose option 3 (anesthesia consent) as the unnecessary item. Review the procedure for closed reduction of a fracture if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 304, 1197). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

977) An older client recently has been taking cimetidine (Tagamet). The nurse monitors the client for which most frequent central nervous system side effect of this medication? a. Tremors b. Dizziness c. Confusion d. Hallucinations Source: Saunders 4th

ANS: C Rationale: Cimetidine is a histamine 2 (H₂)-receptor antagonist. Older clients are especially susceptible to central nervous system side effects of cimetidine. The most frequent of these is confusion. Less common central nervous system side effects include headache, dizziness, drowsiness, and hallucinations. Strategy: Use the process of elimination and note the strategic words most frequent. Use knowledge of the older client and medication effects to direct you to option 3. Review the side effects of cimetidine if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 250). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1656) The nurse manager attends a conference, and the topic of discussion is leadership styles. The nurse is seeking a leadership style that will best empower staff to achieve excellence. Which leadership style would the nurse select to achieve this goal? a. Autocratic b. Situational c. Democratic d. Laissez-faire Source: Saunders 4th

ANS: C Rationale: Democratic styles best empower staff toward excellence because this style of leadership allows nurses an opportunity to grow professionally. The autocratic style is task-oriented and directive. Situational leadership uses a style that depends on the situation and events. Laissez-faire allows staff to work without assistance, direction, or supervision. Strategy: Note the strategic words empower staff toward excellence. Use the process of elimination and knowledge of the characteristics of the various leadership styles to direct you to option 3. If you had difficulty with this question, review the various leadership styles. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., pp. 13-14). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2074) A nurse is developing a plan of care for an older client that addresses interventions to prevent cold discomfort and the development of accidental hypothermia. The nurse documents which desired outcome in the plan of care? a. The client remains in a fetal position when in bed. b. The client complains of coolness in the hands and feet only. c. The client's body temperature is 98° F. d. The client's fingers and toes are cool to touch. Source: Saunders 4th

ANS: C Rationale: Desired outcomes for nursing interventions to prevent cold discomfort and the development of accidental hypothermia include the following: hands and limbs are warm; body is relaxed and not curled; body temperature is greater than 97° F; the client is not shivering; and the client has no complaints of feeling cold. Strategy: Use the process of elimination. Eliminate option 2 first because of the close-ended word only. Regarding the remaining options, focusing on the subject, a desired outcome, will direct you to option 3. Review interventions and desired outcomes for preventing hypothermia if you had difficulty with this question. Reference: Meiner, S., & Leuckenotte, A. (2006). Gerontologic nursing (3rd ed., p. 686). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1410) The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving didanosine (Videx). The nurse interprets that the client may have the medication discontinued by the physician if which of the following significantly elevated results is noted? a. Serum protein level b. Blood glucose level c. Serum amylase level d. Serum creatinine level Source: Saunders 4th

ANS: C Rationale: Didanosine (Videx) can cause pancreatitis. A serum amylase level that is increased to 1.5 to 2 times normal may signify pancreatitis in the client with acquired immunodeficiency syndrome and is potentially fatal. The medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure. Strategy: Focus on the name of the medication. Recalling that this medication can cause damage to the pancreas and is hepatotoxic will direct you to the correct option. Review this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 354). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

2071) A client has received a dose of dimenhydrinate (Dramamine). The nurse evaluates that the medication has been effective if the client states relief of: a. Headache b. Chills c. Nausea and vomiting d. Buzzing sound in the ears Source: Saunders 4th

ANS: C Rationale: Dimenhydrinate is used to prevent and treat the symptoms of dizziness, vertigo, nausea, and vomiting that accompany motion sickness. The other options are incorrect. Strategy: Use the process of elimination. Recalling that this medication is an antiemetic used to treat motion sickness will direct you to option 3. If the action and effects of this medication are unfamiliar to you, review this content. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 687). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2654) A client has been prescribed disulfiram (Antabuse). Before giving the client the first dose of this medication, the psychiatric home health nurse should be sure to assess for which of the following? a. History of hyperthyroidism b. When the last full meal was consumed c. When the last alcoholic drink was consumed d. History of diabetes insipidus Source: Saunders 4th

ANS: C Rationale: Disulfiram is an adjunctive treatment for some clients with chronic alcoholism to assist in maintaining enforced sobriety. Because clients must abstain from alcohol for at least 12 hours before the initial dose, the most important assessment is when the last alcoholic intake was consumed. The medication should be used cautiously in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, nephritis, and hepatic disease. It is contraindicated in persons with severe heart disease, psychosis, or hypersensitivity to the medication. Strategy: Use the process of elimination. Recalling that the medication is used as an adjunct treatment for selective clients with chronic alcoholism will direct you to option 3. If you are unfamiliar with the uses and actions of this medication, review this content. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., pp. 412-414). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Mental Health Alternate Question Types -> Multiple Choice

960) The client is taking docusate sodium (Colace). The nurse monitors for which sign or symptom to determine whether the client is having a therapeutic effect from this medication? a. Reduction in steatorrhea b. Hematest-negative stools c. Regular bowel movements d. Absence of abdominal pain Source: Saunders 4th

ANS: C Rationale: Docusate sodium is a stool softener that promotes absorption of water into the stool, producing a softer consistency of stool. The intended effect is relief or prevention of constipation. The medication does not decrease the amount of fat in the stools, stop gastrointestinal bleeding, or relieve abdominal pain. Strategy: Use the process of elimination. Recalling that docusate sodium is used to soften the stool will direct you to option 3. Review the expected effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 372). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2655) A home care nurse making an initial home visit notes that a client is taking donepezil hydrochloride (Aricept). The nurse questions the client's spouse about a history of which of the following disorders as indicated by the use of this medication? a. Seizure disorder b. Schizophrenia c. Dementia d. Obsessive-compulsive disorder Source: Saunders 4th

ANS: C Rationale: Donepezil hydrochloride is a cholinergic agent that is used in the treatment of mild to moderate dementia of the Alzheimer's type. It increases concentration of acetylcholine, which slows the progression of Alzheimer's disease. The other options are incorrect. Strategy: Knowledge that donepezil hydrochloride is used to treat dementia is required to answer this question. If you are unfamiliar with the uses and actions of this medication, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 380). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Mental Health Alternate Question Types -> Multiple Choice

908) The nurse is providing discharge instructions to a client following gastrectomy and instructs the client to take which measure to assist in preventing dumping syndrome? a. Ambulate following a meal. b. Eat high carbohydrate foods. c. Limit the fluids taken with meals. d. Sit in a high-Fowler's position during meals. Source: Saunders 4th

ANS: C Rationale: Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a Billroth II procedure. Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low-Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed. Strategy: Use the process of elimination. Eliminate options 1 and 4 first because these measures will promote gastric emptying. From the remaining options, select option 3 because this measure will delay gastric emptying. If you are unfamiliar with this syndrome, review the important client teaching points. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1303). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1588) The nurse is conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by: a. Contracting and then consciously relaxing different muscle groups. b. Contracting an area of the body, such as an arm or leg, and then concentrating on letting tension go from the rest of the body. c. Massaging the abdomen during contractions, using both hands in a circular motion. d. Instructing the significant other to stroke or massage a tightened muscle by the use of touch. Source: Saunders 4th

ANS: C Rationale: Effleurage is massage of the abdomen during contractions. Women learn to do effleurage using both hands in a circular motion. Progressive relaxation involves contracting and then consciously releasing different muscle groups. Neuromuscular disassociation helps the woman relax her body, even when one group of muscles is strongly contracted. In this procedure, the woman contracts an area such as an arm or leg and then concentrates on letting tension go from the rest of the body. Touch relaxation helps the woman learn to loosen taut muscles when she is touched by her partner. Strategy: Use the process of elimination, focusing on the subject, effleurage. It is necessary to know the procedure for this technique to answer the question correctly. If you had difficulty with this question or are unfamiliar with this cutaneous stimulation technique, review these techniques. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 417). St. Louis: W.B. Saunders. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., pp. 231-232). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1633) Lindane is prescribed for the treatment of scabies. The nurse reviews the client's record knowing the medication therapy is contraindicated if the client is: a. A 42-year-old female b. An older client c. A 6-year-old child d. A 52-year-old male with hypertension Source: Saunders 4th

ANS: C Rationale: Lindane can penetrate the intact skin and can cause seizures if absorbed in sufficient quantities. Clients at highest risk for seizures are premature infants, children, and those with preexisting seizure disorders. Lindane should not be used on pediatric clients unless safer medications have failed to control infection. Strategy: Use the process of elimination. Remembering that the medication can cause seizures will direct you to option 3. Review the contraindications associated with the use of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 498). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1576) A pregnant human immunodeficiency virus (HIV)-positive woman delivers a newborn infant and the nurse provides instructions to help the mother regarding the newborn infant care. Which statement by the client indicates the need for further instructions? a. "I will be sure to wash my hands before and after bathroom use." b. "Support groups are available to assist me with understanding my diagnosis of HIV." c. "I need to breast-feed, especially for the first 6 weeks postpartum." d. "My newborn infant should be on antiviral medications for the first 6 weeks after delivery." Source: Saunders 4th

ANS: C Rationale: The mode of perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding. Therefore, HIV-positive clients should be encouraged to bottle-feed their neonates. Frequent hand washing is encouraged. Support groups and community agencies can be identified to assist the parents with the newborn infant's home care, the impact of the diagnosis of HIV infection, and available financial resources. It is recommended that newborn infants of HIV-positive clients receive antiviral medications for their first 6 weeks of life. Strategy: Use the process of elimination. Note the strategic words need for further instructions in the question. These words indicate a negative event query and ask you to select an option that is incorrect. Recalling that breast-feeding is discouraged in the HIV-positive woman will direct you to the correct option. Review home care measures for the HIV-positive client if you had difficulty with this question. Reference: Lowdermilk, D., & Perry, A. (2004). Maternity and woman's health care (8th ed., p. 422). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

124) A nurse is caring for a restless client who is beginning nutritional therapy with parenteral nutrition (PN). The nurse should plan to ensure that which of the following is done to prevent the client from injury? a. Calculate daily intake and output. b. Monitor the temperature once daily. c. Secure all connections in the PN system. d. Monitor blood glucose levels every 12 hours. Source: Saunders 4th

ANS: C Rationale: The nurse should plan to secure all connections in the tubing (tape is used per agency protocol). This will help prevent the restless client from pulling the connections apart accidentally. The nurse should also monitor intake and output, but this does not relate specifically to a risk for injury as presented in the question. Also, options 2 and 4 do not relate to a risk for injury as presented in the question. In addition, the client's temperature and blood glucose levels are monitored more frequently than the time frames identified in the options to detect signs of infection and hyperglycemia, respectively. Strategy: Note the strategic words restless, ensure, prevent, and injury. Focus on the subject of the question and use the process of elimination to direct you to option 3. Review the precautions related to PN if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., p. 1057). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2134) A client has slight weakness in the right leg. On the basis of this assessment finding, the nurse determines that the client would benefit most from the use of: a. A walker b. A wooden crutch c. A Lofstrand crutch d. A straight leg cane Source: Saunders 4th

ANS: D Rationale: A straight leg cane is useful for the client with slight weakness in one leg. A walker is beneficial to the client with greater or bilateral weakness, or the client who is at risk for falls. Wooden crutches often are used by clients with a leg cast. Lofstrand crutches aid clients who need crutches but have limited arm strength. Strategy: Use the process of elimination. Giving a walker to a client with a slight leg weakness is excessive and is eliminated first. Because the question presents no evidence that the client described has difficulty with weight bearing, crutches are not indicated either. Review the use of assistive devices for the client with leg weakness if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1204). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1850) A nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which of the following nursing actions would be appropriate? a. Document the findings. b. Reinforce the dressing. c. Mark the area of drainage with a pen and monitor for further drainage. d. Notify the physician. Source: Saunders 4th

ANS: D Rationale: Cerebrospinal fluid (CSF) leakage after cranial surgery may be detected by noting drainage that is serosanguineous surrounded by an area of straw colored or pale drainage. The physical appearance of CSF drainage is that of a halo. If the nurse notes the presence of this type of drainage, the physician needs to be notified. Options 1, 2, and 3 are inappropriate nursing actions. Strategy: Use the process of elimination. Think about the anatomical location of the surgical procedure and the risk of CSF leakage after this type of surgery. If you had difficulty with this question, review the complications and nursing interventions associated with this type of surgery. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 2092. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1464). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2694) A home health nurse is visiting a client who has been started on therapy with clotrimazole (Lotrimin). The nurse evaluates the effectiveness of the medication by noting a decrease in which of the following problems? a. Fever b. Pain c. Sneezing d. Rash Source: Saunders 4th

ANS: D Rationale: Clotrimazole is a topical antifungal agent used in the treatment of cutaneous fungal infections. It is not used for sneezing, fever, or pain. Strategy: Recalling that this medication is an antifungal will direct you to option 4. Review this type of antiinfective if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 278). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2282) A nurse is preparing to give a postcraniotomy client medication for incisional pain. The family asks the nurse why the client is receiving codeine sulfate (Codeine) and not "something stronger." In formulating a response, the nurse incorporates the understanding that codeine sulfate: a. Is one of the strongest opioid analgesics available b. Cannot lead to physical or psychological dependence c. Does not cause gastrointestinal (GI) upset or constipation as do other opioids d. Does not alter respirations or mask neurological signs as do other opioids Source: Saunders 4th

ANS: D Rationale: Codeine sulfate is an opioid analgesic used for clients after craniotomy. It often is combined with a nonopioid analgesic such as acetaminophen (Tylenol) for added effect. It does not alter the respiratory rate or mask neurological signs as do other opioids. Side effects of codeine sulfate include GI upset and constipation. Chronic use of the medication can lead to physical and psychological dependence. Strategy: Use the process of elimination, recalling that codeine sulfate is an opioid analgesic. General knowledge about opioid analgesics helps you to eliminate options 2 and 3. Because codeine sulfate is not the strongest opioid available, eliminate option 1 next. Review the characteristics of codeine sulfate if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1064). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., pp. 268, 278). Philadelphia: W.B. Saunders. Reference: Lilley, L., Harrington, S., & Snyder, J. (2005). Pharmacology and the nursing process (4th ed., pp. 588-589). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1409) The client with acquired immunodeficiency syndrome has begun therapy with zidovudine (Retrovir, azidothymidine, AZT, ZDV). The nurse carefully monitors which of the following laboratory results during treatment with this medication? a. Blood culture b. Blood glucose level c. Blood urea nitrogen level d. Complete blood count Source: Saunders 4th

ANS: D Rationale: Common side effects of this medication therapy are leukopenia and anemia. The nurse monitors the complete blood count results for these changes. Options 1, 2, and 3 are unrelated to the use of this medication. Strategy: Focus on the name of the medication. Recalling that zidovudine (AZT) causes leukopenia will direct you to option 4. Review this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1231). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1235) The nurse is caring for a client with a diagnosis of detached retina. Which assessment sign would indicate that bleeding has occurred as a result of the retinal detachment? a. Total loss of vision b. A reddened conjunctiva c. A sudden sharp pain in the eye d. Complaints of a burst of black spots or floaters Source: Saunders 4th

ANS: D Rationale: Complaints of a sudden burst of black spots or floaters indicates that bleeding has occurred as a result of the detachment. Options 1, 2, and 3 are not signs of bleeding. Strategy: Focus on the client's diagnosis. Recalling the pathophysiology associated with retinal detachment will direct you to the correct option. Review the manifestations associated with the complications of a detached retina if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1952). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1308) The nurse is caring for the client in the emergency department following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing that this is compatible with: a. Concussion b. Skull fracture c. Subdural hematoma d. Epidural hematoma Source: Saunders 4th

ANS: D Rationale: The changes in neurological signs from an epidural hematoma begin with loss of consciousness as arterial blood collects in the epidural space and exerts pressure. The client regains consciousness as the cerebrospinal fluid is reabsorbed rapidly to compensate for the rising intracranial pressure. As the compensatory mechanisms fail, even small amounts of additional blood cause the intracranial pressure to rise rapidly, and the client's neurological status deteriorates quickly. Strategy: Use the process of elimination. Begin to answer this question by ruling out skull fracture and concussion as being responsible for fluctuating neurological signs. Recall that a subdural hematoma is a collection of venous blood, which may accumulate more slowly and cause a steadier deterioration of neurological signs. This will help you discriminate between epidural and subdural hematomas. Review the clinical manifestations associated with the various types of head injury if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2204-2205). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1046-1047). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1936) A client being discharged to home after renal transplantation has a nursing diagnosis of risk for infection related to immunosuppressive medication therapy. The nurse determines that the client needs further instruction on measures to prevent and control infection if the client states to: a. Take an oral temperature daily. b. Use good hand-washing technique. c. Take all scheduled medications exactly as prescribed. d. Monitor urine character and output at least 1 day each week. Source: Saunders 4th

ANS: D Rationale: The client receiving immunosuppressive medication therapy must learn and use infection control methods for use at home. The client must learn proper hand-washing technique and should take the temperature daily to detect early infection. This is especially important because the client also takes corticosteroids, which mask signs and symptoms of infection. The client self-monitors urine output and its characteristics on a daily basis. All medications should be taken exactly as ordered. Strategy: Use the process of elimination. Note the strategic words needs further instruction. This phrasing indicates a negative event query and directs you to select an incorrect statement. Reading each option carefully and noting the insufficient frequency (1 day each week) in option 4 will direct you to this option. Review home care instructions for the client after renal transplantation if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 970). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1762-1763). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1944) A nurse is preparing to perform an abdominal examination on a client. The nurse should place the client in which of the following positions for this examination? a. Supine with the head raised slightly and the knees slightly flexed b. Semi-Fowler's with the head raised 45 degrees and the knees flat c. Sims position d. Supine with the head and feet flat Source: Saunders 4th

ANS: A Rationale: During the abdominal examination, the client lies supine (flat on their back) with the head raised slightly and with the knees slightly flexed. This position relaxes the abdominal muscles. The abdomen could not be accurately assessed if the head was raised 45 degrees. Sims position is a side-lying position and would not adequately expose the abdomen for examination. Placing the head and feet flat would result in the abdominal muscles being taut. Strategy: Use the process of elimination. Attempt to visualize this assessment procedure as you eliminate each option. Sims position is inaccurate because it is a side lying-position. If the head of the bed is elevated, adequate examination of the abdomen is not possible, and having the head flat results in a tension of the abdominal muscles. Raising the head slightly relaxes the abdominal muscles. Review this assessment technique if you had difficulty with this question. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., p. 570). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 741-742). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

948) A client is admitted with a diagnosis of acute diverticulitis. What nursing intervention is appropriate for this client? a. Instruct the client to remain NPO. b. Encourage ambulation at least four times daily. c. Administer cholinergic medications to reduce pain. d. Encourage coughing and deep breathing every 2 hours. Source: Saunders 4th

ANS: A Rationale: During the acute phase of diverticulitis, the goal of treatment is to rest the bowel and allow the inflammation to subside. The client remains NPO and is placed on bed rest. Pain occurs from bowel spasms and increased intraabdominal pressure may precipitate an attack. Options 2, 3, and 4 are not interventions for the client with acute diverticulitis. Strategy: Use the process of elimination. Ambulation and cholinergics will increase peristalsis eliminating options 2 and 3. Coughing and deep breathing will increase intraabdominal pressure, eliminating option 4. Knowing that NPO status allows the bowel to rest directs you to option 1. Review care of the client with acute diverticulitis if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1095). St. Louis, Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1500) The nurse has been observing a client closely who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is least helpful to this client at this time? a. Initiate confinement measures. b. Acknowledge the client's behavior. c. Assist the client to an area that is quiet. d. Maintain a safe distance with the client. Source: Saunders 4th

ANS: A Rationale: During the escalation period, the client's behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client, if appropriate. To initiate confinement measures during this period is not appropriate. Initiation of confinement measures is most appropriate during the crisis period. Strategy: Note the strategic words behavior, escalating, and least helpful. Recalling that the least restrictive measures should be used will direct you to option 1. Review care of the client with aggressive behavior if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 509). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 502). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2524) The clinic nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which of the following will the nurse avoid when performing the irrigation? a. Position the client to turn the head so that the ear to be irrigated is facing upward. b. Warm the irrigating solution to a temperature that is close to body temperature. c. Direct a slow steady stream of irrigation solution toward the upper wall of the ear canal. d. Position the client with the affected side down after the irrigation. Source: Saunders 4th

ANS: A Rationale: During the irrigation, the client is positioned so that the ear to be irrigated is facing downward, because this allows gravity to assist in the removal of the earwax and solution. Delivery of irrigation solutions at temperatures that are not close to body temperature can cause discomfort for the client and may result in tissue injury, nausea, and vertigo. A slow, steady stream of solution should be directed toward the upper wall of the ear canal, not toward the tympanic membrane. After the irrigation, the client should lie on the affected side for a period of time that is necessary to allow the irrigating solution to finish draining (usually 10 to 15 minutes). Too much force could cause the tympanic membrane to rupture. Strategy: Note the strategic word avoid in the question. Focusing on the subject, ear irrigation, and visualizing the steps of the procedure will assist in directing you to option 1. Review this procedure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1127-1128). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

909) The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which of the following indicate this occurrence? a. Sweating and pallor b. Bradycardia and indigestion c. Double vision and chest pain d. Abdominal cramping and pain Source: Saunders 4th

ANS: A Rationale: Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. Strategy: Use the process of elimination and recall the pathophysiology associated with dumping syndrome. Focus on the strategic word early to direct you to option 1. Review the early manifestations of this syndrome if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1303). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1979) A client receives education regarding self-administration of enoxaparin (Lovenox) upon discharge to home. The client complains, "I feel as if the doctor is discharging me too soon, if I still have to take injections at home." The nurse's best response would be: a. "It's been found to be better for the client and less costly in the long run for clients to administer this medication at home versus staying in the hospital." b. "You'll have to take that up with the doctor." c. "Are you not happy about going home?" d. "Do you want to stay in the hospital forever?" Source: Saunders 4th

ANS: A Rationale: Enoxaparin (Lovenox) is a low-molecular-weight heparin that can be administered without the usual activated partial thromboplastin time (aPTT) testing that is required with the use of heparin. Option 2 places the client's feelings on hold. Options 3 and 4 devalue the client's feelings. Strategy: Use the process of elimination and therapeutic communication techniques to eliminate options 2, 3, and 4. Recall that the nurse should, when possible, offer education that will help the client to cope and adapt to changes. Option 1 is the only option that provides information that is useful to the client. Review therapeutic communication techniques if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 593). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 437). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1910) A client with renal failure has a medication order for epoetin alfa (Epogen, Procrit). The nurse should administer this medication: a. Subcutaneously b. Intramuscularly c. With a full glass of water d. Diluted in juice to enhance taste Source: Saunders 4th

ANS: A Rationale: Epoetin alfa is erythropoietin that has been manufactured through the use of recombinant DNA technology. It is used to treat anemia in the client with chronic renal failure. The medication may be administered subcutaneously or intravenously. Strategy: Specific knowledge of epoetin alfa is necessary to answer this question. Recall that this medication is administered subcutaneously or intravenously. If the medication or its methods of administration are unfamiliar to you, review this content. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 491). St. Louis: Mosby. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 423). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1222) A client with chronic renal failure is receiving epoetin alfa (Epogen, Procrit). Which laboratory result would indicate a therapeutic effect of the medication? a. Hematocrit of 32% b. Platelet count of 400,000 cells/mm³ c. Blood urea nitrogen level of 15 mg/dL d. White blood cell count of 6,000 cells/mm³ Source: Saunders 4th

ANS: A Rationale: Epoetin alfa is used to reverse anemia associated with chronic renal failure. Therapeutic effect is seen when the hematocrit is between 30% and 33%. Options 2, 3, and 4 are not associated with the action of this medication. Strategy: Use the process of elimination. Relate the name of the medication, erythropoietin, to the potential action or effect. The only laboratory test that would reflect the effect of this medication is option 1. Review the therapeutic effect of this medication and normal serum laboratory results if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 319). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2004) An older client is seen in the health care clinic and an eye examination is performed. The client is diagnosed with a refraction error. The nurse anticipates that which of the following will most likely be prescribed for this client? a. Corrective lens b. A surgical keratoplasty c. Eye drops to lower intraocular pressure d. Contact lens Source: Saunders 4th

ANS: A Rationale: Errors of refraction include astigmatism, presbyopia, myopia, and hyperopia. Eyeglasses are most commonly used. Surgery is not the primary treatment, and eye drops will not resolve the condition. A keratoplasty is a surgical procedure for cataracts. Eye drops that lower intraocular pressure are used to treat glaucoma. Insertion of contact lenses requires skill and dexterity and may be difficult for an older client. Strategy: Knowledge regarding the treatment for refractive errors is needed to answer this question. Use the process of elimination and eliminate option 2 first, recalling that surgery is not required. Recalling that eye drops that lower intraocular pressure are used to treat glaucoma will assist in eliminating option 3. Regarding the remaining options, focusing on the strategic word older in the question will assist in directing you to option 1. Review the treatment for refractive errors if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1075, 1104). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1683) Fludrocortisone acetate (Florinef Acetate) is prescribed for the client with Addison's disease. The nurse prepares to administer the medication knowing that the primary action of this medication is to: a. Enhance the reabsorption of sodium and chloride ions in the distal tubules of the kidney. b. Promote the retention of potassium in the distal tubules of the kidney. c. Promote the retention of hydrogen ions in the distal tubules of the kidney. d. Promote the excretion of water in the distal tubules of the kidney. Source: Saunders 4th

ANS: A Rationale: Fludrocortisone acetate (Florinef Acetate) has mineralocorticoid activity and also has a modest glucocorticoid effect. It acts primarily on the kidneys distal tubules, enhancing the resorption of sodium and chloride ions and the excretion of potassium and hydrogen ions. It promotes water retention. Strategy: Use the process of elimination and knowledge regarding the action of fludrocortisone acetate. Recalling the pathophysiology associated with Addison's disease will assist in answering the question. Review this medication action if you are unfamiliar with it. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 488-489). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2593) A nurse caring for a client with a closed chest drainage system notes that the fluctuation (tidaling) in the water seal compartment has stopped. On the basis of this assessment finding, the nurse would suspect that: a. The chest tubes are obstructed. b. Suction needs to be increased. c. The system needs changing. d. Suction needs to be decreased. Source: Saunders 4th

ANS: A Rationale: Fluid in the water seal compartment should rise with inspiration and fall with expiration (tidaling). When tidaling occurs, the drainage tubes are patent and the apparatus is functioning properly. Tidaling stops when the lung has reexpanded or if the chest drainage tubes are kinked or obstructed. Options 2, 3, and 4 are incorrect interpretations. Strategy: Use the process of elimination. Recalling that tidaling stops when the lung has reexpanded or if the chest drainage tubes are kinked or obstructed will direct you to option 1. Review the expected findings in a closed chest drainage system if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1863-1864). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1177) A client with chronic renal failure has completed a hemodialysis treatment. The nurse would use which of the following standard indicators to evaluate the client's status after dialysis? a. Vital signs and weight b. Potassium level and weight c. Vital signs and blood urea nitrogen level d. Blood urea nitrogen and creatinine levels Source: Saunders 4th

ANS: A Rationale: Following dialysis, the client's vital signs are monitored to determine whether the client is remaining hemodynamically stable. Weight is measured and compared with the client's predialysis weight to determine effectiveness of fluid extraction. Laboratory studies are done as per protocol but are not necessarily done after the hemodialysis treatment has ended. Strategy: Use the process of elimination. Note the subject, measures to determine the client's status after dialysis. Recalling the purpose of the dialysis will direct you to option 1. Review postdialysis nursing assessments if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1756, 1759). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

930) The nurse has given instructions to the client with an ileostomy about foods to eat to thicken the stool. The nurse determines that the client needs further instructions if the client states that which food makes the stool less watery? a. Bran b. Pasta c. Boiled rice d. Low-fat cheese Source: Saunders 4th

ANS: A Rationale: Foods that help thicken the stool of the client with an ileostomy include pasta, boiled rice, and low-fat cheese. Bran is high in dietary fiber and thus will increase the output of watery stool by increasing propulsion through the bowel. Ileostomy output is liquid. Addition or elimination of various foods can help to thicken or loosen this liquid drainage. Strategy: Use the process of elimination noting the strategic words needs further instructions. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Recalling that high-fiber foods such as bran can cause watery stools in the client with an ileostomy will direct you to the correct option. Review dietary measures for the client with an ileostomy if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1325). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1093). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2246) Nitrofurantoin (Macrodantin) is prescribed for an adult client for treatment of acute urinary tract infection (UTI). The nurse reviews the physician's order knowing that which of the following is the appropriate adult dose? a. 50 mg three to four times daily b. 100 mg three times daily c. 300 mg administered at bedtime d. 1 g distributed evenly throughout the day Source: Saunders 4th

ANS: A Rationale: For treatment of acute UTI, the adult dosage is 50 mg three to four times a day. For prophylaxis of recurrent UTI, low doses are used, such as 50 to 100 mg at bedtime for adults. Strategy: Knowledge regarding the normal adult dosage of nitrofurantoin is required to answer this question. Remember that the normal dose is 50 mg three to four times daily. If you are unfamiliar with this normal medication dosage, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 841). Philadelphia: W.B. Saunders. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 485). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1797) The client newly diagnosed with diabetes mellitus is instructed by the physician to obtain glucagon for emergency home use. The client asks the home care nurse about the purpose of the medication. The nurse instructs the client that the purpose of the medication is to treat: a. Hypoglycemia from insulin overdose b. Hyperglycemia from insufficient insulin c. Lipoatrophy from insulin injections d. Lipohypertrophy from inadequate insulin absorption Source: Saunders 4th

ANS: A Rationale: Glucagon is used to treat hypoglycemia resulting from insulin overdose. The family of the client is instructed in how to administer the medication. In an unconscious client, arousal usually occurs within 20 minutes of glucagon injection. Once consciousness has been regained, oral carbohydrates should be given. Lipoatrophy and lipohypertrophy result from insulin injections. Strategy: Use the process of elimination. Noting the word glucagon will assist in determining that the medication contains some form of glucose. This relationship should direct you to option 1. Review the purpose of this medication if you are unfamiliar with it. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 789). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2047) A nurse is providing instructions to a nursing assistant who is assigned to care for a client with hemiparesis of the right arm and leg. The nurse should instruct the nursing assistant to place personal articles for morning care: a. Within the client's reach on the left side b. Within the client's reach on the right side c. Just out of the client's reach on the right side d. Just out of the client's reach on the left side Source: Saunders 4th

ANS: A Rationale: Hemiparesis is weakness of the face, arm, and leg on one side. The nurse would instruct the nursing assistant to place objects on the unaffected side and within reach of the client. Options 2, 3, and 4 are incorrect and would not be helpful or safe for the client. Strategy: Begin to answer this question by eliminating options 3 and 4 first, because it is not safe to have articles out of the client's reach. Recall that objects should be placed to the side unaffected by the paralysis that the client can move to assist in directing you to option 1. If you had difficulty with this question, review care of the client with hemiparesis. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2111-2112). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1915) A client undergoing hemodialysis is at risk for bleeding from the heparin used during the hemodialysis treatment. The nurse assesses for this occurrence by periodically checking the results of which of the following laboratory tests? a. Partial thromboplastin time (PTT) b. Prothrombin time (PT) c. Thrombin time (TT) d. Bleeding time Source: Saunders 4th

ANS: A Rationale: Heparin is the anticoagulant used most often during hemodialysis. The hemodialysis nurse monitors the extent of anticoagulation by checking the PTT, which is the appropriate measure of heparin effect. The PT is used to monitor the effect of warfarin (Coumadin) therapy. Thrombin and bleeding times are not used to measure the effect of heparin therapy, although they are useful in the diagnosis of other clotting abnormalities. Strategy: Use the process of elimination. Knowledge of the effects of heparin therapy on blood coagulation is necessary to answer this question. Recall that the PTT is monitored for the effects of heparin. Review the nursing assessments for the client receiving heparin if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1752-1753). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

925) The client with hiatal hernia chronically experiences heartburn following meals. The nurse plans to teach the client to avoid which action because it is contraindicated with a hiatal hernia? a. Lying recumbent following meals b. Taking in small, frequent, bland meals c. Raising the head of bed on 6-inch blocks d. Taking H₂-receptor antagonist medication Source: Saunders 4th

ANS: A Rationale: Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm where the esophagus usually is positioned. The client usually experiences pain from reflux caused by ingestion of irritating foods, lying flat following meals or at night, and eating large or fatty meals. Relief is obtained with the intake of small, frequent, and bland meals, use of H₂-receptor antagonists and antacids, and elevation of the thorax following meals and during sleep. Strategy: Use the process of elimination noting the strategic word contraindicated. Thinking about the pathophysiology that occurs in hiatal hernia will direct you to option 1. Review this pathophysiology if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 726-727). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1270, 1273). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1597) The mother of an infant diagnosed with Hirschsprung's disease asks the nurse about the disorder. The nurse tells the mother that this disease is a: a. Congenital aganglionosis or megacolon. b. Complete small intestinal obstruction. c. Condition that causes the pyloric valve to remain open. d. Severe inflammation of the gastrointestinal tract. Source: Saunders 4th

ANS: A Rationale: Hirschsprung's disease also known as congenital aganglionosis or megacolon. It is the result of an absence of ganglion cells in the rectum and to varying degrees upward in the colon. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination and knowledge regarding the pathophysiology associated with Hirschsprung's disease to answer this question. Remember that Hirschsprung's disease is also known as congenital aganglionosis or megacolon. If you are unfamiliar with this disorder, review the pathophysiology associated with it. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 853). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

1751) The nurse is caring for the client who has been taking hydrocodone (Hycodan) for the last 3 months. The nurse assesses the client for which of the following side effects of this medication? a. Psychological and physical dependence b. Tachycardia and hypertension c. Diarrhea and abdominal cramping d. Increased respiratory rate and bronchospasm Source: Saunders 4th

ANS: A Rationale: Hydrocodone is an opioid analgesic that also has antitussive properties. Side effects of this medication include physical and psychological dependence, bradycardia and hypotension, respiratory depression, nausea, vomiting, constipation, sedation, and confusion. Strategy: Use the process of elimination. Recalling that this medication is an opioid analgesic will direct you to option 1. If this question was difficult, review information on the implications of opioid use and the side effects of these medications. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 581). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1049) A nurse has administered a dose of salmeterol (Serevent Diskus) to a client. The client develops a generalized rash and urticaria, and the eyelids begin to swell. The nurse should: a. Call the physician immediately. b. Apply a lanolin-based cream to the rash. c. Encourage the client to drink fluids quickly. d. Assess the client's vision with a Snellen chart. Source: Saunders 4th

ANS: A Rationale: Hypersensitivity reaction can occur in clients taking salmeterol. Signs and symptoms include rash, urticaria, and swelling of the face, lips, or eyelids. The nurse should call the physician immediately if any of these occur. The other options are incorrect. Strategy: Use the process of elimination. Recognizing that the signs and symptoms listed in the question are typical of a hypersensitivity reaction allows you to eliminate options 2 and 4 first. From the remaining options, recall that the client needs treatment with an antihistamine or epinephrine, not oral fluids. Review this medication if the question was difficult. Reference: Lilley, L., Harrington, S. & Snyder, J. (2005). Pharmacology and the nursing process (4th ed., p. 302). St. Louis: Mosby. Reference: Skidmore-Roth, L. (2006). Mosby's drug guide for nurses (6th ed., p. 772). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2416) A nurse is caring for a client with a diagnosis of hypoparathyroidism. The nurse reviews the laboratory results of blood tests for this client and notes that the calcium level is extremely low. The nurse would expect to note which of the following on assessment of the client? a. Positive Trousseau's sign b. Negative Chvostek's sign c. Unresponsive pupils d. Hyperactive bowel sounds Source: Saunders 4th

ANS: A Rationale: Hypoparathyroidism is related to a lack of parathyroid hormone secretion or to a decreased effectiveness of parathyroid hormone on target tissues. The end result of this disorder is hypocalcemia. When serum calcium levels are critically low, the client may exhibit Chvostek's and Trousseau's signs, which indicate potential tetany. Options 2, 3, and 4 are not related to the presence of hypocalcemia. Strategy: Use the process of elimination. Recalling that positive Chvostek's and Trousseau's signs would be noted in this disorder will direct you to option 1. Review the assessment findings in hypoparathyroidism and hypocalcemia if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1214). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

2451) A physician writes an order to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SIMV). The nurse determines that the process of weaning will occur by: a. Gradually decreasing the respiratory rate until the client can assume the work of breathing without ventilatory assistance b. Providing pressure support to decrease the workload of breathing and increase the client's ability to initiate spontaneous breathing efforts c. Attaching a T-piece to the ventilator and providing supplemental oxygen at a concentration that is 10% higher than the ventilator setting d. Removing the ventilator from the client and closely monitoring the client's ability to breathe spontaneously for a predetermined amount of time Source: Saunders 4th

ANS: A Rationale: IMV/SIMV is one of the methods used for weaning. With this method, the respiratory rate is gradually decreased until clients assumes all of the work of breathing on their own. This method works exceptionally well in the weaning of clients from short-term mechanical ventilation, such as that used in clients who have undergone surgery. The respiratory rate frequently is decreased in increments on an hourly basis until the client is weaned and is ready for extubation. Strategy: Use the process of elimination. Focus on the name and description of the type of weaning process to assist in directing you to option 1. If you had difficulty with this question, review this method of weaning a client from a ventilator. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 669). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1560) The nurse is preparing to care for a client who has undergone myelography using a oil-based contrast agent. The nurse plans to position the client on bed rest for: a. 6 to 8 hours, with the head of bed flat. b. 6 to 8 hours, with head of bed elevated 15 to 30 degrees. c. 2 to 4 hours, with the head of bed flat. d. 2 to 4 hours, with head of bed elevated 15 to 30 degrees. Source: Saunders 4th

ANS: A Rationale: If an oil-based dye is used during myelography, the dye is removed at the end of the procedure. The client is positioned flat in bed for 6 to 8 hours after the dye is removed. When a water-based contrast medium is used, the client is positioned with the head of bed elevated for at least 8 hours to keep the dye from irritating the cerebral meninges. Strategy: Use the process of elimination. Note the strategic words oil-based contrast agent. Use knowledge regarding care of the client following this procedure to direct you to option 1. Review this procedure if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2047). Philadelphia: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 653). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1181) Following a renal biopsy, the client complains of pain at the biopsy site that radiates to the front of the abdomen. The nurse interprets this complaint and further assesses the client for: a. Bleeding b. Infection c. Renal colic d. Bladder perforation Source: Saunders 4th

ANS: A Rationale: If pain originates at the biopsy site and begins to radiate to the flank area and around the front of the abdomen, bleeding should be suspected. Hypotension, a decreasing hematocrit level, and gross or microscopic hematuria also would indicate bleeding. Signs of infection would not appear immediately following a biopsy. The biopsy site would be the flank area and not the lower abdomen. No data are given to support the presence of renal colic. Strategy: Use the process of elimination. Focusing on the data in the question will assist in eliminating options 3 and 4. Recalling that signs of infection may not appear immediately following biopsy will assist you in eliminating option 2. Review the complications following renal biopsy if you had difficulty with this question. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 794). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1680) A client with diabetes mellitus is being discharged following treatment for hyperglycemic hyperosmolar nonketotic syndrome (HHNS) precipitated by acute illness. The client tells the nurse, "I will call the doctor next time I can't eat for more than a day or so." Which of the following statements reflects the most appropriate analysis of this client's level of knowledge? a. The client needs immediate education prior to discharge. b. The client's statement is accurate but knowledge should be evaluated further. c. The client's statement is inaccurate and the client should be scheduled for outpatient diabetic counseling. d. The client requires follow-up teaching regarding the administration of insulin. Source: Saunders 4th

ANS: A Rationale: If the client becomes ill and cannot retain fluids or food for a period of 4 hours, the physician should be notified. The client's statement in this question indicates a need for immediate education to prevent hyperglycemic hyperosmolar nonketotic syndrome (HHNS), a life-threatening emergency situation. Strategy: Use the process of elimination and focus on the subject. Eliminate option 2 first because the client's statement is inaccurate. Eliminate option 3 next because the client requires immediate education. Eliminate option 4 because HHNS most commonly occurs with type 2 diabetes mellitus and insulin is not the subject of the question. Review diabetic management during times of illness if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1545). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

1725) The client has had radical neck dissection, and begins to hemorrhage at the incision site. Which action by the nurse would be contraindicated? a. Lowering the head of the bed to a flat position b. Applying manual pressure over the site c. Monitoring the client's airway d. Calling the physician immediately Source: Saunders 4th

ANS: A Rationale: If the client begins to hemorrhage from the surgical site following radical neck dissection, the nurse elevates the head of the bed to maintain airway patency and prevent aspiration. The nurse applies pressure over the bleeding site, and calls the physician immediately. Strategy: Use the process of elimination, noting the strategic word contraindicated. Options 2 and 3 are indicated if the client is hemorrhaging. Calling the physician is also indicated immediately, but lowering the head of bed does not help with airway maintenance. Review nursing actions if a client begins to hemorrhage if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 579). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 585). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1159) The client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious. The nurse suspects air embolism. The priority action for the nurse is to: a. Discontinue dialysis and notify the physician. b. Monitor vital signs every 15 minutes for the next hour. c. Continue dialysis at a slower rate after checking the lines for air. d. Bolus the client with 500 mL of normal saline to break up the air embolus. Source: Saunders 4th

ANS: A Rationale: If the client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, notify the physician, and administer oxygen as needed. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination. Recalling that air embolism is an emergency situation that affects the cardiopulmonary system suddenly and profoundly will direct you to option 1. Review the emergency care of a client who develops air embolism if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 264, 1752). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1390) The client is brought to the emergency room and is experiencing an anaphylactic reaction from eating shellfish. The nurse implements which immediate action? a. Maintaining a patent airway b. Administering a corticosteroid c. Administering epinephrine (Adrenalin) d. Instructing the client on the importance of obtaining a Medic-Alert bracelet Source: Saunders 4th

ANS: A Rationale: If the client experiences an anaphylactic reaction, the immediate action would be to maintain a patent airway. The client then would receive epinephrine. Corticosteroids also may be prescribed. The client will need to be instructed about obtaining and wearing a Medic-Alert bracelet, but this is not the immediate action. Strategy: Focus on the strategic word immediate, which tells you that you need to prioritize your nursing actions. Use the ABCs—airway, breathing, and circulation—to answer the question. The airway is always the priority. Review care of the client experiencing an anaphylactic reaction if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2325). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 251). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

2516) A client has a medication order for phenytoin (Dilantin) to be administered by the intravenous route. After drawing up the medication, the nurse notes the presence of precipitate in the syringe. Which of the following is the appropriate action by the nurse? a. Discard the syringe and begin again. b. Draw up an additional 1 mL of normal saline into the syringe. c. Add sterile water to dissolve the precipitate. d. Chart the medication as "not given," and write a note in the medical record. Source: Saunders 4th

ANS: A Rationale: If the injectable solution is not clear or if precipitate is present, the medication should not be used and should be discarded. The nurse may have to call the pharmacy department to obtain another vial of the medication. Options 2, 3, and 4 are inaccurate actions. Strategy: Focus on the strategic words precipitate in the syringe. Basic principles of safe medication administration tell you that the medication must be discarded or the precipitate will be injected directly into the client's bloodstream. Review the principles related to the administration of phenytoin if you had difficulty with this question Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 993). St. Louis: Mosby. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., pp. 233-234). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

19) The nurse calls the physician regarding a new medication order because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the physician and the medication is due to be administered. Which action should the nurse take? a. Contact the nursing supervisor. b. Administer the dose prescribed. c. Hold the medication until the physician can be contacted. d. Administer the recommended dose until the physician can be located. Source: Saunders 4th

ANS: A Rationale: If the physician writes an order that requires clarification, the nurse's responsibility is to contact the physician for clarification. If there is no resolution regarding the order because the physician cannot be located or because the order remains as it was written after talking with the physician, the nurse then should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the order until obtaining clarification. Strategy: Use the process of elimination and eliminate options 2 and 4 first because they are comparative or alike and are unsafe actions. Holding the medication can result in client injury. The nurse needs to take action. Option 1 clearly identifies the required action in this situation. Review nursing responsibilities related to the physician's orders if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 419). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2259) Azathioprine (Imuran) is prescribed for the client to suppress rejection of a renal transplant. The nurse understands that the mechanism of action of this medication is that it: a. Inhibits the proliferation of B and T lymphocytes b. Cross-links DNA c. Blocks all T-cell functions d. Decreases the activity of thymus-derived lymphocytes Source: Saunders 4th

ANS: A Rationale: Imuran suppresses cell-mediated and humoral immune responses by inhibiting the proliferation of B and T lymphocytes. It generally is used as an adjunct to cyclosporine (Sandimmune) and glucocorticoids to help suppress transplant rejection. Options 2, 3, and 4 are incorrect. Strategy: Focus on the client's diagnosis and the use of the medication to direct you to option 1. Review the actions of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 110). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 798). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 85). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2436) A nurse is developing a nursing care plan for a client with a circumferential burn injury of the extremity. The nursing diagnosis states ineffective tissue perfusion. Which of the following nursing interventions should the nurse include in the plan of care for the client? a. Monitor peripheral pulses every hour. b. Keep the extremities in a dependent position. c. Document any changes that occur in the pulse. d. Place pressure dressings and wraps around the burn sites. Source: Saunders 4th

ANS: A Rationale: In a client with ineffective tissue perfusion related to a circumferential burn injury, peripheral pulses should be assessed every hour for 72 hours. The affected extremity should be elevated, and the physician should be notified of any changes in pulses, capillary refill, or pain sensation. Pressure dressings and wraps should not be applied around the circumferential burn because they could cause a further alteration in peripheral circulation. Strategy: Focus on the type of injury and the nursing diagnosis. Use the process of elimination, noting that the intervention that would actively prevent further injury in this client is option 1. If you had difficulty with this question, review care of the client with ineffective peripheral tissue perfusion. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1448-1449). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

2039) A nurse is reviewing the plan of care for a client with a diagnosis of depression. The nurse notes that a nursing diagnosis of imbalanced nutrition with less than body requirements is documented in the plan of care. The nurse avoids which intervention in the plan of care? a. Allow the client to eat alone in the room if the client requests to do so. b. Assist the client in selecting foods from the food menu. c. Offer small, high-calorie, high-protein snacks during the day and evening. d. Offer high-calorie fluids throughout the day and evening. Source: Saunders 4th

ANS: A Rationale: In caring for a client with depression and a nursing diagnosis of imbalanced nutrition with less than body requirements, the nurse should remain with the client during the meal. The nurse also should assist the client in selecting foods from the menu because the client is more likely to eat the foods that he or she likes. Offering small, high-calorie, high-protein snacks, and high-calorie fluids throughout the day and evening are appropriate interventions for the client to maintain nutrition. Strategy: Note the strategic word avoids in the question. This indicates a negative event query and directs you to select an incorrect intervention. Use the process of elimination, focusing on the interventions that may affect both nutritional intake and monitoring intake in the client. If you had difficulty with this question, review measures to improve nutritional status of the client with depression. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 335-338). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2116) A nurse is caring for a client who is receiving intermittent feeding via a nasogastric (NG) tube. Before administering an NG feeding to the client, the nurse should first: a. Check the placement of the tube. b. Check the last time medications were given. c. Rinse the Asepto syringe with warm water. d. Warm the feeding to 103° F. Source: Saunders 4th

ANS: A Rationale: In order to prevent aspiration while administering a tube feeding, the nurse would place the client in an upright sitting position or elevate the head of the bed at least 30 degrees. Before the feeding, the nurse checks the placement of the tube by aspirating gastric contents and measuring the pH. Formulas are administered at room temperature. Options 2 and 3 are not directly related to the subject of the question. Strategy: Use the process of elimination and note the strategic word first. Use the ABCs—airway, breathing, and circulation. In order to prevent the complication of aspiration when feeding a client with an NG tube, the nurse would first assess accurate placement of the tube. Review the principles related to NG tube feedings if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1431). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1928) A nursing student is assigned to care for a client with a diagnosis of acute renal failure, diuretic phase. The nursing instructor asks the student about the primary goal of the treatment plan for this client. Which of the following statements if made by the nursing student would indicate an adequate understanding of the treatment plan for this client? a. Prevent loss of electrolytes b. Reduce the urine specific gravity c. Promote the excretion of wastes d. Prevent fluid overload Source: Saunders 4th

ANS: A Rationale: In the diuretic phase, fluids and electrolytes are lost in the urine. As a result, the plan of care focuses on fluid and electrolyte replacement and monitoring. Options 2, 3, and 4 are not the primary concerns in this phase of renal failure. Strategy: Use the process of elimination. Note the strategic words diuretic phase. Knowing that during this phase the client experiences a high urine output will direct you to option 1. Review the goals of treatment in the diuretic phase if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 945). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1736). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1902) A client is admitted to the nursing unit after undergoing radical prostatectomy for cancer. The nurse anticipates that which of the following nursing diagnoses will be most likely for this client in the immediate postoperative period? a. Fear related to the outcome of surgery b. Chronic pain related to the effects of cancer c. Body image disturbance related to presence of a suprapubic catheter d. Impaired home maintenance related to insufficient help after discharge Source: Saunders 4th

ANS: A Rationale: In the immediate postoperative period, the client who has had surgery for cancer may experience fear related to the uncertain outcome of surgery. Postoperative pain is classified as acute, not chronic. The client may experience a disturbed body image, but this would be more likely to be related to the anticipated change in sexual function than to the presence of the suprapubic catheter. The priority focus in the immediate postoperative period is not on diagnoses that apply to hospital discharge. Strategy: Use the process of elimination. Note the strategic words immediate postoperative period. Begin to answer this question by eliminating option 4 as the least appropriate in the time period immediately following surgery. The question presents no data supporting a nursing diagnosis of chronic pain, so option 2 is eliminated next. Regarding the remaining options, recalling that the suprapubic catheter is temporary will assist in eliminating option 3. Review care of the client after radical prostatectomy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 278, 1020-1021). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2020) A nurse is reviewing the laboratory test results for a client receiving chemotherapy. The nurse notes that the white blood cell count is extremely low. The client is placed on neutropenic precautions. Which of the following interventions is an incorrect component of neutropenic precautions? a. Allowing only fresh fruits only in the client's room b. Removing fresh cut flowers from the client's room c. Instructing family members to wear a mask when entering the client's room d. Instructing family members on the proper technique for hand washing Source: Saunders 4th

ANS: A Rationale: In the immunocompromised client, a low-bacteria diet is necessary. This includes avoiding the intake of fresh fruits and vegetables. Thorough cooking of all food also is required. Anyone who enters the client's room should perform strict and thorough hand washing and wear a mask. Cut flowers or any standing water is removed from the room because either will tend to harbor bacteria. Strategy: Focus on the subject of the question, neutropenic precautions. Use the process of elimination, noting the strategic word incorrect. Visualizing each of the options in terms of its risk to the client in producing infection will direct you to option 1. Review interventions for the client on neutropenic precautions if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 382). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

1031) A client with uncomplicated or simple silicosis is being monitored yearly at the health care clinic. In this type of silicosis, the nurse expects that the client would: a. Be asymptomatic b. Complain of severe dyspnea c. Experience malaise and fatigue d. Experience anorexia and weight loss Source: Saunders 4th

ANS: A Rationale: In uncomplicated or simple silicosis, the client would be asymptomatic, although evidence of fibrosis on an x-ray would be present. Malaise, anorexia, weight loss, and severe dyspnea on exertion would occur in a client with chronic complicated silicosis. Strategy: Use the process of elimination. Noting the words uncomplicated or simple will direct you to option 1. Review the manifestations associated with silicosis if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 612). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1396) The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is at most risk for developing this type of allergy? a. Hairdressers b. The homeless c. Children in day care centers d. Individuals living in a group home Source: Saunders 4th

ANS: A Rationale: Individuals at risk for developing a latex allergy include health care workers, individuals who work in the rubber industry or those who have had multiple surgeries, have spina bifida, wear gloves frequently, such as food handlers, hairdressers, and auto mechanics, or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts. Strategy: Focus on the subject, a latex allergy. Recalling the cause and the source of the allergic reaction will direct you easily to option 1. Review the cause of this type of allergy and the individuals at risk if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 461). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

2285) A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and formulates which nursing diagnosis? a. Ineffective breathing pattern b. Impaired gas exchange c. Risk for aspiration d. Risk for injury Source: Saunders 4th

ANS: A Rationale: Ineffective breathing pattern is diagnosed when the respiratory rate, depth, rhythm, timing, or chest wall movements are insufficient for optimal ventilation of the client. This is a risk for clients with spinal cord injury in the lower cervical area. Impaired gas exchange occurs when oxygenation or carbon dioxide elimination is altered at the alveolar-capillary membrane. Risk for aspiration and risk for injury are unrelated to the question. Strategy: Focus on the data provided in the question. The client's clinical signs do not correlate with the defining characteristics of risk for aspiration and risk for injury. Knowing that the respiratory difficulty is due to a motor problem helps you choose ineffective breathing pattern over impaired gas exchange for the correct nursing diagnosis. Additionally, the question states that the client has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. These findings indicate an ineffective breathing pattern. Review appropriate nursing diagnoses for the client with a spinal cord injury if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 987, 991). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

73) A nurse caring for a client with an ileostomy understands that the client is most at risk for developing which acid-base disorder? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis Source: Saunders 4th

ANS: A Rationale: Intestinal secretions are high in bicarbonate and may be lost through enteric drainage tubes or an ileostomy, or with diarrhea. These conditions result in metabolic acidosis. Options 2, 3, and 4 are incorrect because they do not occur in the client with an ileostomy. Strategy: Use the process of elimination. Note that the client's condition described in the question is a gastrointestinal disorder. This will direct you toward a metabolic disorder. Remembering that intestinal fluids are primarily alkaline will assist you in selecting the correct option. When excess bicarbonate is lost, acidosis will result. If you had difficulty with this question, review the causes of metabolic acidosis. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1327). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2088) A nurse is administering care to a client immediately after nephrectomy and renal transplantation. The nurse administers intravenous fluids as ordered, recognizing that the hourly rate should be calculated on the basis of: a. The number of milliliters in the previous hour's urine output b. One half of the previous hour's urine output c. A strict hourly rate of 100 mL d. A strict hourly rate of 150 mL Source: Saunders 4th

ANS: A Rationale: Intravenous fluids are managed very carefully after nephrectomy and renal transplantation. Fluids are given according to a formula that takes into account the previous hour's urine output. The desired urine output is generally high. Therefore, options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination. Begin to answer this question by eliminating options 3 and 4 first, knowing that the intravenous fluid rate is titrated according to the urine output immediately after nephrectomy and renal transplantation. Regarding the remaining options, it is necessary to know that the formula adds the previous hour's urine output to a base rate. Review postoperative care with renal transplantation if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 924). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1724). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1427) A client has been admitted to the mental health unit. On admission assessment, the nurse notes that the client was admitted by involuntary status. Based on this type of admission, the nurse would most likely expect that the client: a. Presents a harm to self b. Requested the admission c. Consented to the admission d. Provided written application to the facility for admission Source: Saunders 4th

ANS: A Rationale: Involuntary admission is made without the client's consent. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment. Options 2, 3, and 4 describe the process of voluntary admission. Strategy: Use the process of elimination and note the strategic words involuntary status. This should direct you easily to option 1. Also, note that options 2, 3, and 4 are comparative or alike. Review the process of involuntary admission if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 50). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 150). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1551) The nurse provides instructions to a malnourished client regarding iron supplementation during pregnancy. Which statement, if made by the client, would indicate an understanding of the instructions? a. "The iron is best absorbed if taken on an empty stomach." b. "Meat does not provide iron and should be avoided." c. "Iron supplements will give me diarrhea." d. "My body has all the iron it needs and I don't need to take supplements." Source: Saunders 4th

ANS: A Rationale: Iron is needed both to allow for transfer of adequate iron to the fetus and to permit expansion of the maternal RBC mass. During pregnancy, the relative excess of plasma causes a decrease in the hemoglobin concentration and hematocrit, known as physiological anemia of pregnancy. This is a normal adaptation during pregnancy. Meats are an excellent source of iron. Iron supplements usually cause constipation. Iron is best absorbed if taken on an empty stomach. Strategy: Use the process of elimination, focusing on the strategic words understanding of the instructions. Knowledge of basic principles related to nutrition during pregnancy will assist in eliminating options 2 and 4. From the remaining options, remember that iron causes constipation. Review client teaching points related to iron supplementation if you had difficulty with this question. Reference: Lowdermilk, D., & Perry, A. (2004). Maternity and woman's health care (8th ed., p. 379). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1263) The nurse prepares the client for an ear irrigation as prescribed by the physician. In performing the procedure, the nurse: a. Warms the irrigating solution to 98° F b. Positions the client with the affected side up following the irrigation c. Directs a slow steady stream of irrigation solution toward the eardrum d. Assists the client to turn his or her head so that the ear to be irrigated is facing upward Source: Saunders 4th

ANS: A Rationale: Irrigation solutions that are not close to the client's body temperature can be uncomfortable and may cause injury, nausea, and vertigo. The client is positioned so that the ear to be irrigated is facing downward, because this allows gravity to assist in the removal of the ear wax and solution. Following the irrigation, the client is to lie on the affected side to finish draining the irrigating solution. A slow steady stream of solution should be directed toward the upper wall of the ear canal and not toward the eardrum. Too much force could cause the tympanic membrane to rupture. Strategy: Use the process of elimination. Read each option carefully and remember that the nurse's concern is to prevent damage to the tympanic membrane. Additionally, remember that the client should be positioned with the affected side downward to allow drainage of the irrigation solution. Review the procedure for performing an ear irrigation if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1128). Philadelphia: W.B. Saunders. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 738). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 862-863). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

1731) The nurse is administering a dose of isoproterenol hydrochloride (Isuprel) to a client. The nurse monitors for which of the following side effects of this medication? a. Increased pulse and blood pressure b. Drowsiness c. Hyperglycemia d. Hypokalemia Source: Saunders 4th

ANS: A Rationale: Isoproterenol is an adrenergic bronchodilator. Side effects can include tachycardia, hypertension, chest pain, dysrhythmias, nervousness, restlessness, and headache. The nurse monitors for these effects during therapy. Strategy: Use the process of elimination. Recall that this medication is an adrenergic agent. Thus, it causes bronchodilation but also increases pulse and blood pressure because of its cardiovascular effects. With this in mind, you can eliminate each incorrect option. Remembering that tachycardia is a side effect should assist in selecting the option that identifies an increased pulse, option 1. Review the side effects of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 466). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1677) The postpartum nurse teaches a mother how to give a bath to the newborn infant and observes the mother performing the procedure. Which of the following indicates a lack of understanding of the instructions? a. The mother bathes the newborn infant after a feeding. b. The mother fills a clean basin or sink with 2 to 3 inches of water and then checks the temperature with her wrist. c. The mother states she would never leave the newborn infant in the tub of water alone. d. The mother states she would gather all supplies before the bath is started. Source: Saunders 4th

ANS: A Rationale: It is not advisable to bathe a newborn infant after a feeding because handling may cause regurgitation. Because bathing is thought to be relaxing to the infant, bathing before feeding may be the best time. Options 2, 3, and 4 are appropriate interventions in teaching the mother how to bathe a newborn. Strategy: Use the process of elimination. Note the strategic words lack of understanding of the instructions in the question. Recalling that handling the baby may cause regurgitation will assist in directing you to option 1. Review teaching points regarding bathing of a newborn if you had difficulty with this question. Reference: Lowdermilk, D., & Perry, A. (2004). Maternity and woman's health care (8th ed., p. 795). St. Louis: Mosby. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 581). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

2423) A home care nurse is visiting a male client who is recovering at home after suffering a brain attack (stroke) 2 weeks ago. The client's wife states that the client has difficulty feeding himself and difficulty with swallowing food and fluids. Which of the following would be the most appropriate initial nursing action? a. Observe the client feeding himself. b. Observe the wife feeding the client. c. Arrange for a home health aide to assist at mealtimes. d. Instruct the wife in the use of a feeding syringe to feed the client. Source: Saunders 4th

ANS: A Rationale: It is not uncommon for a client to have difficulty swallowing after experiencing a stroke. Often the client has hemiplegia. The arm on the affected side may be paralyzed, and the client may have to learn to use the opposite arm for self-feeding. Using the nondominant arm may require rehabilitation and retraining. Also, a client may have partial paralysis of the mouth, tongue, or esophagus. To best assist the client, the nurse should first assess the situation by watching the self-feeding process. Perhaps the problem lies in the feeding technique, the type of feeding tool used, or the types of foods being served, or a combination. Having someone else feed the client may be necessary if self-feeding is not possible. This approach, however, does not promote independence for the client. A feeding syringe is not recommended for feeding most clients. Strategy: Focus on the subject of the question as it relates to the client's inability to feed himself and difficulty with swallowing food and fluids. Use the nursing process to answer the question, recalling that assessment comes first. Observing the client feeding himself would be the appropriate initial nursing action. Review assessment of the client for feeding disorders if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2111, 2129, 2132-2133). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1879) A nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which of the following data if noted on the client's record would alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy? a. The client's last baby weighed 10 pounds at birth. b. The client's previous deliveries were by cesarean birth. c. The client has a family history of cardiovascular disease. d. The client is 5 feet 3 inches in height and weighs 165 pounds. Source: Saunders 4th

ANS: A Rationale: Known risk factors that increase the risk of developing gestational diabetes include obesity (over 198 pounds), chronic hypertension, family history of diabetes mellitus, previous birth of a large infant (over 4000 g), and gestational diabetes in a previous pregnancy. Options 2, 3, and 4 are not risk factors associated with the development of gestational diabetes. Strategy: Focus on the subject of the question, risk factors associated with development of gestational diabetes. Use the process of elimination and knowledge regarding these risk factors to assist in directing you to option 1. If you are unfamiliar with the risk factors associated with gestational diabetes, review this content. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 667). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1400) The camp nurse prepares to instruct a group of children about Lyme disease. Which of the following information would the nurse include in the instructions? a. Lyme disease is caused by a tick carried by deer. b. Lyme disease is caused by contamination from cat feces. c. Lyme disease can be contagious through skin contact with an infected individual. d. Lyme disease can be caused by the inhalation of spores from bird droppings. Source: Saunders 4th

ANS: A Rationale: Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. Persons bitten by the Ixodes scapularis or I. pacificus tick can become infected with the spirochete Borrelia burgdorferi. Lyme disease cannot be transmitted from one person to another. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. Toxoplasmosis is caused by the ingestion of cysts from contaminated cat feces. Strategy: Use the process of elimination. Recalling that this disease is caused by a tick bite will assist in eliminating the incorrect options. If you had difficulty with this question, review the cause of Lyme disease. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 418). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1736). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

970) The client has an order to take magnesium citrate (citrate of magnesia) to prevent constipation following a barium study of the upper gastrointestinal tract. How should the nurse administer this medication? a. With ice b. With fruit juice only c. At room temperature d. With two full glasses of water Source: Saunders 4th

ANS: A Rationale: Magnesium citrate is available as an oral solution and is used commonly as a laxative in preparation for or after certain studies of the gastrointestinal tract. Magnesium citrate should be served chilled and not be allowed to stand for prolonged periods, which would reduce the carbonation and make the solution even less palatable. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination. Eliminate options 2 and 4 first, knowing that magnesium citrate is itself a liquid. From the remaining options, you must know that magnesium citrate should be given cold to enhance its palatability. Review this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 719). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2007). Mosby's 2007 nursing drug reference (20th ed., p. 630). St. Louis: Mosby. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 519). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1609) The private duty nurse has been caring for a terminally ill client whose death is imminent. The nurse has developed a close relationship with the family of the client. Which of the following nursing interventions will the nurse avoid in dealing with the family during this difficult time? a. Making decisions for the family b. Encouraging family discussion of feelings c. Facilitating the use of spiritual practices identified by the family d. Accepting the family's expressions of anger Source: Saunders 4th

ANS: A Rationale: Maintaining effective and open communication among family members affected by death and grief is of utmost importance. The nurse needs to maintain and enhance communication as well as preserve the family's sense of self-direction and control. Option 1 removes autonomy and decision making from the family at a time when they are already experiencing feelings of loss of control. This is an ineffective intervention that could impair communication. Option 2 is likely to enhance communication. Option 3 is an effective intervention because spiritual practices give meaning to life and have an impact on how people react to crisis. Option 4 is also an effective technique, and the family needs to know that someone will be there who is supportive and nonjudgmental. Strategy: Note the strategic word avoid in the question. Use the process of elimination, focusing on therapeutic communication techniques, to direct you to option 1. Review therapeutic techniques for individuals in crisis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 110, 113). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1516) A client taking lithium carbonate (Eskalith) reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L. The nurse interprets this level as: a. Toxic b. Normal c. Slightly above normal d. Excessively below normal Source: Saunders 4th

ANS: A Rationale: Maintenance serum levels of lithium are 0.6 to 1.2 mEq/L. Symptoms of toxicity begin to appear at levels of 1.5 to 2 mEq/L. Lithium toxicity requires immediate medical attention with lavage and possible peritoneal dialysis or hemodialysis. Strategy: Use the process of elimination. Recalling that the high end of the maintenance level is 1.2 mEq/L will direct you to option 1. Review the maintenance level and signs of toxicity if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 478). St. Louis: Mosby. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., pp. 214-216). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1913) A nurse is giving general instructions to a client receiving hemodialysis. Which of the following statements would be appropriate for the nurse to include? a. "Several types of medications should be withheld on the day of dialysis until after the procedure." b. "Medications should be double-dosed on the morning of hemodialysis to prevent loss." c. "It's acceptable to exceed the fluid restriction on the day before hemodialysis." d. "It's acceptable to eat whatever you want on the day before hemodialysis." Source: Saunders 4th

ANS: A Rationale: Many medications are dialyzable, which means they are extracted from the bloodstream during dialysis. Therefore, many medications may be withheld on the day of dialysis until after the procedure. It is not typical for medications to be "double-dosed," because there is no way to be certain how much of each medication is cleared by dialysis. Clients receiving hemodialysis are not routinely taught that it is acceptable to disregard dietary and fluid restrictions. Strategy: Use the process of elimination. Knowing that clients are not taught to disregard dietary or fluid restriction will help you eliminate options 3 and 4. Regarding the remaining options, recall that hemodialysis decreases serum medication levels, and that some medications are not generally given pre-dialysis. Review dialysis procedures if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1756). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2490) A nursing student is assigned to provide care for a client recently diagnosed with a melanoma. The clinic nurse asks the student about the characteristics of this type of skin lesion. Which statement by the student indicates an understanding of this type of lesion? a. "It is highly metastatic." b. "Metastasis is rare." c. "It is characterized by local invasion." d. "It is contagious." Source: Saunders 4th

ANS: A Rationale: Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. This skin cancer is highly metastatic, and the affected person's survival depends on early diagnosis and treatment. It is not a contagious lesion. Basal cell carcinomas arise in the basal cell layer of the epidermis. Early malignant basal cell lesions often go unnoticed, and although metastasis is rare, underlying tissue destruction can progress to include vital structures. Squamous cell carcinomas are malignant neoplasms of the epidermis. They are characterized by local invasion and the potential for metastasis. Strategy: Use the process of elimination and knowledge regarding the various types of skin cancers to answer this question. Recalling that melanomas are highly metastatic will assist in directing you to the correct option. If you had difficulty with this question, review the characteristics of skin cancers. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1416). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

166) The nurse is caring for a client diagnosed with meningitis and implements which transmission-based precautions for this client? a. Private room or cohort client b. Personal respiratory protection device c. Private room with negative airflow pressure d. Mask worn by staff when the client needs to leave the room Source: Saunders 4th

ANS: A Rationale: Meningitis is transmitted by droplet infection. Precautions for this disease include a private room or cohort client and use of a standard precaution mask. Private negative airflow pressure rooms and personal respiratory protection devices are required for clients with airborne disease such as tuberculosis (TB). When appropriate, a mask must be worn by the client and not the staff when the client leaves the room. Strategy: Use the process of elimination to determine the correct precaution needs for this client. Focusing on the client's diagnosis and recalling that meningitis is transmitted by droplets will direct you to option 1. If you had difficulty with this question, review transmission-based categories, including precaution criteria. Reference: Potter, A., and Perry, P. (2005). Fundamentals of nursing (6th ed., p. 965). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2510) A client who has had a myocardial infarction has an order to take psyllium (Metamucil) after discharge. The nurse should plan to include which of the following information when teaching the client about this medication? a. Mix the medication with a full glass of water or juice. b. Decrease fluid intake following administration of the medication. c. Mix the medication with applesauce. d. Decrease the amount of fiber in the diet when taking this medication. Source: Saunders 4th

ANS: A Rationale: Metamucil is a bulk-forming laxative that should be taken with a full glass of water or juice (not applesauce), followed by another glass of liquid. This will help prevent impaction of the medication in the stomach or small intestine. Both fiber in the diet and fluid intake should not be decreased unless specifically prescribed by the physician. Strategy: Focus on the subject, proper administration of this medication. Recalling that the medication is supplied in powdered form will direct you to option 1. Review the client teaching points related to this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 987). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1741) Methenamine mandelate (Mandelamine) is prescribed for the client with a gram-positive urinary tract infection. Which of the following conditions, if noted in the client's record, would alert the nurse to question the order for this prescribed medication? a. Cirrhosis of the liver b. Diabetes mellitus c. Peripheral vascular disease d. Hypothyroidism Source: Saunders 4th

ANS: A Rationale: Methenamine (Mandelamine) is contraindicated in clients with renal or hepatic disease or clients with severe dehydration. The nurse would question the physician's prescription for this medication in the client with cirrhosis of the liver. Options 2, 3, and 4 are not contraindicated with this medication. Strategy: Use the process of elimination. Knowledge that this medication is contraindicated in hepatic disease will easily direct you to option 1. If you are unfamiliar with this medication and its contraindications, review this content. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 488). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1822) Methylergonovine (Methergine) has been prescribed for a woman who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside? a. Blood pressure cuff b. Tape measure c. Reflex hammer d. Peripads Source: Saunders 4th

ANS: A Rationale: Methylergonovine is an oxytocic agent used to prevent or control postpartum hemorrhage by contracting the uterus. It causes constant uterine contractions and may cause the blood pressure to elevate. A priority assessment before administering this medication is obtaining a baseline blood pressure. The client's blood pressure should also be monitored during the administration of the medication. Methylergonovine is administered cautiously in the presence of hypertension and the physician should be notified if hypertension occurs. Strategy: Note the strategic word priority in the question. Use the ABCs—airway, breathing, and circulation—to assist in selecting the correct option. Review the nursing responsibilities related to administration of methylergonovine if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 756). Philadelphia: W.B. Saunders. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 411). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

2648) A nurse in the postpartum unit notes that a new mother was given methylergonovine (Methergine) intramuscularly following delivery. The nurse evaluates the client for which of the following to determine that the medication was effective? a. Decreased uterine bleeding b. Lochia that is serous c. Decreased uterine contractions d. Normal blood pressure Source: Saunders 4th

ANS: A Rationale: Methylergonovine, an oxytocic, is an agent that is used to prevent or control postpartum hemorrhage by contracting the uterus. The immediate dose usually is given intramuscularly, and then if addition medication is needed, it is given by mouth. It increases the strength and frequency of contractions and may elevate the blood pressure. A priority assessment component before the administration of methylergonovine is blood pressure. No relationship exists between the action of this medication and lochial drainage. Strategy: Use the process of elimination and focus on the subject, whether the medication was effective. Recalling that methylergonovine is an oxytocic will direct you to option 1. If you are unfamiliar with this medication, review its action and use. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 818). St. Louis: Mosby. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 547). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2361) A client taking metronidazole (Flagyl) telephones the home health nurse to report dark discoloration to the urine. The nurse interprets that the client's complaint warrants which of the following nursing actions at this time? a. Tell the client that this is a harmless medication side effect. b. Instruct the client to increase fluid intake. c. Instruct the client to call the physician. d. Tell the client to discontinue the medication. Source: Saunders 4th

ANS: A Rationale: Metronidazole can produce a variety of side effects, but they rarely require termination of treatment. Harmless darkening of the urine may occur and the client should be told of this effect. It is not necessary to discontinue the medication or call the physician. Increasing fluid intake is a good health measure but will not prevent this side effect from occurring. Strategy: Use the process of elimination. Recalling that harmless darkening of the urine can occur will direct you to option 1. If you are unfamiliar with the side effects of this medication, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 769). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1327) The client arrives at the emergency department complaining of back spasms. The client states, "I have been taking two to three aspirin every 4 hours for the last week, and it hasn't helped my back." Aspirin intoxication is suspected, and the nurse assesses the client for which of the following? a. Tinnitus b. Diarrhea c. Constipation d. Photosensitivity Source: Saunders 4th

ANS: A Rationale: Mild intoxication with acetylsalicylic acid (aspirin) is called salicylism and is experienced commonly when the daily dosage is higher than 4 g. Tinnitus (ringing in the ears) is the most frequent effect noted with intoxication. Hyperventilation may occur because salicylate stimulates the respiratory center. Fever may result, because salicylate interferes with the metabolic pathways coupling oxygen consumption and heat production. Options 2, 3, and 4 are not associated specifically with toxicity. Strategy: Use the process of elimination. Note that the question refers to aspirin intoxication. Options 2 and 3 relate to gastrointestinal symptoms, are comparative or alike, and are eliminated first. From the remaining options, you must know that tinnitus occurs. If you had difficulty with this question, review aspirin intoxication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 95). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2507) A client who has been taking high doses of acetylsalicylic acid (ASA), or aspirin, to relieve pain from osteoarthritis now has more generalized joint pain and an elevated temperature. The nurse should assess for which of the following to determine whether the client has other signs of aspirin toxicity? a. Ringing in the ears b. Double vision c. Diarrhea d. Constipation Source: Saunders 4th

ANS: A Rationale: Mild intoxication with acetylsalicylic acid, called salicylism, commonly occurs when the daily dosage is more than 4 g. Tinnitus (ringing in the ears) is the most frequent effect noted with intoxication. Hyperventilation also may occur because salicylate stimulates the respiratory center. Fever may result because salicylate interferes with the metabolic pathways coupling oxygen consumption and heat production. Options 2, 3, and 4 are not signs of aspirin toxicity. Strategy: Use the process of elimination and focus on the subject, aspirin toxicity. Eliminate options 3 and 4 first because gastric upset would be most likely to occur with intake of high aspirin doses. Regarding the remaining options, it is necessary to know that tinnitus occurs with aspirin toxicity. If you had difficulty with this question, review aspirin intoxication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 95). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2392) A client with hypertension has a new prescription for a medication called moexipril (Univasc). The nurse plans to provide written directions that tell the client to take the medication: a. 1 hour before meals b. With a snack in late afternoon c. With meals d. At bedtime Source: Saunders 4th

ANS: A Rationale: Moexipril is an angiotensin-converting enzyme (ACE) inhibitor. The client should be instructed to take the medication at least 1 hour before meals. The other ACE inhibitor that should be taken 1 hour before meals is captopril (Capoten). The other options are incorrect instructions to the client. Strategy: There are several medications that are in the ACE inhibitor classification. If you can remember that moexipril and captopril are the ones that are taken 1 hour before meals, you will easily be able to answer questions similar to this one. Review client teaching points related to moexipril if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 790). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1647) The nursing instructor asks the nursing student to describe Montgomery's tubercles of the breast. The student indicates an understanding of this anatomical structure if the student states that Montgomery's tubercles are: a. Sebaceous glands in the areola. b. Lobes of glandular tissue that secrete milk. c. Small sacs that contain acinar cells to secrete milk. d. Ducts containing milk from all areas of the breast. Source: Saunders 4th

ANS: A Rationale: Montgomery's tubercles are sebaceous glands located in the areola. They are inactive and not obvious, except during pregnancy and lactation, when they enlarge and secrete a substance that keeps the nipple soft. Within each breast are lobes of glandular tissue that secrete milk. Alveoli are small sacs that contain acinar cells to secrete milk. The alveoli drain into lactiferous ducts, which connect to drain milk from all areas of the breast. Strategy: Use the process of elimination and knowledge regarding the anatomy and physiology of the breast to answer this question. Remember that Montgomery's tubercles are sebaceous glands located in the areola. If you are unfamiliar with the structures of the female breast, review these structures. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1770). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2) A nurse is providing discharge instructions to a Chinese client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. Which nursing action is appropriate? a. Continue with the instructions, verifying client understanding. b. Walk around the client so that the nurse constantly faces the client. c. Give the client a dietary booklet and return later to continue with the instructions. d. Tell the client about the importance of the instructions for the maintenance of health care. Source: Saunders 4th

ANS: A Rationale: Most Chinese maintain a formal distance with others, which is a form of respect. Many Chinese are uncomfortable with face-to-face communications, especially when eye contact is direct. If the client turns away from the nurse during a conversation, the most appropriate action is to continue with the conversation. Walking around to the client so that the nurse faces the client is in direct conflict with the cultural practice. The client may consider returning later to continue with the explanation as a rude gesture. Telling the client about the importance of the instructions for the maintenance of health care may be viewed as degrading. Strategy: Use the process of elimination. Eliminate options 3 and 4 first because these actions are nontherapeutic. From the remaining options, option 1 is the therapeutic action. If you had difficulty with this question, review the communication practices of this cultural group. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., pp. 68, 70). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2007) A nurse is developing a plan of care for a client with a diagnosis of Ménière's disease who is being admitted to the hospital. The priority nursing intervention in the plan of care should focus on: a. Safety measures b. Self-care measures c. Knowledge about medication therapy d. Food items to avoid Source: Saunders 4th

ANS: A Rationale: Ménière's disease can cause severe vertigo in the client. The priority in the nursing care plan should focus on safety issues to prevent falls or injury in the client. Although self-care measures, medication therapy, and dietary therapy may be components of the plan of care, safety is the priority issue. Strategy: Focus on the client's disorder, Ménière's disease, and recall that severe vertigo can occur. Use the process of elimination and Maslow's Hierarchy of Needs theory to assist you in answering the question. Recall that safety is a priority need. Review care of the client with Ménière's disease if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1140). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

1811) A nurse is developing a plan of care for a client receiving a nasogastric (NG) tube feeding. When formulating the plan of care, the nurse keeps in mind that: a. Aspiration is a concern with an NG tube feeding. b. The client needs to be maintained in a supine position. c. The NG tube needs to be changed with every other feeding. d. The rate of the feeding needs to be increased if the infusion rate falls behind schedule. Source: Saunders 4th

ANS: A Rationale: NG tube feedings are beneficial for some clients but present several significant possible complications such as diarrhea, lactose intolerance, dumping syndrome, or excess fluid volume. A common complication is aspiration pneumonia, which is caused by regurgitation of formula contents from the stomach into the respiratory tract. Keeping the head of the bed elevated to 30 degrees at all times assists in the prevention of this complication. NG tubes may be left in from weeks to months depending on the type of tube inserted. The rate of the feedings should not be increased unless prescribed. A rate that is too rapid may also cause diarrhea or fluid overload. Strategy: Use the process of elimination. Eliminate option 4 first because a physician's order is needed to increase the rate of the feeding and because this action could lead to fluid overload problems. Eliminate option 2 because a supine position could cause aspiration. Eliminate option 3 next, recalling that NG tubes may be left in place from weeks to months, depending on the type of tube inserted. Review the care of a client receiving NG tube feedings if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 705). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 856). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2248) Nalidixic acid (NegGram) is prescribed for the adult client with a urinary tract infection (UTI). The nurse understands that the normal adult dosage for this medication is: a. 1 g four times daily for a period of 1 week b. 500 mg daily administered at bedtime c. 250 mg administered twice daily d. 100 mg administered three times daily Source: Saunders 4th

ANS: A Rationale: Nalidixic acid is dispensed in tablets of 250 mg, 500 mg, and 1 g and in suspension of 50 mg/mL for oral use. The adult dosage is 1 g four times a day for 1 week. It should not be administered to children younger than 3 years because it may produce intracranial hypertension in pediatric clients. Strategy: Knowledge regarding the normal adult dosage of nalidixic acid is required to answer this question. Remember that the normal dose is 1 g four times daily. If you are unfamiliar with this medication and its normal dosage, review this content. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 487, 451). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1151) Which of the following would be an expected outcome of nesiritide (Natrecor) administration? a. Client will have an increase in urine output. b. Client will have an absence of dysrhythmias. c. Client will have an increase in blood pressure. d. Client will have an increase in pulmonary capillary wedge pressure. Source: Saunders 4th

ANS: A Rationale: Nesiritide is a recombinant version of human B-type natriuretic peptide, which vasodilates arteries and veins. It is used for the treatment of decompensated heart failure, increases renal glomerular filtration, and increases urine output. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination. Nesiritide does not have antidysrhythmic properties. Dysrhythmias may be a side effect of the medication, so option 2 should be eliminated. Eliminate option 3 because the medication is a vasodilator and causes a decrease in blood pressure. Eliminate option 4 because the medication decreases pulmonary capillary wedge pressure (PCWP). Review the effects of this medication if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, L. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed., p. 757). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1591) A diagnostic workup is being performed on a 1-year-old child suspected of a diagnosis of neuroblastoma. The nurse reviews the results of the diagnostic tests and understands that which finding is most specifically related to this type of tumor? a. Elevated vanillylmandelic acid (VMA) urinary levels b. Presence of blast cells in the bone marrow c. Projectile vomiting, usually in the morning d. Positive Babinski's sign Source: Saunders 4th

ANS: A Rationale: Neuroblastoma is a solid tumor found only in children. It arises from neural crest cells that develop into the sympathetic nervous system and the adrenal medulla. Typically, the tumor compresses adjacent normal tissue and organs. Neuroblastoma cells may excrete catecholamines and their metabolites. Urine samples will indicate elevated vanillylmandelic acid (VMA) levels. The presence of blast cells in the bone marrow occurs in leukemia. Projectile vomiting occurring most often in the morning and a positive Babinski's sign are clinical manifestations of a brain tumor. Strategy: Use the process of elimination. If you are unfamiliar with this type of tumor, recall that blast cells are noted in leukemia and eliminate option 2. Next, eliminate options 3 and 4, noting that these manifestations are found in the child with a brain tumor. Review the manifestations associated with neuroblastoma if you had difficulty with this question. Reference: Mosby. (2006). Mosby's medical, nursing, and allied health dictionary (7th ed., p. 1280). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Child Health Alternate Question Types -> Multiple Choice

1991) A nurse is reviewing the physician orders for a client recently admitted to the hospital and notes that the physician has prescribed ticlopidine (Ticlid) therapy. Which of the following findings if noted on the client's record would indicate a need to contact the physician before initiating the medication prescription? a. Neutropenia b. Complaints of gastrointestinal (GI) disturbances c. Client history of stroke d. Client history of hypertension Source: Saunders 4th

ANS: A Rationale: Neutropenia or agranulocytosis is the most serious adverse effect associated with the use of ticlopidine. A baseline complete blood cell count with differential will be performed for the client. Neutropenia occurs most often within the first 3 months of therapy; therefore, a complete blood cell count with differential is recommended every 2 weeks during the first 3 months. If a diagnosis of neutropenia is determined, then the client will be withdrawn from therapy. This medication is used to prevent a stroke and is not contraindicated in hypertension. GI disturbances can occur as a result of taking the medication, and the client is instructed to take the medication with food to minimize these side effects. Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they are comparative or alike. Regarding the remaining options, note that option 1 is the most serious concern. This will assist in directing you to option 1. Review this medication if you are unfamiliar with it. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1129). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

5) An ambulatory care nurse is discussing preoperative procedures with a Chinese-American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. The nurse interprets this nonverbal behavior as: a. Reflecting a cultural value b. An acceptance of the treatment c. The client is agreeable to the required procedures d. The client understands the preoperative procedures Source: Saunders 4th

ANS: A Rationale: Nodding or smiling by a Chinese-American client may reflect only the cultural value of interpersonal harmony. This nonverbal behavior may not be an indication of agreement with the speaker, an acceptance of the treatment, or an understanding of the procedure. Strategy: Use the process of elimination. Eliminate options 2 and 3 first because they are comparative or alike. From the remaining options, select option 1 because it is characteristic of Chinese-American culture. In addition, option 4 is an incorrect interpretation of the client's nonverbal behavior. Review the cultural characteristics of the Chinese-American population if you had difficulty with this question. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., p. 65). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1994) A nurse caring for a postpartum client with a diagnosis of endometritis notes that the client has little interest in caring for her newborn. Which of the following nursing interventions would be appropriate to facilitate participation in newborn care? a. Encourage the client to take pain medication as prescribed. b. Maintain the client in a supine position. c. Limit fluid intake. d. Ask family members to care for the newborn. Source: Saunders 4th

ANS: A Rationale: Nursing responsibilities for the care of the client with endometritis include maintaining adequate hydration (3,000 to 4,000 mL/day), bedrest in Fowler's position to facilitate drainage and lessen congestion, providing appropriate analgesia to lessen the pain, and administering antibiotics as prescribed. Asking family members to care for the newborn will not facilitate client participation in newborn care. Strategy: Focus on the subject of the question, facilitating participation in newborn care. This will assist in eliminating option 4. Use the process of elimination and knowledge regarding the therapeutic management of endometritis to select from the remaining options. If you had difficulty with this question, review the therapeutic management of the client with endometritis. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., pp. 712-714). St. Louis: W.B. Saunders. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 748). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

2684) An older client has recently been started on cimetidine (Tagamet). The nurse updates the care plan to include assessment for central nervous system (CNS) effects of this medication. Which of the following is the most frequent CNS side effect of cimetidine? a. Confusion b. Dizziness c. Tremors d. Hallucinations Source: Saunders 4th

ANS: A Rationale: Older clients are especially susceptible to the CNS effects of cimetidine, of which confusion is most frequent. Less common CNS side effects include headache, dizziness, drowsiness, and hallucinations. Strategy: Note that the strategic words older and most frequent. Knowledge that this medication causes confusion will direct you to option 1. Review the most common side effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 250). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2225) A nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the physician in this procedure, which initial nursing action is appropriate? a. Suction the ET tube. b. Deflate the cuff. c. Turn off the ventilator. d. Obtain a code cart and place it at the bedside. Source: Saunders 4th

ANS: A Rationale: Once the client has been weaned successfully and has achieved an acceptable level of consciousness to sustain spontaneous respiration, an ET tube may be removed. The ET tube is suctioned first, and then the cuff is deflated and the tube is removed. Placing a code cart at the bedside is unnecessary and may cause alarm and concern in the client. Additionally, resuscitative equipment should already be available at the client's bedside. Option 3 is not the initial action. Strategy: Note the strategic word initial. Use the ABCs—airway, breathing, and circulation. Option 1 addresses airway. Remember that airway is the first priority. Review this procedure if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1888, 1893-1894). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1487) The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which of the following priority nursing interventions will the nurse include in the plan of care? a. One-to-one suicide precautions b. Suicide precautions with 30-minute checks c. Checking the whereabouts of the client every 15 minutes d. Asking the client to report suicidal thoughts immediately Source: Saunders 4th

ANS: A Rationale: One-to-one suicide precautions are required for the client who has attempted suicide. Options 2 and 3 may be appropriate, but not at the present time, considering the situation. Option 4 also may be an appropriate nursing intervention, but the priority is identified in option 1. The best intervention is constant supervision so that the nurse may intervene as needed if the client attempts to cause harm to self. Strategy: Use the process of elimination, noting the strategic words attempted suicide. Option 1 is the only option that provides a safe environment. Review interventions for the suicidal client if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 369). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 481). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1421) A client admitted to the mental health unit is experiencing disturbed thought processes and believes that the food is being poisoned. Which communication technique does the nurse plan to use to encourage the client to eat? a. Using open-ended questions and silence b. Focusing on self-disclosure regarding food preferences c. Identifying the reasons that the client may not want to eat d. Offering opinions about the necessity of adequate nutrition Source: Saunders 4th

ANS: A Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Options 3 and 4 are not helpful to the client because they do not encourage the client to express feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the behavior. Option 2 is not a client-centered intervention. Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they do not support client expression of feelings. Eliminate option 2 next because it is not a client-centered response. Focusing on the client's feelings will direct you to option 1. Review therapeutic communication techniques if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 125). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-34, 112-113). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 190). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2512) A nursing student is assisting with the care of a client with a chronic mental illness. The nursing instructor informs the student that a behavior modification approach (operant conditioning) will be used in treatment for the client. Which of the following statements by the nursing student indicates a need for further information about the therapy? a. "It uses negative reinforcement." b. "It increases the level of self-care in the client." c. "It increases social behaviors in the client." d. "It uses positive reinforcement." Source: Saunders 4th

ANS: A Rationale: Operant conditioning entails rewarding a client for desired behaviors and is the basis for behavior modification. It uses a positive reinforcement approach. Options 2, 3, and 4 are accurate characteristics of this form of therapy. Strategy: Use the process of elimination. Note the strategic words need for further information in the question. This phrasing indicates a negative event query and the need to select an incorrect statement. Note the similarity between options 2, 3, and 4. This should easily direct you to the correct option. If you had difficulty with this question, review the characteristics of operant conditioning. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 22, 28, 650). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Teaching and Learning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1976) A client will be taking a subcutaneous anticoagulant at home and says to the nurse, "I'm not sure I will be able to take this medication at home." Which of the following statements by the nurse is appropriate? a. "What are your concerns about taking this medication at home?" b. "Don't worry. Your doctor knows what's best for you." c. "You'll be fine once you get used to giving your own shots." d. "Maybe your spouse can give your shot." Source: Saunders 4th

ANS: A Rationale: Option 1 restates the client's concern and provides the opportunity to verbalize. The statements in options 2 and 3 are false reassurances, which invalidates the client's concern. Option 4 offers advice without knowing what the client's concerns really are. Strategy: Use therapeutic communication techniques and the process of elimination to assist in answering the question. Always focus on the client's feeling first. Option 1 is the only option that focuses on the client's feelings and concerns. Review therapeutic communication techniques if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 591). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 437). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1658) The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which of the following responses, if made by the student, indicates an understanding of this physiological process? a. "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high." b. "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are low." c. "The low levels of estrogen and progesterone increase the release of the follicle-stimulating hormone and luteinizing hormone." d. "The high levels of estrogen and progesterone promote the release of the follicle-stimulating hormone and luteinizing hormone." Source: Saunders 4th

ANS: A Rationale: Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high, inhibiting the release of follicle-stimulating and luteinizing hormones, which are necessary for ovulation. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination. Knowledge regarding the hormonal changes that occur during the menstrual cycle and during pregnancy is required to answer this question. Remember that ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high. If you are unfamiliar with these physiological changes, review this content. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 112). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

2678) A client has begun medication therapy with pancrelipase (Pancrease). The nurse determines that the medication is effective by noting: a. Decrease in the amount of fat in the stools b. Elimination of abdominal pain c. Relief of heartburn d. Stabilization of blood glucose levels Source: Saunders 4th

ANS: A Rationale: Pancrelipase is a pancreatic enzyme used as a digestive aid for clients with pancreatitis. It should reduce the amount of fatty stools (steatorrhea). Another recognized beneficial effect is improved nutritional status. It is not used to treat abdominal pain or heartburn and does not regulate blood glucose. Strategy: The name of the medication provides a clue to the possible uses of this medication. Recall that the suffix -ase indicates an enzyme. Use knowledge of the physiology of the pancreas and the name of the medication to direct you to option 1. Review the action of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 657). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1702) The client with pheochromocytoma is scheduled for surgery and says to the nurse, "I'm not sure that surgery is the best thing to do." The appropriate response by the nurse is which of the following? a. "You have concerns about the surgical treatment for your condition?" b. "There is no reason to worry. Your doctor is a wonderful surgeon." c. "You are very ill. Your physician has made the correct decision." d. "I think you are making the right decision to have the surgery." Source: Saunders 4th

ANS: A Rationale: Paraphrasing is restating the client's messages in the nurse's own words. Option 1 addresses the therapeutic communication technique of paraphrasing. In option 2, the nurse is offering a false reassurance and this type of response will block communication. Option 3 also represents a communication block in that it reflects a lack of the client's right to an opinion. In option 4, the nurse is expressing approval, which can be harmful to the nurse-client relationship. Strategy: Use the process of elimination and therapeutic communication techniques. Select the option that will enhance communication. Always address the client's concerns and feelings. Review therapeutic communication techniques if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1478-1479). Philadelphia: W.B. Saunders. Reference: Varcarolis, E. (2002) Foundations of psychiatric mental health nursing (4th ed., p. 258). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

111) At 8 <sc>AM</sc>, a nurse checks the amount of solution left in a parenteral nutrition (PN) infusion bag for an assigned client. It is a 3000-mL bag with 1000 mL remaining. The solution is running at a rate of 100 mL/hr. The bag was hung the previous day at noon. The nurse plans to change the infusion bag and tubing today at: a. Noon b. 2 <sc>PM</sc> c. 4 <sc>PM</sc> d. 8 <sc>PM</sc> Source: Saunders 4th

ANS: A Rationale: Parenteral nutrition solution should be changed every 24 hours because the PN solution is a high-concentrate glucose solution and is a medium for bacterial growth. Infection control is also aided by use of aseptic technique with bag and tubing changes. Most agencies recommend that tubing be changed every 24 hours along with the bag, although some agencies recommend changing tubing every 48 to 72 hours. The nurse always should adhere to specific agency policies. Options 2, 3, and 4 identify insufficient time frames and present the risk for infection. Strategy: Use the process of elimination. Recalling that the infusion bag should be changed every 24 hours will direct you to the correct option. Review the principles related to the prevention of infection in the client receiving PN if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 intravenous medications (22nd ed., p. 1055). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2202) A physician is planning to prescribe a medication for a client with major depression. Which of the following medications would the nurse expect to be prescribed? a. Paroxetine hydrochloride (Paxil) b. Amitriptyline c. Tranylcypromine sulfate (Parnate) d. Thioridazine hydrochloride (Mellaril) Source: Saunders 4th

ANS: A Rationale: Paroxetine is an antidepressant used in the treatment of major depression. Amitriptyline is a tricyclic antidepressant (TCA) used to treat various forms of depression. Tranylcypromine is a monoamine oxidase (MAO) inhibitor used in the symptomatic treatment of severe depression in hospitalized or closely supervised clients, and thioridazine is an antipsychotic medication. Strategy: Knowledge regarding the actions and uses of the medications identified in the options is required to answer the question. Noting the strategic words major depression will direct you to option 1. If you are unfamiliar with these medications, review their actions and uses. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 897). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 660). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2373) A nurse caring for a client receiving vincristine (Oncovin) is monitoring the client for toxicity. The nurse interprets that the client is experiencing a toxic effect of this medication on the basis of which of the following assessment findings? a. Weakness and sensory loss in the legs b. Decreased platelet count c. Nausea and vomiting d. Decreased white blood cell count Source: Saunders 4th

ANS: A Rationale: Peripheral neuropathy is the major dose-limiting toxicity associated with vincristine. Nearly all clients exhibit signs and symptoms of sensory or motor nerve injury such as decreased reflexes, weakness, paresthesia, and sensory loss. In contrast with most anticancer medications, vincristine causes little toxicity to bone marrow. Nausea and vomiting are rare with the use of this medication. Strategy: Use the process of elimination, noting the strategic words toxic effect. Eliminate options 2 and 4 first, knowing that vincristine causes little toxicity to bone marrow. Regarding the remaining options, focusing on the strategic words will direct you to option 1. If you are unfamiliar with the toxic effects of this medication, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 1209-1210). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

138) The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client experienced: a. Phlebitis of the vein. b. Infiltration of the IV line. c. Hypersensitivity to the IV solution. d. Allergic reaction to the IV catheter material. Source: Saunders 4th

ANS: A Rationale: Phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth, and swelling proximal to the catheter. If phlebitis occurs, the nurse should discontinue the IV line and insert a new IV line at a different site. Coolness at the site would be noted if the IV catheter was infiltrated. An allergic reaction produces a rash, redness, and itching. A major reaction, such as hypersensitivity, can cause dyspnea, a swollen tongue, and cyanosis. Strategy: Use the process of elimination. Remember that options that are comparative or alike are not likely to be correct. In this situation, options 3 and 4 are comparative or alike and therefore are eliminated. Choose option 1 over option 2 after recalling the signs of common IV complications. Review the signs and symptoms of phlebitis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 260). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1173). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Communication and Documentation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1203) The client with chronic renal failure is at risk of developing dementia related to excessive absorption of aluminum. The nurse teaches the client that this is the reason why the client is being prescribed which of the following phosphate-binding agents? a. Tums (calcium carbonate) b. Alu-Cap (aluminum hydroxide) c. Basaljel (aluminum hydroxide) d. Amphojel (aluminum hydroxide) Source: Saunders 4th

ANS: A Rationale: Phosphate-binding agents that contain aluminum include Alu-Caps, Basaljel, and Amphojel. These products are made from aluminum hydroxide. Tums are made from calcium carbonate and also bind phosphorus. Tums are prescribed to avoid the occurrence of dementia related to high intake of aluminum. Phosphate-binding agents are needed by the client in renal failure because the kidneys cannot eliminate phosphorus. Strategy: Use the process of elimination and focus on the data in the question. Options 2, 3, and 4 may be eliminated because the name of the medication gives a clue about its ingredients. Otherwise, specific knowledge of the types of antacids is needed to answer this question accurately. Review the various phosphate-binding agents if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 127). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1695) A nurse is assessing the learning readiness of a client newly diagnosed with diabetes mellitus. Which client behavior indicates to the nurse that the client is not ready to learn? a. The client complains of fatigue whenever the nurse plans a teaching session. b. The client asks if the spouse can attend the teaching session. c. The client asks for written materials about diabetes mellitus before class. d. The client asks appropriate questions about what will be taught. Source: Saunders 4th

ANS: A Rationale: Physical symptoms can interfere with an individual's ability to learn and can also indicate to the teacher that the student lacks motivation to learn if the symptoms repeatedly recur when teaching is initiated. Options 2, 3, and 4 identify active client participation in learning. Strategy: Use the process of elimination and note the strategic words not ready to learn. Options 2, 3, and 4 identify the client as actively seeking information. Option 1 suggests avoidance on the part of the client. Review teaching and learning concepts if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 8, 1549). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

2301) A client experienced an open pneumothorax and a chest wound, which has been covered with an occlusive dressing. The client begins to experience severe dyspnea, and the blood pressure begins to fall. The nurse should first: a. Remove the dressing. b. Reinforce the dressing. c. Call the physician. d. Measure oxygen saturation by oximetry. Source: Saunders 4th

ANS: A Rationale: Placement of a dressing over a chest wound could convert an open pneumothorax to a closed (tension) pneumothorax. This may result in a sudden decline in respiratory status, mediastinal shift with twisting of the great vessels, and circulatory compromise. If clinical changes occurs, the nurse removes the dressing immediately, allowing air to escape. Strategy: Use the process of elimination and note the strategic word first. Remembering that an open pneumothorax can be transformed into a tension pneumothorax with closure will direct you to option 1. Review the nursing actions for a client with an open pneumothorax if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2492). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1017) A client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of: a. Right pneumothorax b. Pulmonary embolism c. Displaced endotracheal tube d. Acute respiratory distress syndrome Source: Saunders 4th

ANS: A Rationale: Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi. Strategy: Use the process of elimination. Focus on the symptoms presented in the question and note the relationship between right upper lobe and right pneumothorax in option 1. Review the manifestations associated with pneumothorax if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 671). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 621-622). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2337) A nurse provides instructions to a client who is scheduled for an electroencephalogram (EEG). Which statement by the client indicates a need for further instruction? a. "All medications need to be withheld on the day of the test." b. "The test will take between 45 minutes and 2 hours." c. "My hair should be washed the evening before the test." d. "Cola, tea, and coffee are restricted on the day of the test." Source: Saunders 4th

ANS: A Rationale: Pre-procedural instructions include informing the client that the procedure is painless. The procedure requires no dietary restrictions other than avoidance of cola, tea, and coffee on the morning of the test. These products have a stimulating effect and should be avoided. The hair should be washed the evening before the test and gels, hairsprays, and lotion should be avoided. The client is informed that the test will take 45 minutes to 2 hours and that medications usually are not withheld before the test. Strategy: Use the process of elimination and note the strategic words need for further instruction in the question. This phrasing indicates a negative event query and asks you to select an incorrect statement. Knowing that this procedure amplifies and records electrical activity of the brain will assist in eliminating options 2, 3, and 4. If you had difficulty with this question, review client preparation for an EEG. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 490). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1870) A nurse in the prenatal clinic is taking a nutritional history from a 16-year-old pregnant adolescent. Which of the following statements if made by the adolescent would alert the nurse to a potential psychosocial problem? a. "I only want to gain 10 pounds because I want to have a small, petite baby." b. "I will continue drinking my afternoon milkshake." c. "I don't like dairy products." d. "I'm not used to eating so much food, but I will try." Source: Saunders 4th

ANS: A Rationale: Pregnant adolescents are at higher risk for complications. Peer pressure is an important influence on nutritional status. Adolescents often are concerned about their body image. If weight is a major focus for the adolescent, the adolescent is more likely to restrict calories to avoid weight gain. Option 1 is the only option that suggests a possible psychosocial problem. Options 2, 3, and 4 relate to physiological issues. Strategy: Use the process of elimination. Focus on the subject, a psychosocial problem, and recall that body image is a concern with an adolescent. Read each option carefully and note that options 2, 3, and 4 relate to physiological issues. Review nutrition and adolescent pregnancy if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 191). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1299) The nurse has given the client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will: a. Expose the face to cold and drafts. b. Massage the face with a gentle upward motion. c. Perform facial exercises. d. Wrinkle the forehead, blow out the cheeks, and whistle. Source: Saunders 4th

ANS: A Rationale: Prevention of muscle atrophy with Bell's palsy is accomplished with facial massage, facial exercises, and electrical stimulation of the nerves. Exposure to cold or drafts is avoided. Local application of heat to the face may improve blood flow and provide comfort. Strategy: Use the process of elimination, noting the strategic words needs additional information. These words indicate a negative event query and ask you to select an option that is incorrect. Evaluate each option regarding its effect on preserving muscle tone in the face. Option 1 is unrelated to muscle tone and also is contraindicated in clients with this condition. Review teaching points for the client with Bell's palsy if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1606). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1682) A nursing student is asked to describe the size of the uterus in a nonpregnant client. The student responds correctly by stating that the uterus in a nonpregnant client: a. Weighs approximately 2 oz. b. Weighs approximately 2.2 lb. c. Has a capacity of about 50 mL. d. Is round in shape and weighs approximately 1000 g. Source: Saunders 4th

ANS: A Rationale: Prior to conception, the uterus is a small pear-shaped cavity contained entirely in the pelvic cavity. Before pregnancy, the uterus weighs approximately 60 g (2 oz) and has a capacity of about 10 mL (⅓ oz). At the end of pregnancy, the uterus weighs approximately 1000 g (2.2 lb) and has sufficient capacity for the fetus, placenta, and amniotic fluid, a total of about 5000 mL. Strategy: Use the process of elimination and knowledge regarding the structure of the uterus to answer this question. Attempt to visualize each item identified in the options. Note the strategic word nonpregnant to assist in directing you to the correct option. Review the anatomical structure of the uterus if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 110). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2351) A home health nurse is providing dietary instructions to a client who is taking probenecid (Benemid) for the treatment of gout. Which of the following foods should the nurse instruct the client to continue to eat? a. Spinach b. Scallops c. Shrimp d. Liver Source: Saunders 4th

ANS: A Rationale: Probenecid inhibits the reabsorption of uric acid by the kidney and promotes excretion of uric acid in the urine. Clients taking this medication are instructed to limit excessive purine intake. High-purine foods to avoid or limit include organ meats, roe, sardines, scallops, anchovies, broth, mincemeat, herring, shrimp, mackerel, gravy, and yeast. Strategy: Remember that the client with gout is instructed to limit purine intake. Eliminate options 2 and 3 first because they are comparative or alike. Recalling that organ meats are high in purines will then direct you to option 1. If you had difficulty with this question, review foods that are high in purine. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 964). Philadelphia: W.B. Saunders. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 421). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1212) Propantheline bromide (Pro-Banthine) is prescribed for a client with bladder spasms. Which of the following disorders, if noted in the client's record, would alert a nurse to question the prescription for this medication? a. Glaucoma b. Myxedema c. Hypothyroidism d. Coronary artery disease Source: Saunders 4th

ANS: A Rationale: Propantheline bromide (Pro-Banthine) is contraindicated in clients with narrow-angle glaucoma, obstructive uropathy, gastrointestinal disease, or ulcerative colitis. The medication decreases bladder muscle spasms. Strategy: Use the process of elimination. Eliminate options 2 and 3 because they are comparative or alike. From the remaining options, you must know the contraindications associated with the medication and remember that the medication is contraindicated in glaucoma. Review these contraindications if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 726). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2187) A clinic nurse is performing an assessment on a client with a diagnosis of rheumatoid arthritis (RA). The nurse understands that which assessment finding is unassociated with RA? a. Complaints of pain that is more severe after activity b. Complaints of pain that is more severe on arising in the morning c. Swollen, shiny joints d. Skin nodules near bony prominences Source: Saunders 4th

ANS: A Rationale: RA is characterized by chronic joint pain of variable intensity, which is more severe on rising in the morning. The pain subsides once the client moves around. The nurse would note that joint involvement is symmetrical and the joints are swollen, shiny, reddened, and painful. Rheumatoid nodules, which are painless subcutaneous movable skin nodules near bony prominences, may occur anywhere on the body. Strategy: Use the process of elimination. Note the strategic word unassociated. Also, options 1 and 2 both address the component of pain and its occurrence. This should lead you to suspect that one of these options is correct. Remember that in RA, pain is more severe in the morning. Review the characteristics associated with RA if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2333, 2335, 2337). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

980) The physician has written an order for ranitidine (Zantac), 300 mg once daily. The nurse schedules the medication for which time? a. At bedtime b. After lunch c. With supper d. Before breakfast Source: Saunders 4th

ANS: A Rationale: Ranitidine is a histamine 2 (H₂)-receptor antagonist. A single daily dose of ranitidine is scheduled to be given at bedtime. This allows for a prolonged effect, and the greatest protection of the gastric mucosa. The other options are incorrect. Strategy: Use the process of elimination. Recalling the action of the medication and focusing on the strategic words once daily will direct you to option 1. Review this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 2008). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2493) A nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse plans to tell the client to: a. Stop smoking because it causes cutaneous vasospasm. b. Always wear warm clothing even in warm climates to prevent vasoconstriction. c. Use nail polish to protect the nail beds from injury. d. Wear gloves for all activities involving use of both hands. Source: Saunders 4th

ANS: A Rationale: Raynaud's disease is peripheral vascular disease characterized by abnormal vasoconstriction in the extremities. Smoking cessation is one of the most important lifestyle changes that the client needs to make. The nurse should emphasize the effects of tobacco on the blood vessels and the principles involved in stopping smoking. The nurse needs to provide information to the client about smoking cessation programs available in the community. Options 2 and 3 are incorrect. It is not necessary to wear gloves for all activities. Strategy: Use the process of elimination. Eliminate options 2 and 4 first because of the close-ended words always and all. Regarding the remaining options, think about the physiology associated with Raynaud's disease to direct you to option 1. Review client teaching points for Raynaud's disease if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 414). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

112) A nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse next assesses which of the following items? a. Client's temperature b. Expiration date on the bag c. Time of last dressing change d. Tightness of tubing connections Source: Saunders 4th

ANS: A Rationale: Redness at the catheter insertion site is a possible indication of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess. The tightness of tubing connections should be assessed each time the PN is checked; loose connections would result in leakage, not skin redness. The expiration date on the bag is a viable option, but this also should be checked at the time the solution is hung and with each shift change. The time of the last dressing change should be checked with each shift change. Strategy: Note the strategic word next. This question requires that you prioritize based on the information provided in the question. Also note the relationship between site appears reddened in the question and the word temperature in the correct option. Focusing on the subject of infection will direct you to option 1. Review the signs of infection in the client receiving PN if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 708-709). Philadelphia: W.B. Saunders. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., pp. 1055, 1060). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1279) The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? a. Moving the client quickly as one unit b. Applying TEDs or compression stockings c. Using vasopressor medications as prescribed d. Monitoring vital signs before and during position changes Source: Saunders 4th

ANS: A Rationale: Reflex vasodilation below the level of the spinal cord injury places the client at risk for orthostatic hypotension, which may be profound. Measures to minimize this include measuring vital signs before and during position changes, use of a tilt table with early mobilization, and changing the client's position slowly. Venous pooling can be reduced by using TEDs (compression stockings) or pneumatic boots. Vasopressor medications are administered as per protocol. Strategy: Use the process of elimination. Note the strategic words least helpful. Note the word quickly in option 1. Knowing that quick position changes and movement would aggravate hypotension will direct you to this option. Review care of the client with spinal shock if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 665). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 655, 989). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2518) A client has begun a course of therapy with rifampin (Rifadin). The home care nurse instructs the client to do which of the following while taking this medication? a. Avoid wearing contact lens. b. Always take the medication with food or antacids. c. Double the next medication dose if one is forgotten. d. Stop the medication if symptoms disappear in 2 months. Source: Saunders 4th

ANS: A Rationale: Rifampin causes orange-red discoloration of body secretions and will permanently stain soft contact lenses. Rifampin should be taken exactly as directed, and doses should not be doubled or skipped. The medication should be taken on an empty stomach unless it causes gastrointestinal upset, and then it may be taken with food. Antacids, if prescribed, should be taken at least 1 hour before the medication. The client should not stop therapy until directed to do so by a physician. Strategy: Use the process of elimination. Options 3 and 4 are eliminated first in accordance with general medication administration principles. Regarding the remaining options, eliminate option 2 because of the close-ended word always. If you had difficulty with this question, review the side effects of this medication. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 758). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1775) Ringer's lactate solution IV is prescribed for the postoperative client. The nursing instructor asks the nursing student who is caring for the client about the tonicity of the prescribed IV solution. The nursing student responds correctly by stating that this solution is: a. Isotonic. b. Normotonic. c. Hypotonic. d. Hypertonic. Source: Saunders 4th

ANS: A Rationale: Ringer's lactate solution is an isotonic solution. Isotonic solutions include 5% dextrose in water (D₅W), 0.9% saline (NS), and 5% dextrose in 0.225% saline (5% D/¼ NS); 0.45% saline (½ NS) is hypotonic; and 10% dextrose in water (D₁₀W), 5% dextrose in 0.9% saline (5% D/NS), and 5% dextrose in 0.45% saline (5% D/(½ NS) are hypertonic solutions. Strategy: Use the process of elimination and knowledge regarding the tonicity of the various IV solutions. Remember that Ringer's lactate solution is an isotonic solution. If you had difficulty with this question, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 220). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2184) A nurse is obtaining a health history from a client and is assessing for risk factors associated with osteoporosis. Which of the following assessment findings is an unassociated risk factor? a. High-calcium diet b. Postmenopausal age c. Long-term use of corticosteroids d. Family history of osteoporosis Source: Saunders 4th

ANS: A Rationale: Risk factors associated with osteoporosis include a diet that is deficient in calcium. Options 2, 3, and 4 include risk factors associated with osteoporesis. Additional risk factors include sedentary lifestyle, cigarette smoking, excessive alcohol consumption, chronic illness, and long-term use of anticonvulsants and furosemide (Lasix). Strategy: Use the process of elimination and note the strategic word unassociated. Recalling that a low-calcium diet is a risk factor associated with osteoporosis will direct you to option 1. Review these risk factors if you are not familiar with them. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1158). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1605) Russell's traction is prescribed for a child with a lower leg fracture. The mother of the child asks the nurse about the purpose of the traction. The nurse explains to the mother that this type of traction: a. Reduces or realigns a fracture site. b. Keeps the child from moving around in bed. c. Provides a form of restraint for the child. d. Will relieve the child's pain. Source: Saunders 4th

ANS: A Rationale: Russell's traction uses skin traction to realign a fracture in the lower extremity and immobilize the hip and knee in a flexed position. It is important to keep the hip flexion at the prescribed angle to prevent fracture malalignment. The traction may also relieve pain by reducing muscle spasms, but this is not the primary reason for this traction. The child can still move in bed with some restriction as a result of the traction. Traction is never used to restrain a child. Strategy: Use the process of elimination and eliminate options 2 and 3 first because they are comparative or alike. Recalling the purpose of this type of traction and noting the strategic word primarily will assist in directing you to option 1. If you had difficulty with this question, review Russell's traction. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1408). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Child Health Alternate Question Types -> Multiple Choice

1473) The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, the nurse's immediate priority of care is to: a. Provide safety for the client and other clients on the unit. b. Provide the clients on the unit with a sense of comfort and safety. c. Assist the staff in caring for the client in a controlled environment. d. Offer the client a less stimulated area to calm down and gain control. Source: Saunders 4th

ANS: A Rationale: Safety of the client and other clients is the priority. Option 1 is the only option that addresses the client and other clients' safety needs. Option 2 addresses other clients' needs. Option 3 is not client-centered. Option 4 addresses the client's needs. Strategy: Note the strategic words immediate priority and use Maslow's hierarchy of needs theory to prioritize. Note the words agitated, aggressive, and belligerent. Safety is the strategic subject. Option 1 is the umbrella option and addresses the safety of all. Review nursing interventions to provide safety to clients if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 438). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 80, 400). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

1407) Saquinavir (Invirase) is prescribed for the client who is seropositive for human immunodeficiency virus. The nurse reinforces medication instructions and tells the client to: a. Avoid sun exposure. b. Eat low-calorie foods. c. Eat foods that are low in fat. d. Take the medication on an empty stomach. Source: Saunders 4th

ANS: A Rationale: Saquinavir is an antiretroviral (protease inhibitor) used with other antiretroviral medications to manage human immunodeficiency virus infection. Saquinavir is administered with meals and is best absorbed if the client consumes high-calorie, high-fat meals. Saquinavir can cause photosensitivity, and the nurse should instruct the client to avoid sun exposure. Strategy: Use the process of elimination. Options 2 and 3 can be eliminated first, knowing that these dietary measures likely would not be prescribed for this client. From the remaining options, you must know that this medication can cause photosensitivity. Review this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1043). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1959) A community health nurse is visiting a homeless shelter and is assessing the clients in the shelter for the presence of scabies. Which assessment finding would the nurse expect to note if scabies is present? a. Multiple straight or wavy thread-like lines underneath the skin b. White patches noted on the elbows and knees c. Pustules on the trunk of the body d. Brown red macules with scales Source: Saunders 4th

ANS: A Rationale: Scabies can be identified by the multiple straight or wavy thread-like lines beneath the skin. The skin lesions are caused by the female, which burrows beneath the skin to lay its eggs. The eggs hatch in a few days, and the baby mites find their way to the skin surface, where they mate and complete the life cycle. Options 2, 3, and 4 are not characteristics of scabies. Strategy: Knowledge that scabies burrows beneath the skin surface will assist in the process of elimination and direct you to the correct option. If you are unfamiliar with the assessment findings in this disorder, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1419). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

2428) A community health nurse is providing a teaching session to firefighters in a small community regarding care of a burn victim at the scene of injury. The nurse instructs the firefighters that in the event of a tar burn, the immediate action should be: a. Cooling the injury with water b. Removing all clothing immediately c. Removing the tar from the burn injury d. Leaving any clothing that is saturated with tar in place Source: Saunders 4th

ANS: A Rationale: Scald burns and tar or asphalt burns are treated by immediate cooling with water if available, or immediate removal of the saturated clothing. Clothing that is burned into the skin is not removed because increased tissue damage and bleeding may result. No attempt is made to remove tar from the skin at the scene. Strategy: Use the process of elimination. Think about the physiological integrity of the skin in this type of injury to direct you to option 1. If you had difficulty with this question, review care of the client who received a burn injury from tar. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 520). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

2508) A preoperative client has received a dose of scopolamine as prescribed by the anesthesiologist. The nurse assesses the client for which of the following anticipated side effects of this medication? a. Dry oral mucous membranes b. Pupillary constriction c. Increased urinary output d. Diaphoresis Source: Saunders 4th

ANS: A Rationale: Scopolamine is an anticholinergic medication that causes the frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. The other options are incorrect. Strategy: Use the process of elimination. Note that the client is a preoperative client. Also, recalling that scopolamine is an anticholinergic will direct you to option 1. Review the side effects of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 778). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

44) A nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 mL daily." The nurse understands that this type of fluid loss can occur through: a. The skin b. Urinary output c. Wound drainage d. The gastrointestinal tract Source: Saunders 4th

ANS: A Rationale: Sensible losses are those of which the person is aware, such as through wound drainage, gastrointestinal tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Strategy: Note that the subject of the question is insensible fluid loss. Use the process of elimination, noting that options 2, 3, and 4 are comparative or alike. In options 2, 3 and 4, these types of losses can be measured for accurate output. Fluid loss through the skin cannot be measured accurately, only approximated. If you had difficulty with this question, review the difference between sensible and insensible fluid loss. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 203). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Communication and Documentation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

145) A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The nurse takes the client's blood pressure and it is 90/50 mm Hg, from a baseline of 125/78 mm Hg. The client's temperature is 100.8° F orally, from a baseline of 99.2° F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? a. Septicemia b. Hyperkalemia c. Circulatory overload d. Delayed transfusion reaction Source: Saunders 4th

ANS: A Rationale: Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level. Strategy: Focus on the data in the question. Noting that the client's temperature is elevated will direct you to option 1. Review the signs of complications of a blood transfusion if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1192). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1685) The nursing instructor asks the nursing student to identify the priorities of care for an assigned client. The student correctly identifies the client needs that are the priority by telling the nursing instructor that: a. Actual or life-threatening concerns are the priority b. Time constraints related to the client's needs are the priority c. Obtaining needed supplies to care for the client is the priority d. Completing care in a reasonable time frame is the priority Source: Saunders 4th

ANS: A Rationale: Setting priorities means deciding which client needs or problems require immediate action and which can be delayed until a later time because they are not urgent. Client problems that involve actual or life-threatening concerns are always considered first. Although time constraints, obtaining needed supplies, and completing care in a reasonable time frame are components of time management, these items are not the priority in planning care for the client, based on the options provided. Strategy: Use the process of elimination and principles related to prioritizing to answer the question. Noting the strategic word life-threatening in option 1 will assist in directing you to this option. Review the principles related to prioritizing if you had difficulty with this question. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., p. 167). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

2200) A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which of the following medical diagnoses if noted on the client's record would indicate a need to contact the physician scheduled to perform the ECT? a. Recent myocardial infarction b. Diabetes mellitus c. Hyperthyroidism d. Peripheral vascular disease Source: Saunders 4th

ANS: A Rationale: Several conditions present risks in the client scheduled for ECT. These include recent myocardial infarction, brain attack (stroke), and cerebrovascular malformation or an intracranial lesion. Strategy: Use the process of elimination. Note the word recent in option 1. This will direct you to option 1. Review the risk factors associated with ECT if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 605). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Mental Health Alternate Question Types -> Multiple Choice

103) A client who recently has been started on enteral feedings begins to complain of abdominal cramping, followed by the passage of two liquid stools. A nurse notes that the client has abdominal distention as well. The nurse reviews the nutritional content on the label of the can of feeding to see if it has which of the following ingredients? a. Lactose b. Sucrose c. Fructose d. Maltose Source: Saunders 4th

ANS: A Rationale: Several tube feeding formulas contain lactose. A client with an unreported history of lactose intolerance would develop symptoms such as abdominal cramping, distention, and the passage of liquid stool in response to nutritional therapy with these formulas. If the client is diagnosed as lactose intolerant, a lactose-free formula should be prescribed by the physician. This will resolve the client's symptoms and promote adequate nutrition for the client. Strategy: Focus on the data in the question. Recalling the association of the symptoms experienced by the client with the symptoms of lactose intolerance will direct you to the correct option. If you had difficulty with this question, review the symptoms of lactose intolerance and the nursing considerations related to enteral feedings. Reference: Nix, S. (2005). Williams' basic nutrition and diet therapy (12th ed., p. 26). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1230) During the early postoperative period, the client who has had a cataract extraction complains of nausea and severe eye pain over the operative site. The initial nursing action is to: a. Call the physician. b. Reassure the client that this is normal. c. Turn the client on his or her operative side. d. Administer the ordered pain medication and antiemetic. Source: Saunders 4th

ANS: A Rationale: Severe pain or pain accompanied by nausea is an indicator of increased intraocular pressure and should be reported to the physician immediately. Options 2, 3, and 4 are inappropriate actions. Strategy: Use the process of elimination. Note the strategic word severe. Eliminate option 2 because this is not a normal condition. The client should not be turned to the operative side; therefore, eliminate option 3. From the remaining options, focusing on the strategic word will direct you to option 1. If you had difficulty with this question, review the postoperative complications of cataract surgery requiring physician notification. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1951). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

60) A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client? a. Twitching b. Negative Trousseau's sign c. Hypoactive bowel sounds d. Hypoactive deep tendon reflexes Source: Saunders 4th

ANS: A Rationale: Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea. Strategy: Use the process of elimination, noting that options 2, 3, and 4 are comparative or alike in that they reflect a hypoactivity. The option that is different is option 1. Review the assessment signs and symptoms noted in hypocalcemia if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 238). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1037) A nurse is taking the history of a client with silicosis. The nurse assesses whether the client wears which of the following items during periods of exposure to silica particles? a. Mask b. Gown c. Gloves d. Eye protection Source: Saunders 4th

ANS: A Rationale: Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure. Options 2, 3, and 4 are not necessary. Strategy: Use the process of elimination. Recalling that exposure to silica dust causes the illness and that the dust is inhaled into the respiratory tract will direct you to option 1. If you had difficulty with this question, review the protective measures associated with silicosis. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 612). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 795, 798-799). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2188) A client is suspected of having systemic lupus erythematosus (SLE). On reviewing the client's record, the nurse would expect to note documentation of which characteristic sign of SLE? a. Rash on the face across the bridge of the nose and on the cheeks b. Fatigue c. Fever d. Elevated red blood cell count Source: Saunders 4th

ANS: A Rationale: Skin lesions or a rash on the face across the bridge of the nose and on the cheeks is a characteristic sign of SLE. Fever and fatigue may occur before and during exacerbation, but these signs and symptoms are vague. Anemia is most likely to occur in SLE. Strategy: Use the process of elimination. Note the strategic words characteristic sign. Recalling the characteristic "butterfly rash" that occurs in SLE will direct you to option 1. Review the clinical manifestations of SLE if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2354). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

2682) A client reports using sodium bicarbonate on a frequent basis to relieve heartburn that follows meals. The nurse interprets that the client is at risk for which of the following conditions with long-term frequent use of this medication? a. Metabolic alkalosis b. Respiratory acidosis c. Urinary calculi d. Chronic bronchitis Source: Saunders 4th

ANS: A Rationale: Sodium bicarbonate is an electrolyte modifier and antacid. With large doses or long-term use, it can cause metabolic alkalosis. The other options are incorrect. Strategy: Focusing on the name of the medication and noting the strategic words long-term frequent use will direct you to option 1. Review the adverse effects of sodium bicarbonate if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 786). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1926) A client is undergoing diagnostic testing because of suspected renal disease. Which of the following laboratory tests best evaluates the kidneys' ability to regulate fluid balance? a. Urine specific gravity b. Blood urea nitrogen (BUN) c. Creatinine d. Urinary protein Source: Saunders 4th

ANS: A Rationale: Specific gravity evaluates the kidneys' ability to regulate fluid balance and evaluates the hydration status of the body. The BUN and creatinine more specifically evaluate renal function. Although a small amount of protein in the urine may be normal, a high level of protein may be an indicator of renal pathology. Strategy: Use the process of elimination. Note the strategic words regulate fluid balance. This will assist you in eliminating options 2, 3, and 4. If you are unfamiliar with the purposes of these tests and their relationship to renal function, review this content. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 1013). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1664). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2151) A client is being discharged to home after spinal fusion with insertion of instrumentation (rod). The unit nurse should consult with the continuing care nurse regarding the need for follow-up modification of the home environment if the client states that: a. The bedroom and bathroom are on the second floor of the home. b. The bathroom has hand railings in the shower. c. The family has rented a commode for use by the client. d. There are three steps to get up to the front door. Source: Saunders 4th

ANS: A Rationale: Stair climbing may be restricted or limited for several weeks after spinal fusion with instrumentation. The nurse ensures that resources are in place before discharge so that the client may sleep and perform all activities of daily living on a single living level. Strategy: Use the process of elimination. Options 2 and 3 are useful to the client and can be eliminated. Of the remaining options (both of which involve stairs), option 1 poses a significant problem to the client who is restricted from stair climbing. Review home care needs for the client after spinal fusion if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2146). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 124). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1079) A nurse assesses the sternotomy incision of a client on the third day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is nonreddened, with no apparent drainage. Temperature is 99° F orally. The white blood cell count is 7500 cells/mm³. How should the nurse interpret these findings? a. Incision is slightly edematous but shows no active signs of infection. b. Incision shows early signs of infection, although the temperature is nearly normal. c. Incision shows early signs of infection, supported by an elevated white blood cell count. d. Incision shows no sign of infection, although the white blood cell count is elevated. Source: Saunders 4th

ANS: A Rationale: Sternotomy incision sites are assessed for signs and symptoms of infection, such as redness, swelling, induration, and drainage. Elevated temperature and white blood cell count after 3 to 4 days postoperatively usually indicate infection. Strategy: Use the process of elimination. Eliminate options 3 and 4 because the white blood cell count is within normal range. From the remaining options, focus on the data in the question. A nonreddened incision with no apparent drainage indicates no signs of infection. Review the signs of infection if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1648). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 346, 861, 1587). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2231) An older client is diagnosed with a rib fracture and asks the nurse why strapping the ribs is not being done. Which response by the nurse is appropriate? a. "That isn't done anymore because people often would develop pneumonia from the constricting effect on the lungs." b. "That might help you to breathe better, but this facility does not carry the necessary supplies in the stockroom. When you get home, you can purchase them at the medical supply store." c. "Strapping is useful only if the ribs are fractured in several places at once." d. "That's a good idea. I'll ask the physician for an order for the needed supplies." Source: Saunders 4th

ANS: A Rationale: Strapping the ribs has a constricting effect on the ribs and deep breathing and can actually increase the risk of atelectasis and pneumonia. Therefore, options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination and answer the question by logically thinking through the physiological effects of restricting lung mobility. This will direct you to option 1. Review interventions for rib fractures if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 670). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1261) Pilocarpine hydrochloride (Isopto Carpine) is prescribed for the client with glaucoma. Which of the following medications does the nurse plan to have available in case of systemic toxicity? a. Atropine sulfate b. Pindolol (Visken) c. Protamine sulfate d. Naloxone hydrochloride (Narcan) Source: Saunders 4th

ANS: A Rationale: Systemic absorption of pilocarpine hydrochloride can produce toxicity and includes manifestations of vertigo, bradycardia, tremors, hypotension, syncope, cardiac dysrhythmias, and seizures. Atropine sulfate must be available in the event of systemic toxicity. Pindolol is a β blocker. Naloxone hydrochloride is an opioid antagonist used to reverse narcotic-induced respiratory depression. Protamine sulfate is the antidote for heparin. Strategy: Use the process of elimination and knowledge regarding antidotes related to various medications to answer this question. Remember that atropine sulfate is the antidote for systemic reactions that occur with pilocarpine. Review antidotes if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach. (5th ed., pp. 286-287). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

108) The nurse plans care for a client receiving total parenteral nutrition (TPN), understanding that which of the following statements regarding TPN and peripheral parenteral nutrition (PPN) is true? a. TPN is usually indicated for clients needing long-term nutritional support, whereas PPN is for short-term support. b. TPN is used to deliver isotonic or mildly hypertonic solutions, whereas PPN is used to deliver highly hypertonic solutions. c. PPN is indicated for clients needing more than 2000 cal, whereas TPN is indicated for clients needing less than 2000 cal. d. PPN is indicated for clients who are NPO (nothing by mouth), whereas TPN is indicated for clients who need to supplement oral intake. Source: Saunders 4th

ANS: A Rationale: TPN is usually indicated for clients receiving long-term nutritional support and PPN is usually used for short-term support. PPN can supplement oral intake, whereas TPN is usually administered to clients who are NPO. TPN can provide a greater number of calories than PPN. PPN is used to deliver isotonic or mildly hypertonic solutions and TPN can be used to deliver highly hypertonic solutions. Strategy: Note the strategic words TPN, PPN, and true and remember that for an option to be correct, all parts of that option must be correct. Remembering that the "T" in "TPN" means "total" will assist in directing you to option 1. Review the types of parenteral nutrition (PN) if you had difficulty with this question. Reference: Mahan, L. K., & Escott-Stump, S. (2004). Krause's food, nutrition, & diet therapy (11th ed., p. 544). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1218) Tacrolimus (Prograf) is prescribed for a client. Which disorder, if noted in the client's record, would indicate that the medication needs to be administered with caution? a. Pancreatitis b. Ulcerative colitis c. Diabetes insipidus d. Coronary artery disease Source: Saunders 4th

ANS: A Rationale: Tacrolimus (Prograf) is used with caution in immunosuppressed clients and in clients with renal, hepatic, or pancreatic function impairment. Tacrolimus is contraindicated in clients with hypersensitivity to this medication or hypersensitivity to cyclosporine. Strategy: Use the process of elimination. Many medications affect renal, hepatic, and pancreatic function. If you had to select an option and were unsure, select the option that addresses these body systems. Review the cautions and contraindications associated with the administration of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1091). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2257) Tacrolimus (Prograf) is prescribed for a client for prevention of organ rejection after renal transplantation. Which of the following would the nurse anticipate to be prescribed along with the tacrolimus for this client? a. Prednisone (Deltasone) b. Erythromycin (Erythrocin) c. Fluconazole (Diflucan) d. Phenytoin (Dilantin) Source: Saunders 4th

ANS: A Rationale: Tacrolimus is an alternative medication to cyclosporine (Sandimmune) for prevention of organ rejection in clients after transplantation. The medication is more effective than cyclosporine but is more toxic. Concurrent use of glucocorticoids is recommended during administration of this medication. Strategy: Use the process of elimination. Recalling that glucocorticoids are administered concurrently with some of the medications used to prevent organ rejection will easily direct you to option 1. Review the use and actions of this medication if you are unfamiliar with it. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 797). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 813). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2197) A nurse is caring for a client who has been treated with long-term antipsychotic medication. During the assessment, the nurse checks the client for tardive dyskinesia. If tardive dyskinesia is present, the most likely assessment findings would be: a. Abnormal movements and involuntary movements of the mouth, tongue, and face b. Abnormal breathing through the nostrils accompanied by a thrill c. Severe headache, flushing, tremors, and ataxia d. Severe hypertension, migraine headache, and "marbles in the mouth" syndrome Source: Saunders 4th

ANS: A Rationale: Tardive dyskinesia is a severe reaction associated with long-term use of antipsychotic medication. The clinical manifestations include abnormal movements (dyskinesia) and involuntary movements of the mouth, tongue ("fly-catcher tongue"), and face. In its more severe form, tardive dyskinesia involves the fingers, arms, trunk, and respiratory muscles. When this occurs, the medication is discontinued. Strategy: Knowledge regarding the clinical manifestations of tardive dyskinesia is needed to answer this question. Remember that this reaction involves abnormal and involuntary movements. If you had difficulty with this question, review the characteristics associated with this disorder. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 410). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1489) The emergency room nurse is caring for an adult client who is a victim of family violence. Which priority instruction would be included in the discharge instructions? a. Information regarding shelters b. Instructions regarding calling the police c. Instructions regarding self-defense classes d. Explaining the importance of leaving the violent situation Source: Saunders 4th

ANS: A Rationale: Tertiary prevention of family violence includes assisting the victim once the abuse has already occurred. The nurse should provide the client with information regarding where to obtain help. This includes a specific plan for removing self from the abuser, information as to escaping, hotlines, and the location of shelters. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not the appropriate action for the victim when dealing with a violent person. Strategy: Note the strategic word priority. Focus on the subject of the question, which relates to providing the client with a safe environment. Use Maslow's Hierarchy of Needs theory to assist in directing you to option 1. If you had difficulty with this question, review the nursing measures for caring for a victim of family violence. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 465, 521). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2582) A nurse is reviewing the electrocardiogram (ECG) rhythm strip obtained on a client with a diagnosis of myocardial infarction. The nurse notes that the PR interval is 0.20 second. The nurse determines that this is: a. A normal finding b. Indicative of atrial flutter c. Indicative of impending reinfarction d. Indicative of atrial fibrillation Source: Saunders 4th

ANS: A Rationale: The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The normal range for the PR interval is 0.12 to 0.20 second. Options 2, 3, and 4 are incorrect. Strategy: Specific knowledge regarding the normal PR interval is required to answer this question. Knowing this normal range will direct you to option 1. If you had difficulty with this question, review normal ECG concepts. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1585). Philadelphia: W.B. Saunders. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 488). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1146) Intravenous heparin therapy is ordered for a client. While implementing this order, a nurse ensures that which of the following medications is available on the nursing unit? a. Protamine sulfate b. Potassium chloride c. Aminocaproic acid (Amicar) d. Vitamin K (AquaMEPHYTON) Source: Saunders 4th

ANS: A Rationale: The antidote to heparin is protamine sulfate; it should be readily available for use if excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin sodium. Aminocaproic acid is the antidote for thrombolytic therapy. Potassium chloride is administered for a potassium deficit. Strategy: Knowledge regarding the various antidotes is needed to answer this question. Remember the antidote to heparin is protamine sulfate. Learn these antidotes if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 intravenous medications (22nd ed., p. 639). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1844) A nurse is developing a plan of care for an infant following surgical intervention for imperforate anus. The nurse includes in the plan that the appropriate position for the infant in the postoperative period is which of the following? a. Prone position b. Supine with no head elevation c. Supine with the head elevated 45 degrees d. Side-lying with the legs extended Source: Saunders 4th

ANS: A Rationale: The appropriate position following surgical intervention for an imperforate anus is a side-lying position with the legs flexed, or a prone position to keep the hips elevated. These positions will reduce edema and pressure on the surgical site. Options 2, 3, and 4 will promote pressure at the surgical site. Strategy: Use the process of elimination. Eliminate options 2 and 3 first because these positions will cause pressure on the surgical site. Read the remaining options carefully and consider the anatomical location of the surgery to select the correct option. Review postoperative care after surgical repair of imperforate anus if you had difficulty with this question. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 885). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Child Health Alternate Question Types -> Multiple Choice

33) A new unit nurse manager is holding her first staff meeting. The manager greets the staff and comments that she has been employed to bring about performance improvement. The manager provides a plan that she developed, as well as a list of tasks and activities for which each staff member must volunteer to perform. In addition, she instructs staff members to report any problems directly to her. What type of leadership style do the new manager's characteristics suggest? a. Autocratic b. Situational c. Democratic d. Laissez-faire Source: Saunders 4th

ANS: A Rationale: The autocratic leader is focused, maintains strong control, makes decisions, and, addresses all problems. Furthermore, the autocrat dominates the group and commands rather than seeks suggestions or input. In this situation, the manager addresses a problem (performance improvement) with the staff, designs a plan without input, and wants all problems reported directly back to her. A situational leader will use a combination of styles, depending on the needs of the group and the tasks to be achieved. The situational leader would work with the group to validate that the information that the leader gained as a new employee was accurate and that a problem existed, and would then take the time to get to know the group and determine which approach to change (if needed) would work best according to the needs of the group and the nature and substance of the change that was required. A democratic leader is participative and would likely meet with each staff person individually to determine the staff member's perception of the problem. The democratic leader would also speak with the staff about any issues and ask the staff for input with developing a plan. A laissez-faire leader is passive and nondirective. The laissez-faire leader would state what the problem was and inform the staff that the staff needed to come up with a plan to "fix it." Strategy: Focus on the data in the question and note the strategic words provides a plan that she developed, each staff member must volunteer to perform and instructs staff members to report any problems directly to her. Remember, autocratic managers take control and dominate. Review the various types of leadership styles if you had difficulty with this question. Reference: Marriner-Tomey, A. (2004). Guide to nursing management and leadership (7th ed., pp. 167-176). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Leadership and Management Alternate Question Types -> Multiple Choice

1873) A clinic nurse is discussing nutrition with a client who has lactose intolerance. The nurse should instruct the client to supplement the dietary source of calcium by eating which of the following foods? a. Dried fruits b. Creamed spinach c. Fresh squeezed orange juice d. Hard cheese Source: Saunders 4th

ANS: A Rationale: The best source of calcium is dairy products. Women with lactose intolerance need other sources of calcium. Calcium is present in dark, green, leafy vegetables, broccoli, legumes, nuts, and dried fruits. Spinach contains calcium, but it also contains oxalates that decrease calcium availability. Additionally, creamed spinach may not be tolerated by a client with a lactose intolerance. Orange juice does not contain significant amounts of calcium unless fortified with calcium. Cheese is a dairy product and is not tolerated by the client with a lactose intolerance. Strategy: Focus on the subject of the question and the client's diagnosis. Recalling that a client with a lactose intolerance cannot tolerate dairy products will assist in eliminating options 2 and 4. Regarding the remaining options, recalling that orange juice does not contain calcium unless it is fortified with calcium will assist in directing you to option 1. Review food items high in calcium that can be tolerated by a client with lactose intolerance if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., pp. 181, 190). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

2623) A client has been given a prescription for tacrine (Cognex) to control moderate dementia of the Alzheimer's type. The nurse determines that the client's spouse understands how to administer the medication if the spouse states: a. "If jaundice develops, I need to notify the physician." b. " I should not administer food with the medication." c. "If flu-like symptoms occur, I should call the physician immediately." d. "If a dose is missed, I should double the next dose." Source: Saunders 4th

ANS: A Rationale: The caregiver is instructed to notify the physician if nausea, vomiting, diarrhea, rash, jaundice, or changes in the color of the stool occur, because these signs could indicate the development of hepatitis. Tacrine is administered between meals on an empty stomach but may be administered with food if gastrointestinal (GI) upset occurs. Flu-like symptoms without fever and GI symptoms are frequent side effects that may occur with use of this medication. The client or spouse should never double the dose of the medication. Strategy: Use the process of elimination. Recalling that an adverse reaction associated with the use of the medication is hepatitis will direct you to the correct option. Remember that sertraline is contraindicated with the use of an MAOI. If you are unfamiliar with the use of this medication and its potential adverse reactions, review this content. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 812). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1265) The home health nurse visits a client at home and instructs the client on the administration of the prescribed eye drops. Which of the following statements by the client indicates a need for further education? a. "I can lie down, pull up on the upper lid, and place the drop in the lower lid." b. "I can lie down, pull down on the lower lid, and place the drop in the lower lid." c. "I can sit and tilt my head back, pull down on the lower lid, and place the drop in the lower lid." d. "I can lie on my side opposite to the eye I am going to place the drop, put the drop in the corner of the lid nearest my nose, and then slowly turn to my other side while blinking." Source: Saunders 4th

ANS: A Rationale: The client can lie down or sit with the head tilted back. The lower lid should be pulled downward with the thumb or fingers. The client holds the bottle like a pencil, with the tip downward, and squeezes the bottle gently, allowing one drop to fall into the sac. The client gently closes the eye. Options 2, 3, and 4 identify correct methods for administering eye drops. Strategy: Use the process of elimination. Note the strategic words need for further education. These words indicate a negative event query and ask you to select an option that is incorrect. Knowing that the client places drops into the eye by pulling down on the lower lid will direct you to the correct option. Review the procedure for the administration of eye medications if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 34, 733). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1545) The client has undergone mastectomy. The nurse interprets that the client is making the best adjustment to the loss of the breast if which of the following behaviors is observed? a. Participating in the care of the surgical drain b. Reading the postoperative care booklet c. Refusing to look at the wound d. Asking for pain medication when needed Source: Saunders 4th

ANS: A Rationale: The client demonstrates the best adaptation by participating in her own care. This would include care of surgical drains that would be in place for a short time after discharge. Asking for pain medication is also an action-oriented option, but it does not relate to acceptance of the loss of the breast. Reading the postoperative care booklet is useful, but is not the best of the options presented here. Refusing to look at the wound indicates no adaptation to the loss. Strategy: Use the process of elimination. Note the strategic word best. This tells you that more than one or all of the options may be partially or totally correct. Use your prioritizing ability to determine the best option of those presented, keeping in mind the subject, "best adjustment." Review psychosocial adaptation to the loss of a breast if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1375). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

1291) The client with myasthenia gravis is having difficulty speaking. The speech is dysarthric and has a nasal tone. The nurse would avoid using which of the following communication strategies when working with this client? a. Encouraging the client to speak quickly b. Asking yes and no questions when able c. Using a communication board when necessary d. Repeating what the client said to verify the message Source: Saunders 4th

ANS: A Rationale: The client has speech that is nasal and dysarthric because of cranial nerve involvement of the muscles governing speech. The nurse listens attentively and verbally verifies what the client has said, asks questions requiring a yes or no response, and develops alternative communication methods (letter board, picture board, pen and paper, flash cards). Encouraging the client to speak quickly is unsuccessful and counterproductive. Strategy: Use the process of elimination, noting the strategic word avoid. Options 2 and 3 are classic examples of alternative communication methods that are useful and are eliminated first. Because option 4 is also helpful, this leaves option 1 as the correct option. Speaking quickly is difficult for a client with a speech impairment. Review communication strategies for the client with speaking difficulty if this question was difficult. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1016). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1739) The client with tuberculosis (TB), whose status is being monitored in an ambulatory care clinic, asks the nurse when it is permissible to return to work. The nurse replies that the client may resume employment when: a. Three sputum cultures are negative. b. Five sputum cultures are negative. c. A sputum culture and a chest x-ray are negative. d. A sputum culture and a Mantoux test are negative. Source: Saunders 4th

ANS: A Rationale: The client must have sputum cultures performed every 2 to 4 weeks after initiation of antituberculosis drug therapy. The client may return to work when the results of three sputum cultures are negative, because the client is considered noninfectious at that point. Strategy: Use the process of elimination. Knowing that a positive Mantoux test never reverts to negative helps you eliminate option 4. From the remaining options, it is necessary to know that three negative sputum cultures are required. If this question was difficult, review these concepts related to TB. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 644). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2095) A client who is to have a cystectomy with creation of an ileal conduit asks the nurse why the bowel needs to be cleansed before surgery if the bladder is being removed. The nurse would give the best response using which of the following pieces of information? a. A portion of the bowel will be used to create the conduit for urinary diversion. b. All clients undergo bowel preparation with major surgery. c. This will reduce the chance that the surgeon will nick the bowel during surgery. d. This will decrease the chance of postoperative paralytic ileus. Source: Saunders 4th

ANS: A Rationale: The client scheduled for surgical creation of either an ileal conduit or a reservoir undergoes bowel preparation the night before the procedure. Preparation includes intake of copious clear liquids, laxatives, enemas, and antibiotics. This is done primarily because a loop of bowel will be used to create the urinary diversion. Strategy: Use the process of elimination. Note the strategic words ileal conduit. Recalling that a portion of the bowel is used to create the conduit will direct you to option 1. Review this surgical procedure if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 872). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2572) The home care nurse is visiting a prenatal client who has a history of heart disease. The nurse provides instructions to the client regarding home care measures to promote a healthy pregnancy. Home care for this client will include which of the following measures? a. Restrict visitors who may have an active infection. b. Avoid becoming concerned about placing stress on the heart. c. Increase daily calories to ensure weight gain. d. Sleep in a supine position at night. Source: Saunders 4th

ANS: A Rationale: The client should avoid exposure to infection and not allow those persons with active infections to visit. Stress causes increased heart workload, with the potential for adverse consequences. Too much weight gain causes an increase in body requirements and increases stress on the heart. The client should rest on the left side to promote blood return. Strategy: Focus on the diagnosis identified in the question. Use the process of elimination recalling that an infection can increase the workload of the heart. This should easily direct you to option 1. Review home care measures for the pregnant client with cardiac disease if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 676). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

2481) A clinic nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the total cholesterol level is normal if which of the following values is noted on the laboratory report? a. 150 mg/dL b. 220 mg/dL c. 250 mg/dL d. 300 mg/dL Source: Saunders 4th

ANS: A Rationale: The client should be counseled to keep the total cholesterol level under 200 mg/dL or even lower as recommended by the physician. Controlling cholesterol levels will aid in prevention of atherosclerosis, which can lead to a number of cardiovascular disorders later in life. Strategy: Knowledge of the normal cholesterol level will direct you to option 1. Also, focusing on the subject, a normal cholesterol level, will direct you to select the option that identifies the lowest value. Review this laboratory test if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 549). Philadelphia: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 262). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2395) A client scheduled to undergo subtotal thyroidectomy is taking a potassium iodide solution (Lugol's solution). The client complains to the ambulatory care nurse that she experiences a brassy taste in the mouth when taking the medication. Which instruction should the nurse provide to the client? a. Report the symptom to the physician. b. Take one-half dose of the prescribed medication for the next 2 days. c. Continue to take the medication because the symptoms are normal. d. Dilute the medication in 8 ounces of water. Source: Saunders 4th

ANS: A Rationale: The client should be instructed about symptoms of iodism that can occur with the administration of potassium iodide solution. These symptoms include a brassy taste, burning sensation in the mouth, and soreness of the gums and teeth. The client should be instructed to withhold the medication and notify the physician if these symptoms are noted. Strategy: Recalling that iodism can occur with this medication and knowing that a brassy taste is a symptom of mild toxicity will direct you to the correct option. Review the adverse effects associated with this medication if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 682). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1011) A nurse teaches a client about the use of a respiratory inhaler. Which action by the client indicates a need for further teaching? a. Inhales the mist and quickly exhales b. Removes the cap and shakes the inhaler well before use c. Presses the canister down with the finger as he breathes in d. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed Source: Saunders 4th

ANS: A Rationale: The client should be instructed to hold his or her breath for at least 10 to 15 seconds before exhaling the mist. Options 2, 3, and 4 are accurate instructions regarding the use of the inhaler. Strategy: Use the process of elimination, noting the strategic words need for further teaching. These words indicate a negative event query and ask you to select an option that is incorrect. Visualize this procedure to answer the question. If you are unfamiliar with the client teaching points related to the use of an inhaler, review this procedure. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 593). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 868-869). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2023) A nurse has provided instructions to a client with glaucoma regarding measures that will prevent an increase in intraocular pressure. Which statement if made by the client would indicate a need for further instruction? a. "I should limit my fluid intake to prevent an increase in pressure." b. "I should eat foods that are high in fiber." c. "I should avoid lifting objects that weigh more than 20 pounds." d. "I should move objects by using my feet and pushing them along the floor, rather than by lifting them." Source: Saunders 4th

ANS: A Rationale: The client should be instructed to maintain a diet high in fiber and to consume a high intake of liquids, unless contraindicated, to prevent constipation and straining at stool. Objects weighing 20 pounds or more should be moved by pushing the object along the floor using the feet, rather than by bending over. Activities such as bending over and straining at stool will increase intraocular pressure. Strategy: Note the strategic words indicate a need for further instruction and focus on the subject, preventing an increase in intraocular pressure. Using principles related to activities that will increase intraocular pressure will direct you to option 1. Review activities that should be avoided in the client with glaucoma if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1095). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1840) A nurse is providing instructions to a client with a colostomy about measures to reduce the odor from the colostomy. Which statement if made by the client indicates an understanding of these measures? a. "Beet greens, parsley, or yogurt will help to control the colostomy odor." b. "I should be sure to eat at least one cucumber every day." c. "I will need to increase my egg intake and try to eat 1/2 to 1 egg per day." d. "Green vegetables such as spinach and broccoli will prevent odor, and I should eat these foods every day." Source: Saunders 4th

ANS: A Rationale: The client should be taught to include deodorizing foods in the diet such as beet greens, parsley, buttermilk, and yogurt. Spinach also may reduce odor, but it is a gas-forming food and should be avoided. Cucumbers, eggs, and broccoli also are gas-forming foods and should be avoided or limited by the client. Strategy: Focus on the subject, reducing the odor from the colostomy. Recalling that cucumbers, eggs, and broccoli are gas forming will direct you to option 1. Review foods that cause odor or gas, and those food items that may have a deodorizing effect in the client with an ostomy if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1325). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2182) A client with myasthenia gravis is taking neostigmine (Prostigmin). The client has frequent exacerbations of myasthenic crisis and cholinergic crisis. The nurse teaches the client that it is very important that this medication be: a. Taken on time b. Double-dosed if one dose is missed c. Taken on an empty stomach d. Titrated for dosage depending on the symptoms Source: Saunders 4th

ANS: A Rationale: The client should take neostigmine exactly on time. Taking the medication early or late could result in myasthenic or cholinergic crisis. Taking the medication on time is especially important for the client with dysphagia, because the client may not be able to swallow the medication if it is given late. These clients are taught to set a battery alarm clock to remind them of dosage times. The client should never skip or double up on missed doses. The medication should be administered with food or milk to minimize side effects. Strategy: Use the process of elimination. The question tells you that the client has frequent myasthenic and cholinergic crises. Recalling that these crises are triggered by insufficient and excessive medication, respectively, will direct you to option 1. Review the causes of myasthenic and cholinergic crisis if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 367). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 138). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2672) A client has just been given a prescription for diphenoxylate with atropine (Lomotil). The nurse determines that the client understands important information about this medication if the client states: a. "This medication contains a habit-forming ingredient." b. "It's best to take this medication with a laxative." c. "Drooling may occur while I am taking this medication." d. "Irritability may occur while I am taking this medication." Source: Saunders 4th

ANS: A Rationale: The client should understand that this medication may be habit-forming, so careful adherence to proper dose is important. The medication is an antidiarrheal and therefore should not be taken with a laxative (cathartic). Side effects of the medication include dry mouth and drowsiness. Drooling and irritability are not associated with the use of this medication. Strategy: Recalling that this medication is an antidiarrheal will assist in eliminating option 2. From the remaining options, it is necessary to know that the medication is habit-forming. Review the adverse effects of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 277). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2649) Benztropine mesylate (Cogentin) is prescribed for a client with a diagnosis of Parkinson's disease. The nurse determines that the client needs additional information about the medication if the client states: a. "I will sit in the sun for an hour a day to enhance medication effectiveness." b. "I'll watch my urinary output and look for signs of constipation." c. "I will avoid driving if I get drowsy or dizzy." d. "I will call the physician if I have difficulty swallowing or if I start vomiting." Source: Saunders 4th

ANS: A Rationale: The client taking benztropine mesylate may have decreased tolerance to heat as a result of diminished ability to sweat and should plan rest periods in cool places during the day. The client also is instructed to avoid driving or operating hazardous equipment if drowsy or dizzy. The client should be instructed to stop taking the medication if difficulty swallowing or speaking develops or if vomiting occurs; to inform the physician if central nervous system effects occur; and to monitor urinary output and watch for signs of constipation. Strategy: Use the process of elimination. Note the strategic words needs additional information. This phrasing indicates a negative event query and the need to select an incorrect statement. Recalling the action of benztropine mesylate and use of general principles related to medication instructions will direct you to option 1. If you had difficulty with this question, review client teaching points related to this medication. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 95). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1556) The client is about to undergo a lumbar puncture (LP). The nurse describes to the client that which of the following positions will be used during the procedure? a. Side-lying with the legs pulled up and the head bent down onto the chest b. Side-lying with a pillow under the hip c. Prone with a pillow under the abdomen d. Prone in slight Trendelenburg Source: Saunders 4th

ANS: A Rationale: The client undergoing lumbar puncture (LP) is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae and allows for easier needle insertion by the physician. Each of the other options identifies incorrect positions for this procedure. Strategy: Use the process of elimination. Recalling that an LP is the introduction of a needle into the subarachnoid space will direct you to option 1. It is reasonable that the position of the client must facilitate this and the correct option is the only position that flexes the vertebrae and widens the spaces between them. Review care of the client undergoing an LP if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 739). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2084) A client with renal cancer is being treated preoperatively with radiation therapy. The nurse determines that the client demonstrates understanding of proper care of the skin over the treatment field by stating to: a. Avoid skin exposure to direct sunlight and chlorinated water. b. Use lanolin-based cream on the affected skin on a daily basis. c. Remove the lines or ink marks using a gentle soap after each treatment. d. Use the hottest water possible to wash the treatment site twice daily. Source: Saunders 4th

ANS: A Rationale: The client undergoing radiation therapy should avoid washing the site until instructed to do so. The client should then wash using mild soap and warm or cool water, and pat the area dry. No lotions, creams, alcohol, or deodorants should be placed on the skin over the treatment site. Lines or ink marks that are placed on the skin to guide the radiation therapy should be left in place. The affected skin should be protected from temperature extremes, direct sunlight, and chlorinated water (as from swimming pools). Strategy: Use the process of elimination. Begin to answer this question by eliminating options 2 and 4, because they are contraindicated in the care of this client. Also note the strategic word hottest in option 4. Knowing that markings used to guide therapy are to be left in place will help you to choose option 1 over option 3. Review client instructions regarding skin care if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 491). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1173) The client has epididymitis as a complication of a urinary tract infection. The nurse is giving the client instructions to prevent urinary tract infection recurrence. The nurse determines that the client needs further instruction if the client states that he will: a. Consume more acidic foods. b. Drink increased amounts of fluids. c. Limit the force of the stream during voiding. d. Use latex condoms to prevent contracting chlamydia and gonorrhea. Source: Saunders 4th

ANS: A Rationale: The client who experiences epididymitis from urinary tract infection should decrease intake of acidic foods and increase fluid intake to flush the urinary system. Because organisms can be forced into the vas deferens and epididymis from strain or pressure during voiding, the client should limit the force of the stream. Condom use can help prevent urethritis and epididymitis. Strategy: Use the process of elimination and note the strategic words needs further instruction. These words indicate a negative event query and ask you to select an option that is incorrect. Careful reading will direct you to option 1. Review client instructions regarding epididymitis and prevention of urinary tract infections if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1039). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1935) A client is having difficulty coughing and deep breathing because of pain after a nephrectomy. Which action by the nurse is least helpful in promoting optimal respiratory function? a. Administering pain medication only before ambulation b. Encouraging use of incentive spirometer hourly c. Assisting the client to splint the incision during respiratory exercise d. Offering PRN pain medication every 4 hours when due Source: Saunders 4th

ANS: A Rationale: The client who has had a nephrectomy may have pain with coughing and deep breathing and other respiratory exercises because the location of the incision is so close to the diaphragm. The nurse assists the client by administering opioid analgesics, encouraging incentive spirometer use, and assisting the client to splint the incision during coughing. If the client takes pain medication only before ambulation, control of pain may be insufficient, which will not promote optimal respiratory function. Strategy: Use the process of elimination. Note the strategic words least helpful in the question and focus on the subject, promoting optimal respiratory function. Then noting the word only in option 1 will assist in directing you to this option. Review pain relief measures for the client after nephrectomy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 924-925). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1552) The nurse has given discharge instructions to the client who has undergone vein ligation and stripping early in the day. The nurse evaluates that the client understands activity and positioning limitations if the client states that it is appropriate to: a. Lie down with the legs elevated and avoid sitting. b. Cross the ankles at the ankle only, but not at the knee. c. Sit in the chair 3 times a day for 3 hours at a time. d. Walk upright for as much as possible each day. Source: Saunders 4th

ANS: A Rationale: The client who has had vein ligation and stripping should avoid standing or sitting for prolonged periods. The client should remain lying down unless performing a specific activity for the first few days following the procedure. Prolonged standing and sitting increase the risk of edema in the legs by decreasing blood return to the heart. The client should avoid crossing the legs at any level for the same reason. Strategy: Use the process of elimination and principles associated with gravity and blood flow to answer this question. Eliminate option 2 first because of the close-ended word only. Knowing that prolonged standing or sitting is harmful helps eliminate options 3 and 4. Review client instructions following a vein ligation and stripping if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 817-818). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1849) A nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which of the following assessment data would indicate to the nurse that the dehydration is not resolved? a. A urine specific gravity of 1.033 b. A urine output that is pale yellow in color c. A blood pressure of 120/80 mm Hg d. An oral temperature of 98.8. F Source: Saunders 4th

ANS: A Rationale: The client who is underhydrated will have a urine specific gravity of greater than 1.030. Normal values for urine specific gravity are 1.010 to 1.030. Pale yellow urine is a normal finding. A blood pressure of 120/80 mm Hg is within normal range. A temperature of 98.8° F is only 0.2 point above the normal temperature and would not be as specific an indicator of hydration status as would the urine specific gravity. Strategy: Use the process of elimination and knowledge regarding the signs of dehydration and normal fluid balance. Eliminate options 3 and 4 first because they are close to or within normal limits. Regarding the remaining options, recalling that pale urine is a normal finding will assist in directing you to option 1. If you had difficulty with this question, review the normal and abnormal findings in the client with dehydration. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 208). Philadelphia: W.B. Saunders. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 1013). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1144). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2688) A client is receiving heparin sodium by continuous intravenous (IV) infusion. The nurse should notify the physician if ongoing nursing assessment reveals which of the following? a. Ecchymoses b. Tinnitus c. Increased blood pressure d. Increased pulse rate Source: Saunders 4th

ANS: A Rationale: The client who receives a continuous IV infusion of heparin is at risk for bleeding. The nurse assesses for signs of bleeding, which include bleeding from the gums, ecchymoses on the skin, cloudy or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood. The other options are not side effects related to this medication. Strategy: Note the strategic words notify the physician. Recalling that this medication is an anticoagulant and that bleeding is a concern will direct you to option 1. If this question was difficult, review the nursing considerations related to the administration of this medication. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 639). St. Louis: Mosby. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 572). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2433) An emergency department nurse is performing an assessment on a client who sustained circumferential burns of both legs. Which of the following assessments would be the initial priority in caring for this client? a. Assessing peripheral pulses b. Assessing respiratory rate c. Assessing heart rate d. Assessing blood pressure (BP) Source: Saunders 4th

ANS: A Rationale: The client who receives circumferential burns to the extremities is at risk for altered peripheral circulation. The priority assessment would be to assess for peripheral pulses to ensure that adequate circulation is present. Although the respiratory rate and BP also would be assessed, the priority with a circumferential burn is the assessment for the presence of peripheral pulses. Strategy: Focus on the strategic words circumferential burns of both legs to direct you to the correct option. Note the relevance of this type of burn to option 1. If you had difficulty with this question or are unfamiliar with the priority assessment in a client who has sustained a circumferential burn of an extremity, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1448-1449). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 519). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

1967) A nurse is preparing a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which nursing intervention should the nurse implement in preparation for the arrival of the client? a. Prepare a private room at the end of the hallway. b. Place a sign on the door that indicates that visitors are limited to 60-minute visits. c. Assign one primary nurse to care for the client during the hospital stay. d. Place a linen bag outside of the client's room for discarding linens after morning care. Source: Saunders 4th

ANS: A Rationale: The client with an internal cervical radiation implant should be placed in a private room at the end of the hall because this location provides less of a chance of exposure of radiation to others. The client's room should be marked with appropriate signs that indicate the presence of radiation. Visitors should be limited to 30-minute visits. Nurses assigned to this client should be rotated so that one nurse is not consistently caring for the client and exposing him or herself to excess amounts of radiation. All linens should be kept in the client's room until the implant is removed in case the implant has dislodged and needs to be located. Strategy: Note that the client has a radiation implant. Recalling the principles related to time, distance, and shielding with radiation will direct you to option 1. If you had difficulty with this question, review care of the client with a radiation implant and the principles related to time, distance, and shielding with radiation. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 363). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Leadership and Management Alternate Question Types -> Multiple Choice

938) The nurse is evaluating the effect of dietary counseling on the client with cholecystitis. The nurse evaluates that the client understands the instructions given if the client states that which food item(s) is (are) acceptable in the diet? a. Baked fish b. Fried chicken c. Sauces and gravies d. Fresh whipped cream Source: Saunders 4th

ANS: A Rationale: The client with cholecystitis should decrease overall intake of dietary fat. Foods that should be avoided include sauces and gravies, fatty meats, fried foods, products made with cream, and heavy desserts. The correct option is baked fish, which is low in fat. Strategy: Use the process of elimination. Recalling the function of the gallbladder and knowledge of the foods that are low in fat will direct you to option 1. Review dietary measures for the client with cholecystitis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1399, 1401). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

936) The client with chronic pancreatitis needs information on dietary modification to manage the health problem. The nurse teaches the client to limit which item in the diet? a. Fat b. Protein c. Carbohydrate d. Water-soluble vitamins Source: Saunders 4th

ANS: A Rationale: The client with chronic pancreatitis should limit fat in the diet and also take in small meals, which will reduce the amount of carbohydrates and protein that the client must digest at any one time. The client does not need to limit water-soluble vitamins in the diet. Strategy: Use the process of elimination and note the strategic word limit. Recalling the function of the pancreas will direct you to option 1. Review dietary measures for the client with chronic pancreatitis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1411). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

105) A nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of: a. Pork b. Milk c. Chicken d. Broccoli Source: Saunders 4th

ANS: A Rationale: The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in this vitamin. Other good food sources include nuts, whole grain cereals, and legumes. Milk contains vitamins A, D, and B₂. Poultry contains niacin. Broccoli contains vitamins C, E, and K and folic acid. Strategy: Note the strategic words best understanding in the stem of the question. This may indicate that more than one option may be a food that contains thiamine. Remembering that pork products are especially rich in thiamine will direct you to option 1. Review food items high in thiamine if you had difficulty with this question. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed., p. 170). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1022) A nurse is assessing a client with chronic airflow limitation and notes that the client has a "barrel chest." The nurse interprets that this client has which of the following forms of chronic airflow limitation? a. Emphysema b. Bronchial asthma c. Chronic obstructive bronchitis d. Bronchial asthma and bronchitis Source: Saunders 4th

ANS: A Rationale: The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. These lead to increased anteroposterior diameter, referred to as "barrel chest." The client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion. Strategy: Use the process of elimination. Recall that the barrel chest is a result of long-term hyperinflation of the lungs and air trapping. Knowing that emphysema is the only type of chronic airflow limitation in which this occurs will enable you to eliminate each of the other, incorrect options. Review the characteristics of emphysema if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 598). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 558). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2562) A nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? a. Listening to lung sounds b. Assessing for peripheral and sacral edema c. Assessing for jugular vein distention d. Monitoring for organomegaly Source: Saunders 4th

ANS: A Rationale: The client with heart failure may present with different symptoms depending on whether the right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of problems with right-sided heart function. Lung sounds constitute an accurate indicator of left-sided heart function. Strategy: Use the process of elimination and focus on the subject of the question, left-sided heart failure. Correlate left and lungs. Options 2, 3, and 4 reflect right-sided heart failure. Review the signs of right- and left-sided heart failure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 753-754). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1030) A client who is human immunodeficiency virus-positive has had a Mantoux skin test. The nurse notes a 7-mm area of induration at the site of the skin test. The nurse interprets the results as: a. Positive b. Negative c. Inconclusive d. Indicating the need for repeat testing Source: Saunders 4th

ANS: A Rationale: The client with human immunodeficiency virus (HIV) infection is considered to have positive results on Mantoux skin testing with an area larger than 5 mm of induration. The client without HIV is positive with an induration larger than 10 mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor. Options 2, 3, and 4 are incorrect interpretations. Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they are comparative or alike. From the remaining options, recalling that the client with HIV is immunosuppressed will assist in determining the interpretation of the area of induration. Review results of tuberculosis skin testing in an immunosuppressed client if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed., p. 642). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1391) The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency. The nurse would incorporate which of the following as a priority in the plan of care? a. Protecting the client from infection b. Providing emotional support to decrease fear c. Encouraging discussion about lifestyle changes d. Identifying factors that decreased the immune function Source: Saunders 4th

ANS: A Rationale: The client with immunodeficiency has inadequate or absence of immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. Options 2, 3, and 4 may be components of care but are not the priority. Strategy: Use Maslow's Hierarchy of Needs theory to answer the question. Remember that physiological needs are the priority. This will direct you to option 1. Review the care of a client with immunodeficiency if you had difficulty with this question. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., pp. 192-193). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

2117) A nurse has provided instructions to a client with a diagnosis of myasthenia gravis about home care measures. Which client statement indicates the need for further instruction? a. "I can change the time of my medication on the mornings when I feel strong." b. "I will rest each afternoon after my walk." c. "If I get abdominal cramps and diarrhea, I should call my doctor." d. "I should cough and deep breathe many times during the day." Source: Saunders 4th

ANS: A Rationale: The client with myasthenia gravis and his or her family should be taught information about the disease and its treatment. They should be aware of the adverse reactions of anticholinesterase medications and corticosteroids and should be taught that timing of anticholinesterase medication is critical. It is important to instruct the client to administer the medication on time to maintain a chemical balance at the neuromuscular junction. If it is not given on time, the client may become too weak to even swallow. Options 2, 3, and 4 include all of the necessary information that the client requires to understand how to maintain health with this neurological degenerative disease. Strategy: Use the process of elimination and general principles related to the administration of medication. Note the strategic words need for further instruction. This phrasing indicates a negative event query and asks you to select an incorrect statement. Recalling that medication should not be adjusted or changed will direct you to option 1. Review instructions for the client with myasthenia gravis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1017-1018). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1762) The client who has just suffered a large flail chest is experiencing severe pain and dyspnea. The client's central venous pressure (CVP) is rising, and the arterial blood pressure is falling. The nurse interprets that the client is experiencing: a. Mediastinal flutter. b. Mediastinal shift. c. Hypovolemic shock. d. Fat embolism. Source: Saunders 4th

ANS: A Rationale: The client with severe flail chest will have significant paradoxical chest movement. This causes the mediastinal structures to swing back and forth with respiration. This movement can affect hemodynamics. Specifically, the client's central venous pressure (CVP) rises, the filling of the right side of the heart is impaired, and the arterial blood pressure falls. This is referred to as mediastinal flutter. Strategy: Use the process of elimination. Because the question makes no mention of hemorrhage or bleeding, hypovolemic shock is eliminated first. Knowing that these signs and symptoms are not compatible with fat embolism helps you eliminate that option next. From the remaining options, knowing that mediastinal shift is a result of tension pneumothorax helps you choose mediastinal flutter as the correct option. Review the complications of a flail chest if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 670). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2308) A nurse is developing a teaching plan for a client with viral hepatitis. The nurse plans to tell the client which of the following in the teaching session? a. Activity should be limited to prevent fatigue. b. The diet should be low in calories. c. Meals should be large to conserve energy. d. Alcohol intake should be limited to 2 ounces per day. Source: Saunders 4th

ANS: A Rationale: The client with viral hepatitis should limit activity to avoid fatigue during the recuperation period. The diet should be optimal in calories, proteins, and carbohydrates. The client should take in several small meals per day. Alcohol is strictly forbidden. Strategy: Use the process of elimination and focus on the client's diagnosis. Recalling the importance and goal of allowing the liver to heal will direct you to option 1. Review care of the client with hepatitis if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1329). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

941) The client with cirrhosis complicated by ascites is admitted to the hospital. The client has stated a 10-lb weight gain over the last 1½ weeks. The client has edema of the feet and ankles and his abdomen is distended, taut, and shiny with striae. The nurse selects which nursing diagnosis as the most appropriate for this client? a. Fluid volume, excess b. Gas exchange, impaired c. Skin integrity, impaired, risk for d. Nutrition: more than body requirements, imbalanced Source: Saunders 4th

ANS: A Rationale: The client with weight gain that also has cirrhosis complicated by ascites most often is retaining fluid. This is especially true when the client has not demonstrated an appreciable increase in food intake or when the weight gain is massive in relation to the time frame given. Therefore, Fluid volume, excess is the most appropriate nursing diagnosis. The client does not have Nutrition: more than body requirements, imbalanced; in fact, this client is most likely malnourished as part of the overall clinical picture. No data are given to support Gas exchange, impaired, although in some clients, upward pressure on the diaphragm from ascites does impair respiration. Skin integrity, impaired, risk for assumes a lower priority than actual diagnoses. Strategy: Focus on the data provided in the question and note the strategic words most appropriate. Begin to answer this question by eliminating option 3 because it is not an actual nursing diagnosis. Eliminate option 2 next because there are no supportive data. Choose correctly between the remaining options, knowing that the weight gain is because of fluid retention. Review the complications associated with cirrhosis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1375). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

17) The nurse has just assisted a client back to bed after a fall. The nurse and physician have assessed the client, and have determined that the client is not injured. After completing the incident report, the nurse should take which action next? a. Reassess the client. b. Conduct a staff meeting to describe the fall. c. Document in the nurse's notes that an incident report was completed. d. Contact the nursing supervisor to update information regarding the fall. Source: Saunders 4th

ANS: A Rationale: The client's fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only those participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is desired. After a client's fall, the nurse must frequently reassess the client, because potential complications do not always appear immediately after the fall. Strategy: Focus on the data in the question and the subject, the next nursing action. Using the steps of the nursing process will direct you to option 1. Review guidelines related to incident reports and care to the client after sustaining a fall if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 411, 419). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2311) A client who has undergone radical neck dissection for a tumor has a nursing diagnosis of ineffective airway clearance related to obstruction secondary to postoperative edema, drainage, and secretions. To promote adequate respiratory function in this client, the nurse needs to avoid which of the following activities? a. Placing the bed in low Fowler's position b. Supporting the neck incision when the client coughs c. Suctioning the client as needed d. Encouraging coughing every 2 hours Source: Saunders 4th

ANS: A Rationale: The client's respiratory status is promoted by the use of high Fowler's position after this surgery. Low Fowler's position is avoided because it could result in increased venous pressure on the graft and increased risk of regurgitation and aspiration. It also is helpful to encourage the client to cough and deep breathe every 2 hours, to support the neck incision when the client coughs, and to suction periodically as needed by the client. Strategy: Note the strategic word avoid in the question. Noting the anatomical location of the surgical procedure and knowledge of basic principles of airway management will direct you to option 1. Remember that the head of the bed needs to be elevated. Review the basic principles of promoting adequate respiratory function if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1795). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1415) The nurse completes the initial assessment of a client admitted to the mental health unit. The nurse analyzes the data obtained on assessment and determines that which of the following presents a priority concern? a. The client's report of suicidal thoughts b. The client's report of not eating or sleeping c. The presence of bruises on the client's body d. The significant other's disapproval of the treatment Source: Saunders 4th

ANS: A Rationale: The client's thoughts are important when verbalized. A client's report of suicidal thoughts is of highest priority. Options 2, 3, and 4 will affect the treatment of the client but are not of greatest importance at this time. Strategy: The client is the focus of the question; therefore, eliminate option 4. Use the process of elimination and principles related to prioritizing to select the correct option. The life-threatening concern is identified in option 1. Review the techniques of assessment and analysis of assessment data from a client with a mental health disorder if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 94-96, 561-562). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

1456) The nurse is performing an assessment on a client with dementia. Which data gathered during the assessment indicate a manifestation associated with dementia? a. Confabulation b. Improvement in sleeping c. Absence of sundown syndrome d. Presence of personal hygienic care Source: Saunders 4th

ANS: A Rationale: The clinical picture of dementia varies from the development of mild cognitive defects to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or the fabrication of events or experiences to fill in memory gaps is not unusual. Often, lack of inhibitions on the part of the client may constitute the first indication of anything being "wrong" to the client's significant others (the client may undress in front of others or demonstrate slovenly table manners but was formerly well mannered). As the dementia progresses, the client will have episodes of wandering or sundowning. Strategy: Use the process of elimination and focus on the client's diagnosis. Noting the subject, a manifestation, will direct you to option 1. If you had difficulty with this question, review the manifestations associated with dementia. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 331). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 451-452, 459). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2261) A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse would evaluate that the client is adequately adapting to this problem if the client states a plan to obtain: a. A hearing aid b. A walker c. Eyeglasses d. A bath thermometer Source: Saunders 4th

ANS: A Rationale: The cochlear division of cranial nerve VIII is responsible for hearing. Clients with hearing difficulty may benefit from the use of a hearing aid. The vestibular portion of this nerve controls equilibrium; difficulty with balance due to dysfunction of this division could be addressed with use of a walker. Eyeglasses would correct visual problems (cranial nerve II); a bath thermometer would be of use to clients with sensory deficits of peripheral nerves, such as with diabetic neuropathy. Strategy: Use the process of elimination. Knowing that this nerve has two parts may be of use to you in remembering that it has to do with the two functions of the ear (hearing and balance). This would assist in eliminating options 3 and 4. Regarding the remaining options, recalling that the cochlear division is responsible for hearing will direct you to option 1. Review the function of cranial nerve VIII if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2029). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 931). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1010) A client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? a. Dyspnea b. Bradypnea c. Bradycardia d. Decreased respirations Source: Saunders 4th

ANS: A Rationale: The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain. Strategy: Use the process of elimination. Eliminate options 2, 3, and 4 because they are comparative or alike. Review the clinical manifestations of pulmonary embolism if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 650). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1664) Lispro insulin (Humalog), a rapid-acting form of insulin, is prescribed for the client. The client is instructed to administer the insulin prior to meals. The nurse instructs the client to administer the insulin: a. Immediately before eating. b. 30 minutes before eating. c. 45 minutes before eating. d. 60 minutes before eating. Source: Saunders 4th

ANS: A Rationale: The effect of lispro insulin begins within 10 minutes of subcutaneous injection, peaks in 1 hour, and has a duration of action of 3 hours. Lispro insulin acts more rapidly than Regular insulin and has a shorter duration of action. Because of its rapid onset, it can be administered immediately before eating. In contrast, Regular insulin is generally administered 30 to 60 minutes before meals. Strategy: Use the process of elimination. Note the strategic words rapid-acting. This will assist in eliminating options 3 and 4. From the remaining options, remember that the question is asking about lispro, not Regular, insulin. This should direct you to option 1. Review the characteristics of lispro insulin if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 620). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1447) The client is preparing to attend a Gamblers Anonymous meeting for the first time. The prototype used by this group is the 12-step program developed by Alcoholics Anonymous. The nurse tells the client that the first step in the 12-step program is which of the following? a. Admitting to having a problem b. Substituting other activities for gambling c. Stating that the gambling will be stopped d. Discontinuing relationships with friends who are gamblers Source: Saunders 4th

ANS: A Rationale: The first step in the 12-step program is to admit that a problem exists. Options 3 and 4 are unrealistic as a first step in the process to recovery. Although option 2 may be a strategy, it is not the first step. Strategy: Use the process of elimination and note the strategic words first step in the question. This will assist in directing you to option 1. If you are unfamiliar with the 12-step program, review this content. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 321-322). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 566). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2478) A client with diabetes mellitus reports to the health care clinic for determination of the glycosylated hemoglobin A_1c level. Which of the following values on this laboratory test indicates client compliance with the prescribed diabetic regimen? a. 5.0% b. 8.0% c. 10.0% d. 15.0% Source: Saunders 4th

ANS: A Rationale: The glycosylated hemoglobin measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. The glycosylated hemoglobin level in a diabetic client with good control will be 7.5% or less. Elevations in blood glucose will cause elevations in the amount of glycosylation. Elevations indicate continued need for teaching related to prevention of hyperglycemic episodes. Strategy: Knowledge of the normal glycosylated hemoglobin A_1c concentration is required to answer this question. Focusing on the subject, client compliance, will direct you to select the option that identifies the lowest value. Review this laboratory test if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 615). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

1802) Two nurses are leaving a client's room whose care required them to wear a gown, mask, and gloves. Which of the following actions by these nurses could lead to the spread of infection? a. Removing the gown without rolling it from inside out b. Taking off the gloves first before removing the gown c. Washing the hands after the entire procedure has been completed d. Removing the gloves and then removing the gown using the neck ties Source: Saunders 4th

ANS: A Rationale: The gown must be rolled from inside out to prevent the organisms on the outside of the gown from contaminating other areas. Gloves are considered the dirtiest piece of equipment and therefore must be removed first. Hands must be washed after removal of the protective garb to remove any unwanted germs still present. Ungloved hands should be used to remove the gown to prevent contaminating the back of the gown with germs from the gloves. Strategy: Use the process of elimination and knowledge regarding standard precautions to assist in answering the question. Attempt to visualize the process of removing protective garb remembering to remove the dirtiest items first. Be sure to understand the order in which to remove protective garb. A slight change in the order can have devastating effects and compromise the care of the client. Review this procedure if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 796, 803). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1606) The home care nurse's assignment is to visit a new mother at home 24 to 48 hours after discharge. What of the following would the nurse expect to note in a healthy mother who is breast-feeding her newborn infant? a. A mother breast-feeding with the infant in a tummy to tummy position without signs of cracked nipples; baby demonstrates bursts of sucking, followed by a pause and swallow b. A mother breast-feeding the infant with the infant's head turned toward her breast, with the body flat in her arms; mother with sore nipples and infant with a suck blister c. A mother complaining of breast engorgement, with the infant demonstrating difficulty in latching onto the breast d. A mother with cracked nipples feeding the infant with a supplemental bottle Source: Saunders 4th

ANS: A Rationale: The infant should be positioned completely facing the mother with head, neck, and spine aligned. Poor positioning increases the number of attempts for latching on. Option 2 is incorrect because it demonstrates improper positioning. Options 3 and 4 are the result of improper positioning. Additionally, options 2, 3, and 4 all identify complications (sore nipples, breast engorgement, cracked nipples). Strategy: Use the process of elimination. Options 2, 3, and 4 are comparative or alike and all identify complications (sore nipples, breast engorgement, cracked nipples). Option 1 is the only option that identifies a normal expectation. Review normal expectations of a mother who is breast-feeding if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., pp. 544-545). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

2506) A nurse is teaching a mother to instill drops in her infant's ear. The nurse explains that in order to give the eardrops correctly, the mother must: a. Pull down and back on the earlobe and direct the solution toward the wall of the canal. b. Pull up and back on the earlobe and direct the solution toward the eardrum. c. Pull up and back on the auricle and direct the solution toward the wall of the canal. d. Pull down and back on the auricle and direct the solution onto the eardrum. Source: Saunders 4th

ANS: A Rationale: The infant should be turned on the side with the affected ear uppermost. With the wrist of the nondominant hand resting on the infant's head, the mother pulls down and back on the earlobe and aims the solution at the wall of the canal, rather than directly onto the eardrum. In the adult, the auricle is pulled up and back to straighten the auditory canal. Strategy: Use the process of elimination and recall basic principles for the safe administration of ear medications to an infant to answer this question. Visualize the steps of the procedure to direct you toward the correct option. Review the procedure for administering ear medications in an infant and an adult if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1126-1127). Philadelphia: W.B. Saunders. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 982). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1691) In the prenatal clinic, the nurse is interviewing a new client and obtaining health history information. The nurse plans to do which of the following to elicit most appropriately accurate responses to the questions that refer to sexually transmitted diseases? a. Establish a therapeutic relationship. b. Use specific close-ended questions. c. Omit these types of questions because they are highly personal. d. Apologize for the embarrassment that these questions will cause the client. Source: Saunders 4th

ANS: A Rationale: The initial assessment interview establishes the therapeutic relationship between the nurse and the pregnant woman. It is planned purposeful communication that focuses on specific content. Options 2, 3, and 4 are incorrect and would not lend themselves to eliciting accurate information from the client. Strategy: Use the process of elimination focusing on the subject of the question. Remember that establishing a therapeutic relationship is most meaningful. Review therapeutic communication techniques and care of the client with a sexually transmitted disease if you had difficulty with this question. Reference: Lowdermilk, D., & Perry, A. (2004). Maternity and woman's health care (8th ed., pp. 111, 213). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1119) Cardiac magnetic resonance imaging (MRI) is prescribed for a client. The nurse identifies that which of the following is a contraindication for performance of this diagnostic study? a. Client has a pacemaker. b. Client is allergic to iodine. c. Client has diabetes mellitus. d. Client has a biological porcine valve. Source: Saunders 4th

ANS: A Rationale: The magnetic fields used for magnetic resonance imaging (MRI) can deactivate the pacemaker. Options 2, 3, and 4 are not contraindications for an MRI. Strategy: Focus on the name of the test and note the strategic word magnetic. Remember that the magnetic fields of the MRI can deactivate the pacemaker. Review the contraindications for an MRI if you had difficulty with this question. Reference: Ignatavicius, D. & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed., p. 703). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2445) Vasopressin (Pitressin) therapy is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse is preparing to administer the medication to the client. Which of the following essential items is needed during the administration of this medication? a. A cardiac monitor b. An airway c. A suction setup d. A tracheotomy set Source: Saunders 4th

ANS: A Rationale: The major action of vasopressin is constriction of the splanchnic blood flow. Continuous electrocardiogram and blood pressure monitoring is essential because of the constrictive effects of the medication on the coronary arteries. Options 2, 3, and 4 are not essential items required during the administration of this medication. However, these items may be needed if a complication arises. Strategy: Use the process of elimination. Recalling that this medication causes vasoconstriction will direct you to option 1. If you had difficulty with this question, review care of the client receiving vasopressin therapy. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 1219). St. Louis: Mosby. Reference: Kee, J., Hayes, E., & Cuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 912). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., pp. 692-694). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

148) A physician tells a client that the client needs a blood transfusion and that a blood sample must be drawn first for blood typing and crossmatching. After the physician leaves, the client asks the nurse, "What exactly is a blood type, anyway?" The nurse responds with which of the following statements? a. "The blood type represents an antigen found on the surface of the red blood cell." b. "The blood type represents an antibody found on the surface of the red blood cell." c. "The blood type represents an antibody that normally circulates in the blood plasma." d. "The blood type represents an antigen that normally circulates in the blood plasma." Source: Saunders 4th

ANS: A Rationale: The major blood types are A, B, AB, and O. The blood type indicates an antigen found on the surface of the red blood cell. Acute hemolytic transfusion reaction (ABO incompatibility) can occur if a client receives blood that is not compatible with his or her blood type. Acute hemolytic reaction is the most serious adverse reaction to a blood transfusion. Strategy: Use the process of elimination and specific knowledge related to the meaning of blood groups. Remember that the blood type indicates an antigen found on the surface of the red blood cell. If you had difficulty with this question, review these concepts. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 913). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1190-1192). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1186) The nurse is preparing to care for a client receiving peritoneal dialysis. Which of the following would be included in the nursing plan of care to prevent the major complication associated with peritoneal dialysis? a. Maintain strict aseptic technique. b. Add heparin to the dialysate solution. c. Change the catheter site dressing daily. d. Monitor the client's level of consciousness. Source: Saunders 4th

ANS: A Rationale: The major complication of peritoneal dialysis is peritonitis. Strict aseptic technique is required in caring for the client receiving this treatment. Although option 3 may assist in preventing infection, this option relates to an external site. Options 2 and 4 are unrelated to the major complication of peritoneal dialysis. Strategy: Use the process of elimination. Visualize this procedure and recall the major concern related to peritonitis. This will direct you to option 1. Review the complications associated with peritoneal dialysis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1755, 1759). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1106) A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. A nurse also notes superficial thrombophlebitis of the lower leg. For which risk factor should the nurse assess based on these clinical findings? a. Smoking history b. Recent exposure to allergens c. History of recent insect bites d. Familial tendency toward peripheral vascular disease Source: Saunders 4th

ANS: A Rationale: The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger's disease). This disorder is characterized by inflammation and thrombosis of smaller arteries and veins. It typically is found in young adult males who smoke. The cause is not known precisely but is suspected to have an autoimmune component. Strategy: Use the process of elimination and knowledge of this disorder to answer the question. Eliminate options 2 and 3 because they most likely would cause local skin reactions. From the remaining options, focus on the subject, risk factors to assess. Assessing a modifiable factor before a nonmodifiable one is often the best approach. Review this disorder if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 810). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1783) The nurse conducting a weight loss program prepares to monitor a client's weight loss. What method would most accurately assess the effectiveness of weight loss? a. Daily weighing b. Serum protein level c. Calorie count d. Daily intake and output Source: Saunders 4th

ANS: A Rationale: The most accurate measurement of weight loss is daily weighing of the client at the same time, in the same clothes, and using the same scale. Options 2, 3, and 4 assist in measuring nutrition and hydration status rather than actual loss of pounds. Strategy: Note the strategic words most accurate. Also, note the subject of the question and the comparative or alike words in the question and the correct option. If you had difficulty with this question, review the methods of monitoring weight loss. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 993). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2394) A client is admitted to the hospital with suspected bladder cancer. The nurse assesses the client for which of the following as the earliest manifestation of the disease? a. Hematuria with no pain b. Painful urination and hematuria c. Pyuria and palpable abdominal mass d. Proteinuria and dysuria Source: Saunders 4th

ANS: A Rationale: The most common earliest manifestation of bladder cancer is hematuria that is not accompanied by pain. The hematuria is intermittent at first. Later signs and symptoms include hematuria with dysuria and frequency due to bladder irritation. Pyuria and proteinuria are not part of the clinical picture. A mass usually is not palpable. Strategy: Use the process of elimination. Note the strategic word earliest. Eliminate option 3 first. Because this is not an infectious process, the client should not have pyuria. Knowing that pain and discomfort are later signs will help you to eliminate options 2 and 4 next. Review the early manifestations of bladder cancer if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 869). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1457) The community health nurse visits a client who has recently retired. The client states, "Lately I'm getting forgetful about things. Do you think I'm getting Alzheimer's disease?" Which response by the nurse is therapeutic? a. "Tell me more about your forgetfulness." b. "I am so forgetful too. I have to make out lists now to go shopping." c. "Now, I'm not going to discuss this with you because I think you're just normal." d. "Oh, I'm certain it's not Alzheimer's disease because there's no family history of it." Source: Saunders 4th

ANS: A Rationale: The most effective communication technique is the one in which the nurse gives information. Regarding memory functioning, with the aging process, the normal older adult will find that the time required for memory scanning is longer for recent and remote memory recall. Dementia of the Alzheimer's type involves a disorder characterized by a syndrome of symptomatology that has a slow and insidious onset, with a generally progressive and deteriorating course. In option 4, the nurse gives false reassurance, which devalues the client's feelings and discourages the client from expressing feelings. In option 3, the nurse is rejecting the client by refusing to consider the client's ideas or demonstrating ridicule or contempt for the client's ideas or behavior. In option 2, the nurse makes a social, not a professional, comment and belittles the client's concerns, which will discourage the expression of feelings. Strategy: Use the process of elimination and knowledge of therapeutic communication techniques. Option 1 is the only option that identifies the use of a therapeutic communication technique. Review these techniques if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 329). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-34, 459). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 442-443). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2058) A nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve? a. Separate the client's jaw by pushing down on the chin. b. Bring a wisp of cotton in from the side of the eye and lightly touch the cornea. c. Place a small amount of sugar on the client's tongue and ask the client to identify the taste. d. Ask the client to rotate the head forcibly against resistance applied to the side of the client's chin. Source: Saunders 4th

ANS: A Rationale: The motor function (muscles of mastication) of cranial nerve V (trigeminal nerve) is assessed by palpating the temporal and masseter muscles as the person clenches the teeth. The muscles should feel equally strong on both sides. The nurse should try to separate the client's jaws by pushing down on the chin; normally the jaws cannot be separated. Bringing a wisp of cotton in from the side of the eye and lightly touching the cornea will assess the corneal reflex. Placing an object on the client's tongue tests sense of taste and the sensory function of the facial nerve. Checking for equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the client's chin assesses cranial nerve XI, the spinal accessory nerve. Strategy: Use the process of elimination. Recalling that cranial nerve V is the trigeminal nerve will assist in directing you to option 1. If you are unfamiliar with these assessment techniques, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2028.). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2419) A left atrial catheter is inserted into a client during cardiac surgery. The nurse is monitoring the left atrial pressure (LAP) and documents that the pressure is normal if which of the following LAP values is noted? a. 8 mm Hg b. 15 mm Hg c. 25 mm Hg d. 32 mm Hg Source: Saunders 4th

ANS: A Rationale: The normal LAP is 1 to 10 mm Hg. Because the left atrium does not generate significant pressure during atrial contraction, the atrial pressure is recorded as an average (mean) pressure, rather than as a systolic or diastolic pressure. Options 2, 3, and 4 are incorrect. Strategy: Knowledge regarding the normal LAP is required to answer this question. Noting the strategic word normal in the question will direct you to option 1. Review this content if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 267). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Communication and Documentation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2249) Bethanechol chloride (Urecholine) is prescribed for a client with postoperative bladder spasm. The nurse reviews the physician's order, knowing that the normal adult oral dosage for this medication is: a. 10 to 50 mg three to four times a day b. 50 to 100 mg three to four times a day c. 100 mg every 4 hours d. 100 mg at bedtime Source: Saunders 4th

ANS: A Rationale: The normal adult dosage of bethanechol chloride ranges from 10 to 50 mg three to four times daily. Strategy: Knowledge regarding the normal dosage of this medication is required to answer this question. Remember that the normal dose is 10 to 50 mg three to four times daily. Review the normal adult dosage for this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 135). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2472) A nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the client's fasting serum glucose level is normal if which of the following values is noted? a. 100 mg/dL b. 140 mg/dL c. 160 mg/dL d. 180 mg/dL Source: Saunders 4th

ANS: A Rationale: The normal fasting blood glucose is 70 to 110 mg/dL in the adult client. Options 2, 3, and 4 indicate elevated fasting serum glucose levels. Strategy: Focus on the subject, a normal serum glucose level. Recalling that this level is 70 to 110 mg/dL will direct you to option 1. Review this level if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 599). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1776) The nurse reviews the arterial blood gas results of a client with Guillain-Barré syndrome. The pH is 7.30 and the P<sc>co</sc>₂ is 50 mm Hg. The nurse interprets that this client is experiencing which acid-base imbalance? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis Source: Saunders 4th

ANS: A Rationale: The normal pH is 7.35 to 7.45. The normal Pco₂ is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and the Pco₂ is elevated. This is an expected finding in a client with a neuromuscular disorder such as Guillain-Barré syndrome, because the client may retain carbon dioxide resulting from ventilatory failure as paralysis ensues. Strategy: Remember that in a respiratory imbalance you will find an opposite response between the pH and the Pco₂. Also, remember that the pH is low in an acidotic condition. Recalling this information will allow you to eliminate each incorrect option. Review interpretation of blood gas results if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 283, 1009). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

59) A nurse is reviewing a client's laboratory report and notes that the serum calcium level is 4.0 mg/dL. The nurse understands that which condition most likely caused this serum calcium level? a. Prolonged bed rest b. Renal insufficiency c. Hyperparathyroidism d. Excessive ingestion of vitamin D Source: Saunders 4th

ANS: A Rationale: The normal serum calcium level is 8.6 to 10.0 mg/dL. A client with a serum calcium level of 4.0 mg/dL is experiencing hypocalcemia. The excessive ingestion of vitamin D and hyperparathyroidism are causative factors associated with hypercalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. Strategy: Note the strategic words most likely. First, you must determine that the client is experiencing hypocalcemia. This should assist in eliminating option 4. Next, you must recall the causative factors associated with hypocalcemia to direct you to option 1. If you had difficulty with the question, review the causative factors associated with hypocalcemia. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1142). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

88) An adult client who had preadmission testing before surgery had blood drawn for serum electrolyte testing. The nurse should report which of the following abnormal values to the surgeon's office preoperatively? a. Sodium, 148 mEq/L b. Chloride, 101 mEq/L c. Potassium, 3.8 mEq/L d. Bicarbonate, 26 mEq/L Source: Saunders 4th

ANS: A Rationale: The normal serum electrolyte ranges for adults are as follows: sodium, 135 to 145 mEq/L; potassium, 3.5 to 5.1 mEq/L; chloride, 98 to 107 mEq/L; and bicarbonate (venous), 22 to 29 mEq/L. The only abnormal value identified in the options is the serum sodium level. The nurse reports any abnormal preoperative laboratory value to the surgeon's office. Strategy: Use the process of elimination and knowledge of the normal serum electrolyte values to direct you to option 1. If this question was difficult, memorize these common laboratory values. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 492). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

63) A nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level? a. Alcoholism b. Renal insufficiency c. Hypoparathyroidism d. Tumor lysis syndrome Source: Saunders 4th

ANS: A Rationale: The normal serum phosphorus level is 2.7 to 4.5 mg/dL. The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Malnutrition is associated with alcoholism. Hypoparathyroidism, tumor lysis syndrome, and renal insufficiency are causative factors of hyperphosphatemia. Strategy: First you must determine that the client is experiencing hypophosphatemia. From this point, you must know the causes of hypophosphatemia. If you had difficulty with this question, review the causative factors associated with hypophosphatemia. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., p. 119). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

89) A client with a history of cardiac disease is due for a morning dose of furosemide (Lasix). Which serum potassium level should be reported to the surgeon before administering the dose of furosemide? a. 3.2 mEq/L b. 3.8 mEq/L c. 4.2 mEq/L d. 4.8 mEq/L Source: Saunders 4th

ANS: A Rationale: The normal serum potassium level in the adult is 3.5 to 5.1 mEq/L. Option 1 is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. Options 2, 3, and 4 are within the normal range. Strategy: Use the process of elimination and knowledge of the normal serum potassium level to answer this question. This will assist you in identifying the value that is not within normal range. Remember, the normal serum potassium level in the adult is 3.5 to 5.1 mEq/L. If this question was difficult, memorize this common laboratory value. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 887). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1700) The nurse is performing a physical assessment on a client during her first prenatal visit to the clinic. The nurse takes the client's temperature and notes that the temperature is 99.2° F. Based on this finding, which nursing action is appropriate? a. Document the temperature. b. Retake the temperature by the rectal route. c. Notify the physician. d. Inform the client that the temperature is elevated and antibiotics may be required. Source: Saunders 4th

ANS: A Rationale: The normal temperature during pregnancy is 36.2° to 37.6° C (98° to 99.6° F). A temperature above this level may suggest infection that might require medical management. Options 2, 3, and 4 are unnecessary. Strategy: Use the process of elimination. Recalling that the normal body temperature in the prenatal period is 98° to 99.6° F will direct you to option 1. Review the normal vital signs during pregnancy if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 132). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

86) The nurse checks the laboratory result for a serum digoxin level that was determined for a client earlier in the day and notes that the result is 2.4 ng/mL. Which of the following is the most important action on the part of the nurse? a. Notify the physician. b. Check the client's last pulse rate. c. Record the normal value on the client's flow sheet. d. Administer the next dose of the medication as scheduled. Source: Saunders 4th

ANS: A Rationale: The normal therapeutic range for digoxin is 0.5 to 2.0 ng/mL. A level of 2.4 ng/mL exceeds the therapeutic range and indicates toxicity. The most important action is to notify the physician, who may give further orders about holding further doses of digoxin. Option 3 is incorrect because the level is not normal. The next dose should not be administered because the serum digoxin level exceeds the therapeutic range. Checking the client's last pulse rate is not incorrect but may have limited value in this situation. Depending on the time that has elapsed since the last assessment, a current assessment of the client's status may be more useful. Strategy: Use the process of elimination and note the strategic words most important action. To choose correctly, you must be familiar with the therapeutic range for this medication and note that the level of 2.4 ng/mL is a toxic one. If this question was difficult, review the information on this commonly used medication and measurement of its therapeutic serum level. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 477). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1168) A nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent? a. Palpation of a thrill over the fistula b. Presence of a radial pulse in the left wrist c. Absence of a bruit on auscultation of the fistula d. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand Source: Saunders 4th

ANS: A Rationale: The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. The presence of a thrill and bruit indicate patency of the fistula. Although the presence of a radial pulse in the left wrist and capillary refill shorter than 3 seconds in the nail beds of the fingers on the left hand are normal findings, they do not assess fistula patency. Strategy: Use the process of elimination. Eliminate options 2 and 4 first because they are comparative or alike and assess for adequate circulation in the distal portion of the extremity (not the fistula). From the remaining options, focusing on the subject (patency) and noting the word absence in option 3 will assist you in eliminating this option. Review the expected findings when assessing an arteriovenous fistula if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1753). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2165) A client is receiving anticonvulsant therapy with phenytoin (Dilantin). To monitor for side effects of this medication, the nurse assesses the results of which of the following laboratory tests? a. Complete blood count (CBC) b. Serum sodium c. Serum potassium d. Blood urea nitrogen (BUN) Source: Saunders 4th

ANS: A Rationale: The nurse monitors the CBC, because hematological side effects of this therapy include aplastic anemia, agranulocytosis, leukopenia, and thrombocytopenia. Other test results that warrant monitoring include serum calcium levels and the results of urinalysis, hepatic, and thyroid function tests. Strategy: Use the process of elimination. Recalling that phenytoin has a number of hematological side effects will direct you to option 1. Review the side effects of phenytoin if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 929). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1574) A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all the doctor's fault. I have done everything that the doctor has asked me to do!" The nurse interprets the client's statement as a(n): a. Expected coping mechanism b. Need to notify the hospital lawyer c. Expression of guilt on the part of the client d. Ineffective coping mechanism Source: Saunders 4th

ANS: A Rationale: The nurse needs to be aware of the effective and ineffective coping mechanisms that can occur in a client when loss is anticipated. The expression of anger is known to be a normal response to impending loss, and the anger may be directed toward the self, God or other spiritual being, or caregivers. Notifying the hospital lawyer is inappropriate. Guilt may or may not be a component of the client's feelings and the data in the question do not indicate that guilt is present. Strategy: Focus on the data provided in the question. Note that options 1 and 4 address coping mechanisms. This provides you with the clue that one of these options may be the correct response. Additionally, knowledge of the stages of grief associated with loss will direct you to option 1. Review these stages and expected client responses if you had difficulty with this question. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 243, 437). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

146) The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which of the following items is important to check regarding the age of blood cells before the transfusion is begun? a. Expiration date b. Presence of clots c. Blood group and type d. Blood identification number Source: Saunders 4th

ANS: A Rationale: The nurse notes the expiration date on the unit of blood to ensure that the blood is fresh. Blood cells begin to deteriorate over time, so safe storage usually is limited to 35 days. Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood. The nurse also notes the blood identification (unit) number, blood group and type, and client's name. The nurse also inspects the unit of blood for clots and returns the unit to the blood bank if clots are noted. Strategy: Use the process of elimination and note that the strategic word in this question is deteriorate. To answer this question correctly, you must know which part of the pretransfusion verification procedure relates to the freshness of the unit of blood. Keeping this in mind should allow you to eliminate each of the incorrect options systematically. Review the procedure for checking blood if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 913). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1349) A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should take which of the following actions? a. Petal the cast edges with adhesive tape. b. Massage the skin at the rim of the cast. c. Use a rough file to smooth the cast edges. d. Apply lotion to the skin at the rim of the cast. Source: Saunders 4th

ANS: A Rationale: The nurse petals the edges of the cast with tape to minimize skin irritation. If a client has a cast applied and returns home, the client can be taught to do the same. Strategy: Use the process of elimination. Options 2 and 4 are comparative or alike and neither helps eliminate the cause of the irritation, so eliminate them first. Imagine the use of a "rough file"—it would create plaster chips and dust that could go underneath the cast. By the process of elimination, the nurse would petal the cast to cushion the skin from the irritating cast material. Review care of the client with a cast if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., 1198). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

153) The nurse has discontinued a unit of blood that was infusing into a client because the client experienced a transfusion reaction. After documenting the incident appropriately, the nurse sends the blood bag and tubing to which of the following departments? a. Blood Bank b. Risk Management c. Environmental Services d. Infection Control Department Source: Saunders 4th

ANS: A Rationale: The nurse returns the blood transfusion bag containing any remaining blood to the blood bank. This allows the blood bank to complete any follow-up testing procedures needed once a transfusion reaction has been documented. The other options are incorrect. Strategy: Use the process of elimination and specific knowledge related to routine transfusion-related procedures to answer the question. Recalling that blood is issued from the blood bank will help you to eliminate each of the incorrect options. Review nursing responsibilities for when a transfusion reaction occurs if you had difficulty with this question. Reference: Perry, A. & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., p. 968). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1193). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2224) A nurse is changing the tracheotomy ties on a client with a tracheotomy and is assessing the security of the ties. What method is used to ensure that the ties are not too tightly placed? a. The nurse places two fingers between the tie and the neck. b. The tracheotomy can be pulled slightly away from the neck. c. The ties leave no marks on the neck. d. The nurse uses a 12-inch tie that is tightly affixed with hook-and-loop closures. Source: Saunders 4th

ANS: A Rationale: The nurse should assess the tracheostomy ties to ensure that they are not too tight. The nurse ensures that there is room for two fingers to slide comfortably under the ties. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination, noting the subject of the question. Option 4 can be eliminated because of the word tightly. Next, eliminate options 2 and 3 because these are not appropriate methods for assessing tightness of the ties. If you had difficulty with this question, review care for a tracheostomy. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 558). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1887) A clinic nurse has provided instructions regarding dental care for toddlers to the mother of a 2-year-old child. Which statement if made by the mother indicates a need for further instruction? a. "Proper dental care is not necessary for a toddler until the permanent teeth erupt." b. "It is best to substitute sweets or snacks with food items such as cheese." c. "My child should have the first dental exam at some point after the second birthday." d. "I do not need to be concerned if the child swallows some toothpaste while brushing the teeth." Source: Saunders 4th

ANS: A Rationale: The nurse should instruct the mother that proper dental care for a toddler is important. It is important to instruct the mother to substitute sweets with healthy food items to prevent dental caries. The first dental visit should be made after the first primary tooth erupts and no later than 30 months of age. It will not hurt the child if some of the toothpaste is swallowed. Strategy: Use the process of elimination noting the strategic words need for further instruction. This phrasing indicates a negative event query and directs you to select an incorrect statement. Knowing that it is important for the mother to initiate proper dental care for the toddler will assist in directing you to option 1. If you had difficulty with this question, review dental care for a toddler. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., pp. 626-627). St. Louis: Mosby. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 403-405). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

139) The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the distal end of the IV tubing to a needleless device, the exposed tubing drops and hits the top of the medication cart. Which of the following is the appropriate action by the nurse? a. Obtain new IV tubing. b. Attach a new needleless device. c. Wipe the distal end of the tubing with Betadine. d. Scrub the needleless device with an alcohol swab. Source: Saunders 4th

ANS: A Rationale: The nurse should obtain a new IV tubing because contamination has occurred and could cause systemic infection to the client. Wiping with Betadine is insufficient and would be contraindicated anyhow because the tubing will be attached directly to an angiocatheter in the client's vein. The needleless device has not been contaminated and does not need replacement or cleaning. Strategy: Use the process of elimination and knowledge of basic infection control measures and intravenous therapy concepts to answer this question. Clearly, only one option is correct. Remember that if an item is contaminated, discard it and obtain a new sterile item. Review aseptic technique if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 250). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2251) Intravenous (IV) antithymocyte globulin (Atgam) is prescribed for a client for treatment of transplant rejection. Which of the following is the priority in planning the administration of this medication? a. Plan for a skin test dose to identify hypersensitivity. b. Assess bowel sounds. c. Premedicate the client with acetylsalicylic acid (aspirin). d. Assess the neurovascular status. Source: Saunders 4th

ANS: A Rationale: The nurse should plan for a skin test dose before IV administration of antithymocyte globulin to identify hypersensitivity to the medication. Options 2 and 4 are not specific to this medication. The client would not be premedicated with aspirin. Premedication with acetaminophen (Tylenol) or diphenhydramine (Benadryl), or both, may be prescribed to prevent reaction to the medication. Strategy: Use the ABCs—airway, breathing, and circulation. Option 1 addresses an intervention that could prevent a life-threatening situation. Review nursing implications related to this medication if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 776). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2498) A nurse enters the client's room with a pulse oximetry machine and tells the client that the physician has ordered continuous oxygen saturation readings. The client's facial expression changes to one of apprehension. The nurse can quickly and most effectively alleviate the client's anxiety by stating that pulse oximetry: a. Is painless and safe b. Causes only mild discomfort at the site c. Requires insertion of only a very small catheter d. Has an alarm to signal dangerous drops in oxygen saturation levels Source: Saunders 4th

ANS: A Rationale: The nurse should reassure the client that pulse oximetry is a safe, painless, noninvasive method of monitoring oxygen saturation levels. No discomfort is involved because the oximeter uses a sensor that is attached to a fingertip, a toe, or an earlobe. The machine does have an alarm that will sound in response to interference with monitoring or when the percent of oxygen saturation falls below a preset level. Strategy: Use the process of elimination, focusing on the subject, client anxiety. Option 1 is a true statement about pulse oximetry and is the option that will relieve anxiety in the client. Review the procedure for pulse oximetry if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 538-539). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 650-652). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1760) The nurse is preparing to perform an otoscopic examination on an adult client. The nurse does which of the following to perform this examination? a. Pulls the pinna up and back before inserting the speculum b. Pulls the earlobe down and back before inserting the speculum c. Uses the smallest speculum available to decrease the discomfort of the exam d. Tilts the clients head forward and down before inserting the speculum Source: Saunders 4th

ANS: A Rationale: The nurse tilts the client's head slightly away and holds the otoscope upside down as if it were a large pen. The pinna is pulled up and back and the nurse visualizes the external canal while slowly inserting the speculum. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination. Note that the question addresses the adult client. Use basic knowledge regarding the administration of ear medications to select the correct option. In the adult, the pinna is pulled up and back. Review the procedure for performing an otoscopic examination if you had difficulty with this question. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., pp. 349-350). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

1359) A nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be concerned especially with which of the following assessment findings? a. Temperature of 101.6° F orally b. Complaints of discomfort during repositioning c. Old bloody drainage outlined on the surgical dressing d. Discomfort during coughing and deep-breathing exercises Source: Saunders 4th

ANS: A Rationale: The nursing assessment conducted after spinal surgery is similar to that done after other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101.6° F should be reported. Strategy: Use the process of elimination. Note the strategic words concerned especially. Thus, you are looking for the option that has the greatest deviation from normal. Options 2 and 4 are expected after surgery and, although the nurse tries to minimize discomfort, the client is likely to have some discomfort, even with proper analgesic use. The words old and outlined in option 3 indicate that this is not a new occurrence. This leaves the temperature of 101.6° F, which is excessive and should be reported. Review the signs of complications following this surgical procedure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 980). St. Louis: W.B. Saunders. Reference: Monahan, F., Sands, J., Neighbors, M., et al. (2007). Phipps&#39; Medical-surgical nursing: Health and illness perspectives (8th ed., p. 1599). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2078) A client with acute pyelonephritis who was started on antibiotic therapy 24 hours earlier is still complaining of burning with urination. The nurse should check the physician's orders to see if which of the following medications is prescribed? a. Phenazopyridine (Pyridium) b. Bethanechol chloride (Urecholine) c. Oxybutinin chloride (Ditropan) d. Propantheline bromide (Pro-Banthine) Source: Saunders 4th

ANS: A Rationale: The pain experienced with pyelonephritis usually resolves as antibiotic therapy becomes effective. However, clients may be treated for urinary tract pain with phenazopyridine, which is a urinary analgesic. Bethanechol chloride is a cholinergic agent used to treat neurogenic bladder or urinary retention. Oxybutinin chloride and propantheline bromide are antispasmodics that are used to treat bladder spasm. Strategy: Use the process of elimination. Knowing that phenazopyridine is a urinary analgesic will direct you to option 1. If this question was difficult for you, review the actions of these medications. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 918). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2288) A client with trigeminal neuralgia asks the nurse what causes the painful episodes associated with the condition. The nurse's response is based on an understanding that the symptoms can be triggered by: a. Stimulation of the affected nerve by pressure and temperature b. A hypoglycemic effect on the cranial nerve c. Release of catecholamines with infection or stress d. A local reaction to nasal stuffiness Source: Saunders 4th

ANS: A Rationale: The paroxysms of pain that accompany this neuralgia are triggered by stimulation of the terminal branches of the trigeminal nerve. Symptoms can be triggered by pressure from washing the face, brushing the teeth, shaving, eating, and drinking. Symptoms also can be triggered by thermal stimuli such as a draft of cold air. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination. Recalling that trigeminal neuralgia is triggered by mechanical and thermal events will direct you to option 1. Review the causes of this disorder if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1023). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1167) The female client is admitted to the emergency department following a fall from a horse and the physician orders insertion of a Foley catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should: a. Notify the physician. b. Use a smaller size of catheter. c. Administer pain medication before inserting the catheter. d. Use extra povidone-iodine solution in cleansing the meatus. Source: Saunders 4th

ANS: A Rationale: The presence of blood at the urinary meatus may indicate urethral trauma or disruption. The nurse notifies the physician, knowing that the client should not be catheterized until the cause of the bleeding is determined by diagnostic testing. Therefore, options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination. Noting the strategic words blood at the urinary meatus will direct you to option 1. Review the assessment findings in a client with trauma to the urinary tract if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 790). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 790). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1663) The nurse manager is planning to implement a change is the nursing unit from team nursing to primary nursing. The nurse anticipates that there will be resistance to the change during the change process. The primary technique that the nurse would use in implementing this change is which of the following? a. Introduce the change gradually. b. Confront the individuals involved in the change process. c. Use coercion to implement the change. d. Manipulate the participants in the change process. Source: Saunders 4th

ANS: A Rationale: The primary technique that can used to handle resistance to change during the change process is to introduce the change gradually. Confrontation is an important strategy used to meet resistance when it occurs. Coercion is another strategy that can be used to decrease resistance to change but is not always a successful technique for managing resistance. Manipulation usually involves a covert action, such as leaving out pieces of vital information that the participants might receive negatively. It is not the best method of implementing a change. Strategy: Use the process of elimination and knowledge regarding techniques used to handle resistance during the change process to direct you to option 1. Note the strategic words primary technique in the question. If you had difficulty with this question, review the techniques that can be used to deal with resistance during the change process. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., pp. 814-816). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Leadership and Management Alternate Question Types -> Multiple Choice

1714) The nurse is preparing to administer an enema. The nurse positions the client in the: a. Left lateral position, with the right leg acutely flexed. b. Right Sims' position. c. Dorsal recumbent position. d. Right lateral position, with the left leg acutely flexed. Source: Saunders 4th

ANS: A Rationale: The sigmoid and descending colons are located on the left side. Therefore, the left lateral position uses gravity to facilitate the flow of solution into the sigmoid and descending colons. Acute flexion of the right leg allows for adequate exposure of the anus. Options 2, 3, and 4 are incorrect positions. Strategy: Knowledge of the anatomy of the rectum will assist in eliminating options 2 and 4. Attempt to visualize the remaining positions to eliminate option 3. Review the procedure for administering an enema if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1399). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1867) A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which of the following assessment findings would indicate the presence of concealed bleeding? a. Increase in fundal height b. Heavy vaginal bleeding c. Early deceleration on the fetal heart monitor d. Back pain Source: Saunders 4th

ANS: A Rationale: The signs of concealed bleeding include increase in fundal height, hard board-like abdomen, persistent abdominal pain, late decelerations in fetal heart rate, or decreasing baseline variability. Options 2, 3, and 4 are not specific signs of concealed bleeding. Strategy: Use the process of elimination. Noting the strategic words concealed bleeding will assist in eliminating option 2. Regarding the remaining options, focus on the subject of the question and knowledge regarding the signs of concealed bleeding to assist in directing you to option 1. Review these signs if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., pp. 634-635). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Maternity—Intrapartum Alternate Question Types -> Multiple Choice

1386) The client with acquired immunodeficiency syndrome has raised, dark purplish-colored lesions on the trunk of the body. The nurse anticipates that which of the following procedures will be done to confirm whether these lesions are caused by Kaposi's sarcoma? a. Skin biopsy b. Lung biopsy c. Western blot d. Enzyme-linked immunosorbent assay Source: Saunders 4th

ANS: A Rationale: The skin biopsy is the procedure of choice to diagnose Kaposi's sarcoma, which frequently complicates the clinical picture of the client with acquired immunodeficiency syndrome. Lung biopsy would confirm Pneumocystis jiroveci infection. The enzyme-linked immunosorbent assay and Western blot are tests to diagnose human immunodeficiency virus status. Strategy: Use the process of elimination. Eliminate options 3 and 4, which are used to diagnose whether the client is human immunodeficiency virus-positive. Knowledge of the meaning of Kaposi's sarcoma, or attention to the words lesions and trunk, will help you choose correctly between the remaining options. Review the diagnostic testing to confirm Kaposi's sarcoma if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 435). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 269, 284). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1599) The nurse is developing a plan of care for a preterm newborn infant and is addressing measures to provide skin care. The nurse develops measures, knowing that the preterm newborn infant's skin appears: a. Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat and open posture. b. Thin and gelatinous, with increased subcutaneous fat. c. Thin and gelatinous, with increased amounts of brown fat. d. With fine downy hair on thin epidermal and dermal layers, with increased amount of brown fat. Source: Saunders 4th

ANS: A Rationale: The skin of a newborn infant plays a significant role in thermoregulation and as a barrier against infection. The skin of a preterm newborn infant is immature in contrast to a term newborn infant. The skin of a preterm newborn is thin and gelatinous, with decreased amounts of subcutaneous fat, brown fat, and glycogen stores. In addition, preterm newborn infants lose heat because of their large body surface area in relation to their weight and because their posture is more relaxed, with less flexion. Therefore, preterm newborn infants are less able to generate heat, which places them at risk for increased heat loss and increased fluid requirements. Strategy: Use the process of elimination. Focus on the subject, preterm newborn infant. Options 2, 3, and 4 are comparative or alike and address an "increased" amount of fat. Review the characteristics of a preterm newborn infant if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., pp. 770-771). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

1441) A client with an eating disorder is planning to attend group meetings with Overeaters Anonymous, and the nurse describes this group to the client. The nurse determines that the client needs additional information if the client states which of the following about this self-help group? a. "The leader is a nurse or psychiatrist." b. "The members provide support to each other." c. "People who have a similar problem are able to help others." d. "It is designed to serve people who have a common problem." Source: Saunders 4th

ANS: A Rationale: The sponsor of a self-help group is an experienced member of the group. A nurse or psychiatrist may be asked by the group to serve as a resource but would not be the leader of the group. Options 2, 3, and 4 are characteristics of a self-help group. Strategy: Use the process of elimination and focus on the subject, self-help group. Note the strategic words needs additional information in the question. Note that options 2, 3, and 4 are comparative or alike. This should direct you easily to option 1, the correct option. Review the characteristics of a self-help group if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 321-322). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 725-726). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Teaching and Learning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1387) The client with acquired immunodeficiency syndrome has a respiratory infection from Pneumocystis jiroveci and a nursing diagnosis of Impaired gas exchange written in the plan of care. Which of the following indicates that the expected outcome of care has not yet been achieved? a. Client limits fluid intake. b. Client has clear breath sounds. c. Client expectorates secretions easily. d. Client is free of complaints of shortness of breath. Source: Saunders 4th

ANS: A Rationale: The status of the client with a diagnosis of Impaired gas exchange would be evaluated against the standard outcome criteria for this nursing diagnosis. These would include the client stating that breathing is easier and is coughing up secretions effectively, and has clear breath sounds. The client should not limit fluid intake because fluids are needed to decrease the viscosity of secretions for expectoration. Strategy: Use the process of elimination and note the strategic words expected outcome and has not yet been achieved. These words indicate a negative event query and ask you to select an option that is incorrect. This will direct you easily to option 1. Review care of the client with acquired immunodeficiency syndrome if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 443, 447-448). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

85) A client who takes theophylline for chronic obstructive pulmonary disease is seen in the urgent care center for respiratory distress. Once the client is stabilized, the nurse begins discharge teaching. The nurse would be especially vigilant to include information about complying with medication therapy if the client's baseline theophylline level was: a. 10 mcg/mL b. 12 mcg/mL c. 15 mcg/mL d. 18 mcg/mL Source: Saunders 4th

ANS: A Rationale: The therapeutic range for the serum theophylline level is 10 to 20 mcg/mL. If the level is below the therapeutic range, the client may experience frequent exacerbations of the disorder. Although all the options identify values within the therapeutic range, option 1 is the option that reflects a need for compliance with medication. Strategy: Use the process of elimination. Note the strategic words especially vigilant. Recalling the therapeutic level of theophylline will direct you to option 1. Review this therapeutic range if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 1040). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1899) A nurse in the delivery room is performing an initial assessment on a newborn infant. When examining the umbilical cord, the nurse would expect to observe which of the following? a. Two arteries b. Two veins c. One artery d. A musty odor Source: Saunders 4th

ANS: A Rationale: The umbilical cord is made up of two arteries to carry blood from the embryo to the choronic villi and one vein that returns blood to the embryo. There should be no odor noted from the umbilical cord. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination. Recalling that the umbilical cord is made up of two arteries and one vein will direct you to option 1. Note that options 1 and 3 oppose each other, suggesting that one of them may be correct. Review the anatomy of the umbilical cord if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 324). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

2309) A nurse is preparing to teach a client with a new colostomy about the procedure to perform a colostomy irrigation. Which of the following should the nurse include in the teaching plan? a. Use 500 to 1000 mL of warm tap water. b. Suspend the irrigant 36 inches above the stoma. c. Insert the irrigation cone ½ inch into the stoma. d. If cramping occurs, open the irrigation clamp further. Source: Saunders 4th

ANS: A Rationale: The usual procedure for colostomy irrigation includes using 500 to 1000 mL of warm tap water. The solution is suspended 18 inches above the stoma. The cone is inserted 2 to 4 inches into the stoma but should never be forced. If cramping occurs, the client should decrease the flow rate of the irrigant as needed by closing the irrigation clamp. Strategy: Use the process of elimination. Eliminate option 4 first, using basic principles related to the administration of an enema. Eliminate option 2 next, knowing that 36 inches is much too high, followed by option 3 because a ½-inch insertion would not be effective. If you are unfamiliar with a colostomy irrigation, review the content for this procedure. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 638). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1641) The nurse is caring for an 18-month-old child who has been vomiting. The appropriate position for this child while sleeping is : a. Side-lying position. b. Prone with the face turned to the side. c. Supine. d. Prone with the head elevated. Source: Saunders 4th

ANS: A Rationale: The vomiting child should be placed in an upright or side-lying position to prevent aspiration. Options 2, 3, and 4 will place the child at risk for aspiration if vomiting occurs. Strategy: Use the process of elimination. Eliminate options 2 and 4 first because they are comparative or alike. Additionally, these positions would place the child at risk for aspiration if vomiting occurred. Visualize the remaining two positions. Option 3 is also inappropriate and would cause aspiration. Review appropriate positioning techniques if you had difficulty with this question. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 855). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Child Health Alternate Question Types -> Multiple Choice

1048) A client has begun therapy with theophylline (Theolair). A nurse plans to teach the client to limit the intake of which of the following while taking this medication? a. Coffee, cola, and chocolate b. Oysters, lobster, and shrimp c. Melons, oranges, and pineapple d. Cottage cheese, cream cheese, and dairy creamers Source: Saunders 4th

ANS: A Rationale: Theophylline (Theolair) is a methylxanthine bronchodilator. The nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These foods include coffee, cola, and chocolate. Strategy: Use the process of elimination. Recall that theophylline is a xanthine bronchodilator and know that intake of excessive amounts of foods naturally high in xanthines should be curtailed. Review the foods naturally high in xanthines if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 647). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1126) A client who is receiving digoxin (Lanoxin) daily has a serum potassium level of 3.0 mEq/L and is complaining of anorexia. A physician orders a digoxin level to rule out digoxin toxicity. A nurse checks the results, knowing that which of the following is the therapeutic serum level (range) for digoxin? a. 0.5 to 2 ng/mL b. 1.2 to 2.8 ng/mL c. 3 to 5 ng/mL d. 3.5 to 5.5 ng/mL Source: Saunders 4th

ANS: A Rationale: Therapeutic levels for digoxin range from 0.5 to 2 ng/mL. Therefore, options 2, 3, and 4 are incorrect. Strategy: Knowledge of the therapeutic serum digoxin level will direct you to option 1. If you had difficulty with this question, learn the therapeutic level for digoxin. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 358). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1111) A client is scheduled for a dipyridamole (Persantine) thallium-201 scan. A nurse would assess to make sure that the client avoided which of the following before the procedure? a. Caffeine b. Fatty meal c. Excess sugar d. Milk products Source: Saunders 4th

ANS: A Rationale: This test is an alternative to the exercise thallium-201 scan. Dipyridamole (Persantine) dilates the coronary arteries as exercise would. Before the procedure, any form of caffeine should be withheld, as should bronchodilators such as theophylline. Theophylline may decrease the effects of dipyridamole. The client does not have to avoid the items identified in options 2, 3, and 4. Strategy: Use the process of elimination, noting the strategic word avoided. Factors that put a strain on the heart, such as nicotine and caffeine, can interfere with cardiac diagnostic test results. Look for items such as these in similarly worded questions. Review preprocedure client instructions for this test if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 702). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1974) Streptokinase (Streptase), a thrombolytic, is administered to a client in the hospital emergency department who has had a myocardial infarction. The client's spouse asks the nurse about the purpose of the medication. The nurse bases the response on which of the following information regarding this medication? a. Thrombolytics act to dissolve thrombi that have already formed. b. Thrombolytics act to prevent thrombus formation. c. Thrombolytics suppress the production of fibrin. d. Streptokinase (Streptase) has been proved to reverse all detrimental effects of heart attacks. Source: Saunders 4th

ANS: A Rationale: Thrombolytics such as streptokinase (Streptase) are most effective when started within 4 to 6 hours of symptom onset. Streptokinase (Streptase) acts to dissolve or lyse existing thrombi that are causing a blockage. Options 2, 3, and 4 are incorrect. Strategy: Note the name of the medication classification to assist in answering the question. Recalling that the term lytic indicates "breaking down" will assist in directing you to option 1. Review the action of thrombolytics if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1079). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1989) A nurse provides instructions to a client who has a prescription for ticlopidine (Ticlid). Which of the following statements if made by the client indicates a need for further teaching? a. "Food will affect the medication, so I need to take the medication on an empty stomach." b. "I should not stop the medication without talking to my doctor first." c. "Blood work will be done every 2 weeks for the first 3 months." d. "I'll take my medicine with meals." Source: Saunders 4th

ANS: A Rationale: Ticlopidine is an antiplatelet that is used for the prevention of thrombotic stroke. Ticlopidine is best tolerated when taken with meals. Blood work is monitored closely, particularly in early therapy, because the medication can cause neutropenia. A client should not stop medication without the physician's permission. Strategy: Note the strategic words indicates a need for further teaching. This phrasing indicates a negative event query and directs you to select an incorrect statement. General principles related to client education regarding medications will assist in eliminating option 2. Regarding the remaining options, recalling that the complete blood count is monitored and the medication is taken with food to minimize gastrointestinal (GI) upset will direct you to option 1. Review client teaching points related to the use of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1130). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2219) A client with viral hepatitis states, "I am so yellow." The appropriate nursing response would be to: a. Assist the client in expressing feelings. b. Perform most of the activities of daily living for the client. c. Provide information to the client only when the client requests it. d. Restrict visitors until the jaundice subsides. Source: Saunders 4th

ANS: A Rationale: To assist the client in adapting to changes in appearance, it is important for the nurse to encourage participation in self-care to foster independence and self-esteem. The client should be encouraged to ask questions in order to clarify misconceptions, learn ways to prevent the spread of hepatitis to reduce fear, and make appropriate decisions. The client should be supported to explore feelings about the disease process and altered appearance so that appropriate interventions can be planned. Restricting visitors will reinforce the client's negative self-esteem. Strategy: Note the client's statement. Remembering to focus on the client's feelings will direct you to option 1. Review therapeutic communication techniques if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1385). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 437). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1604) The home care nurse is assigned to visit a Mexican American client to perform an admission assessment. On initial meeting of the client, the nurse would: a. Greet the client with a handshake. b. Avoid touching the client. c. Avoid any affirmative nods during the conversations with the client. d. Smile and use humor throughout the entire admission assessment. Source: Saunders 4th

ANS: A Rationale: To demonstrate respect, compassion, and understanding, health care providers should greet Mexican American clients with a handshake. On establishing rapport, providers may further demonstrate approval and respect through touch, smiling, and affirmative nods of the head. Given the diversity of dialects and the nuances of language, culturally congruent use of humor is difficult to accomplish and therefore should be avoided. Strategy: Use the process of elimination and knowledge regarding the cultural communication patterns of the Mexican American. Remember that at the initial meeting, a health care provider should greet a Mexican American client with a handshake. Review the characteristics of this cultural group if you had difficulty with this question. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., p. 68). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

916) The nurse is teaching a client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the client to do? a. Increase fluid intake. b. Place heat on the abdomen. c. Perform the irrigation in the evening. d. Reduce the amount of irrigation solution. Source: Saunders 4th

ANS: A Rationale: To enhance effectiveness of the irrigation and fecal returns, the client is instructed to increase fluid intake and to take other measures to prevent constipation. Options 2, 3, and 4 will not enhance the effectiveness of this procedure. Strategy: Focus on the subject of the question, the measure that will enhance the effectiveness of the irrigation. This focus will assist in eliminating options 2, 3, and 4. If you are unfamiliar with this procedure, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 836). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1324). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1385) The nurse provides home care instructions to a client with systemic lupus erythematous and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instructions? a. "I should take hot baths because they are relaxing." b. "I should sit whenever possible to conserve my energy." c. "I should avoid long periods of rest because it causes joint stiffness." d. "I should do some exercises, such as walking, when I am not fatigued." Source: Saunders 4th

ANS: A Rationale: To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness. Strategy: Note the strategic words need for further instructions and focus on the subject, fatigue. By the process of elimination, you should be directed easily to option 1 as the action that would exacerbate fatigue. If you had difficulty with this question, review measures to prevent fatigue in a client with systemic lupus erythematosus. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2357). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1743). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1216) A nurse provides instructions to a client who will be taking cyclosporine (Sandimmune) oral solution. The nurse tells the client to: a. Mix the concentrate with chocolate milk. b. Mix the concentrate with grapefruit juice. c. Avoid diluting the concentrate for administration. d. Dilute the concentrate in a Styrofoam cup before administration. Source: Saunders 4th

ANS: A Rationale: To improve palatability, the client should be taught to mix the concentrated medication solution with chocolate milk or orange juice just before administration. Grapefruit juice is avoided because it can raise cyclosporine levels. The client is instructed to dilute the concentrate in a glass (not Styrofoam) to ensure ingestion of the complete dose. Strategy: Knowledge regarding the administration of the oral concentrate of cyclosporine is required to answer this question. Eliminate option 2 using general medication administration guidelines. From the remaining options, remember that the oral solution should be mixed with chocolate milk or orange juice just before administration. Review the client instructions regarding administering this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 302). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2365) A client with human immunodeficiency virus (HIV) infection is taking indinavir (Crixivan). The nurse plans to tell the client which of the following when providing instructions about the use of this medication? a. Take the medication with water on an empty stomach. b. Take the medication with a high-fat snack. c. Take the medication with the large meal of the day. d. Store the medication in the refrigerator. Source: Saunders 4th

ANS: A Rationale: To maximize absorption, the medication should be administered with water on an empty stomach. The medication can be taken 1 hour before a meal or 2 hours after a meal, or it can be administered with skim milk, coffee, tea, or a low-fat meal. It is not administered with a large meal. The medication should be stored at room temperature and protected from moisture, because moisture can degrade the medication. Strategy: Use the process of elimination. Options 2 and 3 can be eliminated first because they are comparative or alike. Regarding the remaining options, recall that medication absorption is maximized if the medication is taken on an empty stomach. Review administration of this medication if you are unfamiliar with this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 614). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

2526) A clinic nurse conducting a health screening clinic is performing hearing assessments on clients who attend the clinic. Senior nursing students are assisting the nurse with the assessments. The clinic nurse instructs the students to perform a voice test and teaches the students to: a. Stand 1 to 2 feet away from the client and ask the client to block one external ear canal. b. Quietly whisper a statement and test both ears at the same time. c. Whisper a statement with the examiner's back to the client. d. Whisper a statement while the client blocks both ears. Source: Saunders 4th

ANS: A Rationale: To perform a voice test, the examiner stands 1 to 2 feet away from the client and asks the client to block one external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is tested separately. The client is not asked to block both ears, and the examiner should face the client during the test. Strategy: Focus on the subject, a voice test. Eliminate options 3 and 4 because they are not measures that would effectively assess hearing. From the remaining options, knowing that one ear is tested at a time will assist in eliminating option 2. Review the procedure for this test if you had difficulty with this question. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., p. 352). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

2638) A client with a psychotic disorder is receiving haloperidol (Haldol) 1 mg PO three times daily. The nurse assesses for which toxic effect of this medication? a. Excessive salivation b. Blurred vision c. Hypotension d. Nausea Source: Saunders 4th

ANS: A Rationale: Toxic effects include marked drowsiness and lethargy, excessive salivation, a fixed stare, akathisia, acute dystonia, and tardive dyskinesia. Hypotension, nausea, and blurred vision are occasional side effects. Strategy: Use the process of elimination, noting the subject, toxic effect. Note the strategic word excessive in the correct option. If you had difficulty with this question, review the toxic effects of this medication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 569). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1799) The nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn infant. The nurse would tell the client that: a. Hands should be washed thoroughly before holding the infant. b. The newborn infant will not be allowed in the mother's room at all. c. There is no danger of the newborn contracting the disease. d. Visitors are not allowed to hold the baby. Source: Saunders 4th

ANS: A Rationale: Transmission of infectious diseases can occur through contaminated items such as hands and bed linens of clients with endometritis. An important method of preventing infection is to break the chain of infection. Hand washing is one of the most effective methods of preventing the transmission of infectious diseases. The newborn infant is allowed in the mother's room and visitors are allowed to hold the newborn infant as long as hand washing and other protective measures are instituted. Strategy: Use the process of elimination. Eliminate options 2, 3, and 4 because of the close-ended words at all, no, and not. Review content related to the transmission of infection if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., pp. 523-524). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

1542) The client seen in the health care clinic has tested positive for gonorrhea. The nurse anticipates that which medication will be prescribed for the client based on this finding? a. Ceftriaxone (Rocephin) b. Penicillin G benzathine (Bicillin L-A) c. Acyclovir (Zovirax) d. Azithromycin (Zithromax) Source: Saunders 4th

ANS: A Rationale: Treatment for gonorrhea consists of antibiotic therapy with ceftriaxone, plus oral doxycycline, for 7 days; therefore, option 1 is correct. Option 2 is the treatment for syphilis, option 3 is the treatment for genital herpes simplex virus, and option 4 is the treatment for chlamydia. Strategy: The subject of the question is the specific subject content that the question is asking about—in this case, the specific medication required to treat the disease. Review content regarding gonorrhea and the medication used to treat this sexually transmitted disease if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 684). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1720) A depressed client is found unconscious on the floor in the dayroom. The nurse finds several empty bottles of a prescribed tricyclic antidepressant lying near the client. The immediate action of the nurse is to: a. Call a "code," because this incident presents a medical emergency. b. Induce vomiting and notify the physician for further orders. c. Call the Poison Control Center. d. Try to figure out the number of pills taken. Source: Saunders 4th

ANS: A Rationale: Tricyclic antidepressants can be fatal when taken as an overdose, regardless of the amount ingested. Serious life-threatening symptoms can develop after an overdose. Immediate emergency medical attention and cardiac monitoring is necessary with an overdose of tricyclic antidepressants. Strategy: Use the process of elimination. Note the strategic word immediate in the question. Options 2, 3, and 4 would delay measures for providing immediate treatment. Additionally, vomiting is not induced in a client who is unconscious. Review care of the client with an overdose if you had difficulty with this question. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 346-348). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2674) A client has a PRN order for trimethobenzamide (Tigan). The nurse assesses the client for which of the following signs or symptoms to determine whether the client needs a dose of this medication? a. Nausea and vomiting b. Abdominal pain c. Heartburn d. Constipation Source: Saunders 4th

ANS: A Rationale: Trimethobenzamide is an antiemetic agent used for relief of nausea and vomiting. Each of the other options is incorrect. The medication is not used to treat heartburn, constipation, or abdominal pain. Strategy: Recalling that this medication is an antiemetic will direct you to option 1. Review the action of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1179). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1997) A nurse has developed a teaching plan for an older client with hypertension regarding the administration of prescribed medications. The initial nursing action should be to: a. Assess the client's readiness to learn. b. Find out if anyone lives with the client. c. Set priorities for the client. d. Use only one teaching method to prevent confusion. Source: Saunders 4th

ANS: A Rationale: Until the client is ready to learn, teaching sessions will be ineffective. Teaching should be in short sessions, early in the day, when the client is well rested. It is important to include the client in the development of the teaching plan, and set priorities with the client. Varied teaching methods are best, such as verbal instruction with visual aids and the provision of written material for later reference. Although it may be important to determine if anyone lives with the client, this is not the initial nursing action. Strategy: Note the strategic words initial nursing action. Recall that the client's readiness to learn is the initial step in the teaching-learning process. If you had difficulty with this question, review the teaching-learning process. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1498-1499). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 465-468). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2171) A client has an order for valproic acid (Depakene) 250 mg once daily. To maximize the client's safety, the nurse should plan to schedule the medication: a. At bedtime b. Before breakfast c. After breakfast d. With lunch Source: Saunders 4th

ANS: A Rationale: Valproic acid is an anticonvulsant that causes central nervous system (CNS) depression. For this reason, the side effects of the medication include sedation, dizziness, ataxia, and confusion. When the client is taking this medication as a single daily dose, administering it at bedtime negates the risk of injury from sedation and enhances client safety. The medication should be taken at the same time each day. Strategy: Use the process of elimination. Note the strategic words maximize the client's safety. Recalling that this medication is an anticonvulsant with CNS depressant properties will lead you to think of sedation as a side effect. Therefore, select option 1. This would allow the sedative effects of the medication to occur at a time when the client is sleeping, with less likelihood that the client will become injured as a result of medication effects. Review the side effects of this medication if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 348). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 226). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1087) A client has frequent bursts of ventricular tachycardia on the cardiac monitor. Why should the nurse be most concerned about with this dysrhythmia? a. It can develop into ventricular fibrillation at any time. b. It is almost impossible to convert to a normal rhythm. c. It is uncomfortable for the client, giving a sense of impending doom. d. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia. Source: Saunders 4th

ANS: A Rationale: Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Clients frequently experience a feeling of impending doom. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (client awake), or defibrillation (loss of consciousness). Ventricular tachycardia can deteriorate into ventricular fibrillation at any time. Strategy: Use the process of elimination and note the strategic words most concerned. Option 2 is incorrect and is eliminated first. From the remaining options, focusing on the strategic words will direct you to option 1 because this option identifies the life-threatening condition. Review the concerns associated with ventricular tachycardia if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 729, 731). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1250) The clinic nurse is preparing to test the visual acuity of a client using a Snellen chart. Which of the following identifies the accurate procedure for this visual acuity test? a. The right eye is tested, followed by the left eye, and then both eyes are tested. b. Both eyes are assessed together, followed by the assessment of the right and then the left eyes. c. The client is asked to stand at a distance of 40 feet from the chart and is asked to read the largest line on the chart. d. The client is asked to stand at a distance of 40 feet from the chart and to read the line that can be read 200 feet away by an individual with unimpaired vision. Source: Saunders 4th

ANS: A Rationale: Visual acuity is assessed in one eye at a time, and then in both eyes together, with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together. Visual acuity is measured with or without corrective lenses and the client stands at a distance of 20 feet from the chart. Strategy: Use the process of elimination. Remember that normal visual acuity as measured by a Snellen chart is 20/20 vision. This should assist in eliminating options 3 and 4. From the remaining options, remember that it is best to test each eye separately and then test both eyes together. This method assesses visual acuity most accurately. Review the procedure for testing visual acuity with a Snellen chart if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1078). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

2495) A physician orders warfarin (Coumadin) for a client. The home care nurse visits the client at home and teaches the client about the medication and its administration. Which statement by the client indicates a need for further teaching? a. "The urine normally changes to orange in color." b. "This medication will require frequent blood work to monitor its effects." c. "This medicine will still be working 4 to 5 days after it is discontinued." d. "I cannot take aspirin or any aspirin-containing medications while I'm on this medication." Source: Saunders 4th

ANS: A Rationale: Warfarin is an anticoagulant. Bleeding is a concern while the client is taking this medication. Orange-colored urine indicates blood in the urine from an overdose of the medication. Bleeding also may be identified by urine that turns red, smoky, or black. The prothrombin time is determined to monitor the clotting mechanism. The half-life of the medication is 2 days, the peak effect is between 1 and 3 days, and the anticoagulation effect extends 4 to 5 days after discontinuation. Aspirin is an antiplatelet agent and would increase the risk of bleeding. Strategy: Note the strategic words need for further teaching. These words indicate a negative event query and the need to select an incorrect statement. Recalling that bleeding is a concern with this medication will direct you to option 1. Review the client teaching points related to this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1222). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2487) A nursing student prepares a plan of care for a client with a diagnosis of acute cellulitis of the lower leg. On reviewing the plan of care, the nursing instructor determines that the student understands the treatment measures if the care plan includes: a. Warm compresses to the affected area b. Cold compresses to the affected area c. Heat lamp treatments four times daily d. Alternating hot to cold compresses every 2 hours Source: Saunders 4th

ANS: A Rationale: Warm compresses may be used to decrease the discomfort, erythema, and edema associated with cellulitis. After tissue and blood are obtained for culture, antibiotics will be initiated. The nurse should provide supportive care as prescribed to manage associated fatigue, fever, chills, headache, and myalgia. Heat lamps can cause more disruption to already inflamed tissue. Use of alternating cold and hot compresses is not the best measure. Strategy: Use knowledge regarding the pathophysiology of cellulitis and recall that this condition is a skin infection into deeper dermis and subcutaneous fat. This will assist in directing you to option 1. If you had difficulty with this question, review the treatment associated with cellulitis. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1418-1422). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

933) The client with a colostomy has an order for irrigation of the colostomy. The nurse uses which solution for the irrigation? a. Tap water b. Sterile water c. Sterile distilled water d. Sterile lactated Ringer's Source: Saunders 4th

ANS: A Rationale: Warm tap water or saline solution is used to irrigate a colostomy. If the tap water is not suitable for drinking, then bottled water should be used. Options 2, 3, and 4 are incorrect solutions. Strategy: Use the process of elimination. Recalling that the irrigation involves the gastrointestinal tract and that the gastrointestinal tract is not a sterile organ will direct you to option 1. Review the procedure for performing colostomy irrigation if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1092). St. Louis: Mosby. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills and techniques (6th ed., p. 1162). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1644) A postpartum client is attempting to breast-feed for the first time. The nurse notes that the client has inverted nipples. What nursing action can the nurse take to assist the client in breast-feeding the newborn infant? a. Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn infant to grasp. b. Have the mother grasp her nipples between the thumb and forefinger and tug firmly to get the nipple to protrude. c. Massage the breast, applying gentle pressure on the areola. d. Take a cool shower, allowing the water to run over the breasts, because this will encourage the nipples to protrude. Source: Saunders 4th

ANS: A Rationale: Wearing breast shells and using a breast pump before each feeding will make it easier for the newborn infant to grasp the nipple. True inverted nipples will retract if the areola is pressed between the thumb and forefinger, making option 2 incorrect. Option 3 is an appropriate instruction for the mother suffering from engorgement. Option 4 will only make the mother cold, and it has no effect on inverted nipples. Strategy: Use the process of elimination. Focus on the strategic words inverted nipples to assist in directing you to option 1. Review the concepts related to breast-feeding if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 544). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

2557) The emergency department nurse is monitoring a client who received treatment for a severe asthma attack. The nurse determines that the client's respiratory status had worsened if which of the following is noted on assessment? a. Diminished breath sounds b. Wheezing during inhalation c. Wheezing during exhalation d. Wheezing throughout the lung fields Source: Saunders 4th

ANS: A Rationale: Wheezing is not a reliable manifestation to determine the severity of an asthma attack. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Wheezing usually occurs first on exhalation. As the asthma attack progresses, the client may wheeze during both inspiration and expiration. Diminished breath sounds may be an indication of severe obstruction and possibly respiratory failure. Strategy: Focus on the subject of the question, worsening of the client's respiratory status. Use the ABCs—airway, breathing, and circulation—to assist in directing you to option 1. Additionally, note the similarity between options 2, 3, and 4. Remember that diminished breath sounds in a client indicate obstruction and possibly respiratory failure. Review assessment of a client with an asthma attack if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 587, 589). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2101) A nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which of the following as a complication of hypothermia blanket use? a. Skin breakdown b. Frostbite c. Arterial insufficiency d. Venous insufficiency Source: Saunders 4th

ANS: A Rationale: When a hypothermia blanket is used, the skin is inspected frequently for pressure points, which over time could lead to skin breakdown. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination. Options 3 and 4 can be eliminated first because they are other health problems. The temperature of the blanket is not cold enough to produce frostbite. This leaves skin breakdown as the correct option. Review the complications associated with the use of a hypothermia blanket if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills and techniques (6th ed., pp. 1308-1309, 1323-1324). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

116) A client with total parenteral nutrition (TPN) infusing has disconnected the tubing from the central line catheter. A nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position? a. On the left side, with the head lower than the feet b. On the left side, with the head higher than the feet c. On the right side, with the head lower than the feet d. On the right side, with the head higher than the feet Source: Saunders 4th

ANS: A Rationale: When air embolism is suspected, the client should be placed in a left side-lying position. The head should be lower than the feet. This position is used to try to minimize the effect of the air traveling as a bolus to the lungs by trapping it in the right side of the heart. Options 2, 3, and 4 are incorrect positions if an air embolism is suspected. Strategy: Use the process of elimination and recall that the goal is to trap air in the right side of the heart. This will direct you to option 1. If you had difficulty with this question, review the immediate interventions when air embolism is suspected. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., p. 1050). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1257) The client is receiving an eye drop and an eye ointment to the right eye. The nurse should: a. Administer the eye drop first, followed by the eye ointment. b. Administer the eye ointment first, followed by the eye drop. c. Administer the eye drop, wait 10 minutes, and administer the eye ointment. d. Administer the eye ointment, wait 10 minutes, and administer the eye drop. Source: Saunders 4th

ANS: A Rationale: When an eye drop and an eye ointment are scheduled to be administered at the same time, the eye drop is administered first. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination. Recalling the guidelines for administering eye medications will direct you to option 1. Review these guidelines if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1091). Philadelphia: W.B. Saunders. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 34-35). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 859). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1548) The emergency room nurse is caring for a child suspected of epiglottitis and has ensured that the child has a patent airway. The next priority in the care of this child would be to: a. Prepare the child for a chest x-ray. b. Assist the physician with intubation. c. Prepare the child for tracheotomy. d. Prepare to administer epinephrine. Source: Saunders 4th

ANS: A Rationale: When epiglottitis is suspected, the priorities are to maintain a patent airway and obtain a chest x-ray to confirm the diagnosis. If epiglottitis is present, the child is taken promptly to the operating room for tracheal intubation or immediate surgical airway. Epinephrine is not used in the treatment of epiglottitis. Strategy: Use the process of elimination. Note the strategic word suspected in the question. This should assist in directing you to option 1. Confirmation of the diagnosis is necessary to determine the appropriate management. If you had difficulty with this question, review the treatment of this life-threatening condition. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 801). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

2016) A home care nurse is providing instructions to a client regarding the use of crutches. The client asks the nurse to demonstrate the method for going down the stairs with the crutches. The nurse would accurately demonstrate this technique by moving the: a. Crutches and the affected leg down, followed by the unaffected leg b. Crutches and the unaffected leg down, followed by the affected leg c. Unaffected leg down first, followed by the crutches and the affected leg d. Affected leg down first, followed by the crutches and the unaffected leg Source: Saunders 4th

ANS: A Rationale: When going down the stairs with crutches, the client should be instructed to move the crutches and the affected leg, then move the unaffected leg down. To go up the stairs, the client should first move up the unaffected leg and then move up the affected leg and crutches. Strategy: When answering this question, attempt to visualize the process of going down and up the stairs with the use of crutches. If you can remember "good up-bad down" and that the crutches accompany the affected leg, you will easily be able to answer this question. In going down the stairs, the bad or affected leg moves first. In going up the stairs, the good leg or unaffected leg moves first. Review crutch-walking techniques if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2502). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1204). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2399) A nurse is assessing a client in the postpartum period and suspects the presence of uterine atony. The initial nursing action should be to: a. Massage the uterus until firm. b. Take the client's blood pressure. c. Assess the amount of drainage on the peripad. d. Contact the physician. Source: Saunders 4th

ANS: A Rationale: When uterine atony occurs, the initial nursing action would be to massage the uterus until it is firm. If this does not assist in controlling blood loss, then the nurse would contact the physician. Additionally, once bleeding is under control, the nurse would monitor the vital signs and estimate the amount of blood loss. Strategy: Use the process of elimination. Note the strategic word initial in the question. Also, focusing on the word atony will direct you to option 1. If you had difficulty with this question, review nursing interventions related to uterine atony. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., pp. 734-735). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

2661) A client has been given lansoprazole (Prevacid) for the chronic management of Zollinger-Ellison syndrome. The nurse instructs the client to take which of the following products for pain while taking this medication? a. Acetaminophen (Tylenol) b. Ibuprofen (Motrin) c. Naprosyn (Aleve) d. Acetylsalicylic acid (aspirin) Source: Saunders 4th

ANS: A Rationale: Zollinger-Ellison syndrome is a hypersecretory condition of the stomach, associated with increased risk of problems from irritation of the stomach lining. Aspirin and nonsteroidal anti-inflammatory medications (NSAIDs), such as naprosyn and ibuprofen, should be avoided as potential irritants. The client should take acetaminophen for pain relief. Strategy: Use the process of elimination. In general, test question options that are comparative or alike are not likely to be correct. With this in mind, eliminate options 2 and 3 first because they both are NSAIDs. From the remaining options, choose acetaminophen over aspirin because is less irritating to the stomach. Review the client teaching points related to this medication if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 902). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

107) A postoperative client has been placed on a clear liquid diet. Select the items that the client is allowed to consume on this diet. Select all that apply. a. Broth b. Coffee c. Gelatin d. Pudding e. Vegetable juice f. Pureed vegetables Source: Saunders 4th

ANS: A ANS: B ANS: C Rationale: A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include items such as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, Popsicles, and regular or decaffeinated coffee or tea. The incorrect food items are items that are allowed on a full liquid diet. Strategy: Focus on the subject, a clear liquid diet. Recalling that a clear liquid diet consists of foods that are relatively transparent to light and are clear will assist in answering the question. Review foods allowed on a clear and full liquid diet if you had difficulty with this question. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed., pp. 415-417). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1298). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Multiple

1377) In monitoring a client's response to disease-modifying antirheumatic drugs (DMARDs), which assessment findings would the nurse consider acceptable responses? Select all that apply. a. Symptom control during periods of emotional stress b. Normal white blood cell, platelet, and neutrophil counts c. Radiological findings that show nonprogression of joint degeneration d. An increased range of motion in the affected joints 3 months into therapy e. Inflammation and irritation at the injection site 3 days after the injection is given f. A low-grade temperature on rising in the morning that remains throughout the day Source: Saunders 4th

ANS: A ANS: B ANS: C ANS: D Rationale: Because emotional stress frequently exacerbates the symptoms of rheumatoid arthritis, the absence of symptoms is a positive finding. DMARDs are given to slow progression of joint degeneration. In addition, the improvement in the range of motion after 3 months of therapy with normal blood work is a positive finding. Temperature elevation and inflammation and irritation at the medication injection site could indicate signs of infection. Strategy: Use the process of elimination and focus on the subject, acceptable responses to therapy. Recalling that signs of an infection can indicate an unexpected finding will assist in eliminating options 5 and 6. Review the expected effects of this medication if you had difficulty with this question. Reference: Lilly, L., Harrington, S., & Snider, J. (2005). Pharmacology and the nursing process (4th ed., pp. 822-826). St Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Multiple

984) A histamine (H₂)-receptor antagonist will be prescribed for a client. The nurse understands that which medications are H₂-receptor antagonists? Select all that apply. a. Nizatidine (Axid) b. Ranitidine (Zantac) c. Famotidine (Pepcid) d. Cimetidine (Tagamet) e. Esomeprazole (Nexium) f. Lansoprazole (Prevacid) Source: Saunders 4th

ANS: A ANS: B ANS: C ANS: D Rationale: H₂-receptor antagonists suppress secretion of gastric acid, alleviate symptoms of heartburn, and assist in preventing complications of peptic ulcer disease. These medications also suppress gastric acid secretions and are used in active ulcer disease, erosive esophagitis, and pathological hypersecretory conditions. The other medications listed are proton pump inhibitors. Strategy: Focus on the subject, H₂-receptor antagonists. Recalling that these medication names end with -dine will assist in answering this question. Also, recall that proton pump inhibitors medication names end with -zole. Review the H₂-receptor antagonists if you had difficulty with this question. Reference: Mosby. (2005). Mosby's 2005 drug consult for nurses (pp. 931, 935, 937, 939). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Multiple

1121) A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the physician and prepares to implement which priority interventions? Select all that apply. a. Administering oxygen b. Inserting a Foley catheter c. Administering furosemide (Lasix) d. Administering morphine sulfate intravenously e. Transporting the client to the coronary care unit f. Placing the client in a low-Fowler's side-lying position Source: Saunders 4th

ANS: A ANS: B ANS: C ANS: D Rationale: Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful. Strategy: Note the strategic words priority interventions and focus on the client's diagnosis. Recall the pathophysiology associated with pulmonary edema and use the ABCs—airway, breathing, and circulation—to help determine priority interventions. Review priority interventions for the client with pulmonary edema if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 760-761). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Multiple

1268) The nurse is preparing to administer eye drops. Select the interventions that the nurse takes to administer the drops. Select all that apply. a. Wash hands. b. Put gloves on. c. Place the drop in the conjunctival sac. d. Pull the lower lid down against the cheek bone. e. Instruct the client to squeeze the eyes shut after instilling the eye drop. f. Instruct the client to tilt the head forward, open the eyes, and look down. Source: Saunders 4th

ANS: A ANS: B ANS: C ANS: D Rationale: To administer eye medications, the nurse would wash hands and put gloves on. The client is instructed to tilt the head backward, open the eyes, and look up. The nurse pulls the lower lid down against the cheekbone and holds the bottle like a pencil with the tip downward. Holding the bottle, the nurse gently rests the wrist of the hand on the client's cheek and squeezes the bottle gently to allow the drop to fall into the conjunctival sac. The client is instructed to close the eyes gently and not to squeeze the eyes shut to prevent the loss of medication. Strategy: Use guidelines related to standard precautions and visualize this procedure. This will assist in determining the correct interventions. If you are unfamiliar with the procedure for administering eye medications, review these guidelines. Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed., pp. 73-75). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Multiple

1066) Rifabutin (Mycobutin) is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. For which of the following side effects of the medication should the nurse monitor? Select all that apply. a. Signs of hepatitis b. Flu-like syndrome c. Low neutrophil count d. Vitamin B₆ deficiency e. Ocular pain or blurred vision f. Tingling and numbness of the fingers Source: Saunders 4th

ANS: A ANS: B ANS: C ANS: E Rationale: Rifabutin (Mycobutin) may be prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. It inhibits mycobacterial DNA-dependent RNA polymerase and suppresses protein synthesis. Side effects include rash, gastrointestinal disturbances, neutropenia (low neutrophil count), red-orange-colored body secretions, uveitis (blurred vision and eye pain), myositis, arthralgia, hepatitis, chest pain with dyspnea, and flu-like syndrome. Vitamin B₆ deficiency and numbness and tingling in the extremities are associated with the use of isoniazid (INH). Ethambutol (Myambutol) also causes peripheral neuritis. Strategy: Focus on the name of the medication to assist in answering the question and use the process of elimination. Recalling that vitamin B₆ deficiency and numbness and tingling in the extremities is associated with the use of isoniazid will assist in answering. Review the side effects associated with rifabutin if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 1022). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Multiple

1376) A nurse is caring for a hospitalized client who is taking allopurinol (Zyloprim) for a history of gout. Which of the following discharge instructions is appropriate for a client who is to continue taking this medication? Select all that apply. a. Avoid ultraviolet light and sunshine. b. Avoid foods such as organ meats, salmon, and scallops. c. It is acceptable to have a single glass of wine in the evening to relax. d. Maintain a fluid intake of approximately 2000 to 3000 mL a day. e. Take the medication on an empty stomach to prevent drug interactions. f. Take large doses of vitamin C because it is a water-soluble vitamin that will be excreted in large amounts because of the increased fluid intake. Source: Saunders 4th

ANS: A ANS: B ANS: D Rationale: Allopurinol is an antigout medication that decreases uric acid production. Foods high in purine need to be avoided. Kidney stones can occur as a complication of gout and can be decreased by increasing fluids and limiting calcium intake. Gastrointestinal upset is common with this medication and can be minimized when taken with food. Unprotected exposure to ultraviolet light and sunlight can result in visual changes and should be avoided. Alcohol and vitamin C can increase uric acid levels and need to be avoided. Strategy: Focus on the classification and use of this medication. Also, using general medication guidelines will direct you to the correct options. If you had difficulty with this question, review the dietary concerns and recommendations associated with administration of this medication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 35). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Multiple

1535) A hospitalized client is started on phenelzine sulfate (Nardil) for the treatment of depression. The nurse instructs the client to avoid consuming which foods while taking this medication? Select all that apply. a. Figs b. Yogurt c. Crackers d. Aged cheese e. Tossed salad f. Oatmeal cookies Source: Saunders 4th

ANS: A ANS: B ANS: D Rationale: Phenelzine sulfate (Nardil) is a monoamine oxidase inhibitor. The client should avoid taking in foods that are high in tyramine. Use of these foods could trigger a potentially fatal hypertensive crisis. Foods to avoid include yogurt, aged cheeses, smoked or processed meats, red wines, and fruits such as avocados, raisins, or figs. Strategy: Recall that phenelzine sulfate is a monoamine oxidase inhibitor and that foods high in tyramine needed to be avoided. Next, from the food items listed in the question, identify the food that contains tyramine. Review the food items to avoid with monoamine oxidase inhibitors if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 472). St. Louis: Mosby. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., p. 176). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Multiple

1402) Select the interventions that would apply in the care of a client at high risk for an allergic response to a latex allergy. Select all that apply. a. Use nonlatex gloves. b. Use medications from glass ampules. c. Place the client in a private room only. d. Do not puncture rubber stoppers with needles. e. Keep a latex-safe supply cart available in the client's area. f. Use a blood pressure cuff from an electronic device only to measure the blood pressure. Source: Saunders 4th

ANS: A ANS: B ANS: D ANS: E Rationale: If a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonlatex gloves and latex-safe supplies, and would keep a latex-safe supply cart available in the client's area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs, medications with a rubber stopper that requires puncture with a needle, latex-safe syringes, and latex-safe intravenous tubing. It is not necessary to place the client in a private room. Strategy: Focus on the subject, that the client is at high risk for an allergic response to latex. Recalling that items that contain rubber are likely to contain latex will direct you to the correct interventions. Also, noting the close-ended word only in options 3 and 6 will assist in eliminating these options. Review care of the client with a latex allergy if you had difficulty with this question. Reference: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed., p. 1221). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Multiple

1699) A community health nurse is preparing a poster for an educational session for a group of women and will be discussing the risk factors associated with breast cancer. Select the risk factors for breast cancer that the nurse will list on the poster. Select all that apply. a. Family history of breast cancer b. Early menarche c. Early menopause d. Previous cancer of the breast, uterus, or ovaries e. Multiparity f. High-dose radiation exposure to chest Source: Saunders 4th

ANS: A ANS: B ANS: D ANS: F Rationale: Risk factors for breast cancer include family history of breast cancer, age older than 40 years, early menarche, late menopause, or both, previous cancer of the breast, uterus, or ovaries, nulliparity or first child born after age 30 years, and high-dose radiation exposure to chest. Strategy: Focus on the subject, the risk factors associated with breast cancer. Thinking about the physiology associated with the reproductive system and the most common causes of cancer will assist in answering the question. Review these risk factors if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1795-1796). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Multiple

1438) The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which of the following are therapeutic communication techniques? Select all that apply. a. Restating b. Listening c. Asking the client, "Why?" d. Maintaining neutral responses e. Giving advice or approval or disapproval f. Providing acknowledgment and feedback Source: Saunders 4th

ANS: A ANS: B ANS: D ANS: F Rationale: Some of the therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Strategy: Focus on the subject, therapeutic communication techniques. This will assist you in selecting the correct answers. Review therapeutic and nontherapeutic techniques if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 124-125). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Teaching and Learning Content Area -> Mental Health Alternate Question Types -> Multiple Multiple

96) Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Select the laboratory test results that are abnormal. a. Calcium, 7.0 mg/dL b. Magnesium, 1.0 mg/dL c. Phosphorus, 3.6 mg/dL d. Neutrophils, 1000/mm³ e. Serum creatinine, 1.0 mg/dL f. White blood cells, 3000/mm³ Source: Saunders 4th

ANS: A ANS: B ANS: D ANS: F Rationale: The normal values include the following: white blood cells, 4,500 to 11,000/mm³; neutrophils, 56%, or 1,800 to 7,800/mm³; phosphorus, 2.7 to 4.5 mg/dL; magnesium, 1.6 to 2.6 mg/dL; calcium, 8.6 to 10.0 mg/dL; and serum creatinine, 0.6 to 1.3 mg/dL. Strategy: Note the word abnormal in the question. Knowledge of the normal laboratory values for these studies will assist in answering this question. Review these normal values if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 700, 1034, 1163, 1263-1264). St. Louis: Mosby. Reference: Pagana, K., & Pagana, T. (2006). Mosby's manual of diagnostic and laboratory tests (3rd ed., p. 537). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Multiple

1730) A nurse would include which interventions in the plan of care for a client with hypothyroidism (myxedema)? Select all that apply. a. Instruct the client about thyroid replacement therapy. b. Encourage the client to consume fluids and high-fiber foods in the diet. c. Provide a cool environment for the client. d. Instruct the client to consume a high-fat diet. e. Instruct the client to contact the physician if episodes of chest pain occur. f. Inform the client that iodine preparations will be prescribed to treat the disorder. Source: Saunders 4th

ANS: A ANS: B ANS: E Rationale: The clinical manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormone. Interventions are aimed at replacement of the hormones and providing measures to support the signs and symptoms related to a decreased metabolism. The nurse encourages the client to consume a well-balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to prevent constipation. The client often has cold intolerance and requires a warm environment. The client would notify the physician if chest pain occurs because it could be an indication of overreplacement of thyroid hormone. Iodine preparations are used to treat hyperthyroidism. These medications decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone. Strategy: Focus on the client's diagnosis, hypothyroidism. Recalling that in this disorder the client has a decreased metabolic rate will assist in determining the appropriate interventions. Review interventions for the client with hypothyroidism and hyperthyroidism if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1491-1492). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Multiple

955) A nurse is reviewing the orders of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which of the following interventions would the nurse expect to be prescribed for the client? Select all that apply. a. Administer antacids as prescribed. b. Give small, frequent high-calorie feedings. c. Encourage coughing and deep breathing. d. Administer anticholinergics as prescribed. e. Give Meperidine (Demerol) as prescribed for pain. f. Maintain the client in a supine and flat position. Source: Saunders 4th

ANS: A ANS: C ANS: D ANS: E Rationale: The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medication such as meperidine will be prescribed. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and also may help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress gastrointestinal secretions. Strategy: Focus on the pathophysiology associated with pancreatitis and note the strategic word acute. This will assist in answering the question. Review treatment measures for acute pancreatitis if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1138). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Multiple

1474) Select all nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. Select all that apply. a. Communicate expected behaviors to the client. b. Ensure that the client knows that he or she is not in charge of the nursing unit. c. Assist the client in testing out alternative behaviors for obtaining needs. d. Follow through about the consequences of behavior in a nonpunitive manner. e. Enforce rules and inform the client that he or she will not be allowed to attend therapy groups. f. Be clear with the client regarding the consequences of exceeding limits that have been set regarding behavior. Source: Saunders 4th

ANS: A ANS: C ANS: D ANS: F Rationale: Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding limits set; following through with the consequences in a nonpunitive manner; and assisting the client in identifying personal strengths and testing out alternative behaviors for obtaining needs. Enforcing rules and informing the client that he or she will not be allowed to attend therapy groups is a violation of a client's rights. Ensuring that the client knows that he or she is not in charge of the nursing unit is inappropriate; power struggles need to be avoided. Strategy: Focus on the subject, manipulative behavior. Recalling clients' rights and that power struggles need to be avoided will assist in selecting the correct interventions. Review care of the client with manipulative behavior if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 287). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 292-293). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Multiple

1486) Select the appropriate interventions for caring for the client in alcohol withdrawal. Select all that apply. a. Monitor vital signs. b. Maintain an NPO status. c. Provide a safe environment. d. Address hallucinations therapeutically. e. Provide stimulation in the environment. f. Provide reality orientation as appropriate. Source: Saunders 4th

ANS: A ANS: C ANS: D ANS: F Rationale: When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming himself or herself or others. The nurse would provide a low stimulating environment to maintain the client in as calm a state as possible. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained. Strategy: Use therapeutic communication techniques to assist in selecting the correct interventions. Also, recalling the characteristics associated with alcohol withdrawal will assist in answering correctly. Review these interventions if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 319-320). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Multiple

1717) A nurse is preparing a list of home care instructions regarding stoma and laryngectomy care to a client who had a laryngectomy. Select all instructions that would be included in the list. a. Avoid swimming and use care when showering. b. Keep the humidity in the home low. c. Avoid exposure to people with infections. d. Restrict fluid intake. e. Obtain a Medic-Alert bracelet. f. Prevent debris from entering the stoma. Source: Saunders 4th

ANS: A ANS: C ANS: E ANS: F Rationale: The nurse would teach the client how to care for the stoma, depending on the type of laryngectomy performed. Most interventions focus on protection of the stoma and the prevention of infection. Interventions include to avoid swimming, use care when showering, avoid exposure to people with infections, prevent debris from entering the stoma, and obtain a Medic-Alert bracelet. Additional interventions include wearing a stoma guard or high-collared clothing to cover the stoma, increasing the humidity in the home, and increasing fluid intake to 3000 mL/day to keep the secretions thin. Strategy: Recalling that most interventions focus on protection of the stoma and the prevention of infection will assist in identifying the client instructions for home care. Review these instructions if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 575, 580-581). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Multiple

64) The nurse provides instructions to a client with a low magnesium level about the foods that are high in magnesium and tells the client to consume which foods? Select all that apply. a. Peas b. Bacon c. Oranges d. Cauliflower e. Peanut butter f. Canned white tuna Source: Saunders 4th

ANS: A ANS: D ANS: E ANS: F Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. Common food sources of magnesium include avocado, canned white tuna, cauliflower, green leafy vegetables such as spinach and broccoli, milk, oatmeal, peanut butter, peas, pork, beef, chicken, potatoes, raisins, and yogurt. Bacon is high in sodium. Oranges are high in potassium. Strategy: Focus on the subject, foods high in magnesium. Read each food item and recall that bacon is high in sodium and oranges are high in potassium. Review the food items high in magnesium if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 205, 207). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Multiple

1608) A nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Select all interventions that are appropriate. a. Set the room temperature at a comfortable level. b. Provide seating for the client so that the client faces a strong light. c. Ensure that the distance between the client and nurse is at least 6 feet. d. Place a chair for the client across from the nurse's desk. e. Remove distracting objects from the interviewing area. f. Ensure comfortable seating at eye level for the client and nurse Source: Saunders 4th

ANS: A ANS: E ANS: F Rationale: When preparing the physical environment for an interview, the nurse would set the room temperature at a comfortable level. The nurse would provide sufficient lighting for the client and nurse to see each other. The nurse would avoid having the client face a strong light because the client would have to squint into the full light. Distracting objects and equipment should be removed from the interview area. The nurse should arrange seating so that both the nurse and client are seated comfortably at eye level, and the nurse avoids facing the client across a desk or table because this creates a barrier. The distance between the nurse and the client should be set by the nurse at 4 to 5 feet. If the nurse places the client any closer, the nurse will be invading the client&#39;s private space and may create anxiety in the client. If the nurse places the client farther away, the nurse may be seen as distant and aloof by the client. Strategy: Read each intervention carefully. Use the guidelines for preparing the physical environment for conducting an interview to select the appropriate interventions. Review these guidelines if you had difficulty with this question. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., pp. 53, 165). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Multiple

1448) Select the characteristics of the termination stage of group development. Select all that apply. a. The group evaluates the experience. b. The real work of the group is accomplished. c. Group interaction involves superficial conversation. d. Group members become acquainted with each other. e. Some structuring of group norms, roles, and responsibilities take place. f. The group explores members' feelings about the group and the impending separation. Source: Saunders 4th

ANS: A ANS: F Rationale: The stages of group development include the initial stage, the working stage, and the termination stage. During the initial stage, the group members become acquainted with each other and some structuring of group norms, roles, and responsibilities take place. During the initial stage, group interaction involves superficial conversation. During the working stage, the real work of the group is accomplished. During the termination stage. the group evaluates the experience and explores members' feelings about the group and the impending separation. Strategy: Focus on the subject, the termination stage. Reading each item presented and recalling the stages of group development will assist in answering this question. Review these stages if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 444). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Multiple

1882) A nurse in the pediatric unit is admitting a 2½-year-old child. The nurse plans care knowing that the child is in which stage of Erikson's psychosocial stages of development? a. Trust versus Mistrust b. Autonomy versus Shame and Doubt c. Initiative versus Guilt d. Industry versus Inferiority Source: Saunders 4th

ANS: B Rationale: A 2½-year-old child, a toddler, is in the Autonomy versus Shame and Doubt stage. In this stage, the toddler develops a sense of control over the self and bodily functions. Trust versus Mistrust characterizes the stage of infancy. Initiative versus Guilt characterizes the preschool age. Industry versus Inferiority characterizes the school-aged child. Strategy: Knowledge regarding the psychosocial development according to Erikson's stages of development is required to answer this question. Focus on the age of the child in the question to assist in directing you to the correct option. If you are unfamiliar with Erikson's stages of psychosocial development, review this content. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., p. 610). St. Louis: Mosby. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 57). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Planning Content Area -> Child Health Alternate Question Types -> Multiple Choice

1812) A nurse is preparing a plan of care for a client receiving enteral feedings via a gastrostomy tube (G-tube). The nurse plans to include which of the following interventions in the plan of care? a. To provide oral fluids three times per day b. To check around the stoma site for skin irritation c. To medicate with antidiarrheal medications every day d. To use sterile technique when administering the tube feedings Source: Saunders 4th

ANS: B Rationale: A G-tube is a tube inserted directly into the stomach for the purpose of providing direct enteral nutrition. Generally, G-tubes are well tolerated and beneficial to clients on long-term enteral nutrition. Aspiration of stomach contents into the lungs can occur and the client's head of the bed must be kept elevated. Due to the surgical incision, occasionally gastric contents leak out onto the client's skin. Gastric contents are highly acidic and can cause skin irritation. The skin irritation may lead to infection. The nurse must monitor the insertion site for skin irritation. Oral fluids are not generally a component of the plan of care because the client with a G-tube normally does not have the capability of swallowing. Although diarrhea may be a complication of the feedings, antidiarrheals are not administered daily. Aseptic, not sterile, technique is necessary when administering feedings. Strategy: Focus on the subject of the question, a G-tube, and use the process of elimination. Eliminate option 1 because of the word oral in this option. Eliminate option 3 because of the words every day. Regarding the remaining options, recalling that sterile technique is not required with administering feedings will direct you to option 2. Review care of the client with a G-tube if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 704). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1310). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2418) A nurse in the emergency department is caring for a client who was in a motor vehicle accident and is experiencing hypovolemic shock. A pneumatic antishock garment (PASG) is applied for treatment until the client can be transferred to the intensive care unit (ICU). While awaiting client transfer to the ICU, the emergency department nurse performs which critical assessment? a. Monitoring hemoglobin and hematocrit levels b. Monitoring vascular status of the lower extremities c. Assessing radial pulses d. Assessing vascular status of the upper extremities Source: Saunders 4th

ANS: B Rationale: A PASG may be useful in the treatment of hypovolemic shock associated with traumatic injury to provide circulatory assistance. The device is used only as a temporary measure until definitive treatment is given because it can compromise blood flow to the lower half of the body. The critical nursing assessment includes monitoring the vascular status of the lower extremities. Although options 1, 3, and 4 may be components of the nursing assessment, these actions are not part of the critical assessment required with use of a PASG. Strategy: Use the process of elimination. Visualizing the use of this device will assist in directing you to option 2. Review care of a client who has a PASG applied if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 311). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 611). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2612) A client who is due for a dose of warfarin (Coumadin) has a prothrombin time (PT) of 28 seconds. After analyzing this test result, the nurse: a. Gives double the dose b. Calls the physician c. Administers the next dose d. Gives half of the next dose Source: Saunders 4th

ANS: B Rationale: A PT of 28 seconds represents an elevated value. The therapeutic PT for a client receiving warfarin is 1.5 times the normal PT (9.5 to 11.5 seconds). The nurse should withhold the next dose and notify the physician. A medication dose should not be changed without a specific order (options 1 and 4). Strategy: Use the process of elimination. Recalling the normal PT level and that the therapeutic level for a client receiving warfarin is 1.5 times the normal will direct you to the correct option. Review these important medication concepts and associated nursing interventions if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 666). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 906). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2413) A nurse is assigned to provide care for a client with a Sengstaken-Blakemore tube. The nurse suspects which of the following diagnoses for this client? a. Gastritis b. Esophageal varices c. Bowel obstruction d. Small bowel tumor Source: Saunders 4th

ANS: B Rationale: A Sengstaken-Blakemore tube is inserted in a client with a diagnosis of cirrhosis with ruptured esophageal varices. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The gastric balloon holds the tube in the correct position and prevents migration of the esophageal balloon, which could harm the client. Strategy: Use the process of elimination. Recalling that this tube is used for management of clients with ruptured esophageal varices will direct you to option 2. Review the purpose and use of this tube if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1379). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2457) A nurse prepares to assist the physician to examine the client's skin with a Wood's lamp. Which of the following would be included in the preprocedure plan of care? a. Obtain an informed consent. b. Tell the client that the procedure is painless. c. Shave the skin site. d. Prepare a local anesthetic. Source: Saunders 4th

ANS: B Rationale: A Wood's light examination is a painless procedure. Examination of the skin under a Wood's lamp is always carried out in a darkened room. This is a noninvasive examination; therefore, an informed consent is not required. A hand-held long-wavelength ultraviolet light source or Wood's lamp is used. The skin does not need to be shaved, nor is a local anesthetic necessary. Areas of blue green or red fluorescence are associated with certain skin infections. Strategy: Use the process of elimination. Recalling that this is a noninvasive procedure will assist in eliminating options 1, 3, and 4. Review this procedure if you had difficulty answering this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1573). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

2149) A nurse is planning to teach proper use of a thoracolumbosacral orthosis (TLSO) to a client who has had spinal fusion with instrumentation. The nurse should plan to include which of the following teaching points in the discussion with the client? a. Areas of skin redness at the edges of the brace indicate a good, snug fit. b. The device is applied before getting out of bed in the morning. c. The brace should be applied directly next to the skin. d. The self-adhering closures should be fairly loose to avoid constriction. Source: Saunders 4th

ANS: B Rationale: A back brace or TLSO is individually fitted to the client. The brace should not irritate the skin with proper fitting. The brace is applied in the morning before getting out of bed. The closures should be secure, but not overly loose or tight. A layer of clothing is worn between the orthosis and the skin. Strategy: Use the process of elimination. Skin irritation (option 1) is not likely to be a good sign and should be eliminated first. Loose connections also are not likely to indicate proper fit, so option 4 should be eliminated next. From the remaining options, eliminate option 3 because the orthosis is likely to become soiled with perspiration or cause skin irritation if worn directly next to the skin. Review client teaching points related to the use of a back brace if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2149-2150). Philadelphia: W.B. Saunders. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills and techniques (6th ed., pp. 335-336). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2136) A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. The nurse provides the client with the greatest reassurance by stating that: a. Canes prevent falls; they do not cause them. b. The cane has a flared tip with concentric rings to give stability. c. The physical therapist will determine if the cane is inadequate. d. The cane would help to break a fall, even if the client does slip. Source: Saunders 4th

ANS: B Rationale: A cane should have a slightly flared tip with flexible concentric rings. This tip acts as a shock absorber and provides optimal stability. Options 1, 3, and 4 are unrelated to the subject of providing reassurance regarding safety. Strategy: Use the process of elimination. Focus on the subject, providing reassurance. Reading each option carefully and focusing on this subject will direct you to option 2. Review the points regarding canes that will reassure safety if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1204). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 948-949). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2024) A clinic nurse is reviewing the record of a client with a diagnosis of a cataract. Which clinical manifestation is associated with this disorder? a. Loss of central vision b. Opacity of the lens c. Eye pain d. Inability to identify the color red on an eye examination Source: Saunders 4th

ANS: B Rationale: A cataract is an opacity of the crystalline lens of the eye. The classic symptom of a cataract is painless, progressive loss of peripheral vision in one or both eyes. Many affected persons complain of glare from bright lights. Color blindness (option 4) is not an associated symptom. Strategy: Use the process of elimination. Recalling that a cataract is opacity of the lens of the eye will direct you to option 2. Review the manifestations of cataracts if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1949). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1093). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1273) The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the intracranial pressure is rising? a. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure b. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure c. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure d. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure Source: Saunders 4th

ANS: B Rationale: A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise. Strategy: This question looks complex but can be answered logically. If you remember that the temperature rises, then you are able to eliminate options 3 and 4. If you know that the client becomes bradycardic, or know that the blood pressure rises, you are able to select the correct option. Review the signs of increased intracranial pressure if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2201). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1595) Prostaglandin E₁ is prescribed for a child with transposition of the great arteries. The mother of the child is a registered nurse and asks the nurse why the child needs the medication. The most appropriate response would be to tell the mother that the medication: a. Prevents blue (Tet) spells. b. Maintains adequate cardiac output. c. Maintains an adequate hormonal level. d. Maintains the position of the great arteries. Source: Saunders 4th

ANS: B Rationale: A child with transposition of the great arteries may receive prostaglandin E₁ temporarily to increase blood mixing if systemic and pulmonary mixing are inadequate to maintain adequate cardiac output. Options 1, 3, and 4 are incorrect. In addition, tet spells occur in tetralogy of Fallot. Strategy: Use the ABCs—airway, breathing, and circulation—to answer the question. Option 2 addresses circulation. Review the purpose of the medication in this condition if you had difficulty with this question. Reference: Wong, D., Perry, S., Hockenberry, M., et al. (2006). Maternal child nursing care (3rd ed., p. 1568). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Child Health Alternate Question Types -> Multiple Choice

1354) A nurse is caring for a client being treated for fat embolus after multiple fractures. Which of the following data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? a. Minimal dyspnea b. Clear chest radiograph c. Oxygen saturation of 85% d. Arterial oxygen level of 78 mm Hg Source: Saunders 4th

ANS: B Rationale: A clear chest radiograph is a good indicator that a fat embolus is resolving. When fat embolism occurs, the chest radiograph has a "snowstorm" appearance. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be higher than 95%. Strategy: Use the process of elimination. Note the strategic words most favorable indication. Knowing that the arterial oxygen and oxygen saturation levels are below normal helps eliminate options 3 and 4. Dyspnea, even at a minimal level, is not normal, so eliminate option 1. Review the expected outcomes in a client being treated for fat embolism if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1673). St. Louis: Mosby. Reference: Monahan, F., Sands, J., Neighbors, M., et al. (2007). Phipps' medical-surgical nursing: Health and illness perspectives (8th ed., p. 1538). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1428) Following a group therapy session, a client approaches a nurse and verbalizes a need for seclusion because of uncontrollable feelings. The appropriate nursing action would be to: a. Call the client's family. b. Obtain an informed consent. c. Place the client in seclusion immediately. d. Inform the client that seclusion has not been prescribed. Source: Saunders 4th

ANS: B Rationale: A client may request to be secluded or restrained. Unless an emergency situation exists in which an immediate risk to the client or others can be documented, restraining a client against his or her will should not occur. Therefore, an informed consent is necessary. Additionally, the use of seclusion and restraint is permitted only on the written order of a physician, which must be reviewed and renewed every 24 hours and that also must specify the type of restraint to be used. Strategy: Use the process of elimination and knowledge regarding the subject of clients rights to direct you to option 2. The nurse has no reason to call the family at this time; therefore, eliminate option 1. Knowing that a physician's written order is necessary will assist you in eliminating option 3. Option 4 is not the best option because this information, if given to a client experiencing uncontrollable feelings, may cause escalation of the feelings. Review the nursing implications regarding seclusion and restraint if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 53-54). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 645, 749). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 124). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1832) A nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which of the following assessment findings should the nurse expect to note? a. Bradycardia b. Changes in mental status c. Bilateral crackles in the lungs d. Elevated blood pressure Source: Saunders 4th

ANS: B Rationale: A client with dehydration is likely to be lethargic or complaining of a headache. The client would also exhibit weight loss, sunken eyes, poor skin turgor, flat neck and peripheral veins, tachycardia, and a low blood pressure. The client who is dehydrated would not have bilateral crackles in the lungs because these are signs of fluid overload and is an unrelated finding of dehydration. Strategy: Use the process of elimination. Think about the pathophysiology that occurs in a dehydrated state when hypovolemia is present. This will direct you to option 2. If you had difficulty with this question, review the assessment findings in a client with dehydration. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 216-217). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2596) The client arrives in the emergency department after sustaining an injury to the arm from a fall. An x-ray film is obtained because a fractured radius is suspected. The nurse is able to see the x-ray film as it is being reviewed and notes the presence of a complete fracture across the shaft of the bone, with splintering of the bone into fragments. The nurse concludes that the client has sustained which of the following types of fracture? a. Greenstick fracture b. Comminuted fracture c. Compound fracture d. Simple fracture Source: Saunders 4th

ANS: B Rationale: A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone—one side of the bone is fractured, and the other side is bent. A compound fracture, also called an open or complex fracture, is one in which the skin or mucous membrane has been broken and the resulting wound extends to the depth of the fractured bone. A simple fracture is a fracture of the bone across its entire shaft with some possible displacement, but without breaking the skin. Strategy: Use the process of elimination. Recalling that a comminuted fracture describes a fracture in which the bone is broken into minute (small) pieces will direct you to option 2. Review the various types of fractures if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1190). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1501) Which behavior observed by the nurse indicates a suspicion that a depressed female adolescent client may be suicidal? a. The client runs out of the therapy group, swearing at the group leader, and runs to her room. b. The client gives away a prized CD and a cherished autographed picture of the performer. c. The client becomes angry while speaking on the telephone and slams down the receiver. d. The client gets angry with her roommate when the roommate borrows the client's clothes without asking. Source: Saunders 4th

ANS: B Rationale: A depressed suicidal client often gives away that which is of value as a way of saying good-bye and wanting to be remembered. Options 1, 3, and 4 deal with anger and acting-out behaviors that are often typical of any adolescent. Strategy: Use the process of elimination. Eliminate options 1, 3, and 4 because they are comparative or alike. Option 2 is different and is an action that could indicate that the client may be "saying good-bye." Review behaviors that indicate a suicide intent if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 367). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 477). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2041) A mental health nurse notes that a client with schizophrenia is exhibiting an immobile facial expression and a blank look. Which of the following should the nurse document in the client's record? a. The client has an inappropriate affect. b. The client has a flat affect. c. The client is exhibiting bizarre behavior. d. The client's emotional responses exhibit a blunted affect. Source: Saunders 4th

ANS: B Rationale: A flat affect is manifested as an immobile facial expression or blank look. An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client's inner emotions. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. Strategy: Use the process of elimination. Focus on the words immobile facial expression and a blank look. Visualizing this form of expression will assist in directing you to option 2. If you had difficulty with this question, review the behaviors exhibited in a client with schizophrenia. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 395). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2243) A client is taking brompheniramine maleate (Dimaphen). The nurse assesses for which of the following as a side effect of this medication? a. Excitability b. Drowsiness c. Excess salivation d. Diarrhea Source: Saunders 4th

ANS: B Rationale: A frequent side effect of brompheniramine maleate, an antihistamine, is drowsiness or sedation. Others include blurred vision, hypertension (and sometimes hypotension), dry mouth, constipation, urinary retention, and sweating. Strategy: Use the process of elimination. Recalling that antihistamines typically cause drowsiness will direct you to option 2. Review the side effects of antihistamines if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 113). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1598) The nurse is preparing to care for a newborn infant who will be returning from surgery with a colostomy that was created for imperforate anus. When the newborn infant returns from surgery, the nurse assesses the stoma and notes that it is red and edematous. Which of the following is the appropriate nursing intervention? a. Call the physician. b. Document the findings. c. Apply ice immediately. d. Elevate the buttocks. Source: Saunders 4th

ANS: B Rationale: A fresh colostomy stoma will be red and edematous, but this will decrease with time. The colostomy site will then be pink without evidence of abnormal drainage, swelling, or skin breakdown. The nurse would document these findings because this is a normal expectation. Options 1, 3, and 4 are inappropriate interventions. Strategy: Use the process of elimination. Note the strategic words returns from surgery. You would expect redness and edema at this time. Review postoperative colostomy assessment if you had difficulty with this question. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 783). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Child Health Alternate Question Types -> Multiple Choice

1236) The client arrives in the emergency room following an automobile accident. The client's forehead hit the steering wheel and a hyphema is diagnosed. The nurse places the client in which position? a. Flat on bed rest b. Semi-Fowler's on bed rest c. Lateral on the affected side d. Lateral on the unaffected side Source: Saunders 4th

ANS: B Rationale: A hyphema is the presence of blood in the anterior chamber. Hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as a penetrating injury from a BB or pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea. Strategy: Use the process of elimination to answer this question. Remember, placing the client flat will produce an increase in pressure at the injured site. Also, note that option 2 is the option that identifies a position different from the other options. Review care of the client with hyphema if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1105). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

2006) A nurse is caring for a client with acute otitis media. In order to reduce pressure and allow fluid to drain, the nurse anticipates that which of the following would most likely be recommended to the client? a. The administration of diphenhydramine (Benadryl) capsules b. A myringotomy c. Strict bedrest d. A mastoidectomy Source: Saunders 4th

ANS: B Rationale: A myringotomy is a surgical procedure that will allow fluid to drain from the middle ear. Benadryl is an antihistamine with antiemetic properties. Strict bedrest is not necessary, although activity may be restricted. Additionally, bedrest would not assist in reducing pressure or allowing fluid to drain. In some cases, the mastoid bone is removed or partially removed for chronic otitis media. Strategy: Note the word acute in the question. Focus on the subject of the question, reducing pressure and allowing fluid to drain. Options 1, 3, and 4 will not assist in reducing pressure or allowing fluid to drain. If you had difficulty with this question, review the treatment measures for acute otitis media. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1984, 1987). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1128-1129). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

1631) The mother of a child who has had a myringotomy, with insertion of tympanostomy tubes, calls the nurse and tells the nurse that the tubes have fallen out. Which of the following is the appropriate response to the mother? a. "Replace the tubes immediately so that the opening does not close." b. "This is not an emergency. I will speak to the physician and call you right back." c. "Place the tubes in hydrogen peroxide for 1 hour before replacing them in the child's ears." d. "This is an emergency and requires immediate intervention. Bring the child to the emergency room." Source: Saunders 4th

ANS: B Rationale: A myringotomy is the insertion of tympanoplasty tubes into the middle ear to equalize pressure and keep the ear aerated. The size and appearance of the tympanostomy tubes should be described to the parents after surgery. They should be reassured that if the tubes fall out, it is not an emergency, but that the physician should be notified. Strategy: Use the process of elimination. Option 4 should be eliminated first because this will cause concern in the parent. Next, eliminate options 1 and 3 because they are comparative or alike and relate to replacing the tubes. Review parent instructions following this procedure if you had difficulty with this question. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 799). St. Louis: Mosby. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1199). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Child Health Alternate Question Types -> Multiple Choice

1023) A client diagnosed with pleurisy is being started on medication therapy with a nonsteroidal anti-inflammatory drug. A nurse teaches the client that this medication: a. Will alleviate surface pain b. Will relieve pain and enhance coughing and deep breathing c. Is a mild opioid analgesic that will allow the client to breathe deeply d. Is a glucocorticoid that will decrease the inflammatory response at the site Source: Saunders 4th

ANS: B Rationale: A nonsteroidal anti-inflammatory drug, which has an analgesic effect, will relieve pain and allow the client to cough and deep-breathe more effectively. Options 1, 3, and 4 are incorrect. Strategy: Focus on the name of the medication. Recalling the action and purpose of a nonsteroidal anti-inflammatory drug will direct you to option 2. Review this classification of medications if you had difficulty with this question. Reference: Kee, J. Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 407). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 630). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1043) A nurse is reading a Mantoux skin test for a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. The nurse interprets that the result is: a. Positive b. Negative c. Uncertain d. Borderline Source: Saunders 4th

ANS: B Rationale: A positive reading has an induration measuring 10 mm or larger and is considered abnormal. A small area of ecchymosis is insignificant and probably is related to injection technique. Options 1, 3, and 4 are incorrect interpretations. Strategy: Recall that induration is necessary for a positive response. Because the client in this question has no induration, the result can only be negative. Review Mantoux skin test results if you had difficulty with this question. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., p. 773). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1337) A client with possible rib fracture has never had a chest radiograph. The nurse would plan to tell the client which of the following items about the procedure? a. The x-rays stimulate a small amount of pain. b. Removal of jewelry and any other metal objects is necessary. c. The client will be asked to breathe in and out as the x-ray is taken. d. The x-ray technologist will stand next to the client during the procedure. Source: Saunders 4th

ANS: B Rationale: A radiograph is a photographic image of part of the body on a special film, which is used to diagnose a wide variety of conditions. Radiography itself is painless; any discomfort would arise from repositioning a painful part for filming. The nurse may want to premedicate a client who is at risk for pain. Any radiopaque objects such as jewelry or other metal must be removed. The client is asked to breathe in deeply and then hold the breath while the chest radiograph is taken. To minimize risk of radiation exposure, the x-ray technologist stands in a separate area protected by a lead wall. The client also wears a lead shield over his or her gonads. Strategy: Use the process of elimination. Recalling that radiopaque objects need to be removed will direct you to option 2. Review client preparation for chest radiography if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1645). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2234) A nurse is reviewing the results of serum laboratory studies for a client with acquired immunodeficiency syndrome (AIDS) who is receiving didanosine (Videx). The nurse interprets that the client may have the medication discontinued by the physician if which of the following laboratory test results is significantly elevated? a. Serum cholesterol level b. Serum amylase level c. Blood glucose concentration d. Serum protein concentration Source: Saunders 4th

ANS: B Rationale: A serum amylase level that is increased 1.5 to 2 times normal may signify pancreatitis from the medication, which can be potentially fatal. The medication may have to be discontinued. The medication also is hepatotoxic, which can result in liver failure. Options 1, 3, and 4 are not associated with this medication. Strategy: Recalling that didanosine is hepatotoxic and affects the pancreas will direct you to option 2. Review the adverse effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 354). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1495) The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis could be caused by: a. Witnessing a murder b. The death of a loved one c. A fire that destroyed the client's home d. A recent rape episode experienced by the client Source: Saunders 4th

ANS: B Rationale: A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss of or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis is not a part of everyday life; it is unplanned or accidental. Strategy: Use the process of elimination. Eliminate options 1, 3, and 4 because they are comparative types of occurrences. If you had difficulty with this question, review the types of crisis. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 509-510). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 458-459). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1343) A nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which of the following findings? a. Inflammation b. Serous drainage c. Pain at a pin site d. Purulent drainage Source: Saunders 4th

ANS: B Rationale: A small amount of serous oozing is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported to the physician. Strategy: Use the process of elimination. Note the strategic words least concerned. Options 1 and 4 seem to indicate an infectious problem and are eliminated first. From the remaining options, note that the complaint of pain is at "a pin site." Also, because serous drainage is an expected finding, select option 2. Review expected findings in the client with skeletal traction if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1101). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1954) A clinic nurse has obtained a throat culture specimen from a client who is suspected of having a throat infection. The nurse calls the laboratory to have the specimen picked up and is told that the laboratory is short-staffed and that the laboratory assistant will pick up the specimen in 2 hours. Which of the following is the appropriate nursing action? a. Tell the client to return in 1 hour for a repeat throat culture. b. Refrigerate the specimen. c. Tell the laboratory that someone needs to pick up the specimen immediately. d. Contact the physician who ordered the specimen. Source: Saunders 4th

ANS: B Rationale: A specimen for a culture should not be allowed to sit unrefrigerated for longer than 1 hour because the unrefrigerated temperature can affect the results of the testing. It is not appropriate to request that the client return for a repeat culture, and it is inappropriate to demand that the laboratory pick up the specimen immediately. There is no reason to contact the physician. Strategy: Use the process of elimination and knowledge regarding collecting specimens for culture. Noting the word culture and recalling the purpose of this test will direct you to option 2. Review the principles related to the collection of specimens for culture if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 1045). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2063) A nurse is teaching a client with a right arm cast how to prevent stiff or frozen shoulder. The nurse should instruct the client to: a. Keep a sling on the arm at all times. b. Lift the shoulder of the casted arm over the head periodically throughout the day. c. Avoid range-of-motion exercises to the affected arm. d. Wear the sling at nighttime. Source: Saunders 4th

ANS: B Rationale: A stiff or frozen shoulder can develop as a complication of a cast on an upper extremity. The client should be instructed to lift the shoulder of the casted arm over the head periodically throughout the day to prevent this complication. The client should not keep a sling on the arm at all times or wear the sling at nighttime. Range-of-motion exercises to the casted extremity would assist in preventing this complication. Strategy: Focus on the subject of the question as it relates to preventing stiff or frozen shoulder. Use the process of elimination and eliminate options 1 and 4 first because they are comparative or alike. Regarding the remaining options, knowledge that certain range-of-motion exercises will assist in preventing this occurrence will direct you to option 2. If you had difficulty with this question or are unfamiliar with the measures to prevent frozen shoulder, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 571). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2014) A physician orders a Salem sump tube for gastrointestinal intubation. The nurse prepares for the insertion and obtains which of the following items from the supply room? a. A tube with a single lumen that connects to suction b. A tube with a large lumen and an air vent c. A Sengstaken-Blakemore tube d. A Dobbhoff weighted tube Source: Saunders 4th

ANS: B Rationale: A tube with a large lumen and an air vent is a Salem sump tube. A tube with a single lumen is called a Levin's tube. A Sengstaken-Blakemore tube is used to control bleeding in the esophagus. A Dobbhoff weighted tube is used for feedings. Strategy: Knowledge regarding the various types of gastrointestinal tubes is needed to answer this question. Recalling that the Salem sump tube has an air vent will direct you to option 2. Review the content for these various tubes if you are unfamiliar with them. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 745). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2400) A nurse is collecting subjective and objective data from a client and notes that the client is taking abacavir (Ziagen). The nurse determines that this medication has been prescribed to treat: a. Otitis media b. Human immunodeficiency virus (HIV) infection c. Heart failure d. Urinary tract infection Source: Saunders 4th

ANS: B Rationale: Abacavir is used to treat HIV infection, in combination with other agents. It is not used to treat the conditions noted in options 1, 3, and 4. Strategy: Note the name of the medication, abacavir. Note the relationship between the medication name and option 2. Review this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2628) A decision has just been made to give tissue plasminogen activator (t-PA) (Activase) to a client. The nurse should obtain which of the following supplies for standard use as part of safe nursing care related to this medication? a. Flashlight b. Occult blood test strips c. Pulse oximeter d. Suction equipment Source: Saunders 4th

ANS: B Rationale: Activase is a thrombolytic medication that dissolves thrombi or emboli. Bleeding is a frequent and potentially severe adverse effect of therapy. The nurse assesses for signs of bleeding in clients receiving this therapy using occult blood test strips to test urine, stool, or nasogastric drainage. Pulse oximeter and suction equipment would be needed if the client had evidence of oxygenation or respiratory problems. A flashlight is used for pupil assessment as part of the neurological examination in the client who is neurologically impaired. Strategy: Use the process of elimination. Recall that bleeding is a side effect of this therapy, and determine the equipment that would be used to detect subtle signs of bleeding. If this question was difficult, review the nursing interventions related to thrombolytic therapy. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007. Philadelphia: W.B. Saunders, p. 44. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., pp. 607-608). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 31). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2286) A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should: a. Advise the client that rehabilitation progresses more quickly with cooperation. b. Acknowledge the client's anger and continue to encourage participation in care. c. Leave the client alone until ready to participate. d. Ask the family to deliver the care. Source: Saunders 4th

ANS: B Rationale: Adjusting to paralysis is difficult both physically and psychosocially for the client and family. The nurse recognizes that the client goes through the grieving process in adjusting to the loss and may move back and forth among the stages of grief. The nurse acknowledges the client's feelings while continuing to meet the client's physical needs and encouraging independence. The nurse cannot neglect the client until the client is ready. The family also is in crisis and needs the nurse's support and should not be relied on to provide care. Option 1 represents a factual but noncaring approach to the client, which also is not therapeutic. Strategy: Use the process of elimination and the principles related to therapeutic relationships. Option 2 is the only option that addresses the client's feelings. Review the psychosocial issues associated with spinal cord injuries if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 988). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1734) Bethanechol chloride (Urecholine) is prescribed for the client. The nurse instructs the client to take the medication: a. With meals. b. Two hours after meals. c. With a snack in the afternoon. d. At bed time with crackers and cheese. Source: Saunders 4th

ANS: B Rationale: Administration of bethanechol (Urecholine) with food can cause nausea and vomiting in the client. To avoid this problem, oral doses should be administered 1 hour before meals or 2 hours after meals. Strategy: Use the process of elimination. Note that options 1, 3, and 4 are comparative or alike in that they all suggest administering the medication with a food item. Review client teaching points related to this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 93). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2599) The client sustains a burn injury to the entire right and left arms, the right leg, and the anterior thorax. According to the Rule of Nines, the nurse would assess that this injury constitutes which body percentages? Source: Saunders 4th

<answer unitText="%" id="54.">54 Rationale: According to the Rule of Nines, the right arm is equal to 9% and the left arm is equal to 9%. The right leg is equal to 18% and the left leg is equal to 18%. The anterior thorax is equal to 18% and the posterior thorax is equal to 18%. The head is equal to 9% and the perineum is equal to 1%. If the anterior thorax, the right leg, and right and left arm were burned, according to the Rule of Nines, the total area involved would be 54%. Strategy: Knowledge of the percentages associated with the Rule of Nines is required to answer this question. Review the Rule of Nines if you are unfamiliar with this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1631). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Integumentary Alternate Question Types -> Fill in the Blank

183) A physician's order reads phenytoin (Dilantin) 0.2 g orally twice daily. The medication label states 100-mg capsules. A nurse prepares how many capsule(s) to administer one dose? Source: Saunders 4th

<answer unitText="capsule(s)" id="2.">2 <rationale image="formulas/QID183.swf">You must convert 0.2 g to milligrams. In the metric system, to convert larger to smaller, multiply by 1000 or move the decimal three places to the right. Therefore, 0.2 g equals 200 mg. After conversion from grams to milligrams, use the formula to calculate the correct dose. Strategy: In this medication calculation problem, first you must convert grams to milligrams. Once you have done the conversion and reread the medication calculation problem, you will know that two capsules is the correct answer. Recheck your work using a calculator and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 835). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

194) A physician orders 1 unit of packed red blood cells to infuse over 4 hours. The unit of blood contains 250 mL. The drop factor is 10 drops/1 mL. A nurse prepares to set the flow rate at how many drops per minute? (Round answer to the nearest whole number.) Source: Saunders 4th

<answer unitText="drops per minute" id="10.">10 <rationale image="formulas/QID194.swf">Use the IV flow rate formula. Strategy: Use the formula for calculating IV flow rates when answering the question. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. Remember to round the answer to the nearest whole number. Review IV infusion rates if you had difficulty with this question. Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed., p. 202). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

193) A physician orders 500 mL of normal saline (NS) to infuse over 5 hours. The drop factor is 10 drops/1 mL. A nurse sets the flow rate at how many drops per minute? (Round answer to the nearest whole number.) Source: Saunders 4th

<answer unitText="drops per minute" id="17.">17 <rationale image="formulas/QID193.swf">Use the IV flow rate formula. Strategy: Use the formula for calculating IV flow rates when answering the question. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. Remember to round the answer to the nearest whole number. Review IV infusion rates if you had difficulty with this question. Reference: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed., p. 598). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

1723) A physician orders 2000 mL of 5% dextrose and half-normal saline to infuse over 24 hours. The drop factor is 15 drops/1 mL. A nurse sets the flow rate at how many drops per minute? (Round to the nearest whole number.) Source: Saunders 4th

<answer unitText="drops per minute" id="21.">21 <rationale image="formulas/QID1723.swf">Use the IV flow rate formula. Strategy: Use the formula for calculating IV flow rates when answering the question. Verify the answer using a calculator. Review IV infusion rates if you had difficulty with this question. Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed., pp. 80, 120). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

177) The physician's order reads vancomycin (Vancocin) 500 mg in 250 mL of 5% dextrose in water and administer over 2 hours. The drop factor is 10 drops/mL. A nurse sets the flow rate at how many drops per minute? (Round answer to the nearest whole number.) Source: Saunders 4th

<answer unitText="drops per minute" id="21.">21 <rationale image="formulas/QID177.swf">Use the intravenous (IV) flow rate formula. Strategy: Use the formula for calculating IV flow rates when answering the question. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. Remember to round the answer to the nearest whole number. Review IV infusion rates if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1175-1176). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

178) A physician orders 1000 mL of normal saline (NS) to infuse over 12 hours. The drop factor is 15 drops/1 mL. A nurse prepares to set the flow rate at how many drops per minute? (Round answer to the nearest whole number.) Source: Saunders 4th

<answer unitText="drops per minute" id="21.">21 <rationale image="formulas/QID178.swf">Use the intravenous (IV) flow rate formula. Strategy: Use the formula for calculating IV flow rates when answering the question. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. Remember to round the answer to the nearest whole number. Review IV infusion rates if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 835). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

181) A physician orders 3000 mL of 5% dextrose in water (D₅W) to infuse over a 24-hour period. The drop factor is 10 drops/1 mL. A nurse sets the flow rate at how many drops per minute? (Round answer to the nearest whole number.) Source: Saunders 4th

<answer unitText="drops per minute" id="21.">21 <rationale image="formulas/QID181.swf">Use the IV flow rate formula. Strategy: Use the formula for calculating IV flow rates when answering the question. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. Remember to round the answer to the nearest whole number. Review IV infusion rates if you had difficulty with this question. Reference: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed., p. 598). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

185) A physician orders 2000 mL of 5% dextrose and ½ normal saline (NS) to infuse over 24 hours. The drop factor is 15 drops/1 mL. A nurse sets the flow rate at how many drops per minute? (Round answer to the nearest whole number.) Source: Saunders 4th

<answer unitText="drops per minute" id="21.">21 <rationale image="formulas/QID185.swf">Use the intravenous (IV) flow rate formula. Strategy: Use the formula for calculating IV flow rates when answering the question. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. Remember to round the answer to the nearest whole number. Review IV infusion rates if you had difficulty with this question. Reference: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed., p. 598). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

191) Cefuroxime sodium, 1 g in 50 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 15 drops/mL. A nurse sets the flow rate at how many drops per minute? Source: Saunders 4th

<answer unitText="drops per minute" id="25.">25 <rationale image="formulas/QID191.swf">Use the intravenous (IV) flow rate formula. Strategy: Use the formula for calculating IV flow rates when answering the question. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. Review IV infusion rates if you had difficulty with this question. Reference: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed., p. 598). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

184) A physician orders 1000 mL of ½ normal saline (NS) to infuse over 8 hours. The drop factor is 15 drops/1 mL. The nurse sets the flow rate at how many drops per minute? (Round answer to the nearest whole number.) Source: Saunders 4th

<answer unitText="drops per minute" id="31.">31 <rationale image="formulas/QID184.swf">Use the intravenous (IV) flow rate formula. Strategy: Use the formula for calculating IV flow rates when answering the question. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. Remember to round the answer to the nearest whole number. Review IV infusion rates if you had difficulty with this question. Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed., p. 202). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

189) Gentamicin sulfate, 80 mg in 100 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 10 drops/mL. A nurse sets the flow rate at how many drops per minute? (Round answer to the nearest whole number.) Source: Saunders 4th

<answer unitText="drops per minute" id="33.">33 <rationale image="formulas/QID189.swf">Use the intravenous (IV) flow rate formula. Strategy: Use the formula for calculating IV flow rates when answering the question. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. Remember to round the answer to the nearest whole number. Review IV infusion rates if you had difficulty with this question. Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed., p. 202). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

192) A physician orders 1000 mL D₅W to infuse at a rate of 125 mL/hr. A nurse determines that it will take how many hours for 1 L to infuse? Source: Saunders 4th

<answer unitText="hours" id="8.">8 <rationale image="formulas/QID192.swf">You must determine that 1 L equals 1000 mL. Next, use the formula for determining infusion time in hours. Strategy: Read the question carefully, noting that the question is asking about infusion time in hours. First, convert 1 L to milliliters. Next, use the formula for determining infusion time in hours. Verify your answer using a calculator and make sure that the answer makes sense. Review the IV formula for calculating infusion time if you had difficulty with this question. Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed., p. 202). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

197) The physician orders ketorolac 15 mg intravenous push (IVP). The medication vial states 30 mg/1 mL. How many milliliters will the nurse administer? Source: Saunders 4th

<answer unitText="mL" id="0.5.">0.5 <rationale image="formulas/QID197.swf">Use the medication calculation formula. Strategy: Follow the formula for the calculation of the correct dose. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 835-836). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

195) A physician's order reads morphine sulfate, 8 mg stat. The medication ampule reads morphine sulfate, 10 mg/mL. A nurse prepares how many milliliters to administer the correct dose? Source: Saunders 4th

<answer unitText="mL" id="0.8.">0.8 <rationale image="formulas/QID195.swf">Use the formula to calculate the correct dose. Strategy: Follow the formula for the calculation of the correct dose. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 835). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

179) A physician orders an intravenous (IV) dose of 400,000 units of penicillin G benzathine (Bicillin). The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine (Bicillin), 300,000 units/mL. A nurse prepares how many milliliters of medication to administer the correct dose? (Round answer to the nearest tenth.) Source: Saunders 4th

<answer unitText="mL" id="1.3.">1.3 <rationale image="formulas/QID179.swf">Use the medication dose formula. Strategy: Follow the formula for the calculation of the correct medication dose. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. Remember to round the answer to the nearest tenth. If you had difficulty with this question, review medication calculation problems. Reference: Kee, J. & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed., p. 156). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

180) A physician's order reads potassium chloride 30 mEq to be added to 1000 mL normal saline (NS) and to be administered over a 10-hour period. The label on the medication bottle reads 40 mEq/20 mL. A nurse prepares how many milliliters of potassium chloride to administer the correct dose of medication? Source: Saunders 4th

<answer unitText="mL" id="15.">15 <rationale image="formulas/QID180.swf">Use the medication calculation formula. Strategy: Follow the formula for the calculation of the correct medication dose. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Reference: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed., p. 408). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

182) A physician's order reads clindamycin phosphate (Cleocin Phosphate) 0.3 g in 50 mL normal saline (NS) to be administered intravenously over 30 minutes. The medication label reads clindamycin phosphate (Cleocin Phosphate) 900 mg in 6 mL. A nurse prepares how many milliliters of the medication to administer the correct dose? Source: Saunders 4th

<answer unitText="mL" id="2.">2 <rationale image="formulas/QID182.swf">You must convert 0.3 g to milligrams. In the metric system, to convert larger to smaller, multiply by 1000 or move the decimal three places to the right. Therefore, 0.3 g = 300 mg. Following conversion from grams to milligrams, use the formula to calculate the correct dose. Strategy: In this medication calculation problem, first you must convert grams to milligrams. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 835). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

187) A physician's order reads cyanocobalamin (vitamin B₁₂) 1000 mcg by the intramuscular route. The medication label reads cyanocobalamin (vitamin B₁₂) 0.5 mg/mL. A nurse prepares the medication and administers how many milliliters to the client? Source: Saunders 4th

<answer unitText="mL" id="2.">2 <rationale image="formulas/QID187.swf">You must convert 1000 mcg to milligrams (mg). In the metric system, to convert smaller to larger, divide by 1000 or move the decimal three places to the left. Therefore, 1000 mcg equals 1 mg. Next, use the formula to calculate the correct dose. Strategy: In this medication calculation problem, first you must convert micrograms to milligrams. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 835). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

144) The nurse is completing a time tape for a 1000-mL IV bag that is scheduled to infuse over 8 hours. The nurse has just placed the 11:00 <sc>AM</sc> marking at the 500-mL level. The nurse would place the mark for noon at which numerical level (mL) on the time tape? Source: Saunders 4th

<answer unitText="mL" id="375.">375 Rationale: If the IV is scheduled to run over 8 hours, then the hourly rate is 125 mL/hr. Using 500 mL as the reference point, the next hourly marking would be at 375 mL, which is 125 mL less than 500. Strategy: Use basic principles related to pharmacology math and IV administration to answer this question. If this question was difficult, review the concepts related to marking an IV solution by using a time tape. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 831). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

1766) A nurse is calculating a client's fluid intake for an 8-hour period. The client drank 8 oz of tea and 4 oz of orange juice for breakfast, 4 oz of water at 10:00 <sc>AM</sc> and at 1:00 <sc>PM</sc> when taking his medications, and 6 oz of iced tea at lunch. At 8:00 <sc>AM</sc> and again at 2:00 <sc>PM</sc>, the client received his intravenous antibiotics in 50 mL of normal saline. What is the client's total intake in mL? Source: Saunders 4th

<answer unitText="mL" id="880.">880 Rationale: The client consumed a total of 26 oz of fluid (12 oz at breakfast, 8 oz with medications, and 6 oz at lunch). This equals 780 mL (1 oz = 30 mL). The client also received a total of 100 mL of intravenous fluid (50 mL at 8:00 <sc>AM</sc> and 50 mL at 2:00 <sc>PM</sc>). Therefore, the total intake is 880 mL. Strategy: Focus on the subject, the client's intake in milliliters. Read the question carefully, noting the client's oral intake in ounces and then converting the total ounces to milliliters. Remember, 1 oz = 30 mL. Once you have done this, remember to add the 100 mL of intravenous fluid to the oral total. Review procedures for calculating intake and output if you had difficulty with this question. Reference: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed., pp. 580-582). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Child Health Alternate Question Types -> Fill in the Blank

188) A physician orders 3000 mL of D₅W to be administered over a 24-hour period. A nurse determines that how many milliliters per hour will be administered to the client? Source: Saunders 4th

<answer unitText="mL/hr" id="125.">125 <rationale image="formulas/QID188.swf">Use the intravenous (IV) formula to determine milliliters per hour. Strategy: Read the question carefully, noting that the question is asking about milliliters per hour to be administered to the client. Use the formula for calculating milliliters per hour. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. Review the IV formula for calculating milliliters per hour if you had difficulty with this question. Reference: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed., p. 598). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

186) A physician orders heparin sodium, 1300 units/hr by continuous intravenous (IV) infusion. The pharmacy prepares the medication and delivers an IV bag labeled heparin sodium 20,000 units/250 mL D₅W. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 1300 units/hr? (Round answer to the nearest whole number.) Source: Saunders 4th

<answer unitText="mL/hr" id="16.">16 <rationale image="formulas/QID186.swf">Calculation of this problem requires a two-step process. First, you need to determine the amount of heparin sodium in 1 mL. The next step is to determine the infusion rate, or milliliters per hour. Strategy: Read the question carefully, noting that two steps are required to solve this medication problem. Follow the formula, verify your answer using a calculator, and make sure that the answer makes sense. Remember to round the answer to the nearest whole number. If you had difficulty with this question, learn these steps now. These steps can be used for similar medication problems related to the administration of heparin sodium or regular insulin by IV infusion. Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (4th ed., p. 204). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

196) A physician orders regular insulin, 8 units/hr by continuous intravenous (IV) infusion. The pharmacy prepares the medication and then delivers an IV bag labeled 100 units of regular insulin in 100 mL normal saline (NS). An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 8 units/hr? Source: Saunders 4th

<answer unitText="mL/hr" id="8.">8 <rationale image="formulas/QID196.swf">Calculation of this problem requires a two-step process. First, you need to determine the amount of regular insulin in 1 mL. The next step is to determine the infusion rate, or milliliters per hour. Strategy: Read the question carefully, noting that two steps are required to solve this medication problem. Once you have performed the calculation, verify your answer using a calculator and make sure that the answer makes sense. These steps can be used for similar medication problems related to the administration of heparin sodium or regular insulin by IV infusion. Learn these steps if you had difficulty with this question. Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (4th ed., p. 204). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

1666) A physician&#39;s order reads levothyroxine (Synthroid), 150 mcg PO daily. The medication label reads Synthroid, 0.1 mg per tablet. A nurse administers how many tablet(s) to the client? Source: Saunders 4th

<answer unitText="tablet(s)" id="1.5.">1.5 <rationale image="formulas/QID1666.swf">It is necessary to convert 150 mcg to mg. In the metric system, to convert smaller to larger, divide by 1000 or move the decimal three places to the left. Therefore, 150 mcg = 0.15 mg. Next, use the formula to calculate the correct dose. Strategy: In this medication calculation problem, it is necessary first to convert micrograms to milligrams. Next, follow the formula for the calculation of the correct dose. Label each figure, including the answer. Recheck your work, and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed., p. 80). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

190) A physician's order reads levothyroxine (Synthroid), 150 mcg orally daily. The medication label reads Synthroid, 0.1 mg/tablet. A nurse administers how many tablet(s) to the client? Source: Saunders 4th

<answer unitText="tablet(s)" id="1.5.">1.5 <rationale image="formulas/QID190.swf">You must convert 150 mcg to milligrams. In the metric system, to convert smaller to larger, divide by 1000 or move the decimal three places to the left. Therefore, 150 mcg equals 0.15 mg. Next, use the formula to calculate the correct dose. Strategy: In this medication calculation problem, first you must convert micrograms to milligrams. Next, follow the formula for the calculation of the correct dose, verify your answer using a calculator, and make sure that the answer makes sense. If you had difficulty with this question, review medication calculation problems. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 835). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Fill in the Blank

1653) A nurse witnesses an accident on a highway and stops to provide assistance to the victim. The nurse notes that the client has sustained a head injury and a compound fracture to the left leg. The nurse provides the appropriate care prior to transport of the victim to the hospital by ambulance. The client develops a severe bone infection at the site of the fracture that requires amputation of the leg, and files suit against the nurse who provided care at the scene of the accident. Which of the following is accurate regarding the nurse's immunity from this suit? a. The Good Samaritan Law will protect the nurse. b. The Good Samaritan Law will not protect the nurse. c. The Good Samaritan Law will provide immunity from the suit, even if the nurse has accepted compensation for the care provided. d. The Good Samaritan Law protects laypersons and not professional health care providers. Source: Saunders 4th

ANS: A Rationale: A Good Samaritan law is passed by a state legislator to encourage nurses and other health care providers to provide care to a person when an accident, emergency, or injury occurs, without fear of being sued for the care provided. Its protection lies in the inability to sue the nurse or other health care provider for negligence in the care provided at the scene of the accident or during the emergency, even if further injury occurred because of the health care provider's care. Called immunity from suit, this protection usually applies only if all the conditions of the law are met, such as the heath care provider receives no compensation for the care provided, and the care given is not willfully and wantonly negligent. Strategy: Use the process of elimination. Eliminate options 2 and 4 because they are comparative or alike. There are no data in the question regarding the subject of compensation, so the best option is option 1. Review the Good Samaritan law if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 411-412). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2295) A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this alteration? a. Establishing a toileting schedule b. Inserting a Foley catheter c. Using adult diapers d. Padding the bed with an absorbent cotton pad Source: Saunders 4th

ANS: A Rationale: A bladder retraining program, such as use of a toileting schedule, may be helpful to clients experiencing urinary incontinence. A Foley catheter should be used only when necessary because of the associated risk of infection. Use of diapers or pads is the least acceptable alternative because of the risk of skin breakdown. Strategy: Use the process of elimination. Because use of a Foley catheter carries the risk of infection, and the use of diapers or pads carries the risk of skin breakdown, the only acceptable option is the toileting schedule. Review care of the client experiencing urinary incontinence if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 898-899). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1043). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1219) A nurse is reviewing the laboratory results for a client receiving tacrolimus (Prograf). Which laboratory result would indicate to the nurse that the client is experiencing an adverse effect of the medication? a. Blood glucose of 200 mg/dL b. Potassium level of 3.8 mEq/L c. Platelet count of 300,000 cells/mm³ d. White blood cell count of 6,000 cells/mm³ Source: Saunders 4th

ANS: A Rationale: A blood glucose level of 200 mg/dL is significantly elevated above the normal range of 70 to 110 mg/dL and suggests an adverse reaction. Other adverse reactions include neurotoxicity evidenced by headache, tremor, and insomnia, gastrointestinal effects such as diarrhea, nausea, and vomiting, hypertension, and hyperkalemia. Strategy: Use the process of elimination, noting that options 2, 3, and 4 represent normal values. Option 1 is the only abnormal value, reflecting an elevation. Review the adverse effects related to this medication and normal laboratory values if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1093). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

160) The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse assesses which of the following items? a. Vital signs b. Skin color c. Urine output d. Latest hematocrit level Source: Saunders 4th

ANS: A Rationale: A change in vital signs during the transfusion from baseline may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs before the procedure and again after the first 15 minutes. The other options do not identify assessments that are required just before beginning a transfusion. Strategy: Use the process of elimination and note the strategic words just before beginning the transfusion. This tells you that more than one of the options may be partially or totally correct and that the correct option needs to be assessed for possible comparison during the transfusion. Use the ABCs—airway, breathing, and circulation—to direct you to option 1. Review the nursing interventions for preparing to administer a blood transfusion if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 913). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1191). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2438) A nurse is providing instructions to a client regarding ambulation after the application of a fiberglass (nonplaster) cast to the lower leg. The nurse determines that the client understands the instructions if the client states that weight bearing on the casted leg can begin: a. Within 20 to 30 minutes of application b. In approximately 8 hours c. In 24 hours d. In 48 hours Source: Saunders 4th

ANS: A Rationale: A fiberglass cast is made of water-activated polyurethane material that is dry to the touch within minutes and reaches full rigid strength in about 20 minutes. Accordingly, the client can bear weight on the cast within 20 to 30 minutes. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination focusing on the strategic word fiberglass. Options 3 and 4 should be eliminated first, because these time frames are similar to those for drying times for plaster casts. Knowing that the fiberglass type of cast is lighter and dries extremely quickly will help you choose the 20- to 30-minute time frame as correct. Review client interventions regarding a fiberglass cast if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1198). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

173) A nurse enters the nursing lounge and discovers that a chair is on fire. She activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. The next appropriate action for the use of the fire extinguisher is to: a. Aim at the base of the fire. b. Squeeze the handle on the extinguisher. c. Sweep the fire from side to side with the extinguisher. d. Sweep the fire from top to bottom with the extinguisher. Source: Saunders 4th

ANS: A Rationale: A fire can be extinguished by using a fire extinguisher. To use the extinguisher, pull the pin first. The nurse then aims at the base of the fire. The extinguisher is squeezed and the fire is extinguished by sweeping from side to side to coat the area evenly. Strategy: Remember the mnemonic PASS to prioritize in the use of a fire extinguisher. P is pull the pin, A is aim at the base of the fire, S is squeeze the handle, and S is sweep from side to side to coat the area evenly. If you had difficulty with this question, review the steps in the appropriate use of a fire extinguisher. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 992). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2437) An ambulatory care nurse is providing instructions to a client who is scheduled for a gallium scan. Which statement if made by the client indicates an understanding of the instructions? a. "I need to have an injection 2 to 3 hours before the procedure." b. "The procedure will take all day." c. "I need to get a good night's rest because I will have to stand for several hours for this test." d. "I will need to avoid food and fluids and remain on bedrest for 2 days after the procedure." Source: Saunders 4th

ANS: A Rationale: A gallium scan is similar to a bone scan, but with injection of gallium isotope instead of technetium Tc 99m. Gallium is injected 2 to 3 hours before the procedure. The procedure takes 30 to 60 minutes to perform. The client must lie still during the procedure. There is no special aftercare. Strategy: Use the process of elimination. If you know that a gallium scan is similar to a bone scan, then you can begin by eliminating options 3 and 4. The time frame in option 2 is rather lengthy, which directs you to option 1. If you had difficulty with this question or are unfamiliar with this diagnostic test, review this procedure. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 572). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2001) A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. In teaching the client about this condition, the nurse explains that the stomach lining is producing a decreased amount of intrinsic factor, so the client will need: a. Vitamin B₁₂ injections b. Vitamin B₆ injections c. An antibiotic d. An antacid Source: Saunders 4th

ANS: A Rationale: A lack of the intrinsic factor needed to absorb vitamin B₁₂ occurs in pernicious anemia. Vitamin B₁₂ is needed for the maturation of red blood cells. Vitamin B₆ is not necessarily needed for pernicious anemia and can be taken orally. An antibiotic and antacids may be prescribed for certain types of gastric ulcers. Strategy: Focus on the diagnosis of the client to assist in answering the question. It is necessary to know that vitamin B₁₂ injections are used to treat pernicious anemia. If you had difficulty with this question or are unfamiliar with the pathophysiology associated with pernicious anemia, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2290). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

52) A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that the food item lowest in potassium is: a. Apples b. Carrots c. Spinach d. Avocado Source: Saunders 4th

ANS: A Rationale: A medium apple provides about 159 mg of potassium. A large carrot provides 341 mg, spinach (3½ oz) provides 470 mg, and a medium avocado provides 1097 mg of potassium. Strategy: Note the strategic words lowest in potassium. Recalling the potassium content of the foods identified in the options will direct you to option 1. Review the foods that are high and low in potassium content if you had difficulty with this question. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach. (3rd ed., p. 611). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2406) A nurse is performing a neurological assessment on a client who had a brain attack (stroke). The nurse assesses for proprioception by: a. Holding the sides of the client's great toe and while moving it, asking what position it is in b. Tapping the Achilles tendon using the reflex hammer c. Gently pricking the client's skin on the dorsum of the foot in two places d. Firmly stroking the lateral sole of the foot and under the toes with a blunt instrument Source: Saunders 4th

ANS: A Rationale: A method of testing for proprioception is to hold the sides of the client's great toe and while moving it, asking the client what position it is in. Option 2 describes gastrocnemius muscle contraction. Option 3 describes two-point discrimination. Testing the plantar reflex is described in option 4. Strategy: Use the process of elimination. Note the relationship between proprioception in the question and asking what position it is in in the correct option. Review the assessment technique for proprioception if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 936). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1481) A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. The appropriate nursing action is to: a. Call the nursing supervisor. b. Call security to block all exit areas. c. Restrain the client until the physician can be reached. d. Tell the client that the client cannot return to this hospital again if the client leaves now. Source: Saunders 4th

ANS: A Rationale: A nurse can be charged with false imprisonment if a client is made to believe wrongfully that he or she cannot leave the hospital. Most health care facilities have documents that the client is asked to sign relating to the client's responsibilities when the client leaves against medical advice. The client should be asked to sign this document before leaving. The nurse should request that the client wait to speak to the physician before leaving, but if the client refuses to do so, the nurse cannot hold the client against the client's will. Restraining the client and calling security to block exits constitutes false imprisonment. All clients have a right to health care and cannot be told otherwise. Strategy: Use the process of elimination. Keeping the concept of false imprisonment in mind, eliminate options 2 and 3 because they are comparative or alike. Eliminate option 4, knowing that all clients have a right to health care. From the options presented, the best action is option 1. Review the points related to false imprisonment if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 319-320). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 128-129). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2328) Kanamycin sulfate (Kantrex) given by intermittent intravenous infusion is prescribed for a client with a respiratory tract infection. Which of the following would indicate to the nurse that the client is experiencing an adverse reaction to the medication? a. Gastrointestinal disturbances b. Visual disturbances c. Elevated white blood cell (WBC) count d. Decreased blood urea nitrogen (BUN) Source: Saunders 4th

ANS: B Rationale: Adverse reactions associated with kanamycin sulfate include nephrotoxicity evidenced by an increased BUN and creatinine. Irreversible ototoxicity as evidenced by tinnitus, dizziness, ringing in the ears, and reduced hearing and neurotoxicity manifested by headache, dizziness, lethargy, and visual disturbances can occur. Gastrointestinal disturbances can occur as a frequent side effect of the medication. The WBC count may be elevated as a result of the respiratory infection. Strategy: Focus on the strategic words adverse reaction. Recalling that nephrotoxicity, ototoxicity, and neurotoxicity can result from use of this medication will direct you to option 2. If you had difficulty with this question, review the adverse effects associated with the use of kanamycin sulfate. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 727). St. Louis: Mosby. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 452). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 1001). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1432) The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." The appropriate nursing response is which of the following? a. "I cannot discuss any client situation with you." b. "If you want to know about Carol, you need to ask her yourself." c. "I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she is doing great!" d. "I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she really has some problems!" Source: Saunders 4th

ANS: A Rationale: A nurse is required to maintain confidentiality regarding the client and the client's care. Confidentiality is basic to the therapeutic relationship and is a client's right. The most appropriate response to the neighbor is option 1. Option 2 is a rather blunt statement and does not acknowledge the issue that the nurse cannot reveal if the named person is or was a client. Options 3 and 4 identify statements that do not maintain client confidentiality. Option 1 is the most direct and correct. Strategy: Focus on the subject of the question, maintaining confidentiality. This should assist you easily in eliminating options 3 and 4. From the remaining options, select option 1 over option 2 because it is the most direct and correct. Option 2 is a rather blunt and rude statement. Review confidentiality issues if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 50-52). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1451) The nurse reviews the activity schedule for the day and plans which activity for the manic client? a. Tetherball b. Paint by number activity c. Brown bag luncheon and a book review d. Deep breathing and progressive relaxation group Source: Saunders 4th

ANS: A Rationale: A person who is experiencing mania is overactive and full of energy, lacks concentration, and has poor impulse control. The client needs an activity that will allow use of excess energy yet not endanger others during the process. Options 2, 3, and 4 are relatively sedate activities that require concentration, a quality that is lacking in the manic state. Such activities may lead to increased frustration and anxiety for the client. Tetherball is an exercise that uses the large muscle groups of the body and is a great way to expend the increased energy this client is experiencing. Strategy: Use the process of elimination. Eliminate options 2, 3, and 4 because they are comparative or alike and are relatively sedate activities. Review the appropriate interventions for a manic client if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 229). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 351, 355). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 400). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1350) A client is being discharged to home after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client states that he or she should: a. Avoid getting the cast wet. b. Cover the casted leg with warm blankets. c. Use the fingertips to lift and move the leg. d. Use a padded coat hanger end to scratch under the cast. Source: Saunders 4th

ANS: A Rationale: A plaster cast must remain dry to keep its strength. The cast should be handled with the palms of the hands, not the fingertips, until fully dry. Air should circulate freely around the cast to help it dry; the cast also gives off heat as it dries. The client should never scratch under the cast; the client may use a hair dryer on the cool setting to relieve an itch. Strategy: Use the process of elimination. Knowing that a wet cast can be dented with the fingertips, causing pressure underneath, helps eliminate option 3 first. Knowing that the cast needs to dry helps eliminate option 2 next. Option 4 is dangerous to skin integrity and is also eliminated. Remember that plaster casts, once they have dried after application, should not become wet. Review care of the client with a cast if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 1162, 1169). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

927) The nurse is assessing for stoma prolapse in a client with a colostomy. What should the nurse observe if stoma prolapse occurs? a. Protruding stoma b. Sunken and hidden stoma c. Narrowed and flattened stoma d. Dark- and bluish-colored stoma Source: Saunders 4th

ANS: A Rationale: A prolapsed stoma is one in which the bowel protrudes through the stoma. A stoma retraction is characterized by sinking of the stoma. Ischemia of the stoma would be associated with a dusky or bluish color. A stoma with a narrowed opening at the level of the skin or fascia is said to be stenosed. Strategy: Focus on the subject and the strategic word prolapse. This will direct you to option 1. If this question was difficult, review the complications associated with a colostomy stoma. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1324). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1089). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2135) A client who has experienced a brain attack (stroke) has partial hemiplegia of the left leg. The straight leg cane formerly used by the client is not quite sufficient now. The nurse interprets that the client could benefit from the somewhat greater support and stability provided by a: a. Quad cane b. Wooden crutch c. Lofstrand crutch d. Wheelchair Source: Saunders 4th

ANS: A Rationale: A quad cane may be used by the client requiring greater support and stability than is provided by a straight leg cane. The quad cane provides a four-point base of support and is indicated for use by clients with partial or complete hemiplegia. Neither crutches nor a wheelchair is indicated for use with a client such as the one described in the question. Strategy: Use the process of elimination. Giving a wheelchair to a client with partial hemiplegia is excessive and is eliminated first. Wooden crutches are not indicated, as the client has no restriction in weight bearing. A Lofstrand crutch is useful for clients with bilateral weakness. This leaves the quad cane as the correct choice. Review the purpose and use of the various assistive devices if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1204). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 948-949). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2597) The emergency department nurse is performing an assessment on a child with a suspected diagnosis of intussusception. Which of the following assessment questions for the parents will elicit the most specific data related to this disorder? a. "Can you describe the type of pain that the child is experiencing?" b. "Does the child have any food allergies?" c. "Has the child eaten any food in the last 24 hours?" d. "What do the bowel movements look like?" Source: Saunders 4th

ANS: A Rationale: A report of severe colicky abdominal pain in a healthy thriving child between 3 and 17 months of age is the classic presentation of intussusception. Typical behavior includes screaming and drawing the knees up to the chest. Options 2, 3, and 4 are important aspects of a health history but are not specific to the diagnosis of intussusception. Strategy: Use the process of elimination. Recalling that severe colicky abdominal pain is a clinical manifestation associated with this disorder will direct you to option 1. Review the manifestations associated with intussusception if you had difficulty with this question. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., p. 1420). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Child Health Alternate Question Types -> Multiple Choice

50) A nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the electrocardiogram as a result of the laboratory value? a. U waves b. Absent P waves c. Elevated T waves d. Elevated ST segment Source: Saunders 4th

ANS: A Rationale: A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalance and is potentially life threatening. Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia. Strategy: From the information in the question, you need to determine that the client is experiencing hypokalemia. From this point, you must know the electrocardiographic changes that are expected when hypokalemia exists. If you had difficulty with this question, review the electrocardiographic changes that occur in hypokalemia. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 342-344). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2061) A child is brought to the hospital emergency department for an injury to the lower right arm that occurred in a fall off a bicycle. On assessment, the nurse notes that the skin at the site of the injury is intact. A fracture is suspected, and a radiograph is taken. The nurse can see on the radiograph viewer that the fracture of the bone is across the entire bone shaft with some possible displacement. The nurse determines that this child's fracture is a: a. Simple fracture b. Compound fracture c. Greenstick fracture d. Comminuted fracture Source: Saunders 4th

ANS: A Rationale: A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture that occurs through only a part of the cross section of the bone; one side of the bone is fractured and the other side is bent. A comminuted fracture is a complete fracture across the shaft of the bone with splintering of the bone fragments. A compound fracture, also called an open or a complex fracture, is one in which the skin or mucous membrane has been broken and the wound extends to the depth of the fractured bone. Strategy: Use the process of elimination. Focus on the description provided in the question to assist in directing you to the correct option. If you had difficulty with this question, review the characteristics of the various types of fractures. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., pp. 1750-1751). St. Louis: Mosby. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 1154). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Child Health Alternate Question Types -> Multiple Choice

109) A nurse is preparing to care for a client who will receive parenteral nutrition (PN) support. The client is receiving dextrose, amino acids, and lipids all in one solution (total nutrient admixture). The nurse plans to do which of the following? a. Use a 1.2-µm filter. b. Use a 0.22-µm filter to ensure sterility. c. Use a 0.10-µm filter to ensure sterility. d. Administer the solution without a filter. Source: Saunders 4th

ANS: A Rationale: A total nutrient admixture (TNA) is a solution that combines dextrose, amino acids, and lipids in one solution. A 1.2-µm filter or larger filter should be used because the lipid particles are too large to pass through a smaller (0.22- or 0.10-µm) filter. A 0.22-µm filter is used for 2-in-1 solutions containing only dextrose and amino acids. A 0.10-µm filter is smaller than a 1.2-µm filter. Administering the solution without using a filter is not an appropriate action. Strategy: Use the process of elimination and note that dextrose, amino acids, and lipids are all in one solution. Recall that total nutrient admixture (TNA) or 3-in-1 solutions contain lipids, which are too large to pass through 0.22-µm filters. Begin to answer this question by eliminating options 2 and 3 because the filters are too small for lipid particles to pass through. Choose option 1 over option 4 because a 1.2-µm filter would be the correct size to allow lipid particles to pass through. Review the types of PN solutions and the appropriate filter sizes if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 989). St. Louis: Mosby. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., p. 1062). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1901) A client is diagnosed with benign prostatic hyperplasia (BPH) and is scheduled for a transrectal ultrasound exam and a test to measure the prostate-specific antigen (PSA) level. The client says to the nurse, "I can't remember...can you tell me again why I need these tests to be done?" The nurse responds knowing that these tests: a. Help to rule out the presence of cancer b. Specifically predict the course of BPH c. Pinpoint the likelihood of developing urinary obstruction d. Give an indication of whether intermittent self-catheterization is needed Source: Saunders 4th

ANS: A Rationale: A transrectal ultrasound exam and PSA level determination help to rule out the possibility of prostate cancer. They do not specifically predict the course of BPH or the development of complications such as urinary obstruction. These tests have nothing to do with determining need for self-catheterization. Strategy: Use the process of elimination. Eliminate options 2, 3, and 4 because diagnostic tests do not predict the course of a disease, the likelihood of developing complications (such as obstruction), or whether self-catheterization is needed. Review the purpose of these tests in the client with BPH if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., pp. 905-906). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1859). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2075) A nurse has an order to obtain a urinalysis specimen from a client with an indwelling urinary catheter. To prevent contamination of the specimen, the nurse knows to avoid which of the following? a. Obtaining the specimen from the urinary drainage bag b. Clamping the tubing of the drainage bag c. Aspirating a sample from the port on the drainage bag d. Wiping the port with an alcohol swab before inserting the syringe Source: Saunders 4th

ANS: A Rationale: A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag, so its properties do not necessarily reflect current client status. In addition, it may become contaminated with bacteria from opening the system. Strategy: This question tests a basic principle of asepsis. Note the strategic word avoid and visualize the procedure to direct you to option 1. Review the purpose and technique for this procedure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1666). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1905) A client has developed acute renal failure (ARF) as a complication of glomerulonephritis. The nurse assesses the client for which of the following as an expected manifestation of ARF? a. Hypertension b. Bradycardia c. Decreased cardiac output d. Decreased central venous pressure Source: Saunders 4th

ANS: A Rationale: ARF caused by glomerulonephritis is classified as intrinsic or intrarenal failure. This form of ARF is commonly manifested by hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. ARF from prerenal causes is characterized by decreased blood pressure, or a recent history of the same, tachycardia, and decreased cardiac output and central venous pressure. Bradycardia is not part of the clinical picture for any form of renal failure. Strategy: Use the process of elimination. Recalling that renal failure is accompanied by fluid overload will assist in eliminating option 4. Because fluid overload is accompanied by tachycardia (because the heart works harder to pump the volume), option 2 can be eliminated. Regarding the remaining options, knowing that hypertension accompanies ARF due to intrarenal causes, while decreased cardiac output accompanies ARF due to prerenal causes, will direct you to option 1. Review the manifestations of ARF if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1732). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

944) The client with hepatitis is scheduled for a liver biopsy. The nurse implements which of the following to assess for the most common symptom of bile peritonitis following the biopsy? a. Monitoring for abdominal pain b. Monitoring for bloody diarrhea c. Assessing for bradycardia d. Assessing for increased flatulence Source: Saunders 4th

ANS: A Rationale: Abdominal pain is the most common symptom of peritonitis. Tachycardia, rather than bradycardia, will occur. Bloody diarrhea is a symptom of ulcerative colitis. Increased flatulence commonly occurs with irritable bowel syndrome. Strategy: Use the process of elimination and focus on the subject, an assessment finding that indicates peritonitis. Recalling the signs associated with peritonitis will direct you to option 1. Review the assessment findings associated with peritonitis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1385, 1391). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1066). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1192) A week after kidney transplantation, the client develops a temperature of 101° F, the blood pressure is elevated, and the kidney is tender. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse would suspect which of the following complications? a. Acute rejection b. Kidney infection c. Chronic rejection d. Kidney obstruction Source: Saunders 4th

ANS: A Rationale: Acute rejection most often occurs in the first 2 weeks after transplantation. Clinical manifestations include fever, malaise, elevated white blood cell count, acute hypertension, graft tenderness, and manifestations of deteriorating renal function. Chronic rejection occurs gradually over a period of months to years. Although kidney infection or obstruction can occur, the symptoms presented in the question do not relate specifically to these disorders. Strategy: Use the process of elimination and note the strategic words a week after kidney transplantation. These words should direct you easily to option 1, acute rejection. Review the signs of acute rejection if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1762). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2036) A monoamine oxidase inhibitor (MAOI) is prescribed for a client. The nurse instructs the client that signs and symptoms of toxicity related to the use of this medication may include: a. Restlessness b. Feelings of fatigue c. Lack of energy d. Lethargy Source: Saunders 4th

ANS: A Rationale: Acute toxicity of MAOIs is manifested by restlessness, anxiety, and insomnia. Dizziness and hypertension also can occur in acute toxicity. Options 2, 3, and 4 are not signs of toxicity related to MAOIs. Strategy: Use the process of elimination. Eliminate options 2, 3, and 4 because they are comparative or alike. If you had difficulty with this question or are unfamiliar with the toxic effects of MAO inhibitors, review this content. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 395). Philadelphia: W.B. Saunders. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 350). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

136) The nurse has an order to hang an IV bag of 1000 mL 5% dextrose in water with 20 mEq potassium chloride. The nurse should plan to do which of the following immediately after injecting the potassium chloride into the port of the intravenous (IV) bag? a. Rotate the bag gently. b. Attach the tubing to the client. c. Prime the tubing with the IV solution. d. Check the solution for yellowish discoloration. Source: Saunders 4th

ANS: A Rationale: After adding a medication to a bag of intravenous (IV) solution, the nurse should agitate or rotate the bag gently to mix the medication evenly in the solution. The nurse should then attach a completed medication label. The nurse can then prime the tubing. The IV solution should have been checked for discoloration before the medication was added to the solution. The tubing is attached to the client last. Strategy: Use the process of elimination and note the strategic words immediately after injecting. They imply a correct time sequence, and you need to prioritize. Visualize and think through the steps of adding medication to an IV bag, and make your choice accordingly. Review the procedure for adding potassium chloride to an IV bag if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 894-896). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2005) After cataract surgery, a client is taught to avoid strain on the operated eye. Which of the following statements if made by the client would alert the nurse that further teaching is needed? a. "I can lie on my operated side." b. "I cannot rub my eye." c. "I can't lift more than 5 pounds." d. "I need to take stool softeners to prevent straining." Source: Saunders 4th

ANS: A Rationale: After cataract surgery, the client needs to be instructed to lie on the nonoperated side to prevent swelling and pressure in the operative area. Options 2, 3, and 4 are correct measures to take after cataract surgery to reduce strain on the operated eye. Strategy: Use the process of elimination, noting the strategic words further teaching is needed. This phrasing indicates a negative event query and directs you to select an incorrect statement. Recalling that it is necessary to prevent pressure and strain on the operative site will assist in directing you to option 1. If you had difficulty with this question, review the client teaching points related to postoperative cataract surgery. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1951). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

2209) A nurse is providing preoperative teaching to a client scheduled for a cholecystectomy. Which intervention would be of highest priority in the preoperative teaching plan? a. Teaching coughing and deep breathing exercises b. Teaching leg exercises c. Providing instructions regarding fluid restrictions d. Assessing the client's understanding of the surgical procedure Source: Saunders 4th

ANS: A Rationale: After cholecystectomy, respirations tend to be shallow because deep breathing is painful as a result of the location for the surgical procedure. Although all of the options are correct, teaching coughing and deep breathing exercises is the priority. Strategy: Use the ABCs—airway, breathing, and circulation—to answer the question. Option 1 relates to airway. Additionally, recalling the anatomical location for the surgical procedure will assist in directing you to the correct option. Review client teaching points related to this surgical procedure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 309, 1400). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1272) The client has just undergone computed tomography scanning with a contrast medium. The nurse determines that the client understands postprocedure care if the client verbalizes to: a. Increase fluid intake for the day. b. Hold medications for at least 4 hours. c. Eat lightly for the remainder of the day. d. Rest quietly for the remainder of the day. Source: Saunders 4th

ANS: A Rationale: After computed tomography scanning, the client may resume all usual activities. The client should be encouraged to consume extra fluids to replace those lost with diuresis from the contrast dye. Strategy: Use the process of elimination. Noting the strategic words scanning with a contrast medium will direct you to option 1. Review the procedure related to computed tomography scanning if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 100-101). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1097) A nurse would evaluate that defibrillation of a client was most successful if which of the following observations was made? a. Arousable, sinus rhythm, BP 116/72 mm Hg b. Arousable, marked bradycardia, BP 86/54 mm Hg c. Nonarousable, supraventricular tachycardia, BP 122/60 mm Hg d. Nonarousable, sinus rhythm, BP 88/60 mm Hg Source: Saunders 4th

ANS: A Rationale: After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurological status. Respiratory and metabolic acidosis develops during ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and cardiopulmonary complications. Arousable status, adequate blood pressure, and a sinus rhythm indicate successful response to defibrillation. Strategy: Use the process of elimination and note the strategic words most successful. Eliminate options 3 and 4 first because of the word nonarousable. From the remaining options, select option 1 because a sinus rhythm is a more successful response compared with marked bradycardia. Review the expected effects of defibrillation if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1689). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 717, 721). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1108) Postoperatively, a nurse is caring for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse would inspect the surgical site most closely for evidence of which of the following? a. Bleeding and infection b. Thrombosis and infection c. Bleeding and wound dehiscence d. Wound dehiscence and evisceration Source: Saunders 4th

ANS: A Rationale: After inferior vena cava filter insertion, the nurse inspects the surgical site for bleeding and signs and symptoms of infection. Otherwise, care is the same as for any other postoperative client. Strategy: Use the process of elimination. Because inferior vena cava filters are inserted percutaneously through a deep vein, options 3 and 4 are eliminated because no abdominal incision is made. From the remaining options, noting that the client has been on anticoagulant therapy before surgery because of the high risk of pulmonary embolism will direct you to option 1. Review care of the client following insertion of an inferior vena cava filter if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 815). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2092) A client is to undergo weekly intravesical chemotherapy for bladder cancer for the next 8 weeks. The nurse interprets that the client demonstrates understanding of management of the urine as a biohazard by stating to: a. Disinfect the toilet with bleach after voiding for 6 hours after a treatment. b. Have one bathroom strictly set aside for the client's use for the next 2 months. c. Purchase extra bottles of scented disinfectant for daily bathroom cleansing. d. Void into a bedpan and then empty the urine into the toilet. Source: Saunders 4th

ANS: A Rationale: After intravesical chemotherapy, the client treats the urine as a biohazard. This involves disinfecting the urine and the toilet with household bleach for 6 hours after the treatment. Scented disinfectants are of no particular use. The client does not need to have a separate bathroom for personal use. Using a bedpan for voiding is of no value in this situation. Strategy: Use the process of elimination. Eliminate options 3 and 4 first because the actions described have no useful purpose. Eliminate option 2 next because it is unnecessary and may be unrealistic for a number of clients. Review client instructions after this treatment if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 871). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1480) The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife say: a. "I no longer feel that I deserve the beatings my husband inflicts on me." b. "My attendance at the meetings has helped me to see that I provoke my husband's violence." c. "I enjoy attending the meetings because they get me out of the house and away from my husband." d. "I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics." Source: Saunders 4th

ANS: A Rationale: Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. Option 1 is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. In option 2, the nonalcoholic partner should not feel responsible when the spouse loses control. Option 4 indicates that the wife remains codependent. Option 3 indicates that the group is viewed as an escape, not a place to work on issues. Strategy: Use the process of elimination. Note the strategic words benefiting from attending an Al-Anon group. This will direct you to option 1. Review the purpose of this group if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 322). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1459) The nurse develops a nursing diagnosis of self-care deficit for an older client with dementia. Which of the following is an appropriate goal for this client? a. The client will function at the highest level of independence possible. b. The client will complete all activities of daily living independently within a 1-hour time frame. c. The client will be admitted to a long-term care facility to have activities of daily living needs met. d. The nursing staff will attend to all the client's activities of daily living needs during the hospital stay. Source: Saunders 4th

ANS: A Rationale: All clients, regardless of age, need to be encouraged to perform at the highest level of independence possible. Independence contributes to the client's sense of control and sense of well-being. Option 3 is incorrect because what the self-care deficit entails is not known. To assume that the client requires long-term care based on so little information would be erroneous. Options 2 and 4 are close-ended statements. Strategy: Use the process of elimination. Eliminate options 2 and 4 first because of the close-ended word all. From the remaining options, select option 1 because it is the umbrella option. Review care of the client with dementia if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 333, 339). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2218) A nurse is caring for a client with hepatitis A who resides in a group home. Which of the following outcomes would indicate that the most important goal has been achieved for this client? a. Avoids transmitting the virus to others in the group home b. Gains at least 1/2 to 1 pound per week until at ideal weight c. Progressively increases activity with planned rest periods d. Resumes normal bowel elimination patterns Source: Saunders 4th

ANS: A Rationale: All of the options are expected outcomes of care for this client. However, one of the most important goals in management of clients with acute viral hepatitis is preventing the spread of infection. Strategy: Use the process of elimination, focusing on the strategic words most important. Recalling the importance of preventing infection will direct you to option 1. Review the importance of preventing the spread of hepatitis you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1382, 1384-1385). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1444) All treatment team members are seen as equally important in helping clients meet their treatment goals. This type of therapy approach is: a. Milieu therapy b. Interpersonal therapy c. Behavior modification d. Rational emotive therapy Source: Saunders 4th

ANS: A Rationale: All treatment team members are viewed as significant and valuable to the client's successful treatment outcomes in milieu therapy. Behavior modification is based on rewards and punishment. Rational emotive therapy deals with the correction of distorted thinking. Interpersonal therapy on the other hand is based on a one-to-one or group therapy approach in which the therapist-client relationship is often used as a way for the client to examine other relationships in his or her life. Strategy: Focus on the subject. Note the relationship between the words helping clients meet their treatment goals and option 1. Review the types of therapy noted in the options if you had difficulty with this question. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 30-31). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2367) A nurse is monitoring a client with herpes simplex virus who is receiving intravenous (IV) acyclovir (Zovirax). Which of the following laboratory results would be of concern as a possible adverse effect of this medication? a. Blood urea nitrogen (BUN) of 36 mg/dL b. Platelet count of 300,000 cells/mm³ c. White blood cell count of 6000 cells/mm³ d. Red blood cell count of 5.2 million cells/mm³ Source: Saunders 4th

ANS: A Rationale: Although the most common adverse reactions with this medication are phlebitis and inflammation at the IV site, reversible nephrotoxicity evidenced by an elevated serum creatinine and BUN levels can occur in some clients. The cause of nephrotoxicity is deposition of acyclovir in the renal tubules. The risk of renal injury is increased by dehydration and by the use of other nephrotoxic medications. The values identified in options 2, 3, and 4 are within normal limits. Strategy: Use the process of elimination. Recalling that nephrotoxicity is an adverse effect will direct you to the correct option. Also, knowledge of normal and abnormal laboratory values will direct you to option 1. If you had difficulty with this question, review the adverse effects related to IV administration of acyclovir. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., pp. 15-16). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1923) A nurse is reviewing the medication record of a client diagnosed with chronic renal failure (CRF). The nurse notes that the client is receiving aluminum hydroxide (Amphojel). The nurse determines that the purpose of this medication is to: a. Combine with phosphorus and help eliminate phosphates from the body b. Prevent ulcers c. Promote the elimination of potassium from the body d. Prevent constipation Source: Saunders 4th

ANS: A Rationale: Aluminum hydroxide binds with phosphate in the intestines for excretion in the feces, thus lowering phosphorus levels. It can cause constipation, and it does not promote the elimination of potassium. It may be used in the treatment of hyperacidity associated with gastric ulcers, but this is not the purpose of its use in the client with renal failure. Strategy: Use the process of elimination. Focusing on the client's diagnosis and recalling the purpose of this medication in CRF will direct you to option 1. Review the medications prescribed for the client with CRF if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 45). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2680) A nurse is preparing to give the client directions for proper use of aluminum hydroxide tablets (Alu-Caps). Which of the following statements by the nurse is appropriate? a. "Chew the tablet thoroughly and then drink 8 ounces of water." b. "Swallow the tablet whole with a full glass of water." c. "Take the tablet at the same time as an antacid." d. "Take each dose with a laxative to prevent constipation." Source: Saunders 4th

ANS: A Rationale: Aluminum hydroxide tablets should be chewed thoroughly before swallowing, to prevent them from entering the small intestine undissolved. An antacid should not be taken with the medication, to prevent interactive effects. Constipation is a side effect of the use of aluminum products, but the client should not take a laxative with each dose. This would promote laxative abuse and should be avoided if less habit-forming means can be used. Strategy: Use the process of elimination. Eliminate option 4 first because it is not a health-promoting instruction. Eliminate option 3 knowing that antacids are not usually taken with other medications. Regarding the remaining options, use principles of digestion, absorption, and medication use to direct you to option 1. Review client teaching points related to the use of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 33). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2114) A client with a subarachnoid hemorrhage needs to have surgery delayed until a stable clinical condition is achieved. The nurse plans to administer which of the following medications as ordered to prevent clot breakdown and dissolution? a. Aminocaproic acid (Amicar) b. Heparin sodium (Heparin) c. Warfarin (Coumadin) d. Alteplase (Activase) Source: Saunders 4th

ANS: A Rationale: Aminocaproic acid is an antifibrinolytic agent that prevents clot breakdown or dissolution. It is commonly ordered after subarachnoid hemorrhage if surgery is delayed or contraindicated, to prevent further hemorrhage. Heparin sodium and warfarin are anticoagulants, which interfere with propagation or growth of a clot. Alteplase is a fibrinolytic, which actively breaks down clots. Strategy: Use the process of elimination. Recalling that heparin sodium and warfarin are anticoagulants will assist in eliminating options 2 and 3 first, because they are contraindicated. Knowing that alteplase is a fibrinolytic will assist in eliminating this option also, because this medication would actively dissolve the clot (also contraindicated). This leaves aminocaproic acid as the correct option. Review the action and use of aminocaproic acid if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 56). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2591) A nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving aminophylline (Theophylline). The nurse monitors the serum theophylline level and concludes that the medication dosage may need to be increased if which of the following values is noted? a. 5 mg/mL b. 10 mg/mL c. 15 mg/mL d. 20 mg/mL Source: Saunders 4th

ANS: A Rationale: Aminophylline is a bronchodilator. The nurse monitors the theophylline blood serum level daily when a client is on this medication to ensure that a therapeutic range is present and to monitor for the potential for toxicity. The therapeutic serum level range is 10 to 20 mg/mL. If the laboratory result indicated a level of 5 mg/mL, the dosage of the medication would need to be increased. Strategy: Focus on the subject of the question, the need to increase the medication. This focus and recalling the therapeutic blood serum level will direct you to option 1, because it is the lowest value in all of the options. Review the therapeutic blood serum level of theophylline if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 77). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2504) A client with disseminated candidiasis has an order for amphotericin B (Fungizone) by the intravenous (IV) route. During ongoing therapy with this medication, the nurse will most closely assess the client for which of the following? a. Decreased urine output b. Decreased pulse c. Decreased body temperature d. Decreased blood urea nitrogen level Source: Saunders 4th

ANS: A Rationale: Amphotericin B can cause adverse effects such as chills, fever, headache, vomiting, and impaired renal function. The nurse monitors for these adverse effects and also carefully assesses the IV site because of the irritating effects of the medication. Strategy: Use the process of elimination. Recalling that this medication can be toxic to the kidneys will direct you to the correct option. Review nursing care related to the administration of this medication if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., pp. 97-98). St. Louis: Mosby. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 70). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1215) A nurse is caring for a client who will be receiving amphotericin B deoxycholate (Fungizone). The nurse notes that the client is also taking cyclosporine (Sandimmune) to prevent rejection of a kidney transplantation performed 2 years ago. Which prescription would the nurse anticipate to be prescribed for this client during the administration of these medications concurrently? a. A decreased amount of cyclosporine b. An increased amount of cyclosporine c. A decreased amount of amphotericin B deoxycholate d. An increased amount of amphotericin B deoxycholate Source: Saunders 4th

ANS: A Rationale: Amphotericin B deoxycholate, erythromycin, and ketoconazole can elevate cyclosporine levels. When any of these medications is combined with cyclosporine, the dosage of cyclosporine must be reduced to prevent accumulation to toxic levels. Strategy: Knowledge regarding the medications that elevate cyclosporine levels is required to answer this question. Remember that amphotericin B deoxycholate can elevate cyclosporine levels. If you are unfamiliar with these medications, review these medication interactions. Reference: Mosby. (2007). 2007 Mosby's nursing drug reference (20th ed., p. 128). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2369) A client with candidiasis is receiving amphotericin B (Fungizone) by the intravenous route. The nurse determines that the client is having an adverse reaction to the medication if which of the following laboratory study result is noted? a. Elevated serum creatinine b. Lowered hemoglobin and hematocrit c. Elevated platelet count d. Low white blood cell count Source: Saunders 4th

ANS: A Rationale: Amphotericin B exerts direct toxicity on cells of the kidneys and causes renal impairment in most clients. To evaluate renal injury, tests of kidney function should be performed weekly, and intake and output should be monitored. If the serum creatinine level rises above 3.5 mg/dL, the dose of amphotericin B should be reduced. Options 2, 3, and 4 are unrelated to the use of this medication. Strategy: Recalling that amphotericin B is nephrotoxic will direct you to option 1. If you had difficulty with this question, review adverse effects related to the use of amphotericin B. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 97). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2411) A nurse is developing a plan of care for a client who is receiving amphotericin B (Fungizone) intravenously to treat a severe fungal infection of the skin. A main component of the plan of care is monitoring for adverse reactions related to the administration of this medication. Which of the following should the nurse include in a list of manifestations to watch for? a. Visual difficulties b. Increased urinary output c. Fatigue d. Confusion Source: Saunders 4th

ANS: A Rationale: Amphotericin B is an antifungal. Adverse reactions include nephrotoxicity, which occurs commonly and is evidenced by decreased urine output. Cardiovascular toxicity (as evidenced by hypotension and ventricular fibrillation) and anaphylactic reaction occur rarely. Vision and hearing alterations, seizures, hepatic failure, and coagulation defects also may occur. Strategy: Use the process of elimination. If you can remember that this medication causes nephrotoxicity, cardiovascular toxicity, and vision and hearing alterations, you will be able to correctly answer questions with similar content. Review the adverse effects related to this medication if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 98). St. Louis: Mosby. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 464). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

2186) A home health nurse visits a client who is having an acute attack of gout. The nurse determines that the client does not understand the treatment if the client states that he is: a. Restricting fluids b. Eating a low-purine diet c. Maintaining bedrest d. Taking nonsteroidal anti-inflammatory drugs (NSAIDs) Source: Saunders 4th

ANS: A Rationale: Ample fluid intake is encouraged to promote the excretion of uric acid. The client is placed on bedrest until the pain subsides. A diet low in purine normally is prescribed. NSAIDs are used to reduce pain and inflammation. Colchicine, which also may be prescribed, reduces the migration of leukocytes to the synovial fluid. Strategy: Use the process of elimination. Note the strategic words does not understand in the question. This phrasing indicates a negative event query and asks you to select an incorrect statement. Also note the strategic word acute. This will assist in eliminating options 3 and 4. Regarding the remaining options, recalling that a low-purine diet may be recommended for the client with gout will direct you to option 1. Review care of the client with gout if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 607-608). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1941) A client is scheduled for surgical creation of an internal arteriovenous (AV) fistula on the following day. The client says to the nurse, "I'll be so happy when the fistula is made tomorrow. This means I can have that other hemodialysis catheter pulled right out." The nurse interprets that the client: a. Does not understand that the site needs to mature or develop for 1 to 2 weeks before use b. Has an accurate understanding of the procedure and aftercare c. Does not realize how painful removal of the dialysis catheter will be d. Is not aware that the alternate access site is left in place prophylactically for 2 months Source: Saunders 4th

ANS: A Rationale: An AV fistula is the internal creation of an arterial-to-venous anastomosis. This causes engorgement of the vein, allowing both the artery and the vein to be easily cannulated for hemodialysis. Fistulas take 1 to 2 weeks to mature or develop before they can be used for dialysis, so the current method of access must remain in place to be used during that time period. Options 2, 3, and 4 are incorrect statements. Strategy: To answer this question correctly, it is necessary to understand concepts related to the creation and use of internal AV fistulas. Remember that an AV fistula needs 1 to 2 weeks to mature after it is created. If you had difficulty with this question, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 960). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1550) The nurse is caring for a client with possible cholelithiasis who is being prepared for IV cholangiography and the nurse teaches the client about the procedure. Which client statement indicates that the client understands the purpose of this test? a. "They are going to 'look at' my gallbladder and ducts." b. "This procedure will drain my gallbladder." c. "My gallbladder will be irrigated." d. "They will put medication in my gallbladder." Source: Saunders 4th

ANS: A Rationale: An IV cholangiogram is for diagnostic purposes. It outlines both the gallbladder and the ducts, so gallstones that have moved into the ductal system can be detected. X-rays are used to visualize the biliary duct system after IV injection of radiopaque dye. This test is diagnostic and does not involve irrigation, instillation of medications, or draining of the gallbladder. Strategy: Use the process of elimination. Eliminate options 2, 3, and 4 because they are comparative or alike. If you are unfamiliar with this procedure, review its purpose. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1186-1187). Philadelphia: W.B. Saunders. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., pp. 695-696). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 962). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

18) A client arrives in the emergency room and is assessed by the nurse. The client is staggering, confused, and verbally abusive, complains of a headache from drinking alcohol, and is asking for medication. The nurse explains to the client that the physician will need to perform an assessment before the administration of medication. When the client becomes verbally abusive, the nurse obtains leather restraints and threatens to place the client in the restraints. With which of the following can the client legally charge the nurse as a result of the nursing action? a. Assault b. Battery c. Negligence d. Invasion of privacy Source: Saunders 4th

ANS: A Rationale: An assault occurs when a person puts another person in fear of a harmful or offensive contact. For this intentional tort to be actionable, the victim must be aware of the threat of harmful or offensive contact. Battery is the actual contact with one's body. Negligence involves actions below the standards of care. Invasion of privacy occurs with unreasonable intrusion into the individual's private affairs. Strategy: Use the process of elimination. Note the strategic word threatens in the question. This word should direct you to option 1. If you had difficulty with this question, review the descriptions associated with the terms in each option. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 413). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1113) A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How would the nurse correctly interpret the client's neurovascular status? a. The neurovascular status is normal because of increased blood flow through the leg. b. The neurovascular status is moderately impaired, and the surgeon should be called. c. The neurovascular status is slightly deteriorating and should be monitored for another hour. d. The neurovascular status is adequate from an arterial approach, but venous complications are arising. Source: Saunders 4th

ANS: A Rationale: An expected outcome of surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. Therefore, options 2, 3, and 4 are incorrect interpretations. Strategy: Use the process of elimination. Option 2 can be eliminated because the pedal pulse is unchanged from admission. Venous complications from immobilization resulting from surgery would not be apparent within 4 hours, so eliminate option 4. From the remaining options, think about the effects of sudden reperfusion in an ischemic limb. There would be redness from new blood flow and edema from the sudden change in pressure in the blood vessels. Review the expected assessment findings following this surgical procedure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 798). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2040) A nurse is monitoring a client with a diagnosis of schizophrenia. The nurse notes that the client's emotional responses to situations occurring throughout the day are incongruent with the tone of the situation. The nurse documents the findings using which description of the client's behavioral response? a. Inappropriate affect b. Flat affect c. Blunted affect d. Bizarre affect Source: Saunders 4th

ANS: A Rationale: An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation. A flat affect is manifested as an immobile facial expression or blank look. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client's inner emotions. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. Strategy: Use the process of elimination. Note the relationship between the words incongruent in the question and inappropriate in the correct option. If you are unfamiliar with behaviors in a client with schizophrenia, review this content. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 394). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1875) A client arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. The client tells the nurse that a home pregnancy test was positive but that she began to have mild cramps and is now having moderate vaginal bleeding. On physical examination of the client, it is noted that the client has a dilated cervix. The nurse determines that the client is experiencing which type of abortion? a. Inevitable b. Incomplete c. Threatened d. Septic Source: Saunders 4th

ANS: A Rationale: An inevitable abortion is a termination of pregnancy that cannot be prevented. Moderate to severe bleeding with mild cramping and cervical dilation would be noted in this type of abortion. An incomplete abortion manifests with heavy bleeding, severe cramping, cervical dilation, and passage of large clots. A threatened abortion manifests with slight to moderate bleeding and intermittent cramping without dilation. A septic abortion manifests with bleeding with odor, cervical dilation, and fever. Cramping may or may not be present. Strategy: Focus on the data presented in the question. Option 4 can be eliminated first because there is no data in the question indicating that the client is septic. Eliminate option 3 next because in this type of abortion, the cervix would not be dilated. Regarding the remaining options, focusing on the strategic words mild and moderate will assist in directing you to option 1. Review the manifestations of the various types of abortions if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 618). St. Louis: Mosby. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 624). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1047) The nurse is caring for a client with a diagnosis of influenza who first began to experience symptoms yesterday. Antiviral therapy is prescribed and the nurse provides instructions to the client about the therapy. Which statement by the client indicates an understanding of the instructions? a. "I must take the medication exactly as prescribed." b. "Once I start the medication, I will no longer be contagious." c. "I will not get any colds or infections while taking this medication." d. "This medication has minimal side effects and I can return to normal activities." Source: Saunders 4th

ANS: A Rationale: Antiviral medications for influenza must be taken exactly as prescribed. These medications do not prevent the spread of influenza and clients are usually contagious for up to 2 days after the initiation of antiviral medications. Secondary bacterial infections may occur despite antiviral treatment. Side effects occur with these medications and may necessitate change in activities, especially when driving or operating machinery if dizziness occurs. Strategy: Use process of elimination and note the strategic words indicates an understanding. Using general medication guidelines will direct you to option 1. Review these medications if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 1059). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

928) The client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? a. This is a normal, expected event. b. The client is experiencing early signs of ischemic bowel. c. The client should not have the nasogastric tube removed. d. This indicates inadequate preoperative bowel preparation. Source: Saunders 4th

ANS: A Rationale: As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination. Recalling the normal progression of bowel activity following ostomy formation will direct you to option 1. Review the expected findings following creation of a colostomy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 836). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1324-1325). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1703) The nurse has inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts to slowly advance the nasogastric tube with each swallow. The client begins to cough, gag, and choke. Which nursing action would least likely result in proper tube insertion and promote client relaxation? a. Continuing to advance the tube to the desired distance b. Pulling the tube back slightly c. Checking the back of the pharynx using a tongue blade and flashlight d. Instructing the client to breathe slowly and take sips of water Source: Saunders 4th

ANS: A Rationale: As the nasogastric tube is passed through the oropharynx, the gag reflex is stimulated, which may cause coughing, gagging, and/or choking. Instead of passing through to the esophagus, the nasogastric tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway. Because the tube may enter the larynx and obstruct the airway, pulling the tube back slightly will remove it from the larynx; advancing the tube might position it in the trachea. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Slow breathing helps the client relax, which reduces the gag response. The nurse should check the back of the client's throat to note whether the tube has coiled. The tube may be advanced after the client relaxes. Strategy: Use the process of elimination. Note the strategic words least likely. Options 2, 3, and 4 all aim at assessing and promoting relaxation, whereas option 1 could result in an unsafe malposition of the nasogastric tube into the trachea. Review the procedure for inserting an NG tube if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1403, 1405). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

156) The nurse has received an order to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse asks which initial question? a. "Have you ever had a transfusion before?" b. "Why do you think that you need the transfusion?" c. "Have you ever gone into shock for any reason in the past?" d. "Do you know the complications and risks of a transfusion?" Source: Saunders 4th

ANS: A Rationale: Asking the client about personal experience with transfusion therapy provides a good starting point for client teaching about this procedure. Options 3 and 4 are not helpful because they may elicit a fearful response from the client. Although determining whether the client knows the reason for the transfusion is important, option 2 is not an appropriate statement in terms of eliciting information from the client regarding an understanding of the need for the transfusion. Strategy: Use the process of elimination and note that the strategic words in the question are initial question. This tells you that the correct option is the best starting point for discussion about the transfusion therapy. Options 3 and 4 have emotionally laden trigger words, including gone into shock and risks, respectively, which make them incorrect. From the remaining options, focus on the strategic words and use therapeutic communication techniques to direct you to option 1. Review pretransfusion assessment procedures if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 913). Philadelphia: W.B. Saunders. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., pp. 972, 977). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1190). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1981) A home care nurse visits a client to perform a dressing change on a leg ulcer. The client has diabetes mellitus and a history of cardiac disease and is taking one aspirin daily in addition to other medications as prescribed. The client tells the nurse that dental surgery is scheduled and asks the nurse if the aspirin should be discontinued. The nurse should appropriately tell the client that: a. Dental surgery can safely be done 10 days after stopping the aspirin, depending on the physician's preference. b. Aspirin has no effect on the surgical procedure and that it may minimize discomfort. c. There is no risk to having such a minor surgery while taking aspirin. d. The pharmacist should be called. Source: Saunders 4th

ANS: A Rationale: Aspirin is an antiplatelet and affects the platelet for its life, which is 7 to 10 days. For an elective procedure such as dental surgery, aspirin therapy should be stopped approximately 10 days before the procedure to prevent bleeding complications. Options 2 and 3 are incorrect. Option 4 is not an appropriate response and places the client's issue on hold. Strategy: Use the process of elimination. Eliminate options 2 and 3 first because they are comparative or alike. Use therapeutic communication techniques to eliminate option 4 because it places the client's issue on hold. If you had difficulty with this question, review the relationship of aspirin and surgery. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., pp. 814, 824-825). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 437). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1636) A client has refused to eat more than a few spoonfuls of breakfast. The physician has ordered that tube feedings be initiated if the client fails to eat at least half of a meal, because the client had been losing weight for the prior 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The client begins crying and tries to eat more. Based on the nurse's actions, the nurse may also be accused of a tort known as which of the following? a. Assault b. Battery c. Slander d. Invasion of privacy Source: Saunders 4th

ANS: A Rationale: Assault occurs when a person puts another person in fear of harmful or offensive contact and the victim fears and believes that harm will result as a result of the threat. In this situation, the nurse could be accused of the tort of assault. Battery is the intentional touching of another's body without the person's consent. Slander is verbal communication that is false and harms the reputation of another. Invasion of privacy is committed when the nurse intrudes into the client's personal affairs or violates confidentiality. Strategy: Use the process of elimination. Focusing on the words used by the nurse and noting that the nurse threatens the client will direct you to option 1. Review the descriptions of each item in the options if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 413). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1684) The nurse is performing an assessment on a pregnant client at 16 weeks of gestation. On assessment, the nurse would expect that the fundus of the uterus would be located at which of the following areas? a. Midway between the symphysis pubis and the umbilicus b. At the umbilicus c. Just above the symphysis pubis d. At the level of the xiphoid process Source: Saunders 4th

ANS: A Rationale: At 12 weeks' gestation, the uterus extends out of the maternal pelvis and can be palpated above the symphysis pubis. At 16 weeks' gestation, the fundus reaches midway between the symphysis pubis and umbilicus. At 20 weeks' gestation, the fundus is located at the umbilicus. By 36 weeks' gestation, the fundus reaches its highest level at the xiphoid process. Strategy: Use the process of elimination and knowledge regarding the patterns of uterine growth to answer this question. Focus on the weeks of gestation identified in the question to assist in directing you to the correct option. If you are unfamiliar with the patterns of uterine growth during pregnancy, review this content. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 110). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

2520) The home care nurse is reviewing the record of a client newly diagnosed with glaucoma who is scheduled for a home visit. The nurse notes that the physician has prescribed atropine sulfate (Isopto-Atropine) and pilocarpine hydrochloride (Isopto Carpine) eye drops. The nurse contacts the physician before the home visit to: a. Clarify the order for the atropine sulfate. b. Clarify the order for the pilocarpine hydrochloride. c. Determine the date of the scheduled follow-up physician visit. d. Determine the extent of the intraocular pressure caused by the glaucoma. Source: Saunders 4th

ANS: A Rationale: Atropine sulfate is a mydriatic and cycloplegic medication that is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and cause increased intraocular pressure in the eye. Pilocarpine hydrochloride is a miotic agent used in the treatment of glaucoma. It is unnecessary to contact the physician regarding the date for follow-up treatment. In fact, the client may know this date, which the nurse can ask about during the home care visit. It is unnecessary to know the extent of the intraocular pressure caused by the glaucoma in planning care for the client. Strategy: Focus on the information in the question, noting that the question addresses two medications. This will assist in eliminating options 3 and 4. Recall that mydriatics dilate, so these medications are contraindicated in glaucoma. Review the contraindications associated with glaucoma if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 727-730). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 1196). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1754) The nurse prepares to administer acetylcysteine (Mucomyst) to the client with an overdose of acetaminophen (Tylenol). Which of the following are appropriate actions when administering this antidote? a. Mixing the medication in a flavored ice drink and allowing the client to drink the medication b. Administering the medication by an intravenous (IV) line, mixed in 50 mL of normal saline and piggybacked through c. Administering the medication intramuscularly (IM) in the gluteal muscle d. Administering the medication subcutaneously in the deltoid muscle Source: Saunders 4th

ANS: A Rationale: Because acetylcysteine has a pervasive flavor of rotten eggs, it must be disguised in a flavored ice drink and is preferably drunk through a straw to minimize contact with the mouth. Acetylcysteine is the antidote for acetaminophen. It is a solution that is also used as a mucolytic agent, administered via nebulization. It is not administered by the IV, IM, or subcutaneous route. Strategy: Use the process of elimination. Knowing that the medication is a solution that is also used for nebulization treatments will assist you in selecting the option that indicates an oral route. Note that options 2, 3, and 4 are comparative or alike and indicate parenteral administration and option 1, the correct option, indicates oral administration. Review this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2007). Mosby's 2007 nursing drug reference (20th ed., p. 79). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1373) Cyclobenzaprine hydrochloride (Flexeril) is prescribed for a client for muscle spasms. The nurse is reviewing the client's record. Which of the following disorders, if noted in the record, would indicate a need to contact the physician about the administration of this medication? a. Glaucoma b. Emphysema c. Hypothyroidism d. Diabetes mellitus Source: Saunders 4th

ANS: A Rationale: Because cyclobenzaprine (Flexeril) has anticholinergic effects, it should be used with caution in clients with a history of urinary retention, glaucoma, and increased intraocular pressure. Cyclobenzaprine should be used only for a short term (2 to 3 weeks). Strategy: Use the process of elimination. Recalling that this medication has anticholinergic effects will direct you to option 1. If you are unfamiliar with this medication and the contraindications associated with its administration, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 297). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2501) A client with acquired immunodeficiency syndrome (AIDS) is receiving ganciclovir (Cytovene). The nurse takes which priority nursing action in caring for this client? a. Ensuring that the client uses an electric razor for shaving b. Administering the medication with an antacid c. Monitoring for signs of hyperglycemia d. Administering the medication without food Source: Saunders 4th

ANS: A Rationale: Because ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects, the nurse monitors for signs and symptoms of bleeding and implements the same precautions as for a client receiving anticoagulant therapy. The medication does not have to be taken on an empty stomach or without food and should not be taken with an antacid. The medication may cause hypoglycemia, but not hyperglycemia. Strategy: Use the process of elimination. Noting the strategic word priority and recalling that the medication can cause bleeding from thrombocytopenia will assist in eliminating the incorrect options. Review the nursing care associated with use of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 531). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., pp. 392-393). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

2579) A nurse is developing a plan of care for a client who is scheduled for a thyroidectomy. The nurse develops a nursing diagnosis related to psychosocial needs knowing that which of the following is likely to occur in the client? a. Body image changes b. Infertility c. Sexual dysfunction d. Gynecomastia Source: Saunders 4th

ANS: A Rationale: Because of the location of the incision in the neck area, many clients are afraid of thyroid surgery for fear of having a visible large scar postoperatively. Having all or part of the thyroid gland removed will not cause the client to experience gynecomastia or hirsutism. Sexual dysfunction and infertility could possibly occur if the entire thyroid was removed and the client was not placed on thyroid replacement medications. Strategy: Use the process of elimination. Recalling the anatomical location of the surgical incision will assist in directing you to option 1. Review the psychosocial needs of a client scheduled for thyroidectomy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1423). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

1625) The nurse is performing an initial assessment on a large-for-gestational age (LGA) newborn infant. Which physical assessment technique would the nurse perform to assess for the evidence of birth trauma? a. Palpate the clavicles for a fracture. b. Auscultate the heart for a cardiac defect. c. Blanch the skin for evidence of jaundice. d. Perform Ortolani's maneuver for hip dislocation. Source: Saunders 4th

ANS: A Rationale: Because of the newborn infant's large size, there is an increased risk for shoulder dystocia. This may result in fractured clavicles and/or brachial plexus palsy. Other complications related to birth trauma include facial paralysis, phrenic nerve palsy, depressed skull fractures, hematomas, and bleeding. Option 2 would not be related to birth trauma, even though there is an increase in cardiac defects in the large-for-gestational age (LGA) newborn infant, such as transposition of the great vessels. Jaundice would not be present initially. Hip dislocation is a congenital disorder and is not caused by birth trauma. Strategy: Use the process of elimination, focusing on the strategic words birth trauma. Think of trauma as an injury. Option 1 is the only option that identifies an injury. Review the risks associated with delivery of an LGA newborn infant if you had difficulty with this question. Reference: Wong, D., Perry, S., Hockenberry, M., et al. (2006). Maternal child nursing care (3rd ed., pp. 581-582, 830). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

1920) A nurse is preparing to collect a 24-hour urine specimen from the client. Which of the following is an inaccurate action in collecting the specimen? a. Asking the client to void, saving the specimen, and noting the start time b. Discarding the urine specimen at the start time c. Placing the specimen on ice or refrigerated d. Asking the client to void at the end of the collection and adding this to the collection Source: Saunders 4th

ANS: A Rationale: Because the 24-hour urine is a timed, quantitative determination, it is essential to start the test with an empty bladder. The collected urine should be refrigerated or placed on ice to prevent changes in the urine. Fifteen minutes before the end of the collection time, the client should be asked to void, and this specimen is added to the collection. Strategy: Use the process of elimination. Note the strategic words inaccurate action. This phrasing indicates a negative event query and directs you to select an incorrect action. Think about the purpose of this timed test, and eliminate options 2 and 4 because it would make sense that the test should be started and ended when the client has an empty bladder. Recalling that a urine specimen should not stand unrefrigerated will direct you to option 1. Review this procedure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1666). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2588) A child is brought to the emergency department after the child was accidentally struck in the lower back region with a baseball bat. When gathering assessment data, the nurse discovers that the child has hemophilia. The nurse should immediately assess: a. The urine for hematuria b. The respiratory rate c. For complaints of headache d. For signs of slurred speech Source: Saunders 4th

ANS: A Rationale: Because the kidneys are located in the flank region of the body, trauma to the back area can cause the presence of hematuria, particularly in the child with hemophilia. The nurse would be most concerned about the child's airway and respiratory rate if the child sustained an injury to the neck region. Headache and slurred speech are associated with head trauma. Strategy: Focus on the type and area of injury. Noting the child's history of hemophilia should direct you to consider bleeding as a concern. Noting the anatomical location of the injury and the relationship to the location of the kidneys will direct you to option 1. Review care of the child with hemophilia if you had difficulty with this question. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., pp. 1254, 1535-1536). St. Louis: Mosby. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1317). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Child Health Alternate Question Types -> Multiple Choice

2640) A client with Parkinson's disease is taking benztropine mesylate (Cogentin) 2 mg PO daily. In monitoring this client for medication side effects, the nurse plans to focus the assessment on: a. Voiding pattern b. Prothrombin time c. Pupil response d. Respiratory status Source: Saunders 4th

ANS: A Rationale: Because urinary retention is a side effect of benztropine mesylate, the nurse must assess for dysuria, distended abdomen, infrequent voiding in small amounts, and overflow incontinence. Monitoring of the other options is not necessary with this medication. Strategy: Knowledge of the side effects specific to benztropine mesylate is required to answer the question. Remember that urinary retention is a side effect of benztropine mesylate. Review the side effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 128). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

71) A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas determination. Before the blood is drawn, an Allen's test is performed to determine the adequacy of the: a. Ulnar circulation b. Carotid circulation c. Femoral circulation d. Popliteal circulation Source: Saunders 4th

ANS: A Rationale: Before radial puncture for obtaining an arterial specimen for arterial blood gases, you should perform an Allen's test to determine adequate ulnar circulation. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Options 2, 3, and 4 are incorrect options. Strategy: Use the process of elimination and knowledge regarding the purpose and procedure for the Allen's test. Remember that the purpose of this test is to assess the adequacy of the ulnar circulation. Review the purpose and procedure of the Allen's test if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 248). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 731-732). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1284) The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following? a. Giving the client thin liquids b. Thickening liquids to the consistency of oatmeal c. Placing food on the unaffected side of the mouth d. Allowing plenty of time for chewing and swallowing Source: Saunders 4th

ANS: A Rationale: Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration. Strategy: Use the process of elimination, noting the strategic word avoids. Option 4 is generally a good action for all clients. Option 3 is correct because the client has better sensation and motion on the unaffected side of the mouth. Remember that thickened liquids are easier for the client with impaired facial motion and swallowing ability to manage. Knowing this enables you to choose option 1 as the action to avoid. Review care of the client with residual dysphagia if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2114, 2129). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1042-1043). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1298) The client with Bell's palsy asks the nurse what has caused this problem. The nurse's response is based on an understanding that the cause is: a. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem b. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia c. Primarily genetic in origin, triggered by exposure to meningitis d. Primarily genetic in origin, triggered by exposure to neurotoxins Source: Saunders 4th

ANS: A Rationale: Bell's palsy is a one-sided facial paralysis from compression of the facial nerve. The exact cause is unknown, but may include vascular ischemia, infection, exposure to viruses such as herpes zoster or herpes simplex, autoimmune disease, or a combination of these factors. Strategy: Use the process of elimination. If you know that the cause of Bell's palsy is uncertain, you are able to eliminate options 3 and 4. Recalling that infection, viruses, and the immune system may have an effect in causing this disorder will direct you to option 1. Review the cause of Bell's palsy if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1605). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2630) A client who has begun taking betaxolol (Kerlone) demonstrates satisfactory response to the medication as indicated by which of the following nursing assessment findings? a. Decrease in blood pressure from 142/94 mm Hg to 128/82 mm Hg b. Increase in edema to 3+ c. Weight gain of 5 pounds d. Increase in pulse rate to 74 beats/min from 58 beats/min Source: Saunders 4th

ANS: A Rationale: Betaxolol is a β-adrenergic blocking agent used to lower blood pressure, relieve angina, or decrease the occurrence of dysrhythmias. Side effects include bradycardia and signs and symptoms of congestive heart failure, such as weight gain and increased edema. Strategy: Recognize this medication as a β-adrenergic blocking agent (the names of such agents end with -olol). Note that the question asks for the satisfactory response to the medication. From this point, recalling the action of a β-adrenergic blocking agent will direct you to option 1. Review the actions of β-adrenergic agents if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 132). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2505) A pregnant woman of 30 weeks' gestation is admitted to the maternity unit in preterm labor. The woman asks the nurse about the purpose of betamethasone, which has been prescribed by the obstetrician. The nurse responds that this medication will: a. Promote fetal lung maturity b. Prevent membrane rupture c. Stop the premature uterine contractions d. Delay delivery Source: Saunders 4th

ANS: A Rationale: Bethamethasone, a steroidal anti-inflammatory, increases the surfactant level and promotes lung maturation, thereby reducing the risk of respiratory distress syndrome in the newborn infant. Surfactant production does not become stable until after 32 weeks of gestation, and if adequate amounts of lung surfactant are not present, respiratory distress and death of the newborn infant could result. Delivery should be delayed for at least 48 hours after administration of bethamethasone to allow time for the lungs to mature. The other options are incorrect. Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they are comparative or alike. Knowledge regarding the purpose of this medication is necessary to choose between the remaining options. Review the purpose of this medication if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 718). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., pp. 96-97). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2021) A client reports to the health care clinic for an eye examination, and a diagnosis of macular degeneration is made. Which assessment question will most specifically elicit information regarding the clinical manifestations associated with this disorder? a. "Have you had any blurred vision?" b. "Do you have any pain in your eye?" c. "Are you having difficulty seeing things out of the side of your eyes?" d. "Do bright lights bother you?" Source: Saunders 4th

ANS: A Rationale: Blurred central vision occurs with macular degeneration. Changes in peripheral visual acuity (option 3) most often occurs with glaucoma. Glare from bright lights (option 4) is a common complaint in the client with a cataract. Pain in the eye (option 2) is not specifically associated with macular degeneration. Strategy: Use the process of elimination. It is necessary to know the clinical manifestations associated with macular degeneration to answer this question. Recall that blurred central vision occurs with macular degeneration. Review this condition if you are unfamiliar with the manifestations that occur. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1102). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

2465) A client is suspected of having a skeletal muscle disorder. The nurse assesses for elevations in which of the following isoenzyme values reported with the creatine kinase (CK) level? a. MM b. MB c. BB d. MS Source: Saunders 4th

ANS: A Rationale: CK is a cellular enzyme that can be fractionated into three isoenzymes. The MM band reflects CK from skeletal muscle. This band would be elevated in skeletal muscle disease. The MB band reflects CK from myocardial muscle. The BB band reflects CK from the brain. There is no MS band. Strategy: Knowledge of the CK isoenzymes is needed to answer this question. To answer questions on this topic, correlate MM with muscle, BB with brain, and MB with myocardial tissue. Review this important laboratory value for detecting skeletal muscle disease if you had difficulty with this question. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 322). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

975) The client with a history of duodenal ulcer is taking calcium carbonate chewable tablets. Which finding indicates that the client is experiencing optimal effects of the medication? a. Heartburn is relieved. b. Muscle twitching stops. c. The serum calcium level increases. d. The serum phosphorus level decreases. Source: Saunders 4th

ANS: A Rationale: Calcium carbonate can be used as an antacid for the relief of heartburn and indigestion. Calcium carbonate also can be used as a calcium supplement (option 3) or to bind phosphorus in the gastrointestinal tract with renal failure (option 4). Option 2 is incorrect, although adequate calcium levels are needed for proper neurological function. Strategy: Note the strategic word optimal. Focusing on the client's diagnosis will direct you to option 1. Review this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 128). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1964) A clinic nurse is providing instructions to a client with hypertension who will be taking captopril (Capoten). Which statement by the client indicates a need for further instruction? a. "I need to drink increased amounts of water." b. "I need to change positions slowly." c. "I need to avoid taking hot baths or showers." d. "I need to sit down and rest if dizziness or lightheadedness occurs." Source: Saunders 4th

ANS: A Rationale: Captopril is an antihypertensive medication (angiotension-converting enzyme inhibitor). Orthostatic hypotension can occur in clients taking this medication. Clients are advised to avoid standing in one position for long periods of time, to change positions slowly, and to avoid extreme warmth such as with baths, showers, or heat from the sun in warm weather. The client should be instructed to monitor for signs of orthostatic hypotension such as dizziness, lightheadedness, weakness, and syncope. An increased intake of water could actually aggravate the hypertension. Strategy: Use the process of elimination and note the strategic words need for further instruction. This phrasing indicates a negative event query and directs you to select an incorrect statement. Note that the client has hypertension. This provides you with the clue that captopril is an antihypertensive. Use knowledge regarding the effects of an antihypertensive to direct you to option 1. Review this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 182). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 472). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1093) A client with rapid rate atrial fibrillation asks a nurse why the physician is going to perform carotid sinus massage. Which of the following would be reflective of a correct explanation provided by the nurse? a. The vagus nerve slows the heart rate. b. The diaphragmatic nerve slows the heart rate. c. The diaphragmatic nerve overdrives the rhythm. d. The vagus nerve increases the heart rate, overdriving the rhythm. Source: Saunders 4th

ANS: A Rationale: Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The others include inducing the gag reflex and asking the client to strain or bear down. Medication therapy often is needed as an adjunct to keep the rate down or maintain the normal rhythm. Options 2, 3, and 4 are incorrect descriptions of this procedure. Strategy: Knowledge of anatomy and physiology alone may be sufficient to answer this question. Eliminate options 3 and 4 because a rapid rate dysrhythmia would need to be slowed. Recalling the functions of the vagus nerve and the diaphragmatic nerve will direct you to option 1. The vagus nerve affects heart rate. The diaphragmatic nerve affects respiration. If you are unfamiliar with the functions of these nerves, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 727, 738). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2486) A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg, and a nursing student is assigned to provide care for the client. The nursing instructor asks the student to describe this diagnosis. Which of the following answers demonstrates the student's understanding of the diagnosis? a. "A skin infection into the deep dermis and subcutaneous fat" b. "An acute superficial infection" c. "An inflammation of the epidermis" d. 'An epidermal infection caused by staphylococci" Source: Saunders 4th

ANS: A Rationale: Cellulitis is a skin infection into deeper dermis and subcutaneous fat that results in deep red erythema without sharp borders and spreads widely through tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination. Eliminate options 2, 3, and 4 because they are comparative or alike. If you had difficulty with this question, review the characteristics of cellulitis. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1595-1597). Philadelphia: W.B. Saunders. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., p. 1149). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

1790) A client with liver cancer receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter. The nurse would try to limit which food that is most likely to cause this taste for the client? a. Beef b. Potatoes c. Custard d. Cantaloupe Source: Saunders 4th

ANS: A Rationale: Chemotherapy may cause distortion of taste. Often, beef and pork are reported to taste bitter or metallic. The nurse can promote client nutrition by helping the client choose alternative sources of protein in the diet. Options 2, 3, and 4 are not likely to cause distortion of taste. Strategy: The subject of the question is optimal management of a change in taste sensation. To answer this question accurately, you must be familiar with the most troublesome foods. Remember that beef and pork are often reported to taste bitter or metallic. If you had difficulty with this question, review interventions related to nutrition for the client undergoing chemotherapy. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 322). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

937) The nurse has taught the client with chronic pancreatitis about risk factor modification to reduce the incidence of recurrences. The nurse determines that the client has understood the information if the client states that it will be necessary to control which factor? a. Alcohol intake b. Duodenal ulcer c. Crohn's disease d. Diabetes mellitus Source: Saunders 4th

ANS: A Rationale: Chronic pancreatitis is aggravated by continued alcohol intake. Each of the other options is not associated with pancreatitis. Strategy: Use the process of elimination. Remember that options that are comparative or alike are not likely to be correct. In this question, two of the incorrect options (2 and 3) represent other disorders of the digestive system. Choose option 1 over option 4 by recalling that diabetes mellitus is an endocrine disorder of the pancreas, whereas pancreatitis is an exocrine disorder. Review the factors that contribute to a recurrence of pancreatitis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1412). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1224) Cinoxacin (Cinobac), a urinary antiseptic, is prescribed for the client. The nurse reviews the client's medical record and would contact the physician regarding which documented finding to verify the prescription? a. Client's history b. Medication history c. Diagnostic test result d. Laboratory test results Source: Saunders 4th

ANS: A Rationale: Cinoxacin should be administered with caution in clients with renal impairment. The dosage should be reduced, and failure to do so could result in accumulation of cinoxacin to toxic levels. Therefore, the nurse would verify the prescription with the physician if the client had a documented history of renal insufficiency. The laboratory and diagnostic test results are normal findings. Folic acid (vitamin B₆) may be prescribed for a client with renal insufficiency to prevent anemia. Strategy: Focus on the issue, the need to contact the physician. Eliminate options 3 and 4 because the laboratory and diagnostic test results are normal findings. From the remaining options, note the disorder in the client's history. This directs you to option 1. Review the contraindications associated with this medication if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 1013). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice Chart

919) The nurse is reviewing the laboratory results in a client with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed for this client? a. Low-protein diet b. High-protein diet c. Moderate-fat diet d. High-carbohydrate diet Source: Saunders 4th

ANS: A Rationale: Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein and this results in the formation of ammonia. If the client has hepatic encephalopathy, a low-protein diet would be prescribed. Strategy: Recall the physiology of the liver in answering this question. You should be directed easily to option 1. Also, note that options 1 and 2 are opposite, which should provide you with the clue that one of these options is correct. Review dietary measures for the client with a high ammonia level if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1369, 1380). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1125). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2358) A client with testicular cancer is receiving cisplatin. The nurse assesses for which of the following as a toxic effect of this medication? a. Tinnitus b. Elevated white blood cell (WBC) count c. Nausea and vomiting d. Diarrhea Source: Saunders 4th

ANS: A Rationale: Cisplatin is a medication that kills cells primarily by forming cross-links between and within strands of DNA. Its principal use is in the treatment of testicular cancer, although it also can be used to treat carcinomas of the ovary, bladder, head, and neck. It can cause neurotoxicity, nephrotoxicity, bone marrow depression, and ototoxicity, which manifests as tinnitus and high-frequency hearing loss. Nausea and vomiting are expected effects, which can be severe and begin 1 hour after administration, persisting for 1 to 2 days. Strategy: Use the process of elimination. Note the strategic word toxic. Eliminate option 2 first because the WBC count is likely to decrease, rather than increase. Knowing that nausea and vomiting usually occur when antineoplastic medications are administered will assist in eliminating option 3. Regarding the remaining options, recalling that toxicity to the ear is associated with use of this medication will direct you to the correct option. Review the action and effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 257). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2306) A client with end-stage renal disease (ESRD) has a nursing diagnosis of ineffective coping related to terminal disease. Which of the following nursing interventions would be inappropriate in working with this client? a. Set limits on mood swings and expressions of hostility. b. Assess the client and family coping patterns. c. Explore the meaning of the illness with the client. d. Give the client information when the client is ready to listen. Source: Saunders 4th

ANS: A Rationale: Clients with ESRD also are likely to experience mood swings or to express hostility, anger, and depression, among other responses. The nurse acknowledges the client's feelings, allows the client to express those feelings, and is supportive. Options 2, 3, and 4 are helpful to the client. Strategy: Use the process of elimination and note the strategic word inappropriate in the question. Knowledge of basic communication strategies and psychosocial support will direct you to option 1. Setting limits would not be helpful in this client situation. Review care of the client with ESRD if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 949, 962-963). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1372) A nurse is reviewing the record of a client who has been prescribed baclofen (Lioresal). Which of the following disorders, if noted in the client's history, would alert the nurse to contact the physician? a. Seizure disorder b. Hyperthyroidism c. Diabetes mellitus d. Coronary artery disease Source: Saunders 4th

ANS: A Rationale: Clients with seizure disorders may have a lowered seizure threshold when baclofen is administered. Concurrent therapy may require an increase in the anticonvulsive medication. The disorders in options 2, 3, and 4 are not contraindications or cautions for the use of this medication. Strategy: Use the process of elimination and knowledge about the contraindications and the cautions associated with the administration of baclofen. Remember that baclofen is used with caution for clients with a seizure disorder. If you are unfamiliar with these contraindications and cautions, review this content. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 240). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1697) The nurse in the newborn nursery is assessing a neonate who was born of a mother addicted to cocaine. Which of the following would the nurse expect to note in the neonate? a. Tremors b. Bradycardia c. Flaccid muscles d. Extreme lethargy Source: Saunders 4th

ANS: A Rationale: Clinical symptoms at birth in neonates exposed to cocaine in utero include tremors, tachycardia, marked irritability, muscular rigidity, hypertension, and exaggerated startle reflex. These infants are difficult to console and exhibit an inability to respond to voices or environmental stimuli. They are often poor feeders and have episodes of diarrhea. Strategy: Use the process of elimination. Think about the effects of the drug to assist in directing you to the correct option. Also, note the similarity between options 2, 3, and 4. If you had difficulty with this question, review the effects of cocaine on the fetus and neonate. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 602). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

2604) A client with acquired immunodeficiency syndrome (AIDS) has been started on therapy with zidovudine (also called azidothymidine [AZT]) (Retrovir). The nurse monitors the results of which laboratory blood study for adverse effects of therapy? a. Complete blood count (CBC) b. Blood urea nitrogen (BUN) level c. Creatinine level d. Potassium concentration Source: Saunders 4th

ANS: A Rationale: Common adverse effects of this medication are agranulocytopenia and anemia. The nurse monitors the CBC results for these changes. BUN, creatinine, and potassium are unrelated to this medication. Strategy: Use the process of elimination. Eliminate options 2, 3, and 4 because they are comparative or alike and relate to renal function. Review the adverse affects of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 911). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

2138) A nurse is caring for a client who has just had a plaster leg cast applied. The nurse would plan to prevent the development of compartment syndrome by instructing the licensed practical nurse assigned to care for the client to: a. Elevate the limb and apply ice to the affected leg. b. Elevate the limb and cover the limb with bath blankets. c. Place the leg in a slightly dependent position and apply ice to the affected leg. d. Keep the leg horizontal and apply ice to the affected leg. Source: Saunders 4th

ANS: A Rationale: Compartment syndrome is prevented by controlling edema. This is achieved most optimally with the use of elevation and application of ice. Options 2, 3, and 4 are incorrect. Strategy: Use the process of elimination. Knowing that edema is controlled or prevented with limb elevation helps you to eliminate options 3 and 4. Regarding the remaining options, think about the effects of ice versus bath blankets. Ice will further control edema, whereas bath blankets will produce heat and prevent air circulation needed for the cast to dry. Review the interventions that will prevent compartment syndrome if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 628). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1191, 1198). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Leadership and Management Alternate Question Types -> Multiple Choice

1803) A female client states to the home health nurse that she has not had a bowel movement since coming home from the hospital after surgery 4 days ago. The nurse instructs the client to follow which of the following appropriate diets at this time? a. High-fiber diet b. Full liquid diet c. Low-residue diet d. Low-sodium diet Source: Saunders 4th

ANS: A Rationale: Constipation is the probable cause of the client's lack of bowel movements. Constipation is the difficult or infrequent passage of stools, which are hard and dry. Constipation has numerous causative factors including psychogenic, lack of physical activity, inadequate intake of food and fiber, and medication influences. A high-fiber diet often is indicated for constipation because it will promote bulk and encourage intestinal peristalsis. A full liquid diet will add fluids but no bulk to help relieve the constipation. A low-residue diet (also known as a low-fiber diet) has little bulk to assist with the needed peristalsis. Decreasing the amount of sodium in the diet has little, if any, effect on constipation. Strategy: Focus on the subject, constipation. Recalling that a high-fiber diet will provide bulk will direct you to option 1. If you are unfamiliar with the measures to prevent constipation, review this content. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1379, 1394). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

914) The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to note documented in the client's record? a. Diarrhea b. Chronic constipation c. Constipation alternating with diarrhea d. Stool constantly oozing from the rectum Source: Saunders 4th

ANS: A Rationale: Crohn's disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Options 2, 3, and 4 are not characteristics of Crohn's disease. Strategy: Use the process of elimination. Eliminate option 4 first as the most unlikely occurrence. From the remaining options, think about the pathophysiology associated with Crohn's disease to direct you to option 1. If you are unfamiliar with this disorder, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1355). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1067). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1752) Cromolyn sodium (Intal) is prescribed for the client with allergic asthma. The nurse understands that this medication acts to: a. Inhibit the release of mediators from mast cells after exposure to an antigen. b. Promote the migration of eosinophils into the inflammatory site. c. Increase the number of eosinophils. d. Dilate the bronchi. Source: Saunders 4th

ANS: A Rationale: Cromolyn sodium (Intal) is an antiasthmatic, antiallergic, and mast cell stabilizer that inhibits the release of mediators from mast cells after exposure to an antigen. It can also interrupt the migration of eosinophils into the inflammatory site and decrease the number of eosinophils. These actions decrease airway hyperresponsiveness in some clients with asthma. It has no bronchodilating action. Strategy: Use the process of elimination. Eliminate options 2 and 3 first because they are comparative or alike. From the remaining options, it is helpful to know that cromolyn sodium has no bronchodilating action. Also, note the relationship between the words antigen in the correct option and allergic in the question. Review the action of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 293). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2534) A nurse in the neurological unit is monitoring a client for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by measuring which the following? a. Blood pressure b. Motor response c. Pupillary response d. Level of consciousness Source: Saunders 4th

ANS: A Rationale: Cushing's reflex is a late sign of increased ICP and consists of a widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia. Options 2, 3, and 4 are unrelated to monitoring for Cushing's reflex. Strategy: Use knowledge regarding Cushing's reflex and the ABCs—airway, breathing, and circulation—to assist in directing you to option 1. Review this clinical manifestation if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1049). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2696) A client who is scheduled for cataract surgery requires preoperative instillation of cyclopentolate (Cyclogyl) eye drops as prescribed. The client asks the nurse why this medication is needed. The nurse explains that cyclopentolate: a. Dilates the pupil of the operative eye b. Constricts the pupil of the operative eye c. Provides the necessary lubrication to the nonoperative eye d. Is needed for the initiation of miosis in the operative eye Source: Saunders 4th

ANS: A Rationale: Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication that is used preoperatively to dilate the eye. It is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. The statements in the other options are incorrect. Strategy: Use the process of elimination. Eliminate options 2 and 4 first because they are comparative or alike and both address constriction of the eye. Recalling that the pupil must be dilated for the surgical procedure helps you choose correctly from the remaining options. Review the action and purpose of this medication if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 733). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2587) A nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continuously changes the subject during the teaching session. The nurse interprets that this client's behavior is most likely to indicate: a. An attempt to ignore or deny the need to make lifestyle changes b. Boredom resulting from having already learned the material c. Anxiety related to the need to make lifestyle changes d. Lack of understanding of the material provided at the teaching session and embarrassment about asking questions Source: Saunders 4th

ANS: A Rationale: Denial is a defense mechanism that allows the client to minimize a threat that may be manifested by refusal to discuss what has happened. Denial is a common early reaction associated with chest discomfort, angina, or myocardial infarction (MI). Anxiety usually is manifested by symptoms of sympathetic nervous system arousal. No data are provided in the question that would lead the nurse to interpret the client's behavior as boredom or as either understanding or not understanding the material provided at the teaching session. Strategy: Use the process of elimination. Focus on the information provided in the question to direct you to option 1. Review the clinical manifestations associated with denial if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 525-526, 1706-1707). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2110) A nurse has the following order for a postcraniotomy client: "dexamethasone (Decadron) 4 mg by the intravenous (IV) route now." The nurse administers the medication by: a. IV push over 1 minute b. IV push over 4 minutes c. IV piggyback in 50 mL of normal saline over 10 minutes d. IV piggyback in 50 mL of normal saline over 30 minutes Source: Saunders 4th

ANS: A Rationale: Dexamethasone is an adrenocorticosteroid administered after craniotomy to control cerebral edema. It is given by IV push, and single doses are administered over 1 minute. Dexamethasone IV doses are changed to the oral route after 24 to 72 hours and are tapered in dose until discontinued. Additionally, IV fluids are administered cautiously after craniotomy to prevent increased cerebral edema. Strategy: Specific knowledge of this medication and its administration by the IV route is needed to answer this question. Remember that IV dexamethasone is administered over 1 minute. Review this medication if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 376). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1925) A registered nurse is instructing a new nursing graduate about hemodialysis. Which statement if made by the new nursing graduate would indicate an inaccurate understanding of the procedure for hemodialysis? a. "Sterile dialysate must be used." b. "Warming the dialysate increases the efficiency of diffusion." c. "Heparin sodium is administered during dialysis." d. "Dialysis cleanses the blood from accumulated waste products." Source: Saunders 4th

ANS: A Rationale: Dialysate is made from clear water and chemicals and is free from any metabolic waste products or medications. Bacteria and other microorganisms are too large to pass through the membrane; therefore, the dialysate does not need to be sterile. The dialysate is warmed to approximately 100° F to increase the efficiency of diffusion and to prevent a decrease in the client's blood temperature. Heparin sodium inhibits the tendency of blood to clot when it comes in contact with foreign substances. Option 4 is the purpose of dialysis. Strategy: Note the strategic word inaccurate. This indicates a negative event query and directs you to select an incorrect statement. Use the process of elimination and think about the purpose of dialysis and the procedure to eliminate options 2, 3, and 4. Review the components and characteristics of dialysate if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1752). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2644) A client is to be discharged from the hospital on quinidine gluconate to control ventricular ectopy. The nurse provides instructions to the client about the medication. Which statement by the client indicates a need for further instruction? a. "I need to stop the medication if diarrhea, nausea, or vomiting occurs." b. "I need to avoid alcohol, caffeine, and cigarettes while I am on this medication." c. "I need to take this medication regularly, even if the heartbeat feels strong and regular." d. "The best time to schedule this medication is with meals." Source: Saunders 4th

ANS: A Rationale: Diarrhea, nausea, vomiting, loss of appetite, and dizziness all are common side effects of quinidine gluconate. If any of these occur, the physician or the nurse should be notified; however, the medication should never be discontinued abruptly. Rapid decrease in medication levels of antidysrhythmics could precipitate dysrhythmia. The other options indicate correct information. Strategy: Use the process of elimination. Note the strategic words need for further instruction. This phrasing indicates a negative event query and the need to select an incorrect statement. Use general guidelines related to medication administration and recall that although quinidine is an antidysrhythmic used to control ectopy, it should not be discontinued without first consulting the physician. Review client teaching points related to this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 998). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1074) A nurse is preparing for the admission of a client with heart failure who is being sent directly to the hospital from the physician's office. The nurse would plan on having which of the following medications readily available for use? a. Digoxin (Lanoxin) b. Verapamil (Calan) c. Propranolol (Inderal) d. Diltiazem (Cardizem) Source: Saunders 4th

ANS: A Rationale: Digoxin exerts a positive inotropic effect on the heart while slowing the overall rate through a variety of mechanisms. Digoxin is the medication of choice to treat heart failure. Diltiazem and verapamil (calcium channel blockers) and propranolol (β-adrenergic blocker) have a negative inotropic effect and would worsen the failing heart. Strategy: Focus on the client's diagnosis. Option 3 can be eliminated because it is not a medication used to treat heart failure. From the remaining options, use knowledge of the classification and actions of these medications to direct you to option 1. Review these medications if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 708, 758-759). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1053) A nurse teaches a client about the effects of diphenhydramine (Benadryl), which has been ordered as a cough suppressant. The nurse determines that the client needs further instructions if the client states that he or she will: a. Take the medication on an empty stomach. b. Avoid using alcohol while taking this medication. c. Use sugarless gum, candy, or oral rinses to decrease dry mouth. d. Avoid driving or other activities requiring mental alertness while taking this medication. Source: Saunders 4th

ANS: A Rationale: Diphenhydramine (Benadryl) has several uses, including antihistamine, antitussive, antidyskinetic, and sedative-hypnotic. Instructions for use include to take with food or milk to decrease gastrointestinal upset and to use oral rinses or sugarless gum or hard candy to minimize dry mouth. Because the medication causes drowsiness, the client should avoid use of alcohol or central nervous system depressants, operating a car, or engaging in other activities requiring mental awareness during use. Strategy: Use the process of elimination, noting the strategic words needs further instructions. These words indicate a negative event query and ask you to select an option that is incorrect. Knowing that the medication has a sedative effect helps you eliminate options 2 and 4 first. Recalling that the medication causes a dry mouth helps you choose option 1 as the answer to the question, according to the way the question is stated. If you had difficulty with this question, review client education related to this medication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 366). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 276). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2592) A nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium (Depakote). The nurse instructs the client about the importance of returning to the clinic for monitoring of which of the following laboratory studies? a. Liver function studies b. Renal function studies c. Blood glucose level determination d. Electrolyte panel Source: Saunders 4th

ANS: A Rationale: Divalproex sodium (Depakote), an anticonvulsant, can cause potentially fatal hepatotoxicity. The nurse should instruct the client about the importance of monitoring the results of liver function studies and ammonia level determinations. Options 2, 3, and 4 are not studies that are required with the use of this medication. Strategy: Use the process of elimination. Recalling that divalproex sodium can lead to hepatotoxicity will direct you to option 1. Review the toxic effects of this medication if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 952). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 885). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

149) A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse advises the client to do which of the following to reduce the risk of possible transfusion complications? a. Give an autologous blood donation before the surgery. b. Ask a friend or family member to donate blood ahead of time. c. Take iron supplements before surgery to boost hemoglobin levels. d. Request that any donated blood be screened twice by the blood bank. Source: Saunders 4th

ANS: A Rationale: Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of possible transfusion complications. The next most effective way is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in replacing blood lost during the surgery. Strategy: Use the process of elimination and focus on the subject to reduce the risk of possible transfusion complications. Recalling that an autologous transfusion is the collection of the client's own blood will direct you to option 1. Review the concepts related to disease transmission and blood donation procedures if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 334). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1190). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2166) A client who was started on anticonvulsant therapy with clonazepam (Klonopin) tells the nurse of increasing clumsiness and unsteadiness since starting the medication. The client is visibly upset by these manifestations and asks the nurse what to do. The nurse's response is based on the understanding that these symptoms: a. Are most severe during initial therapy and decrease or disappear with long-term use b. Indicate that the client is experiencing a severe untoward reaction to the medication c. Probably are the result of interaction with another medication d. Usually occur when the client takes the medication with food Source: Saunders 4th

ANS: A Rationale: Drowsiness, unsteadiness, and clumsiness are expected effects of the medication during early therapy. They are dose related and usually diminish or disappear altogether with continued use of the medication. These symptoms do not indicate that a severe side effect is occurring. They also are unrelated to an interaction with another medication. The client is encouraged to take this medication with food to minimize gastrointestinal upset. Strategy: To answer this question correctly, you need to know that these effects occur early in the course of therapy and decrease or disappear with long-term use. Review the expected effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 272). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., pp. 381-382). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1897) A prenatal clinic nurse asks a coassigned nursing student to identify the physiological adaptations of the cardiovascular system that occurs during pregnancy. The nurse determines that the student understands these physiological changes if the student states which of the following? a. "A decrease in cardiac output occurs." b. "An increase in pulse occurs." c. "The systolic and diastolic blood pressures increase by 20 mm Hg." d. "A decrease in blood volume occurs." Source: Saunders 4th

ANS: B Rationale: Between 14 and 20 weeks of gestation, the maternal pulse rate increases slowly, up to 10 to 15 beats/min, which lasts until term. Cardiac output and blood volume increase. Blood pressure decreases in the first half of pregnancy and returns to baseline in the second half of pregnancy. Strategy: Use the process of elimination. Eliminate options 1 and 4 first because an increase rather than a decrease in cardiac output and blood volume occurs. Knowledge that an increase in blood pressure by 20 mm Hg is not a normal expected occurrence will direct you to option 2 from the remaining options. Review the physiological changes that occur in pregnancy if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 113). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1166) The client is admitted to the emergency department following a motor vehicle accident. The client was wearing a lap seat belt when the accident occurred and now the client has hematuria and lower abdominal pain. To assess further whether the pain is caused by bladder trauma, the nurse asks the client if the pain is referred to which of the following area? a. Hip b. Shoulder c. Umbilicus d. Costovertebral angle Source: Saunders 4th

ANS: B Rationale: Bladder trauma or injury is characterized by lower abdominal pain that may radiate to one of the shoulders. Bladder injury pain does not radiate to the umbilicus, costovertebral angle, or hip. Strategy: Use the process of elimination. Recalling the concepts related to dermatomes of the body and pain characteristics of bladder trauma will direct you to option 2. Review the characteristics of bladder trauma if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 790). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1704). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

913) The nurse is caring for a client postoperatively following creation of a colostomy. Which nursing diagnosis should the nurse include in the plan of care? a. Sexual dysfunction b. Body image, disturbed c. Fear related to poor prognosis d. Nutrition: more than body requirements, imbalanced Source: Saunders 4th

ANS: B Rationale: Body image, disturbed relates to loss of bowel control, the presence of a stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch). No data in the question support options 1 and 3. Nutrition: less than body requirements, imbalanced is the more likely nursing diagnosis. Strategy: Use the process of elimination and the data presented in the question to assist you in selecting the correct option. No data in the question support options 1 and 3. Reading option 4 carefully will assist you in eliminating this option. Review care of the client following a colostomy if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1325). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2087) A client is being evaluated as a potential kidney donor for a family member. The client asks the nurse why separate teams of people are evaluating them as donor and as recipient. In formulating a response, the nurse understands that this approach: a. Saves the client and the recipient valuable preoperative time b. Avoids a conflict of interest between the team evaluating the recipient and that evaluating the donor c. Helps reduce the cost of the preoperative workup d. Provides for a sufficient number of people reviewing the case so that no information is overlooked Source: Saunders 4th

ANS: B Rationale: Both the kidney donor and the kidney recipient need thorough medical and psychological evaluation before transplant surgery. Separate teams evaluate the donor and the recipient to avoid a conflict of interest in providing care for the two clients. Options 1, 3, and 4 are not related to the purpose of this approach. Strategy: Use the process of elimination.Begin to answer this question by eliminating options 1 and 3, which are not reasonable. From the remaining options, select option 2, using knowledge of concepts regarding client advocacy. One group cannot advocate for both parties simultaneously. Review preoperative preparation for renal transplantation if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 968, 2430). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1759). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Caring Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1759) The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal compartment. Which of the following is the appropriate action? a. Change the chest tube drainage system. b. Document the findings. c. Check for an air leak. d. Notify the physician. Source: Saunders 4th

ANS: B Rationale: Bubbling in the water seal compartment is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. Strategy: Focus on the strategic words intermittent bubbling and water seal compartment. Recalling that intermittent bubbling is normal will direct you to option 2. If you are unfamiliar with chest tube drainage systems, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1862-1863). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 623). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1139) A client has developed paroxysmal nocturnal dyspnea. Which of the following medications does a nurse anticipate will be prescribed by the physician? a. Propranolol (Inderal) b. Bumetanide (Bumex) c. Lidocaine (Xylocaine) d. Streptokinase (Streptase) Source: Saunders 4th

ANS: B Rationale: Bumetanide (Bumex) is a diuretic. The paroxysmal nocturnal dyspnea may be due to increased venous return when the client is lying in bed, and the client needs diuresis. Propranolol is a β blocker, lidocaine is an antiarrhythmic, and streptokinase is a thrombolytic. Strategy: Use the process of elimination. Knowledge of each medication type and that a diuretic will increase urine output will direct you to option 2. Review the actions of the medications identified in the options, if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 159). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1515) The client who has been taking buspirone (BuSpar) for 1 month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation(s) has occurred? a. Paranoid thought process b. Rapid heartbeat or anxiety c. Alcohol withdrawal symptoms d. Thought broadcasting or delusions Source: Saunders 4th

ANS: B Rationale: Buspirone (BuSpar) is not recommended for the treatment of drug or alcohol withdrawal, thought disorders, or schizophrenia. Buspirone hydrochloride most often is indicated for the treatment of anxiety. Strategy: Note the strategic words absence of which manifestation(s). Recalling that buspirone is an antianxiety medication will direct you to the correct option. Review the action and use of this medication if you had difficulty with this question. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., pp. 237, 243). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1823) Butorphanol tartrate (Stadol) is prescribed for a woman in labor, and the woman asks the nurse about the purpose of the medication. The appropriate nursing response is which of the following statements? a. "The medication will assist in increasing the contractions." b. "The medication provides pain relief during labor." c. "The medication prevents respiratory depression in the newborn infant." d. "The medication will help prevent any nausea and vomiting." Source: Saunders 4th

ANS: B Rationale: Butorphanol tartrate is an opioid analgesic that provides systemic pain relief during labor. It does not relieve nausea, increase uterine contractions, or prevent respiratory depression in the newborn infant. Strategy: Use the process of elimination. Recalling that butorphanol tartrate is an opioid analgesic will assist in directing you to option 2. If you had difficulty with this question, review the action and purpose of this medication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 167). Philadelphia: W.B. Saunders. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 350). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Maternity—Intrapartum Alternate Question Types -> Multiple Choice

1769) A client suspected of having an abdominal tumor is scheduled for a computed tomography (CT) scan with dye injection. The nurse tells the client that: a. The test may be painful. b. The dye injected may cause a warm, flushing sensation. c. Fluids will be restricted following the test. d. The test takes approximately 2 hours. Source: Saunders 4th

ANS: B Rationale: CT scanning causes no pain and can take 15 to 60 minutes to perform. The dye may cause a warm flushing sensation when injected. Fluids are encouraged following the procedure. If an iodine dye is used, the client should be asked about allergies to seafood or iodine. Strategy: Use the process of elimination. Note the strategic words dye injection in the question. This should provide you with the clue that the subject relates to the dye. If you are unfamiliar with this diagnostic test, review the important teaching points related to it. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 295). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

973) A calcium carbonate antacid has been prescribed for a client and the nurse provides instructions to the client about the medication. The nurse tells the client that it is best to take the antacid with which of the following? a. Milk b. Water c. Yogurt d. A vitamin D supplement Source: Saunders 4th

ANS: B Rationale: Calcium carbonate antacids should not be taken with milk, milk products, or foods or supplements high in vitamin D because milk-alkali syndrome (headache, urinary frequency, anorexia, nausea, vomiting, fatigue) can occur. The best item to consume when taking calcium carbonate is water. Strategy: Use the process of elimination. Recalling that antacids should not be taken with food will direct you to option 2. Review this antacid if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 173). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2681) A nurse notes in the medication record that a client is taking calcium carbonate chewable tablets. The nurse asks the client about a history of which of the following symptoms? a. Muscle twitching b. Heartburn c. Flatus d. Rectal pain Source: Saunders 4th

ANS: B Rationale: Calcium carbonate can be used as an antacid for the relief of heartburn and indigestion. It also can be used as a calcium supplement or to bind phosphorus in the gastrointestinal (GI) tract in clients with renal failure. The other options are incorrect and are not indications for the use of calcium carbonate. Strategy: Recalling that this medication is used as an antacid will direct you to option 2. Review the action of this medication if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 863). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 128). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1990) A nurse is reviewing the medication record and notes that a client is to receive heparin 6,000 units subcutaneously. The medication label states heparin 10,000 units per 1 mL. How much heparin will the nurse prepare to administer to the client? a. 1.66 mL b. 0.6 mL c. 0.06 mL d. 0.16 mL Source: Saunders 4th

ANS: B Rationale: Calculate the dosage by dividing the amount ordered by the amount on hand. The physician ordered 6,000 units of heparin; therefore, divide 6,000 units by 10,000 units = 0.6. Then multiply 0.6 × 1 mL = 0.6 mL. Strategy: Read carefully and note that there are 10,000 units of heparin in 1 mL. This means that less than 1 mL of solution will be drawn up, which eliminates option 1. Option 2 results from dividing 6,000 units by 10,000 units. Options 3 and 4 result from miscalculations. Review dosage calculations if you had difficulty with this question. Reference: Kee, J., & Marshall, S. (2004). Clinical calculations: With applications to general and specialty areas (5th ed., p. 80). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2173) A nurse has given medication instructions to a client beginning anticonvulsant therapy with carbamazepine (Tegretol). The nurse determines that the client understands the use of the medication if the client states to: a. Drive so long as it is not at night. b. Use sunscreen when out of doors. c. Keep tissues handy due to excess salivation. d. Discontinue the medication if fever or sore throat occur. Source: Saunders 4th

ANS: B Rationale: Carbamazepine acts by depressing synaptic transmission in the central nervous system (CNS). Because of this, the client should avoid driving or doing other activities that require mental alertness until the effect of the medication on the client is known. The client should use protective clothing and sunscreen to avoid photosensitivity reactions. The medication may cause dry mouth, and the client should be instructed to provide good oral hygiene and use sugarless candy or gum as needed. The medication should not be abruptly discontinued, because this could lead to return of seizures or status epilepticus. Fever and sore throat should be reported to the physician (leukopenia). Strategy: Use the process of elimination. Recall that this is an anticonvulsant medication with CNS depressant properties. This would lead you to eliminate option 1 first, because driving in general could be hazardous until medication effects are known. Option 4 is eliminated next because an anticonvulsant is not just discontinued. Regarding the remaining options, remembering that carbamazepine causes dry mouth will direct you to option 2. Review client instructions regarding this medication if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 224). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2103) A nurse has an order to administer medication to a client who is experiencing shivering as a result of hyperthermia. Which of the following medications would the nurse anticipate to be prescribed? a. Prochlorperazine (Compazine) b. Chlorpromazine (Thorazine) c. Buspirone (BuSpar) d. Fluphenazine (Prolixin) Source: Saunders 4th

ANS: B Rationale: Chlorpromazine is used to control shivering in hyperthermic states. It is a phenothiazine and has antiemetic and antipsychotic uses, especially when psychosis is accompanied by increased psychomotor activity. Prochlorperazine is a phenothiazine that is an antiemetic and antipsychotic. Fluphenazine is a phenothiazine that is used as an antipsychotic. Buspirone is an anxiolytic. Strategy: Use the process of elimination, thinking about the use of these medications. Eliminate options 3 and 4 first, because they are not normally prescribed for medical or surgical clients. Regarding the remaining options, remember that prochlorperazine often is used for nausea, whereas chlorpromazine is used for shivering. Review the action and purpose of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., pp. 182-183). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1761) Cinoxacin (Cinobac) is prescribed for the client with a urinary tract infection. The clinic nurse is instructing the client regarding the administration of the medication. The nurse tells the client to take the medication: a. One hour before meals. b. With meals. c. At bedtime. d. In the morning prior to breakfast. Source: Saunders 4th

ANS: B Rationale: Cinoxacin (Cinobac) is a urinary antiseptic and is administered with meals to decrease gastrointestinal side effects. The normal dosage is 1 g/day administered in two to four divided doses for a period of 7 to 14 days. Strategy: Use the process of elimination. Eliminate options 1 and 4 first because they are comparative or alike. From the remaining options, recalling that this medication is administered more than once daily will direct you to option 2. Review this medication if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 487). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1733) Cinoxacin (Cinobac), a urinary antiseptic, is prescribed for the client. The nurse checks the client's record, knowing that this medication is used with caution in which of the following disorders? a. Hepatic disease b. Renal disease c. Diabetes insipidus d. Congestive heart failure Source: Saunders 4th

ANS: B Rationale: Cinoxacin should be administered with caution in clients with renal impairment. The dosage should be reduced, and failure to do so could result in accumulation of cinoxacin to toxic levels. It is not contraindicated to the disorders identified in options 1, 3, and 4. Strategy: Use the process of elimination. Knowledge that this medication is used with caution in clients with renal impairment will direct you to option 2. If you are unfamiliar with this medication, review its cautions and contraindications. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 450, 487). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

104) A client is recovering from abdominal surgery and has a large abdominal wound. A nurse encourages the client to eat which food item that is naturally high in vitamin C to promote wound healing? a. Milk b. Oranges c. Bananas d. Chicken Source: Saunders 4th

ANS: B Rationale: Citrus fruits and juices are especially high in vitamin C. Bananas are high in potassium. Meats and dairy products are two food groups that are high in the B vitamins. Strategy: Note the strategic words naturally high in the question. Use the process of elimination, recalling that citrus fruits and juices are high in vitamin C. Review the foods high in vitamin C if you are unfamiliar with them. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed., pp. 180-181). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1078) A client with myocardial infarction is going into cardiogenic shock. Because of the risk of myocardial ischemia, for which of the following should the nurse carefully assess the client? a. Bradycardia b. Ventricular dysrhythmias c. Rising diastolic blood pressure d. Falling central venous pressure Source: Saunders 4th

ANS: B Rationale: Classic signs of cardiogenic shock as they relate to this question include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium. Strategy: Use the process of elimination and focus on the strategic words myocardial ischemia. Recall that ischemia makes the myocardium irritable, producing dysrhythmias. Also, knowledge of the classic signs of shock helps eliminate the incorrect options. Review the clinical manifestations associated with cardiogenic shock if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 853-854). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2201) A home care nurse has given instructions to a client who is beginning therapy with digoxin (Lanoxin). The nurse determines a need for reinforcement of the instructions if the client makes which of the following statements? a. "I should call the doctor if my daily pulse rate is under 60 or over 100." b. "If I miss a dose, I should just take two the next day." c. "I shouldn't change brands without asking the doctor first." d. "The pills should be kept in their original container, so they don't get mixed up with my other medicines." Source: Saunders 4th

ANS: B Rationale: Client teaching should include taking the dose exactly as prescribed each day. If the client misses a dose and more than 12 hours goes by, that dose should be omitted and only the next scheduled dose should be taken; the client should not double-dose. A daily pulse check is necessary, and the client should know the parameters for which the physician should be called. Clients are advised not to mix digoxin in pill boxes with other medications. The physician should be consulted before changing brands, because the bioavailability of another preparation of the medication may be different. Strategy: Use the process of elimination, noting the strategic words need for reinforcement. This phrasing indicates a negative event query and asks you to select an incorrect statement. Use the general principles related to medication administration to direct you to option 2. Review these principles if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 358). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 267). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1975) A client who had surgery 3 days earlier is receiving heparin sulfate by subcutaneous injection every 12 hours. In planning for the client's morning care, the priority nursing intervention should be to: a. Not allowing the client to brush the teeth b. Using an electric razor for shaving c. Only allowing the client to sit at the bedside d. Monitoring the prothrombin time (PT) every 4 hours Source: Saunders 4th

ANS: B Rationale: Clients receiving heparin are at risk for bleeding. An electric razor rather than a straight blade razor is used for shaving. Options 1 and 3 are inappropriate and unnecessary nursing actions. It is not necessary to monitor laboratory values every 4 hours when the client is taking subcutaneous heparin. Additionally, the PT is monitored when the client is taking warfarin (Coumadin). Strategy: Use the process of elimination. Eliminate options 1 and 3 first because these options contain the close-ended words not and only. Recognizing that the laboratory values would not need to be monitored every 4 hours in this situation will direct you to option 2. Review nursing care measures for a client receiving subcutaneous heparin if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 573). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2153) A client who has experienced nonunion of a fracture is scheduled for bone grafting using cadaver bone. The client appears restless and anxious about the procedure. After determining that the client understands the surgical procedure, the nurse next explores: a. Concern about the level of postoperative pain b. Potential worry about contracting hepatitis or possibly human immunodeficiency virus (HIV) infection c. Whether the client needs a PRN (pro res nata, as needed) order for an antianxiety agent d. The availability of assistance for the client upon discharge Source: Saunders 4th

ANS: B Rationale: Clients who receive cadaver bone can develop psychological problems because of worry about contracting the HIV virus or hepatitis from the cadaver bone. Clients need reassurance and information about the donor screening that is done to ensure that this does not occur. The level of pain that will be experienced in the postoperative period should be included as part of the basic preparation of the client for surgery. Strategy: Use the process of elimination. Focus on the subject, the client's anxiety. Knowing that a common concern is contracting disease from cadaver bone will direct you to option 2. Additionally, option 2 is specific to the information contained in the question. Review preoperative care related to this procedure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1203). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1483) The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is appropriate? a. Interrupt the client and weigh her immediately. b. Interrupt the client and offer to take her for a walk. c. Allow the client to complete her exercise program. d. Tell the client that she is not allowed to exercise rigorously. Source: Saunders 4th

ANS: B Rationale: Clients with anorexia nervosa frequently are preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise and place limits on rigorous activities. Options 1, 3, and 4 are inappropriate nursing actions. Strategy: Use the process of elimination and focus on the client's diagnosis. Also, focus on the need for the nurse to set firm limits with clients who have this disorder. If you had difficulty with this question, review interventions for the client with anorexia nervosa. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 385-386). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 530). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2279) A nurse is conducting home visits for a head-injured client with residual cognitive deficits. The client has problems with memory, has a shortened attention span, is easily distracted, and processes information slowly. The nurse plans to talk with the primary physician about a referral to: a. A psychologist b. A neuropsychologist c. A social worker d. A vocational rehabilitation specialist Source: Saunders 4th

ANS: B Rationale: Clients with cognitive deficits after head injury may benefit from referral to a neuropsychologist, who specializes in evaluating and treating cognitive problems. The neuropsychologist plans an individual program of therapy and initiates counseling to help the client reach maximal potential. The neuropsychologist works in collaboration with other disciplines that are involved with the client's care and rehabilitation. Options 1, 3, and 4 are incorrect. Strategy: Use the process of elimination, focusing on the client's deficits. Noting that the client has neurological deficits will direct you to option 2. Review the functions and roles of these health care workers if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2210-2211). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 35-36). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2147) A nurse has an order to place a client with a herniated lumbar intervertebral disk on bedrest in William's position to minimize the pain. The nurse plans to put the bed: a. In high Fowler's position, with the foot of the bed flat b. In semi-Fowler's position, with the knees slightly flexed c. In semi-Fowler's position, with the foot of the bed flat d. Flat, with the knees raised Source: Saunders 4th

ANS: B Rationale: Clients with low back pain often are more comfortable when placed in William's position. The bed is placed in semi-Fowler's position with the knee gatch raised sufficiently to flex the knees. This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root. Strategy: Use the process of elimination. Note that the client has back pain with a ruptured intervertebral disk. Recall that positions that relieve this discomfort include those that provide slight flexion of lower back muscles. Keeping the foot of the bed flat will enhance extension of the spine, so options 1 and 3 should be eliminated first. Option 4 would excessively stretch the lower back and also would put the client at risk for thrombophlebitis. Review care of the client with a herniated lumbar intervertebraldisk if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 979). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2108) A home care nurse is making extended follow-up visits to a client discharged from the hospital after a moderately severe head injury. The family states that the client is behaving differently than before the accident. The client is more fatigued and irritable and has some memory problems. The client, who was previously very even-tempered, is prone to outbursts of temper now. The nurse counsels the family on the basis of an understanding that these behaviors: a. Are short-term problems that will resolve in about 1 month b. Will probably be a long-term sequela of the injury c. Indicate a worsening of the original injury d. Will come and go as intracranial pressure changes Source: Saunders 4th

ANS: B Rationale: Clients with moderate to severe head injury usually have residual physical and cognitive disabilities; these include personality changes, increased fatigue and irritability, mood alterations, and memory changes. The client also may require frequent to constant supervision. The nurse assesses the family's ability to cope and makes appropriate referrals to respite services, support groups, and state or local chapter of the National Head Injury Foundation. Strategy: Use the process of elimination. The question states that the client had a moderately severe head injury. Knowing that deficits remain with this level of head injury will help you to eliminate options 3 and 4. Because the injury was more than minor, option 2 is the more reasonable option. Review the manifestations associated with the various types of head injury if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1053-1056). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2432) An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area from a home fire that originated in the basement. Which of the following assessment findings would indicate that the client sustained a respiratory injury as a result of the burn? a. Clear breath sounds b. Use of accessory muscles for breathing c. Fear and anxiety d. Complaints of pain Source: Saunders 4th

ANS: B Rationale: Clinical indicators of respiratory injury in a burn-injured client include the presence of facial burns, the presence of soot around the mouth or nose, and singed nasal hairs. Signs of respiratory difficulty include changes in respiratory rate and the use of accessory muscles for breathing. Although anxiety may be a sign of hypoxemia, anxiety along with bradycardia, arrhythmias, and lethargy would be more likely to indicate a concern related to a respiratory injury. Abnormal breath sounds and abnormal arterial blood gas values also would be noted. Strategy: Use the process of elimination. Note the subject, a respiratory injury. Focusing on the assessment finding related to a respiratory problem will direct you to option 2. If you had difficulty with this question, review assessment findings in the client with a burn injury that may indicate a respiratory injury. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1627-1628). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

69) A nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a P<sc>CO</sc>₂ of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? a. Sodium level of 145 mEq/L b. Potassium level of 3.0 mEq/L c. Magnesium level of 2.0 mg/dL d. Phosphorus level of 4.0 mg/dL Source: Saunders 4th

ANS: B Rationale: Clinical manifestations of respiratory alkalosis include headache, tachypnea, paresthesias, tetany, vertigo, convulsions, hypokalemia, and hypocalcemia. Options 1, 3, and 4 identify normal laboratory values. Option 2 identifies the presence of hypokalemia. Strategy: Use the process of elimination and knowledge regarding the clinical manifestations of respiratory alkalosis and normal laboratory values to answer the question. The only abnormal laboratory value is the potassium level, option 2. Review the clinical manifestations of respiratory alkalosis and normal laboratory values if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1144-1145). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2167) A client is having the dosage of clonazepam (Klonopin) adjusted. The nurse should plan to: a. Monitor blood glucose levels. b. Institute seizure precautions. c. Weigh the client daily. d. Observe for areas of ecchymosis. Source: Saunders 4th

ANS: B Rationale: Clonazepam is a benzodiazepine that is used as an anticonvulsant. During initial therapy and during periods of dosage adjustment, the nurse should initiate seizure precautions for the client. Options 1, 3, and 4 are unrelated to this medication. Strategy: Use the process of elimination. Note the subject, the adjustment of the medication dosage. Knowing that the medication is used as an anticonvulsant will direct you to option 2. Review the nursing considerations related to this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 271). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2170) A client with a history of simple partial seizures is taking clorazepate (Tranxene). The client asks the nurse if there is a risk of addiction with this medication. The nurse's response is based on the understanding that clorazepate: a. Is not habit forming either physically or psychologically b. Leads to physical and psychological dependence with prolonged high-dose therapy c. Leads to physical tolerance, but only after 10 or more years of therapy d. Can result in psychological dependence only, because of the nature of the medication Source: Saunders 4th

ANS: B Rationale: Clorazepate is classified as an anticonvulsant, an anxiolytic (antianxiety agent), and a sedative-hypnotic (benzodiazepine). One of the nursing implications of clorazepate therapy is that the medication can lead to physical or psychological dependence with prolonged therapy at high doses. For this reason, the amount of medication that is readily available to the client at any one time is restricted. Strategy: Use the process of elimination. Recalling that the medication is a benzodiazepine will lead you to conclude that this medication can lead to physical as well as psychological dependence. This will direct you to option 2. Review the effects of this medication if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 377). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2690) A nurse notes that a client has been taking colchicine. The nurse assesses the client for which of the following signs and symptoms that are the indications for the use of this medication? a. Double vision b. Joint inflammation and pain c. Migraine headaches d. Difficulty urinating Source: Saunders 4th

ANS: B Rationale: Colchicine is classified as an antigout agent that interferes with the ability of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client should report a decrease in pain and inflammation in the affected joints, as well as a decrease in number of gout attacks. The other options are incorrect. Strategy: Recalling that this medication is used in the treatment of gout will direct you to option 2. Review the action and use of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 283). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1365) Colchicine is prescribed for a client with a diagnosis of gout. The nurse reviews the client's record, knowing that this medication would be contraindicated in which of the following disorders? a. Myxedema b. Renal failure c. Hypothyroidism d. Diabetes mellitus Source: Saunders 4th

ANS: B Rationale: Colchicine is contraindicated in clients with severe gastrointestinal, renal, hepatic, or cardiac disorders and in clients with blood dyscrasias. Clients with impaired renal function may exhibit myopathy and neuropathy manifested as generalized weakness. This medication should be used with caution in clients with impaired hepatic function, the older client, and the debilitated client. Strategy: Use the process of elimination. Note that options 1, 3, and 4 are endocrine-related disorders. Option 2, the correct option, is different from the others. Review the contraindications associated with this medication if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 844). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2161) A client with Parkinson's disease has been prescribed benztropine (Cogentin). The nurse assesses for which of the following gastrointestinal (GI) problems as a side effect of this medication? a. Diarrhea b. Dry mouth c. Increased appetite d. Hyperactive bowel sounds Source: Saunders 4th

ANS: B Rationale: Common GI side effects of benztropine therapy include constipation and dry mouth. Other GI side effects include nausea and ileus. These effects are the result of the anticholinergic properties of the medication. Strategy: Use the process of elimination. In examining the options, diarrhea and hyperactive bowel sounds are comparative or alike, so it is not likely that either of them is correct. Regarding the remaining options, knowing that the medication is an anticholinergic will direct you to option 2. Review the side effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 128). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1122) A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hr. The nurse would determine that the client is receiving the therapeutic effect based on which of the following results? a. Prothrombin time of 12.5 seconds b. Activated partial thromboplastin time of 60 seconds c. Activated partial thromboplastin time of 28 seconds d. Activated partial thromboplastin time longer than 120 seconds Source: Saunders 4th

ANS: B Rationale: Common laboratory ranges for activated partial thromboplastin time are 20 to 36 seconds. Because the activated partial thromboplastin time should be 1.5 to 2.5 times the normal value, the client's activated partial thromboplastin time would be considered therapeutic if it were 60 seconds. Strategy: Use the process of elimination. Option 1 is eliminated because the prothrombin time assesses response to warfarin (Coumadin) therapy. Eliminate option 3 because at 28 seconds the client is receiving no therapeutic effect from the continuous heparin infusion. Eliminate option 4 because this value is beyond the therapeutic range and the client is at risk for bleeding. Review laboratory tests to monitor the effectiveness of heparin therapy if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, L. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed., p. 654). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1749) A client is admitted to the hospital with acute viral hepatitis. Which of the following signs or symptoms would the nurse expect to note based upon this diagnosis? a. Spider angiomas b. Fatigue c. Pale urine d. Weight gain Source: Saunders 4th

ANS: B Rationale: Common signs of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis. Spider angiomas, small, dilated blood vessels, are commonly seen in cirrhosis of the liver. Strategy: Use the process of elimination. Recalling the function of the liver will direct you to the correct option. Remember that fatigue occurs during all phases of hepatitis. If you had difficulty with this question, review content associated with hepatitis. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1108). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

31) An 87-year-old woman is brought to the emergency room for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which of the following is the appropriate nursing response? a. "Oh, really. I will discuss this situation with your son." b. "This is a legal issue, and I must tell you that I will need to report it." c. "Let's talk about the ways you can manage your time to prevent this from happening." d. "Do you have any friends that can help you out until you resolve these important issues with your son." Source: Saunders 4th

ANS: B Rationale: Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends without the client's permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. The nurse must report situations related to child or elder abuse, gunshot wounds, and certain infectious diseases. Options 1, 3, and 4 do not address the legal implications of the situation and do not ensure a safe environment for the client. Strategy: Use the process of elimination and knowledge regarding the nursing responsibilities related to reporting obligations. Options 1, 3, and 4 should be eliminated because they are comparative or alike in that they do not protect the client from injury. Review the nursing responsibilities related to reporting obligations if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 391-392, 433). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2140) A nurse is assessing a confused older client admitted to the hospital with a hip fracture. Which of the following data obtained by the nurse would not place the client at more risk for disturbed thought processes? a. Stress induced by the fracture b. Hearing aid available and in working order c. Unfamiliar hospital setting d. Eyeglasses left at home Source: Saunders 4th

ANS: B Rationale: Confusion in the older client with a hip fracture could result from the unfamiliar hospital setting, stress due to the fracture, concurrent systemic diseases, cerebral ischemia, or side effects of medications. Use of eyeglasses and hearing aids will enhance the client's interaction with the environment and can reduce disorientation. Strategy: Use the process of elimination. Note the strategic words not place the client at more risk. Stress from the fracture (option 1) and an unfamiliar setting (option 3) are not likely to help the client's functional level and are eliminated. Eyeglasses and hearing aids both are useful adjuncts in communicating with a client. Because the eyeglasses were left at home, they are of no use at the current time. Review measures to prevent disturbed thought processes if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 641). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1616) A nonstress test is performed on a client who is pregnant and the results of the test indicate nonreactive findings. The physician prescribes a contraction stress test. The test is performed and the nurse notes that the physician has documented the results as negative. The nurse interprets this finding as indicating: a. A high risk for fetal demise. b. A normal test result. c. The need for a cesarean delivery. d. An abnormal test result. Source: Saunders 4th

ANS: B Rationale: Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by three contractions of at least 40 seconds duration in a 10-minute period. Repetitive late decelerations render the test results positive. Strategy: Use the process of elimination, noting that options 1, 3, and 4 are comparative or alike in that they indicate an abnormal test result finding. If you had difficulty with this question and are unfamiliar with the interpretation of the results of a contraction stress test, review this content. Reference: Lowdermilk, D., & Perry, A. (2004). Maternity and woman's health care (8th ed., pp. 830-831). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1808) The clinic nurse develops a plan of care for a client with emphysema who will be started on long-term corticosteroid therapy. Which of the following will the nurse include in the plan of care? a. Instruct the client to maintain a low-potassium diet. b. Instruct the client to return to the clinic for monitoring of blood glucose levels. c. Encourage the client to consume a fluid intake of 3000 mL/day. d. Encourage the client to increase the amounts of sodium intake in the diet. Source: Saunders 4th

ANS: B Rationale: Corticosteroid therapy can cause calcium and potassium depletion, sodium retention, and glucose intolerance. The client should be monitored for hyperglycemia. Clients should be encouraged to have an intake of potassium-rich and calcium-rich foods. Also, an increase in potassium and a decrease in sodium are recommended to prevent potassium depletion and sodium retention while taking the corticosteroid. Although increased fluids are important for the client with emphysema to maintain thin respiratory secretions, this action is not specific to the use of corticosteroids. Strategy: Focus on the subject of the question as it relates to corticosteroid therapy. Recalling that this form of therapy promotes sodium retention and potassium depletion will assist in eliminating options 1 and 4. Regarding the remaining options, focusing on the subject of the question will assist in directing you to option 2. Review the side effects associated with the use of corticosteroids if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., pp. 835-836). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2305) A nurse is caring for a client after a renal transplantation who is receiving immunosuppressant therapy including corticosteroids. The nurse should plan to carefully monitor results of which of the following laboratory tests for this client? a. Serum albumin concentration b. Blood glucose level c. Serum magnesium level d. Serum potassium level Source: Saunders 4th

ANS: B Rationale: Corticosteroid therapy can result in glucose intolerance, leading to elevated blood glucose levels. The nurse monitors these levels to detect this side effect of therapy. With successful transplantation, the client's serum electrolyte levels should be better regulated, although corticosteroids also could cause sodium retention. The serum albumin will not be affected. Strategy: Focus on the dual subject, immunosuppressant therapy and corticosteroids. Remembering that corticosteroids affect blood glucose will direct you to the correct option. If this question was difficult for you, review the effects of these medications. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2437). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1762). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2647) A client with previously well-controlled diabetes mellitus has had fasting blood glucose levels ranging from 180 to 200 mg/dL. The client takes glyburide (Diabeta) 5 mg PO daily. The home health care nurse reviewing the client's medication list suspects that which of the following newly added medications could be contributing to the elevated blood glucose levels? a. Ciprofloxacin (Cipro) b. Prednisone (Deltasone) c. Cimetidine (Tagamet) d. Ranitidine (Zantac) Source: Saunders 4th

ANS: B Rationale: Corticosteroids, thiazide diuretics, and lithium may decrease the effect of glyburide, thus causing hyperglycemia. The medications listed in the incorrect options increase the effect of glyburide, leading to hypoglycemia. Strategy: Specific knowledge of medications interacting with glyburide is required to answer this question. Recalling that prednisone can cause hyperglycemia will assist in answering this question. If you are unfamiliar with the medication interactions associated with glyburide, review this content. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 787). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed.). St. Louis: Mosby, p. 405. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1763) The nurse is caring for the client who is suspected of having lung cancer. The nurse assesses the client for which most frequent early symptom of lung cancer? a. Hemoptysis b. Cough c. Hoarseness d. Pleuritic pain Source: Saunders 4th

ANS: B Rationale: Cough is the most frequent symptom of lung cancer, which begins as nonproductive and hacking, and progresses to productive. In the smoker who already has a cough, a change in the character and frequency of cough usually occurs. Wheezing and blood-streaked sputum (hemoptysis) are later signs. Pain is a very late sign, and is usually pleuritic in nature. Hoarseness indicates that the affected tissue is in the upper airway. Strategy: Use the process of elimination. Begin to answer this question by eliminating pain and hemoptysis, because it is reasonable that these would be later signs. To discriminate between cough and hoarseness, think about location. Hoarseness would indicate that the affected tissue is in the upper airway, whereas cough would indicate lower airway. Because the question is asking about lung cancer, which is lower airway, the answer must be cough. Review the frequent early symptoms of lung cancer if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 615-616). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

910) The nurse is preparing a discharge teaching plan for the client who had an umbilical hernia repair. What should the nurse include in the plan? a. Irrigating the drain b. Avoiding coughing c. Maintaining bed rest d. Restricting pain medication Source: Saunders 4th

ANS: B Rationale: Coughing is avoided following umbilical hernia repair to prevent disruption of tissue integrity, which can occur because of the location of this surgical procedure. Bed rest is not required following this surgical procedure. The client should take analgesics as needed and as prescribed to control pain. A drain is not used in this surgical procedure, although the client may be instructed in simple dressing changes. Strategy: Use the process of elimination. General postoperative measures will assist you in eliminating options 3 and 4. From the remaining options, consider the anatomical location of the surgery and the surgical procedure to assist you in selecting option 2. Review postoperative measures following this surgical procedure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1272). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

81) A client is suspected of having a myocardial infarction. The nurse assesses for elevations in which of the following isoenzyme values reported with the creatine kinase level? a. MM b. MB c. BB d. MK Source: Saunders 4th

ANS: B Rationale: Creatine kinase (CK) is a cellular enzyme that can be fractionated into three isoenzymes. The MB band reflects CK from cardiac muscle. This is the level that elevates with myocardial infarction. The MM band reflects CK from skeletal muscle. The BB band reflects CK from the brain. There is no MK band. Strategy: To answer this question correctly, you must have specific knowledge of the isoenzymes produced with elevations in the CK level. Eliminate option 4 because there is no MK band. From the remaining options, recall that the MB band reflects CK from cardiac muscle. Review this important laboratory value for detecting myocardial infarction if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 845). Philadelphia: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2006). Mosby's manual of diagnostic and laboratory tests (3rd ed., p. 202). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1352) A nurse has given a client instructions about crutch safety. The nurse determines that the client needs reinforcement of information if the client states: a. That he or she will not use someone else's crutches b. That crutch tips will not slip even when wet c. The need to have spare crutches and tips available d. That crutch tips should be inspected periodically for wear Source: Saunders 4th

ANS: B Rationale: Crutch tips should remain dry. Water could cause the client to slip by decreasing the surface friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The client should use only crutches measured for the client. The tips should be inspected for wear, and spare crutches and tips should be available if needed. Strategy: Use the process of elimination. Note the strategic words needs reinforcement of information. These words indicate a negative event query and ask you to select an option that is incorrect. Remember that crutch tips can slip when they get wet, posing a possible threat to the unsuspecting client. Review client teaching points related to safety and the use of crutches if you had difficulty with this question. Reference: Elkin, M., Perry, A., & Potter, P. (2004). Nursing interventions and clinical skills (3rd ed., p. 135). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1351) A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse's response is based on the understanding that this could result in: a. A fall and further injury b. Injury to the brachial plexus nerves c. Skin breakdown in the area of the axilla d. Impaired range of motion while the client ambulates Source: Saunders 4th

ANS: B Rationale: Crutches are measured so that the tops are two to three fingerwidths from the axillae. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the crutch, which could result in injury to the nerves of the brachial plexus. Strategy: Use the process of elimination. Recalling the risk associated with brachial nerve plexus injury will direct you to option 2. Review the complications associated with the use of crutches if you had difficulty with this question. Reference: Harkreader, H., & Hogan, M. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed., p. 794). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1204). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1310) The client with a cervical spine injury has Crutchfield (cervical) tongs applied in the emergency department. The nurse would avoid which of the following when planning care for this client? a. Use of a RotoRest bed b. Removing the weights to reposition the client c. Assessment of the integrity of the weights and pulleys d. Comparing the amount of ordered traction with the amount in use Source: Saunders 4th

ANS: B Rationale: Crutchfield (cervical) tongs are applied after drilling holes in the client's skull under local anesthesia. Weights are attached to the tongs, which exert pulling pressure on the longitudinal axis of the cervical spine. Serial x-rays of the cervical spine are taken, with weights being added gradually until the x-ray reveals that the vertebral column is realigned. After that, weights may be reduced gradually to a point that maintains alignment. The client with Crutchfield tongs is placed on a Stryker frame or RotoRest bed. The nurse ensures that weights hang freely, and the amount of weight matches the current order. The nurse also inspects the integrity and position of the ropes and pulleys. The nurse does not remove the weights to administer care. Strategy: Use the process of elimination noting the strategic word avoid. Recalling the basics related to the care of a client in traction will direct you to option 2. Review nursing care of the client with cervical tongs if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2218, 2221). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 989). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1817) A nurse is caring for a client receiving mannitol (Osmitrol) via intravenous (IV) infusion. A vial is sent from the pharmacy, and in preparing the medication, the nurse notes that the vial contains crystals. The appropriate nursing action is to: a. Send the vial back to the pharmacy. b. Place the vial in warm water. c. Discard the vial. d. Shake the vial to dissolve the crystals. Source: Saunders 4th

ANS: B Rationale: Crystals form in a mannitol solution if the solution is cooled but will quickly dissolve if the container is placed in warm water, then cooled to body temperature before administration. Shaking the vial should not be done and will not dissolve the crystals. The medication is not returned to the pharmacy because it is not defective. The nurse would not discard the medication. Strategy: Knowledge regarding the administration of mannitol is required to answer this question. It is necessary to know that crystals may form in the mannitol solution and that the solution is placed in warm water to dissolve the crystals. Remember, however, that not all medications should be placed in warm water if crystals are noted; but with this medication, it is acceptable. If you are unfamiliar with the administration of this medication, review this content. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., pp. 781-782). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1264) In preparation for cataract surgery, the nurse is to administer cyclopentolate (Cyclogyl) eye drops. The nurse administers the eye drops, knowing that the purpose of this medication is to: a. Produce miosis of the operative eye. b. Dilate the pupil of the operative eye. c. Provide lubrication to the operative eye. d. Constrict the pupil of the operative eye. Source: Saunders 4th

ANS: B Rationale: Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication. Cyclopentolate is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis. Strategy: Use the process of elimination. Options 1 and 4 are comparative or alike and are eliminated first. Miosis refers to a constricted pupil. Note that the question identifies a client being prepared for eye surgery. The pupil would need to be dilated for the surgical procedure. Review the action and purpose of this medication if you had difficulty with this question. Reference: Mosby. (2007). 2007 Mosby's nursing drug reference (20th ed., p. 1084). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1062) Cycloserine (Seromycin) is added to the medication regimen for a client with tuberculosis. Which of the following would the nurse include in the client teaching plan regarding this medication? a. Take the medication before meals. b. Return to the clinic weekly for serum drug level determination. c. It is not necessary to call the physician if a skin rash occurs. d. It is not necessary to restrict alcohol intake with this medication. Source: Saunders 4th

ANS: B Rationale: Cycloserine (Seromycin) is an antitubercular medication that requires weekly serum drug level determinations to monitor for the potential of neurotoxicity. Serum drug levels lower than 30 mg/mL reduce the incidence of neurotoxicity. The medication needs to be taken after meals to prevent gastrointestinal irritation. The client needs to be instructed to notify the physician if a skin rash or early signs of central nervous system toxicity are noted. Alcohol needs to be avoided because it increases the risk of seizure activity. Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they are the least likely correct options. From this point, knowing that the medication level needs to be monitored will assist in selecting the correct option. If you had difficulty with this question, review this medication. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 467-468). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1594) A mother of a child with cystic fibrosis (CF) asks the clinic nurse about the disease. The nurse tells the mother that CF is: a. A disease that causes the formation of multiple cysts in the lungs. b. A chronic multisystem disorder affecting the exocrine glands. c. Transmitted as an autosomal dominant trait. d. A disease that causes dilation of the passageways of many organs. Source: Saunders 4th

ANS: B Rationale: Cystic fibrosis (CF) is a chronic multisystem disorder affecting the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait. Strategy: Use the process of elimination. Recalling that this is a multisystem disorder will direct you to option 2. Additionally, option 2 is the umbrella response. Review this disorder if you are unfamiliar with it. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1240). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

2387) Dantrolene sodium (Dantrium) has been administered to a client with a spinal cord injury. The nurse determines that the client is experiencing an adverse effect of the medication if which of the following is noted? a. Dizziness b. Abdominal pain c. Drowsiness d. Lightheadedness Source: Saunders 4th

ANS: B Rationale: Dantrium is hepatotoxic. The nurse observes for indications of liver dysfunction, which include jaundice, abdominal pain, and malaise. The nurse notifies the physician if these occur. The items in options 1, 3, and 4 are expected side effects due to the central nervous system (CNS) depressant effects of the medication. Strategy: Use the process of elimination. Eliminate options 1, 3, and 4 because they are comparative or alike in identifying CNS effects. If you are unfamiliar with this medication and its adverse reactions and effects, review this content. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., pp. 240-241). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

28) The nursing staff is sitting in the lounge taking their morning break. A nursing assistant tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the nursing assistant violated? a. Libel b. Slander c. Assault d. Negligence Source: Saunders 4th

ANS: B Rationale: Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group. Strategy: Use the process of elimination and eliminate options 3 and 4 first. Recalling that slander constitutes verbal defamation will direct you to option 2. If you had difficulty with this question, review the torts identified in each option. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 414). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1532) The client receiving tricyclic antidepressants arrives at the mental health clinic. Which observation would indicate that the client is following the medication plan correctly? a. Client reports not going to work for this past week. b. Client arrives at the clinic neat and appropriate in appearance. c. Client complains of not being able to "do anything" anymore. d. Client reports sleeping 12 hours per night and 3 to 4 hours during the day. Source: Saunders 4th

ANS: B Rationale: Depressed individuals will sleep for long periods, are not able to go to work, and feel as if they cannot "do anything." Once they have had some therapeutic effect from their medication, they will report resolution of many of these complaints and demonstrate an improvement in their appearance. Strategy: Use the process of elimination. The client's behaviors or reports identified in options 1, 3, and 4 are symptoms of depression. The improvement in appearance indicates a therapeutic response to the medication, thus indicating compliance with the medication regimen. Review the expected effect of a tricyclic antidepressant if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 472). St. Louis: Mosby. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., p. 148). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2177) A client on the nursing unit has an order for dextroamphetamine (Dexedrine) 25 mg orally daily. The unit nurse collaborates with the dietitian to limit the amount of which of the following items on the client's dietary trays? a. Starch b. Caffeine c. Protein d. Fat Source: Saunders 4th

ANS: B Rationale: Dextroamphetamine is a central nervous system (CNS) stimulant. Caffeine is a stimulant also, so intake should be limited in the client taking this medication. The client should be taught to limit his or her own caffeine intake as well. Strategy: Use the process of elimination. Remember that this medication is a CNS stimulant. Recalling that caffeine also is a stimulant will direct you to option 2. Review the dietary considerations related to the administration of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 254). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1630) The pregnant client seen in the health care clinic has tested positive for human immunodeficiency virus (HIV). Based on this information, the nurse determines that: a. The client has the herpes simplex virus. b. HIV antibodies are detected by the ELISA test. c. The neonate will definitely develop this disease after birth. d. This client has contacted an airborne disease. Source: Saunders 4th

ANS: B Rationale: Diagnosis of HIV infection depends on serological studies to detect HIV antibodies. The most commonly used test is the enzyme-linked immunosorbent assay (ELISA). Options 1 and 4 are incorrect because HIV infection primarily occurs through the exchange of body fluids. Option 3 is incorrect. A neonate born to an HIV-positive mother is at risk for developing the virus. Strategy: Use the process of elimination. Eliminate option 3 first because of the close-ended word definitely. Next, eliminate options 1 and 4 because HIV infection primarily occurs through the exchange of body fluids. Review the significance of an HIV test in a pregnant client if you had difficulty with this question. Reference: Lowdermilk, D., & Perry, A. (2004). Maternity and woman's health care (8th ed., pp. 203-204). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1249) The nurse is reviewing the physician's orders for a client with Ménière's disease. Which diet most likely would be prescribed for the client? a. Low-fat diet b. Low-sodium diet c. Low-cholesterol diet d. Low-carbohydrate diet Source: Saunders 4th

ANS: B Rationale: Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Options 1, 3, and 4 are not specific to the client with Ménière's disease. Strategy: Use the process of elimination. Recalling the pathophysiology related to Ménière's disease will direct you to option 2. Review the pathophysiology related to this condition and the treatment measures if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1132). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

2120) A client is being treated for moderate hypertension and has been taking diltiazem (Cardizem) for several months. The client schedules an appointment with the physician because of episodes of chest pain, and Prinzmetal's angina is diagnosed. The nurse understands that what action of the diltiazem will provide a therapeutic effect for this new diagnosis? a. Increases oxygen demands within the myocardium b. Prevents influx of calcium ions in vascular smooth muscle c. Leads toan increase in calcium absorption in the vascular smooth muscle d. Increases the force of contraction of ventricular tissues Source: Saunders 4th

ANS: B Rationale: Diltiazem is a calcium channel blocker that inhibits calcium influx through the slow channels of the membrane of smooth muscle cells. These medications decrease myocardial oxygen demands and block calcium channels, thereby decreasing the force of contraction of the ventricular tissue. Strategy: Use the process of elimination. Recalling the action of calcium channel blockers and knowledge of the mechanisms involved in Prinzmetal's angina (coronary artery spasm) will direct you to option 2. Review the action of calcium channel blockers and the pathophysiology of Prinzmetal's angina if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 360). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1184) The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which of the following is the most appropriate nursing action? a. Monitor the client. b. Notify the physician. c. Elevate the head of the bed. d. Medicate the client for nausea. Source: Saunders 4th

ANS: B Rationale: Disequilibrium syndrome may be caused by the rapid decreases in the blood urea nitrogen level during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs of disequilibrium syndrome and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The physician must be notified. Strategy: Use the process of elimination and focus on the client's signs and symptoms. Recalling the complications associated with hemodialysis will direct you to option 2. Review the signs and symptoms of disequilibrium syndrome if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1756). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1479) A female client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes were much too tight and has reduced her calorie intake to 800 calories daily. The nurse analyzes this behavior as: a. Normal behavior b. Evidence of the client's disturbed body image c. Regression as the client is moving toward the community d. Indicative of the client's ambivalence about hospital discharge Source: Saunders 4th

ANS: B Rationale: Disturbed body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and show regressed behavior, the client's coping pattern relates to the basic issue of disturbed body image. The nurse should address this need in the support group. Strategy: Use the process of elimination, focusing on the information provided in the question, which is related directly to an altered body image. This should direct you to the correct option. Review the needs of the client with anorexia nervosa if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 322, 382, 384). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1361) A nurse is caring for a client with osteoarthritis. The nurse performs an assessment, knowing that which of the following is a clinical manifestation associated with the disorder? a. Morning stiffness b. A decreased sedimentation rate c. Joint pain that diminishes after rest d. Elevated antinuclear antibody levels Source: Saunders 4th

ANS: C Rationale: The stiffness and joint pain that occur in osteoarthritis diminish after rest and intensify with activity. No specific laboratory findings are useful in diagnosing osteoarthritis. The client may have a normal or slightly elevated sedimentation rate. Morning stiffness lasting longer than 30 minutes occurs in rheumatoid arthritis. Elevated white blood cell counts, platelet counts, and antinuclear antibody levels occur in rheumatoid arthritis. Strategy: Use the process of elimination and knowledge about the differences between osteoarthritis and rheumatoid arthritis to answer this question. Review the characteristics of osteoarthritis if you had difficulty with the question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 382). St. Louis: W.B. Saunders. Reference: Monahan, F., Sands, J., Neighbors, M., et al. (2007). Phipps' medical-surgical nursing: Health and illness perspectives (8th ed., p. 1619). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1325) The client with epilepsy is taking the prescribed dose of phenytoin (Dilantin) to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL. Which of the following symptoms would be expected as a result of this laboratory result? a. Nystagmus b. Tachycardia c. Slurred speech d. No symptoms, because this is a normal therapeutic level Source: Saunders 4th

ANS: C Rationale: The therapeutic phenytoin level is 10 to 20 mcg/mL. At a level higher than 20 mcg/mL, involuntary movements of the eyeballs (nystagmus) appears. At a level higher than 30 mcg/mL, ataxia and slurred speech occur. Strategy: Use the process of elimination and knowledge regarding the therapeutic phenytoin level. From this point, you must know the symptoms that would be noted in the client when the phenytoin level is 35 mcg/mL. Remember that ataxia and slurred speech occur with levels higher than 30 mcg/mL. Review therapeutic levels and associated symptoms if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 929). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1461) The client is admitted to the mental health unit with a diagnosis of schizophrenia. A nursing diagnosis formulated for the client is thought processes, disturbed, related to paranoia. In formulating nursing interventions with the members of the health care team, the nurse provides instructions to: a. Increase socialization of the client with peers. b. Avoid laughing or whispering in front of the client. c. Begin to educate the client about social supports in the community. d. Have the client sign a release of information to appropriate parties so that adequate data can be obtained for assessment purposes. Source: Saunders 4th

ANS: B Rationale: Disturbed thought process related to paranoia is the client's problem, and the plan of care must address this problem. The client is experiencing paranoia and is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Therefore, laughing or whispering in front of the client would be counterproductive. Options 1, 3, and 4 ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client who is paranoid. Strategy: Use the process of elimination and knowledge regarding this disorder to answer the question. Noting that the client has paranoia will direct you to option 2. Review this disorder if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 249-250, 262). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 418). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2650) Buspirone hydrochloride (BuSpar) is prescribed for a client with an anxiety disorder. The nurse plans to include which of the following teaching points when reviewing this medication with the client? a. The medication is addicting. b. Dizziness and nervousness may occur. c. The medication can produce a sedating effect. d. Tolerance can develop with this medication. Source: Saunders 4th

ANS: B Rationale: Dizziness, nausea, headaches, nervousness, lightheadedness, and excitement, which generally are not major problems, are side effects of buspirone hydrochloride. Buspirone hydrochloride is not sedating, tolerance does not develop, and it is not addicting. Strategy: Knowledge of side effects and advantages of buspirone hydrochloride is required to answer this question. Remember that this medication can cause dizziness and nervousness. If you are unfamiliar with the side effects of this medication and its use, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 164). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1527) A client is receiving fluphenazine (Prolixin) daily. The nurse would teach the client to do which of the following to minimize common side effects of this medication? a. Monitor the temperature daily. b. Use hard sour candy or sugarless gum. c. Eat snacks at midmorning and at bedtime. d. Have the blood pressure checked once a week. Source: Saunders 4th

ANS: B Rationale: Dry mouth is a common side effect. Frequent mouth rinsing with water, sucking on hard candy, and chewing sugarless gum will alleviate this common side effect. Hypotension and hypertension are rare side effects of fluphenazine (Prolixin). Mild leukopenia may occur, but the temperature does not need to be taken daily. Weight gain is a common side effect, and frequent snacks will worsen the problem. Strategy: Use the process of elimination, noting the strategic words common side effects. Eliminate options 1 and 4 because they are assessments rather than interventions. As such, they cannot "minimize" a side effect. From the remaining options, you must recall that a dry mouth is a side effect. Review the common side effects related to this medication if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 461). St. Louis: Mosby. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., p. 118). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1491) The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. These behaviors are interpreted by the nurse as: a. Signs of depression b. Normal reactions to a devastating event c. Evidence that the client is a high suicide risk d. Indicative of the need for hospital admission Source: Saunders 4th

ANS: B Rationale: During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate a normal reaction to an intensely difficult crisis event. Strategy: Use the process of elimination and knowledge regarding client responses to devastating events to answer the question. Focus on the symptoms noted in the question to direct you to option 2. If you had difficulty with this question, review normal and abnormal client responses to dealing with devastating crisis events. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 533-534). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1745) The client is diagnosed with a gastrointestinal (GI) bleed and the bleeding has been controlled. Antacids are prescribed to be administered every hour. The nurse administers the antacids and plans to maintain an approximate gastric pH of: a. 3. b. 6. c. 9. d. 15. Source: Saunders 4th

ANS: B Rationale: During the first few days after hemorrhage, gastric pH should be increased to between 5.5 and 7.0 and maintained at this level to control secretory activity. Ranitidine (Zantac) or cimetidine (Tagamet) may be prescribed in addition to antacids to accomplish this. The use of antacids complements the effectiveness of histamine 2 (H₂) receptor antagonists for maintaining the pH level of gastric secretions. Strategy: Use the process of elimination and knowledge regarding the treatment goals following a GI bleed to answer this question. Remembering that gastric secretions are acidic will assist in eliminating option 1. Options 3 and 4 identify an alkaline pH. Therefore, option 2 is the best choice. Review care of the client with a GI bleed if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1293-1294). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 1025-1026). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1206) A nurse is providing discharge instructions to a client receiving sulfisoxazole. Which of the following would be included in the list of instructions? a. Restrict fluid intake. b. Maintain a high fluid intake. c. If the urine turns dark brown, call the physician immediately. d. Decrease the dosage when symptoms are improving to prevent an allergic response. Source: Saunders 4th

ANS: B Rationale: Each dose of sulfisoxazole should be administered with a full glass of water, and the client should maintain a high fluid intake. The medication is more soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Some forms of sulfisoxazole cause urine to turn dark brown or red. This does not indicate the need to notify the physician. Strategy: Use the process of elimination. Recalling that this medication is used to treat urinary tract infections will direct you to option 2. Review client instructions regarding this medication if you had difficulty with this question. Reference: Mosby. (2007). 2007 Mosby's nursing drug reference (20th ed., p. 936). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2467) A nurse is reviewing the laboratory results of a serum drug level assay for a client seen in the health care clinic who has been taking phenytoin (Dilantin) for the control of seizures. The nurse determines that a therapeutic level of phenytoin is present if which of the following values is noted? a. 3 mcg/mL b. 8 mcg/mL c. 16 mcg/mL d. 24 mcg/mL Source: Saunders 4th

ANS: C Rationale: The therapeutic range for a serum phenytoin level is 10 to 20 mcg/mL. Options 1 and 2 would indicate the need for additional medication. Option 4 indicates a high level. If the level is below the therapeutic range, the client may continue to experience seizure activity. If the level is too high, the client could experience phenytoin toxicity. Strategy: Focus on the subject, a therapeutic level. Recalling that this level for phenytoin is 10 to 20 mcg/mL will direct you to option 3. Review this test if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 869). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1072) A nurse notes bilateral +2 edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. The nurse would plan to do which of the following next? a. Order daily weights starting on the following morning. b. Review the intake and output records for the last 2 days. c. Request a sodium restriction of 1 g/day from the physician. d. Change the time of diuretic administration from morning to evening. Source: Saunders 4th

ANS: B Rationale: Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms. Strategy: Use the process of elimination, noting the strategic word next. Use the steps of the nursing process to prioritize. Option 2 is the only option that addresses assessment of data. Review care of the client with a myocardial infarction if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1656, 1721). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 688, 756, 760). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2252) A nurse is monitoring the client receiving epoetin alfa (Epogen, Procrit) for adverse effects of the medication. Which of the following would indicate an adverse effect? a. Diarrhea b. Hypertension c. Depression d. Bradycardia Source: Saunders 4th

ANS: B Rationale: Epoetin alfa generally is well tolerated. The most significant adverse effect is hypertension. Occasionally, a tachycardia may occur as a side effect. This medication also may cause an improved sense of well-being. Strategy: Use the process of elimination and knowledge regarding the significant side effect associated with epoetin alfa. Remember that hypertension can occur with this medication. Review this medication and its side effects if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 424). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1833) Epoetin alfa (Epogen) is prescribed for a client diagnosed with chronic renal failure. The client asks the nurse about the purpose of the medication. The appropriate response would be which of the following? a. "It is used to lower your blood pressure." b. "It is used to treat anemia." c. "It will help to increase the potassium level in your body." d. "It is an anticonvulsant medication given to all clients after dialysis to prevent seizure activity." Source: Saunders 4th

ANS: B Rationale: Epoetin alfa is a medication that is used to treat anemia. Options 1, 3, and 4 are incorrect. Hypertension is a side effect. Hyperkalemia and seizures are adverse effects of the medication. Strategy: Knowledge of the actions and purpose of this medication is required to answer this question. Remember that epoetin alfa is used to treat anemia. If you had difficulty with this question, review the action and effects of this medication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 422). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2519) A client is taking a prescribed course of therapy with ethambutol (Myambutol). The home health nurse assesses the client at each home visit for which important adverse effect of this medication? a. Orange-colored urine b. Visual disturbances c. Gastrointestinal (GI) upset d. Hearing disturbances Source: Saunders 4th

ANS: B Rationale: Ethambutol causes optic neuritis, which decreases visual acuity and impairs the ability to discriminate between the colors red and green. This form of color blindness poses a potential safety hazard in driving a motor vehicle. The client is taught to report this symptom immediately. The client also is taught to take the medication with food if GI upset occurs. Impaired hearing results from antituberculosis therapy with streptomycin. Orange-red discoloration of secretions occurs with rifampin (Rifadin). Strategy: Note the strategic words important adverse effect. Recalling that this medication causes optic neuritis will direct you to option 2. If this question was difficult, review the adverse effects associated with ethambutol. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 451). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1864) A client with severe preeclampsia is receiving intravenous magnesium sulfate. The nurse is reviewing the laboratory results and determines that which of the following magnesium levels is within the therapeutic range? a. 1 mg/dL b. 3 mg/dL c. 5 mg/dL d. 10 mg/dL Source: Saunders 4th

ANS: C Rationale: The therapeutic range for magnesium sulfate is 4 to 8 mg/dL. Options 1 and 2 are low values. Option 4 is an elevated value. Strategy: Knowledge regarding the therapeutic magnesium level for a client receiving magnesium sulfate is required to answer this question. Recall that a therapeutic level is within the normal range, which would then suggest option 3. If you are unfamiliar with this therapeutic level, review this laboratory value. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 646, 716). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Maternity—Intrapartum Alternate Question Types -> Multiple Choice

83) A client with a history of a seizure disorder that has been compliant with medication therapy is admitted to the hospital with seizure activity. Phenytoin (Dilantin) is administered to the client intravenously, and subsequently a sample for the serum phenytoin level is drawn. The nurse determines that the medication therapy has been most effective if the laboratory result is: a. 3 mcg/mL b. 8 mcg/mL c. 16 mcg/mL d. 24 mcg/mL Source: Saunders 4th

ANS: C Rationale: The therapeutic range for serum phenytoin (Dilantin) level is 10 to 20 mcg/mL. If the level is below the therapeutic range, the client may continue to experience seizure activity. If the level is too high, the client could experience phenytoin toxicity. Strategy: Use the process of elimination. Recalling that the therapeutic range is 10 to 20 mcg/mL will direct you to option 3. Learn this therapeutic range if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 869). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2555) A client with urolithiasis is scheduled for extracorporeal shock wave lithotripsy. The ambulatory care nurse tells the client that which of the following will be necessary before the procedure is performed? a. Clear liquids only on the day of the procedure b. A signed informed consent form c. Insertion of a Foley catheter d. Administration of antihypertensive medication Source: Saunders 4th

ANS: B Rationale: Extracorporeal shock wave lithotripsy is done with the client under epidural or general anesthesia. The client must sign a consent form for the procedure and must have no oral intake beginning the night before the procedure. The client needs an intravenous line for the procedure as well. Insertion of a Foley catheter is not normally done, and there is no reason to administer antihypertensive medication for this procedure. Strategy: Use the process of elimination. Note the strategic words will be necessary before. Recalling the concepts associated with informed consent will direct you to option 2. Review preparation for this procedure if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 280-282). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1699). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2271) A nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client? a. Discouraging the family from touching the client b. Explaining equipment and procedures on an ongoing basis c. Ensuring adherence to visiting hours to ensure the client's rest d. Encouraging the family not to "give in" to their feelings of grief Source: Saunders 4th

ANS: B Rationale: Families often need assistance to cope with the illness of a loved one. The nurse can help family members of an unconscious client by assisting them to work through their feelings of grief. The nurse should explain all equipment, treatments, and procedures and supplement or reinforce information given by the physician. Family members should be encouraged to touch and speak to the client and to become involved in the client's care to the extent they are comfortable with. The nurse should allow the family to stay with the client to the extent possible and should encourage them to eat and sleep adequately to maintain strength. Strategy: Use the process of elimination, focusing on the subject, helping the family to cope with the situation. Each of the incorrect options either inhibits the family's coping or distances the family from the client or the client's care. Avoid selecting these types of options. Review methods of assisting the client and/or family to cope with illness if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2064-2065). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1471) The depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." The best nursing response would be to: a. Tell the client that this is not true, that we all have a purpose in life. b. Identify recent behaviors or accomplishments that demonstrate the client's skills. c. Reassure the client that you know how the client is feeling and that things will get better. d. Remain with the client and sit in silence; this will encourage the client to verbalize feelings. Source: Saunders 4th

ANS: B Rationale: Feelings of low self-esteem and worthlessness are common symptoms of the depressed client. An effective plan of care to enhance the client's personal self-esteem is to provide experiences for the client that are challenging but that will not be met with failure. Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of self. Silence may be interpreted as agreement. Options 1 and 3 give advice and devalue the client's feelings. Strategy: Use the process of elimination and therapeutic communication techniques. Focus on the client's diagnosis. You can eliminate options 1 and 3 easily. From the remaining options, focusing on the client's diagnosis will direct you to option 2. Review care of the client with depression if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 231). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 305-306, 350-351). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 341-342). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2256) A client with chronic renal failure (CRF) is receiving ferrous sulfate (Feosol). The nurse instructs the client that which of the following is a common side effect associated with this medication? a. Fatigue b. Constipation c. Headache d. Weakness Source: Saunders 4th

ANS: B Rationale: Feosol is an iron supplement used to treat anemia. Constipation is a frequent and uncomfortable side effect associated with the administration of oral iron supplements. Stool softeners often are prescribed to prevent constipation. Options 1, 3, and 4 are not associated with this medication. Strategy: Use the process of elimination. Recalling that oral iron can cause constipation will easily direct you to option 2. If you had difficulty with this question, review the side effects of ferrous sulfate preparations. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 356). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2169) A nurse in the physician's office is reviewing the results of a client's phenytoin (Dilantin) level determination performed that morning. The nurse identifies that a therapeutic drug level has been achieved if the client's result is: a. 3 mcg/mL b. 8 mcg/mL c. 15 mcg/mL d. 24 mcg/mL Source: Saunders 4th

ANS: C Rationale: The therapeutic range for serum phenytoin levels is 10 to 20 mcg/mL in clients with normal serum albumin levels and renal function. A level below this range indicates that the client is not receiving sufficient medication and is at risk for seizure activity. In this case, the medication dose should be adjusted upward. A level above this range indicates that the client is entering the toxic range and is at risk for toxic side effects of the medication. In this case, the dose should be adjusted downward. Strategy: To answer this question accurately, you need to know the therapeutic drug level for phenytoin. Remember that this therapeutic range is 10 to 20 mcg/mL. Learn this value if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 869). Philadelphia: W.B. Saunders. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 930). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1773) Which of the following clients is least likely to be at risk for the development of third spacing? a. The client with cirrhosis b. The client with diabetes mellitus c. The client with liver failure d. The client with renal failure Source: Saunders 4th

ANS: B Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. Common sites for third spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors for third spacing include clients with liver or kidney disease, major trauma, burns, sepsis, wound healing or major surgery, malignancy, gastrointestinal malabsorption, malnutrition, and alcoholic or older adult clients. Strategy: Use the process of elimination and note the strategic words least likely. Eliminate options 1 and 4 first because it is likely that fluid balance disturbances will occur with these conditions. From the remaining options, sepsis is the option that is most acute and therefore is most similar to options 1 and 4. Review the risk factors associated with third spacing if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 213). Philadelphia: W.B. Saunders. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., p. 109). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1170) The nurse is planning teaching for a female client diagnosed with urethritis caused by chlamydial infection. The nurse would plan to include which of the following points in the teaching session? a. Altering the perineal pH by using a spermicide with a condom b. Keeping follow-up appointments for repeat cultures in 4 to 7 days c. Discontinuing antibiotics after 3 weeks of uninterrupted administration d. Identifying sexual partners for the last 12 months so they can be treated Source: Saunders 4th

ANS: B Rationale: Follow-up cultures are typically done in 4 to 7 days to evaluate the effectiveness of the medication. Using a spermicide does not change the perineal pH. The infection can be prevented by the use of latex condoms. Chlamydial infection is treated with doxycycline for 7 days or with azithromycin (Zithromax) as a single dose. All sexual partners during the 30 days before diagnosis should be notified, examined, and treated as necessary. Strategy: Use the process of elimination. Eliminate option 1 first, using principles of infection control. Knowing that most courses of antibiotic therapy generally extend from 7 to 10 days may help eliminate option 3. Eliminate option 4; partners within the last month should be notified and treated as needed. Review the teaching points for the client with chlamydia if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1896). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

911) The nurse is instructing the client who had an inguinal hernia repair how to reduce postoperative swelling following the procedure. What should the nurse tell the client? a. Limit oral fluids. b. Elevate the scrotum. c. Apply heat to the abdomen. d. Remain on a low-fiber diet. Source: Saunders 4th

ANS: B Rationale: Following inguinal hernia repair, the client should be instructed to elevate the scrotum and apply ice packs while in bed to decrease pain and swelling. The nurse also should instruct the client to apply a scrotal support when out of bed. Heat will increase swelling. Limiting oral fluids and a low-fiber diet can cause constipation. Strategy: Focus on the subject, to reduce swelling. Basic knowledge regarding the effects of heat and cold will assist you in eliminating option 3. Options 1 and 4 can be eliminated next because they are comparative or alike, and limiting oral fluids and consuming a low-fiber diet can cause constipation. Straining with a bowel movement needs to be avoided. Review postoperative care following herniorrhaphy if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1317). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2468) A nurse in the respiratory care unit is reviewing the laboratory results of a serum drug level assay for a client receiving theophylline. The nurse determines that a therapeutic medication level is achieved if which of the following values is noted? a. 5 mcg/mL b. 9 mcg/mL c. 15 mcg/mL d. 25 mcg/mL Source: Saunders 4th

ANS: C Rationale: The therapeutic range for serum theophylline (or aminophylline) is 10 to 20 mcg/mL. If the level is below the therapeutic range, the client may experience frequent exacerbations of the respiratory disorder. If the level is too high, the medication may need to be stopped or the dose may need to be lowered. Options 1 and 2 indicate low values. Option 4 indicates an elevated value. Strategy: Focus on the subject, a therapeutic level. Recalling that this level for theophylline is 10 to 20 mcg<b>/</b>mLwill direct you to option 3. Review this test if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 81). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2077) A nurse is assisting a client with cystitis with food selection for an acid-ash diet. The nurse encourages the client to select which of the following foods? a. Low-fat milk b. Baked haddock c. Garden peas d. Apples Source: Saunders 4th

ANS: B Rationale: Foods that are allowed on an acid-ash diet include meat, fish, shellfish, cheese, eggs, poultry, grains, cranberries, prunes, plums, corn, lentils, and foods with high amounts of chlorine, phosphorus, and sulfur. Foods that not included are all milk and milk products; all other vegetables except corn and lentils; all fruits except cranberries, plums, and prunes; and foods containing high amounts of sodium, potassium, calcium, and magnesium. Strategy: This question is difficult to answer without specific knowledge of the types of foods that may be included in the acid ash diet. Knowing that most fruits and vegetables are not included may help you to eliminate options 3 and 4. Regarding the remaining options, it is necessary to know that foods such as meat, fish, cheese and eggs are included, whereas milk and milk products are not. Review the components of an acid-ash diet if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 860). Philadelphia: W.B. Saunders. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed., pp. 622-623). St. Louis: Mosby. Reference: Nix, S. (2005). Williams' basic nutrition & diet therapy (12th ed., pp. 406-407). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1952) A home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement if made by the client indicates a need for further instruction? a. "I need to be sure not to go barefoot around the house." b. "I need to be sure that I elevate my leg above my heart level for at least an hour every day." c. "If I cut my toenails I need to be sure that I cut them straight across." d. "It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." Source: Saunders 4th

ANS: B Rationale: Foot care instructions for the client with peripheral arterial disease are the same instructions as those for a client with diabetes mellitus. The client with arterial disease, however, should avoid raising the legs above the level of the heart unless instructed to do so as part of an exercise program, such as Buerger-Allen exercises, or unless venous stasis is also present. Strategy: Use the process of elimination and note the strategic words need for further instruction. This phrasing indicates a negative event query and directs you to select an incorrect statement. Focus on the subject, an arterial condition, and think about the physiology related to arterial blood flow to direct you to option 2. Review teaching points for the client with peripheral arterial ischemic disease if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 796). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2331) A nurse is preparing to care for a client after a lumbar puncture. The nurse plans to place the client in which position immediately after the procedure? a. Supine with a pillow under the head b. Prone with a pillow under the abdomen c. Prone in semi-Fowler's position d. Lateral with the head slightly lower than the rest of the body Source: Saunders 4th

ANS: B Rationale: For 1 hour after the procedure, the client assumes a prone position, if able, with a pillow under the abdomen to increase intra-abdominal pressure. This position retards leakage of cerebrospinal fluid. Options 1, 3, and 4 are incorrect. Strategy: Use the process of elimination. Note the strategic word immediately in the question. Thinking about the complications associated with the procedure will direct you to option 2. If you are unfamiliar with this procedure and the post-procedural care, review this content. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 609). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1707) The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours following a laparotomy. Which of the following findings would indicate the need to notify the physician? a. Light yellowish-brown drainage b. Dark red drainage c. Dark brown drainage d. Greenish-tinged drainage Source: Saunders 4th

ANS: B Rationale: For the first 12 hours following a laparotomy, the nasogastric (NG) tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence of bile may cause a greenish tinge. The physician should be notified if dark red drainage is noted 24 hours postoperatively. Strategy: Focus on the subject, need to notify the physician. Use the process of elimination and recall that bleeding is a concern in the postoperative client. This concept will easily direct you to option 2. Review the signs of postoperative complications following a laparotomy if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 345). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1405). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1726) The nurse has an order to begin administering foscarnet (Foscavir) to the client with cytomegalovirus retinitis and acquired immunodeficiency syndrome (AIDS). The nurse assesses the latest results of which laboratory study prior to administering the dose? a. Serum albumin level b. Serum creatinine level c. CD4 cell count d. Lymphocyte count Source: Saunders 4th

ANS: B Rationale: Foscarnet (Foscavir) is very toxic to the kidneys. The serum creatinine level is monitored prior to therapy, two or three times weekly during induction therapy, and at least weekly during maintenance therapy. It also may cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus, these levels are also measured with the same frequency. Strategy: Use the process of elimination. Recalling that foscarnet is nephrotoxic will direct you to option 2. Review the adverse effects of this medication if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 515-516). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1661) The client has been hospitalized for a cervical radiation implant. The implant is removed and the nurse provides home care instructions to the client. Which statement made by the client indicates a need for further instructions? a. "Cream may be used to relieve dryness or itching." b. "Foul-smelling vaginal discharge is a sign of an infection." c. "Sexual intercourse may be resumed after 7 to 10 days." d. "Some vaginal bleeding is expected for 1 to 3 months." Source: Saunders 4th

ANS: B Rationale: Foul-smelling vaginal discharge is expected and will occur for some time following removal of a cervical radiation implant. Options 1, 3, and 4 are accurate discharge instructions. Strategy: Use the process of elimination. Note the strategic words need for further instructions. These words indicate a negative event query and ask you to select an option that is incorrect. Knowledge regarding the client teaching points related to radiation implants is required to answer the question. Review these points if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1846). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

164) A client is brought to the emergency room having experienced blood loss related to an arterial laceration. Fresh frozen plasma (FFP) is ordered and transfused to replace fluid and blood loss. The nurse understands that the rationale for transfusing FFP in this client is to: a. Treat the loss of platelets b. Promote rapid volume expansion c. That the transfusion must be done slowly. d. That it will increase the hemoglobin and hematocrit levels. Source: Saunders 4th

ANS: B Rationale: Fresh frozen plasma is often used for volume expansion as a result of fluid and blood loss. It does not contain platelets, so it is not used to treat any type of low platelet count disorder. It is rich in clotting factors and can be thawed quickly and transfused quickly. It will not specifically increase the hemoglobin and hematocrit level. Strategy: Focus on the data in the question. Note the relationship between the words experienced blood loss and option 2. Review the purpose and use for FFP if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 748). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2515) A client who has been taking phenytoin (Dilantin) for seizure control has a serum phenytoin drug level of 8 mcg/mL. The nurse interprets that this value indicates: a. The high end of therapeutic range b. A toxic level c. An inadequate drug level d. The low end of therapeutic range Source: Saunders 4th

ANS: C Rationale: The therapeutic serum drug level range for phenytoin is 10 to 20 mcg/mL. A laboratory value of 8 mcg/mL is below the therapeutic range, indicating an inadequate drug level. Strategy: Knowledge regarding the therapeutic serum range of this medication will direct you to option 3. Recognition that the therapeutic ranges for phenytoin, acetaminophen, and theophylline are the same may assist you when answering questions related to these three medications. Review this medication and its therapeutic range if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 930). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1589) During a routine prenatal visit, the client complains of gums that bleed easily with brushing. The nurse performs an assessment and then teaches the client about proper nutrition to minimize this problem. Which statement, if made by the client, indicates an understanding of the proper nutrition to minimize this problem? a. "I will eat three servings of cracked wheat bread each day." b. "I will eat fresh fruits and vegetables for snacks and for dessert each day." c. "I will drink 8 oz of water with each meal." d. "I will eat two saltine crackers before I get up each morning." Source: Saunders 4th

ANS: B Rationale: Fresh fruits and vegetables will provide vitamins and minerals needed for healthy gums. Cracked wheat bread may abrade the tender gums; drinking water with meals has no direct effect on gums, and eating saltine crackers before arising helps decrease nausea. Strategy: Use the process of elimination and focus on the subject of the question. Eliminate options 1 and 4 first because these measures could irritate fragile gums. From the remaining options, eliminate option 3, remembering that drinking water with meals has no direct effect on gums. Review measures that promote dental health during pregnancy if you had difficulty with this question. Reference: Lowdermilk, D., & Perry, A. (2004). Maternity and woman's health care (8th ed., p. 431). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

2159) A nurse is planning measures to increase bed mobility for a client in skeletal leg traction. Which of the following items would the nurse consider to be most helpful for this client? a. Television b. Reading materials c. Overhead trapeze d. Fracture bedpan Source: Saunders 4th

ANS: C Rationale: The use of an overhead trapeze is extremely helpful in helping a client to move about in bed, and to get on and off the bedpan. This device has the greatest value in increasing overall bed mobility. A fracture bedpan is useful in reducing discomfort with elimination. Television and reading materials are helpful in reducing boredom and providing distraction. Strategy: Use the process of elimination. Note the strategic words most helpful and the subject, increasing bed mobility. Although all options are useful to the client in skeletal traction, the only one that helps with overall bed mobility is the trapeze. Review care of the client in skeletal traction if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 637). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1455-1456). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1912) A client undergoing hemodialysis has an arteriovenous (AV) fistula in the left arm. A related nursing diagnosis for the client is risk for infection. The nurse should formulate which of the following outcome goals as most appropriate for this nursing diagnosis? a. The client's temperature remains less than 101° F. b. The client's white blood cell (WBC) count remains within normal limits. c. The client washes hands at least once per day. d. The client states to avoid blood pressure (BP) measurement in the left arm. Source: Saunders 4th

ANS: B Rationale: General indicators that the client is not experiencing infection include a temperature and WBC count within normal limits. The client also should use proper hand-washing technique as a general preventive measure. Hand washing once per day is insufficient. It is true that the client should avoid BP measurement in the affected arm; however, this would relate more closely to the nursing diagnosis risk for injury. Strategy: Use the process of elimination. Focus on the subject, risk for infection, and most appropriate goals. Of the options provided, option 2 is the best indicator that the client is infection free. Review outcome criteria for the risk for infection if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 967). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

30) A client is brought to the emergency room by emergency medical services (EMS) after being hit by a car. The name of the client is not known and the client has sustained a severe head injury and multiple fractures, and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which of the following is the best action? a. Obtain a court order for the surgical procedure. b. Transport the victim to the operating room for surgery. c. Call the police to identify the client and locate the family. d. Ask the EMS team to sign the informed consent. Source: Saunders 4th

ANS: B Rationale: Generally, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option 1 will delay emergency treatment and option 4 is inappropriate. Although option 3 may be pursued, it is not the best action. Strategy: Use the process of elimination. Recalling that when an emergency is present and a delay in treatment for the purpose of obtaining informed consent could result in injury or death will direct you to option 2. Review the issues surrounding informed consent if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 857). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 416-417). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1383) The nurse prepares to give a bath and change the bed linens on a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which of the following would the nurse incorporate into the plan during the bathing of this client? a. Wearing gloves b. Wearing a gown and gloves c. Wearing a gown, gloves, and a mask d. Wear a gown and gloves to change the bed linens and gloves only for the bath Source: Saunders 4th

ANS: B Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items such as those with wound drainage or is caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn. Strategy: Use the process of elimination and think about the method of transmission of infection when answering a question of this type. Read the question, noting the task that is presented; in this case, it is bathing and changing linens. Eliminate option 3 because the method of transmission is not respiratory. Eliminate options 1 and 4 because neither provide adequate protection based on the method of transmission. If you had difficulty with this question, review standard and transmission-based precautions. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 797). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

2566) The ambulatory care nurse is performing an assessment on a client who has returned from the postanesthesia care unit (PACU) after a cystoscopy. Which of the following assessment findings in this client would indicate a need to notify the physician? a. A temperature of 99.4° F b. Grossly bloody urine with clots c. A blood pressure of 130/82 mm Hg d. A bluish or green tinge to the urine Source: Saunders 4th

ANS: B Rationale: Grossly bloody urine with clots following cystoscopy is always an abnormal finding and should be reported to the physician immediately. The client may have clear or blood-tinged urine after cystoscopy. If a contrast agent such as methylene blue is used, the urine may have an unusual bluish or green tinge. A blood pressure of 130/82 mm Hg and a temperature of 99.4° F are not abnormal findings at this time. Strategy: Use the process of elimination, focusing on the subject, after a cystoscopy. Eliminate options 1 and 3 first because they are normal findings. Recalling that contrast agents such as methylene blue may cause the urine to develop an unusual bluish or green tinge will assist in eliminating option 4. Also note the strategic words grossly bloody in the correct option. Review the expected findings after a cystoscopy if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1674). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1051) A client has an order to take guaifenesin (Humibid). A nurse concludes that the client understands the most effective use of this medication if the client states that he or she will: a. Watch for irritability as a side effect. b. Take the tablet with a full glass of water. c. Take an extra dose if the cough is accompanied by fever. d. Crush the sustained-release tablet if immediate relief is needed. Source: Saunders 4th

ANS: B Rationale: Guaifenesin (Humibid) is an expectorant and should be taken with a full glass of water to decrease the viscosity of secretions. Sustained-release preparations should not be broken open, crushed, or chewed. The medication occasionally may cause dizziness, headache, or drowsiness as side effects. The client should contact the physician if the cough lasts longer than 1 week or is accompanied by fever, rash, sore throat, or persistent headache. Strategy: Use the process of elimination. Begin to answer this question by eliminating option 4 first. Sustained-released preparations are not crushed or broken. Option 3 is eliminated next because fever indicates infection, and an "extra dose" of an expectorant is not helpful in treating infection. From the remaining options, knowing that increased fluids helps liquefy secretions for more effective coughing directs you to option 2 as correct. If you had difficulty with this question, review this medication. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 584). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2217) To detect the development of a chronic carrier state in a client with hepatitis, the nurse should assess the client's serum laboratory results for: a. Antibody to surface antigen (anti-HBs) b. Hepatitis B surface antigen (HBsAg) c. Hepatitis B virus DNA d. Prolonged prothrombin time Source: Saunders 4th

ANS: B Rationale: HBsAg is present in chronic carriers. Anti-HBs is a marker for the response to the vaccine and indicates immunity to hepatitis B. Hepatitis B virus DNA indicates viral replication. A prolonged prothrombin time is caused by decreased absorption of vitamin K in the intestine with decreased production of prothrombin by the liver. Strategy: Knowledge of the serological tests for viral hepatitis is needed to answer this question. Remember that HBsAg is present in chronic carriers. If you had difficulty with this question, review these tests. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1328). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1386). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1520) The client with schizophrenia has been started on medication therapy with haloperidol (Haldol). The nurse determines that the client is experiencing the intended effects of the medication if which of the following client behaviors is observed? a. Presence of a fixed stare b. Absence of delusional statements c. Decreased appetite and food intake d. Taking sips of water for dry mouth Source: Saunders 4th

ANS: B Rationale: Haloperidol (Haldol) is an antipsychotic used to manage psychotic disorder. Hallucinations, delusions, and altered thought processes are characteristics of a psychotic disorder and should decrease with effective treatment. Fixed stare (option 1) and dry mouth (option 4) are side effects of therapy. Option 3 is unrelated to this medication. Strategy: Use the process of elimination. Recalling that this medication is an antipsychotic will direct you to option 2. Review the purpose of this medication if you had difficulty with this question. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., pp. 103, 130). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2334) A nurse is monitoring a client who has returned to the nursing unit after a myelogram. Which of the following client complaints would indicate the need to notify the physician? a. Headache b. Neck stiffness c. Feelings of fatigue d. Backache Source: Saunders 4th

ANS: B Rationale: Headache is relatively common after the procedure, but neck stiffness, especially on flexion, and pain should be reported because they signal meningeal irritation. The client also is monitored for evidence of allergic reactions to the dye such as confusion, dizziness, tremors, and hallucinations. Feelings of fatigue may be normal, and back discomfort may be due to the positions required for the procedure. Strategy: Use the process of elimination, noting the strategic words need to notify the physician. Recalling that meningeal irritation is a complication and that neck stiffness is a characteristic sign will direct you to option 2. If you had difficulty with this question, review post-procedural care of the client after a myelogram. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 805). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2590) A nurse in the newborn nursery is preparing to complete an initial assessment on a newborn infant who was just admitted to the nursery. The nurse places a warm blanket on the examining table to prevent heat loss in the infant caused by: a. Convection b. Conduction c. Radiation d. Evaporation Source: Saunders 4th

ANS: B Rationale: Heat loss occurs by four different mechanisms. In conduction, heat loss occurs when the infant is on a cold surface, such as a table. Evaporation of moisture from a wet body surface dissipates heat along with the moisture. In convection, air moving across the infant's skin will transfer heat to the air. Radiation occurs when heat from the body surface radiates to the surrounding environment. Strategy: Focus on the nurse's action in the question. Correlating conduction with a cold surface may help you remember the mechanism of conduction. Review the mechanisms of heat loss if you had difficulty with this question. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., p. 282). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Planning Content Area -> Child Health Alternate Question Types -> Multiple Choice

1283) The nurse is assigned to care for a client with complete right-sided hemiparesis. The nurse plans care knowing that in this condition: a. The client has complete bilateral paralysis of the arms and legs. b. The client has weakness on the right side of the body, including the face and tongue. c. The client has lost the ability to move the right arm but is able to walk independently. d. The client has lost the ability to ambulate independently but is able to feed and bathe self without assistance. Source: Saunders 4th

ANS: B Rationale: Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is weakness of the face and tongue, arm, and leg on one side. Complete bilateral paralysis does not occur in this condition. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating. Strategy: Use the process of elimination. Note the strategic words complete right-sided and focus on the subject, hemiparesis. Recalling that hemiparesis indicates weakness and focusing on the strategic words will direct you to option 2. Review the description of hemiparesis and care to the client with hemiparesis if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2111). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1034-1035, 1041-1042). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1988) A nurse is preparing to administer an intramuscular (IM) injection to a client receiving a continuous heparin infusion. The nurse should prepare to: a. Apply a 4 × 4 pressure dressing at the IM site after the injection. b. Apply prolonged pressure to the IM site after the injection. c. Use a 5/8-inch needle for the injection. d. Decrease the rate of the heparin infusion for 1 hour before and 1 hour after the injection. Source: Saunders 4th

ANS: B Rationale: Heparin is an anticoagulant that increases the risk of bleeding. Prolonged pressure over the site of an intramuscular injection will ensure that the chances of having an increase of bleeding into the tissue are lessened. It is not necessary to apply a pressure dressing to the IM site of injection. A 5/8-inch needle is not an appropriate-size needle for an IM injection. The heparin infusion is not decreased before an injection and the rate is not adjusted unless specifically prescribed by a physician. Strategy: Use the process of elimination. Option 4 can be eliminated first because the rate of an infusion is not adjusted by the nurse. Next, eliminate option 3, knowing that a 5/8-inch needle is used for subcutaneous injections, not for IM injections. From the remaining options, select option 2 because a pressure dressing is not required after an IM injection. Review precautions related to the administration of heparin and the procedures for administering an IM injection if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 591). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2461) A community health nurse is providing an educational session to community members regarding histoplasmosis. The nurse informs the community members that this disease: a. Can be contagious by respiratory contact with an infected person b. Can be caused by the inhalation of spores from bird droppings c. Is caused by contamination from cat feces d. Is caused by a tick bite Source: Saunders 4th

ANS: B Rationale: Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. This disease cannot be transmitted from one person to another. Toxoplasmosis is caused by the ingestion of cysts from contaminated cat feces. Lyme disease is a multisystem infection that results from a bite by a tick that is usually carried by several species of deer. Strategy: Use the process of elimination. Recalling that this disease is caused by the inhalation of spores from bird droppings will direct you to option 2. If you had difficulty with this question, review the cause of histoplasmosis. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 420). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

1970) A nurse is reviewing the medical record for a client who has been diagnosed with Hodgkin's disease. The nurse would expect to note which of the following as the most likely assessment finding related to this diagnosis? a. Weight gain b. Swollen cervical lymph nodes c. Increased appetite d. Complaints of lack of energy Source: Saunders 4th

ANS: B Rationale: Hodgkin's disease is a chronic progressive neoplastic disorder of lymphoid tissue. It is characterized by painless, enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Weight loss rather than weight gain is most likely to be noticed. The client also may have a decreased appetite rather than an increased appetite. Weakness and fatigue and complaints of lack of energy are other possible findings, but these are not specifically related to the disease. Strategy: Note the strategic words most likely in the question. Use the process of elimination and recall that Hodgkin's disease affects the lymph nodes. This will direct you to option 2. If you had difficulty with this question, review the manifestations of Hodgkin's disease. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2412). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

1884) The mother of a 2½-year-old child arrives at the hospital emergency department and reports to the nurse that the child has been complaining of a "tummy ache." The mother also reports that the child has been irritable, and that it has been difficult to awaken the child. On further assessment, the nurse suspects lead poisoning. Which of the following assessment questions would elicit specific data related to this condition? a. "Have you noticed a sweet and fruity odor on the child's breath?" b. "Do you live in a house that is more than 25 years old?" c. "Does your child chew on pencils or crayons?" d. "Has your child been breathing very fast or sweating profusely?" Source: Saunders 4th

ANS: B Rationale: Homes that are older than 25 years may have lead paint and will most likely have lead pipes, which can contribute to lead poisoning. Breathing rapidly and diaphoresis are signs of salicylate poisoning. A sweet and fruity odor to the breath is a symptom of ketoacidosis. Pencil lead is made of graphite so it does not present a hazard to the child. Crayons are not toxic. Strategy: Focus on the etiology related to lead poisoning. Focusing on this subject and using the process of elimination will assist in directing you to option 2. If you had difficulty with this question, review the etiology of lead poisoning. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., pp. 693-694). St. Louis: Mosby. Reference: Wong, D., Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2006). Maternal child nursing care (3rd ed., p. 1546). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Child Health Alternate Question Types -> Multiple Choice

2025) A client comes to the hospital emergency department complaining of redness and pain on the lower eyelid. A diagnosis of hordeolum is made, and the nurse provides instructions to the client regarding measures to treat the disorder. Which statement if made by the client would indicate an understanding of these home care treatment measures? a. "I should apply cool compresses to the eye three times a day." b. "I should apply warm compresses to the eye for 15 minutes four times a day." c. "When the hordeolum comes to a head, I should try to press it to make it open and drain." d. "Antibiotic ointments will not help this condition." Source: Saunders 4th

ANS: B Rationale: Hordeolum is commonly known as a sty, and therapeutic management includes the application of warm compresses for 15 minutes four times a day and the instillation of an ophthalmic antibiotic ointment to combat the causative infectious organism and prevent the spread of infection to surrounding lid glands. Warm compresses promote comfort and aid in bringing purulent contents to a head, causing rupture with drainage. If the sty does not rupture spontaneously, it may need to be incised by the physician. The client should not press or squeeze the sty to produce rupture because this pressure could force infectious material into the venous system, potentially transmitting infection to the brain. Strategy: Use the process of elimination, noting the strategic words indicate an understanding. Read each option carefully, thinking about the effects the action might have on this type of eye disorder. Review the home care measures for hordeolum if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1088). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

2502) A nurse has been given a medication order for intravenous hydralazine (Apresoline). The nurse obtains which of the following pieces of equipment needed for use during administration of this medication? a. Cardiac monitor b. Noninvasive blood pressure cuff c. Nonrebreather oxygen face mask d. Pulse oximetry Source: Saunders 4th

ANS: B Rationale: Hydralazine is an antihypertensive medication used for moderate to severe hypertension. Because the blood pressure and pulse should be monitored frequently after administration, a noninvasive blood pressure cuff should be obtained. The other options are not priority items specific to the use of this medication. Strategy: Use the process of elimination. Recalling that hydralazine is an antihypertensive will direct you to option 2. Also, the name of the medication, apresoline, will guide you to the item used to measure blood pressure. If this question was difficult, review the action and use of this medication. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 645). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1105) A client is having a follow-up physician office visit after vein ligation and stripping. The client describes a sensation of "pins and needles" in the affected leg. Which of the following would be an appropriate action by the nurse based on evaluation of the client's comment? a. Instruct the client to apply warm packs. b. Report the complaint to the physician. c. Reassure the client that this is only temporary. d. Advise the client to take acetaminophen (Tylenol) until it is gone. Source: Saunders 4th

ANS: B Rationale: Hypersensitivity or a sensation of "pins and needles" in the surgical limb may indicate temporary or permanent nerve injury following surgery. The saphenous vein and saphenous nerve run close together in the distal third of the leg. Because complications from this surgery are relatively rare, this symptom should be reported. Strategy: Use the process of elimination. Pins and needles sensations usually indicate nerve irritation or damage. If you know this, you can eliminate options 1 and 4. Reassuring the client about something being "only temporary" is often not an appropriate action, unless this is known to be absolutely true. Review the complications associated with vein ligation and stripping if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1540). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (4th ed., pp. 456, 802). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1262) Betaxolol hydrochloride (Betoptic) eye drops have been prescribed for the client with glaucoma. Which of the following nursing actions is most appropriate related to monitoring for the side effects of this medication? a. Monitoring temperature b. Monitoring blood pressure c. Assessing peripheral pulses d. Assessing blood glucose level Source: Saunders 4th

ANS: B Rationale: Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are systemic effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. Options 1, 3, and 4 are not specifically associated with this medication. Strategy: Use the ABCs—airway, breathing, and circulation—to direct you to option 2. Although option 3, peripheral pulses, also is related to circulation monitoring, the blood pressure is the umbrella option. Review the side effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 133). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1638) A client with a traumatic closed head injury presents signs that indicate the presence of cerebral edema. Which of the following fluids would be inappropriate for this client? a. 0.9% normal saline b. 0.45% normal saline c. 5% dextrose in water d. Lactated Ringer's solution Source: Saunders 4th

ANS: B Rationale: Hypotonic solutions such as 0.45% normal saline are inappropriate for the client with cerebral edema because hypotonic solutions have the potential to cause cellular swelling and cerebral edema. The remaining choices of solutions would be appropriate because they are examples of isotonic solutions and thus are similar in composition to plasma. These fluids would remain in the intravascular space without potentiating the client's cerebral edema. Strategy: Use the process of elimination and note the strategic word inappropriate. Eliminate options 1, 3, and 4 because they are comparative or alike and are isotonic solutions. Review these solutions if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 356-357). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

923) The medication history of a client with peptic ulcer disease reveals intermittent use of several medications. The nurse would teach the client to avoid which of these medications because of the irritating effects on the lining of the gastrointestinal tract? a. Nizatidine (Axid) b. Ibuprofen (Motrin) c. Sucralfate (Carafate) d. Omeprazole (Prilosec) Source: Saunders 4th

ANS: B Rationale: Ibuprofen is a nonsteroidal anti-inflammatory drug that typically is irritating to the lining of the gastrointestinal tract and should be avoided by clients with a history of peptic ulcer disease. The other medications listed are frequently used to treat peptic ulcer disease. Nizatidine is an H₂-receptor antagonist that reduces the secretion of gastric acid. Sucralfate coats the surface of an ulcer to promote healing. Omeprazole is a proton pump inhibitor, which blocks transport of hydrogen ions into the lumen of the gastrointestinal tract. Strategy: Focus on the medication classification. Recalling the types of medications irritating to the gastrointestinal tract and which medications are used to treat peptic ulcer disease will direct you to option 2. Review the pharmacological treatment measures for peptic ulcer disease if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1290). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1893) A nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. The initial nursing action should be which of the following? a. Turn the client on her back and give oxygen by nasal cannula at 2 to 4 L/min. b. Turn the client on her side and give oxygen by face mask at 8 to 10 L/min. c. Turn the client on her back and give oxygen by face mask at 8 to 10 L/min. d. Turn the client on her side and give oxygen by nasal cannula at 2 to 4 L/min. Source: Saunders 4th

ANS: B Rationale: If a fetal heart rate begins to slow or a loss of variability is observed, this could indicate fetal distress. To promote adequate oxygen for the mother and her fetus, the mother is turned to her side, which reduces the pressure of the uterus on the ascending vena cava and descending aorta. Oxygen by face mask at 8 to 10 L/min is applied to the mother. Strategy: Use the process of elimination. Eliminate options 1 and 3 first because the mother would not be turned to her back. From the remaining options, select option 2 because oxygen by face mask at 8 to 10 L/min would provide the most oxygen to both mother and fetus. Review appropriate nursing interventions to treat fetal distress if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 325). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Maternity—Intrapartum Alternate Question Types -> Multiple Choice

155) Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6° F orally. Which of the following is the appropriate nursing action? a. Begin the transfusion as prescribed. b. Delay hanging the blood and notify the physician. c. Administer an antihistamine and begin the transfusion. d. Administer two tablets of acetaminophen (Tylenol) and begin the transfusion. Source: Saunders 4th

ANS: B Rationale: If the client has a temperature higher than 100° F, the unit of blood should not be hung until the physician is notified and has the opportunity to give further orders. The physician likely will prescribe that the blood be administered regardless of the temperature, but the decision is not within the nurse's scope of practice to make. The other options are incorrect. Strategy: Use the process of elimination. Eliminate options 1, 3, and 4 because they all indicate beginning the transfusion. Review the nursing responsibilities before administering a blood transfusion if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 914). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2274) A nurse checks the gastric residual of an unconscious client receiving nasogastric tube feedings continuously at 50 mL/hr. The nurse notes that the residual is greater than 150 mL. The nurse interprets that the client is experiencing: a. Too slow an infusion rate b. Delayed gastric emptying c. Early signs of peptic ulcer d. Air in the stomach Source: Saunders 4th

ANS: B Rationale: If the gastric residual is greater than 150 mL the client may be experiencing delayed gastric emptying. If this occurs, the feeding is stopped and the physician should be notified. The nurse should assess whether abdominal girth is enlarged and should auscultate bowel sounds to rule out intestinal obstruction. Some clients benefit from administration of metoclopramide (Reglan) to stimulate gastric emptying. The infusion rate cannot be too slow (option 1) if the client cannot tolerate the rate. Air in the stomach would be accompanied by abdominal distention and increased abdominal girth. Early peptic ulcer could be detected by Hematest-positive gastric aspirate. Strategy: Focus on the subject, the gastric residual. Thinking about this occurrence will direct you to option 2. Review care of the client receiving nasogastric tube feedings if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2063). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1238) The client arrives in the emergency room with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action? a. Apply an eye patch. b. Perform visual acuity tests. c. Irrigate the eye with sterile saline. d. Remove the piece of wood using a sterile eye clamp. Source: Saunders 4th

ANS: B Rationale: If the laceration is the result of a penetrating injury, an object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea. Strategy: Use the process of elimination to answer this question. Note the strategic word penetrating. This should indicate that a laceration has occurred and that interventions are directed at preventing further disruption of the integrity of the eye. The only option that will prevent further disruption is to assess visual acuity. Review emergency eye care if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1106). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

152) The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should immediately be taken next? a. Remove the IV line. b. Run normal saline at a keep vein open rate. c. Run a solution of 5% dextrose in water. d. Obtain a culture of the tip of the catheter device removed from the client. Source: Saunders 4th

ANS: B Rationale: If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep vein open rate pending further physician orders. This maintains a patent IV access line and aids in maintaining the client's intravascular volume. The nurse would not discontinue the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should not be removed. Second, cultures are performed when infection, not transfusion reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump. Strategy: Use the process of elimination, noting the strategic word next. Knowing that the IV should not be removed or discontinued assists in eliminating options 1 and 4. Recalling that normal saline, not dextrose, is used when administering a unit of blood will direct you to option 2. Review care for the client with a transfusion reaction if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., p. 977). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1191-1193). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

2214) Of the following infection control methods, which would most effectively prevent hepatitis B? a. Hand washing b. Hepatitis B (HBV) vaccine c. Proper personal hygiene d. Immune globulin Source: Saunders 4th

ANS: B Rationale: Immunization with HBV is the most effective method of preventing hepatitis B infection. Hand washing is another effective preventive measure. Immune globulin is used to prevent hepatitis A and is indicated within 1 to 2 weeks after exposure or for prophylaxis in persons traveling to endemic areas. Attention to personal hygiene such as hand washing helps prevent the transmission of hepatitis A virus and other forms of hepatitis. Strategy: Focus on the subject, preventing the transmission of hepatitis B virus. Note the relationship between the subject and option 2. If you had difficulty with this question, review content associated with hepatitis. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1385). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2429) An industrial nurse is providing instructions to a group of employees regarding care to a client in the event of a chemical burn injury. The nurse instructs the employees that the first consideration in immediate care is: a. Leaving all clothing in place until the client is brought to the emergency department b. Removing all clothing including gloves and shoes c. Lavaging the skin with water and avoiding brushing powdered chemicals off the clothing to prevent further spread of the injury d. Determining the antidote for the chemical and placing the antidote on the burn site Source: Saunders 4th

ANS: B Rationale: In a chemical burn injury, the burning process continues so long as the chemical is in contact with the skin. All clothing including gloves and shoes is removed immediately, and water lavage is instituted before and during the transport to the emergency department. Powdered chemicals are first brushed from the clothing and also the skin before lavage is performed. Strategy: Use the process of elimination. Think about the type of burn injury to direct you to option 2. If you had difficulty with this question, review care of the client who sustained a chemical burn injury. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1627). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

1360) A nurse is caring for a client with a diagnosis of gout. Which of the following laboratory values would the nurse expect to note in the client? a. Calcium level of 9.0 mg/dL b. Uric acid level of 8.6 mg/dL c. Potassium level of 4.1 mEq/L d. Phosphorus level of 3.1 mg/dL Source: Saunders 4th

ANS: B Rationale: In addition to the presence of clinical manifestations, gout is diagnosed by the presence of persistent hyperuricemia, with a uric acid level higher than 8 mg/dL; a normal value is 4.0 to 8.5 mg/dL. Options 1, 3, and 4 indicate normal laboratory values. Additionally, the presence of uric acid in an aspirated sample of synovial fluid confirms the diagnosis. Strategy: Use the process of elimination and knowledge of normal laboratory values. Recalling that increased uric acid levels occur in gout and noting that option 2 is the only abnormal value will assist you in answering the question. Review the manifestations of gout and the normal uric acid level if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 415). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

170) An emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the emergency room. The initial nursing action is which of the following? a. Prepare the triage rooms. b. Activate the agency disaster plan. c. Obtain additional supplies from the central supply department. d. Obtain additional nursing staff to assist in treating the casualties. Source: Saunders 4th

ANS: B Rationale: In an external disaster, many victims may be brought to the emergency department for treatment. Although options 1, 3, and 4 may be components of preparing for the casualties, the initial nursing action must be to activate the disaster plan. Strategy: Use the process of elimination to determine the priority action. Note the strategic word initial in the event query. Note that option 2 is the umbrella option. Review procedures related to management of a disaster if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 167-168). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2544) A nurse is providing care for a client who sustained burns over 30% of the body from a fire that occurred in the basement of the client's home. On assessment, the nurse notes that the client is edematous in both burned and unburned body areas. The nurse documents this assessment finding as expected because the edema is caused by: a. A decrease in capillary permeability and hypoproteinemia b. An increase in capillary permeability and hypoproteinemia c. An increase in capillary permeability and hyperproteinemia d. A decrease in capillary permeability and hyperproteinemia Source: Saunders 4th

ANS: B Rationale: In extensive burn injuries (greater than 25% of total body surface area), the edema occurs in both burned and unburned areas as a result of the increase in capillary permeability and hypoproteinemia. Edema also may be caused as a result of the volume and oncotic pressure effects of the large fluid resuscitation volumes required. Strategy: Use the process of elimination. Thinking about the type of injury that occurs will assist in eliminating options 1 and 4, because an increased capillary permeability will occur in a burn injury. From the remaining options, recalling that hypoproteinemia occurs will direct you to option 2. Review the pathophysiologic changes associated with burn injuries if you had difficulty with this question. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., p. 1161). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

2000) A nurse is giving a bed bath to a client and discovers that an additional wash cloth and towel are needed. Which of the following is the appropriate action to take to obtain the needed items? a. Ask the unit secretary to get the needed items. b. Wash hands, leave the client's room, and obtain the needed items. c. Borrow the client's roommate's wash cloth and towel. d. Ask a family member to obtain the needed items. Source: Saunders 4th

ANS: B Rationale: In order to avoid spreading the client's germs, the nurse's hands must be washed before leaving. By going to the linen room without washing the hands first, the nurse will spread those germs into the clean linen. It is never appropriate to borrow other client's supplies because this action may spread germs. It is not appropriate to ask the unit secretary or a family member to obtain the supplies. Strategy: Use the process of elimination and principles of standard precautions to assist in answering the question. Eliminate options 1 and 4 first because they are comparative or alike. Next, eliminate option 3, recalling that it is not appropriate to use the supplies of another client. Review standard precautions if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 797). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1392) A client calls the nurse in the emergency room and tells the nurse that he was just stung by a bee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. The appropriate nursing action is to: a. Advise the client to soak the site in hydrogen peroxide. b. Ask the client if he ever sustained a bee sting in the past. c. Tell the client to call an ambulance for transport to the emergency room. d. Tell the client not to worry about the sting unless difficulty with breathing occurs. Source: Saunders 4th

ANS: B Rationale: In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. The appropriate action, therefore, would be to ask the client if he ever received a bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told "not to worry." Strategy: Use the steps of the nursing process to answer the question. Option 2 is the only option that addresses assessment. Review information related to allergic reactions if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 453-455). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 246-248). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1102) A nurse is caring for a client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. Which of the following activities will assist with preventing dislodgement of the pacing catheter? a. Limiting movement and abduction of the left arm b. Limiting movement and abduction of the right arm c. Assisting the client to get out of bed and ambulate with a walker d. Having the physical therapist do active range-of-motion exercises to the right arm Source: Saunders 4th

ANS: B Rationale: In the first several hours after insertion of a permanent or a temporary pacemaker, the most common complication is pacing electrode dislodgement. The nurse helps prevent this complication by limiting the client's activities of the arm on the side of the insertion site. Strategy: Use the process of elimination. Note that the pacemaker was inserted on the right side. Therefore, to prevent pacing electrode dislodgement, motion must be limited on that side. Options 3 and 4 involve movement of the right arm and are eliminated first. Limiting the movement of the left arm (option 1) is of no benefit to the client. Thus, option 2 is the correct option. Review care of the client following insertion of a pacemaker if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1697). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 743-745). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1756) A nurse manager is providing an educational session to nursing staff members about the phases of viral hepatitis. The nurse manager tells the staff that which clinical manifestation(s) are primarily characteristic of the preicteric phase? a. Right upper quadrant pain b. Fatigue, anorexia, and nausea c. Jaundice, dark-colored urine, and clay-colored stools d. Pruritus Source: Saunders 4th

ANS: B Rationale: In the preicteric phase, the client has nonspecific complaints of fatigue, anorexia, nausea, cough, and joint pain. Options 1, 3, and 4 are clinical manifestations that occur in the icteric phase. In the posticteric phase, jaundice decreases, the color of urine and stool return to normal, and the client's appetite improves. Strategy: Note the strategic word preicteric. This will assist in eliminating options 1, 3, and 4. Also, note that option 2 identifies vague and nonspecific complaints. Review the clinical manifestations associated with the phases of viral hepatitis if you had difficulty with this question. Reference: Phipps, W., Monahan, F., Sands, J., et al. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed., p. 1161). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Leadership and Management Alternate Question Types -> Multiple Choice

1243) A 55-year old woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the emergency room frantic and screaming for help. The nurse should instruct the woman to take which immediate action? a. Call the physician. b. Irrigate the eyes with water. c. Come to the emergency room. d. Irrigate the eyes with diluted hydrogen peroxide. Source: Saunders 4th

ANS: B Rationale: In this type of accident, the client is instructed to irrigate the eyes immediately with running water for at least 20 minutes or until the emergency medical service personnel arrive. In the emergency department, the cleansing agent of choice is normal saline. Calling the physician and going to the emergency room delays necessary intervention. Hydrogen peroxide is never placed in the eyes. Strategy: Use the process of elimination and note the strategic word immediate. Focus on the type of injury and eliminate options 1 and 3 because they delay necessary intervention. Next, eliminate option 4 because hydrogen peroxide is never placed in the eyes. Review immediate interventions for a chemical eye injury if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1105). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1195) A client diagnosed with polycystic kidney disease has been taught about the treatment plan for this disease. The nurse determines that the client needs additional teaching if the client states that the treatment plan includes: a. Genetic counseling b. Sodium restriction c. Increased water intake d. Antihypertensive medications Source: Saunders 4th

ANS: B Rationale: Individuals with polycystic kidney disease seem to waste rather than retain sodium. Thus, they need increased sodium and water intake. Aggressive control of hypertension is essential. Genetic counseling is advisable because of the hereditary nature of the disease. Strategy: Use the process of elimination and note the strategic words needs additional teaching. These words indicate a negative event query and ask you to select an option that is incorrect. Recalling that sodium wasting occurs in polycystic kidney disease will direct you to option 2. Review the manifestations associated with this disease if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 938). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1363) The client has been on treatment for rheumatoid arthritis for 3 weeks. Prior to the administration of etanercept (Enbrel), it is most important for the nurse to assess: a. The injection site for itching and edema b. The white blood cell counts and platelet counts c. Whether the client is experiencing fatigue and joint pain d. A metallic taste in the mouth, with a loss of appetite Source: Saunders 4th

ANS: B Rationale: Infection and pancytopenia are side effects of etanercept (Enbrel). Laboratory studies are performed prior to and during drug treatment. The appearance of abnormal white blood cell counts and abnormal platelet counts can alert the nurse to a potentially life-threatening infection. Injection site itching and edema are common occurrences following administration. A metallic taste and loss of appetite are not common signs of side effects of this medication. Strategy: Use the process of elimination. Option 4 can be eliminated, because this is not a common side effect. In early treatment, residual fatigue and joint pain may still be apparent. Option 2 is suggestive of infection, which could indicate a reason for discontinuing this medication and should be reported. Review this medication if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 405). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1603) An emergency room nurse is caring for a conscious child brought to the emergency room after the ingestion of half a bottle of acetylsalicylic acid (aspirin). The nurse anticipates that the most likely initial treatment will be: a. Dialysis. b. The administration of an emetic. c. The administration of vitamin K. d. The administration of sodium bicarbonate. Source: Saunders 4th

ANS: B Rationale: Initial treatment of salicylate overdose includes the administration of an emetic or gastric lavage. Activated charcoal may be administered to decrease absorption. Fluids and sodium bicarbonate may be administered intravenously to enhance excretion but would not be the initial treatment. Dialysis is used in extreme cases if the child is unresponsive to therapy. Vitamin K is the antidote for warfarin sodium (Coumadin) overdose. Strategy: Use the process of elimination and knowledge regarding the treatment for aspirin overdose to answer this question. Noting the strategic word initial in the question will assist in directing you to option 2. Review the treatment for this common overdose in children if you had difficulty with this question. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., pp. 452-453). St. Louis: Mosby. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 872). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Child Health Alternate Question Types -> Multiple Choice

1245) A client arrives at the emergency room with a foreign body in the left ear that has been determined to be an insect. Which intervention would the nurse anticipate to be prescribed initially? a. Irrigation of the ear b. Instillation of diluted alcohol c. Instillation of antibiotic ear drops d. Instillation of corticosteroid ointment Source: Saunders 4th

ANS: B Rationale: Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which then is removed using ear forceps. When the foreign object is vegetable matter, irrigation is not used, because this material expands with hydration and the impaction becomes worse. Strategy: Use the process of elimination. Focusing on the strategic words foreign body and insect will direct you to option 2. If you had difficulty with this question, review care of the client with a foreign body in the ear. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1128). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

2529) A client arrives at the emergency department with a foreign body in the left ear and tells the nurse that an insect flew into the ear. Which intervention should the nurse implement initially? a. Irrigation of the ear b. Instillation of mineral oil c. Instillation of antibiotic ear drops d. Instillation of corticosteroid ointment Source: Saunders 4th

ANS: B Rationale: Insects are killed before removal unless they can be coaxed out by a flashlight or by a humming noise. Mineral oil or diluted alcohol may be instilled into the ear to suffocate the insect, which is then removed by using ear forceps. When the foreign object is vegetable matter, irrigation is not used because such material may expand with hydration, thereby worsening the impaction. The actions identified in options 3 and 4 are not initial nursing actions. Strategy: Use the process of elimination and note the strategic word initially. Focusing on the type of foreign body, an insect, will direct you to option 2. Review care of the client with a foreign body in the ear if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1128). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

1948) A home care nurse visits a client who is started on oxygen therapy. The nurse provides instructions to the client regarding safety measures for the use of oxygen in the home. Which statement if made by the client indicates a need for further instruction? a. "I need to be sure that no one smokes in my home." b. "I need to be sure that I stay at least 10 feet away from any burning candles." c. "It is all right to use an electric razor for shaving only if I leave it plugged in for a short period of time." d. "I need to be sure that there is space between the oxygen concentrator and the wall in the room." Source: Saunders 4th

ANS: C Rationale: The use of small electric items, tools, or other equipment could emit sparks and should be avoided while oxygen is in use. The use of this equipment could result in fire and injury to the client. The oxygen concentrator is kept away from walls and corners to permit adequate airflow. The client also should be instructed not to allow smoking in the home and to stay at least 10 feet away from any type of flame. Strategy: Use the process of elimination. Note the strategic words need for further instruction. This phrasing indicates a negative event query and directs you to select an incorrect statement. Focusing on the subject, oxygen safety, will direct you to option 3. If you had difficulty with this question, review the highlights of home oxygen safety. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1122). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2031) A nurse in the health care clinic receives a telephone call from the mother of a child who reports that an insect has somehow flown into the child's ear. The mother reports that the child is complaining of a buzzing sound in the ear. Which priority instruction should the nurse provide to the mother? a. Report to the clinic immediately. b. Use a flashlight to coax the insect out of the ear. c. Use a tweezer to try to remove the insect. d. Irrigate the ear. Source: Saunders 4th

ANS: B Rationale: Insects that make their way into an ear often can be coaxed out using a flashlight or a humming noise. If this is unsuccessful, then the insect must be killed before removal. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed by means of an ear forceps. The mother should be instructed not to irrigate the ear or attempt to remove the insect by using tweezers because this could damage the ear. If the mother is unsuccessful in coaxing the insect out of the ear, she should be instructed to report to the clinic or the hospital emergency department. Strategy: Use the process of elimination, noting the strategic words priority instruction. Recall that attempting to coax the insect out of the ear would be the initial action. If you had difficulty with this question, review care of the client with a foreign body in the ear. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., p. 186). St. Louis: Mosby. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills and techniques (6th ed., pp. 664, 666). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Child Health Alternate Question Types -> Multiple Choice

2278) A client is suspected of sustaining a probable minor head injury in a motor vehicle crash and is admitted to the hospital for observation. The nurse leaves the cervical collar applied to the client in place until: a. The physician makes rounds. b. The family comes to visit. c. The results of spinal radiography are known. d. The nurse needs to do physical care. Source: Saunders 4th

ANS: C Rationale: There is a significant association between cervical spine injury and head injury. For this reason, the nurse leaves any form of spinal immobilization in place until spinal radiographs rule out fracture or other damage. Options 1, 2, and 4 are incorrect. Strategy: Use the process of elimination. Recalling that the reason for spinal immobilization is to protect the spine from movement (which could cause further damage if the spine was injured) will direct you to the correct option. Review emergency care of a client who sustained a head injury if this question was difficult. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2217). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2340) A nurse is observing a new nursing graduate who is preparing an intermittent intravenous (IV) infusion of phenytoin (Dilantin) for a client with a diagnosis of seizures. Which solution used by the nursing graduate would indicate to the nurse an understanding of proper preparation of this medication? a. 5% dextrose and 0.45% sodium chloride b. 0.9% sodium chloride (normal saline) c. Lactated Ringer's solution d. 5% dextrose in water Source: Saunders 4th

ANS: B Rationale: Intermittent IV infusion of phenytoin is administered by injection into a large vein using normal saline solution. Dextrose solutions are avoided because the medication will precipitate in these solutions. Options 1, 3, and 4 identify incorrect solutions for IV administration with this medication. Strategy: Use the process of elimination. Eliminate options 1 and 4 first because they are comparative or alike in that these solutions both contain dextrose. Regarding the remaining options, remember that in many situations, but not all, medications can be diluted in normal saline, so this would be the best option to select if you were unfamiliar with the IV administration of this medication. Review the principles related to the administration of this medication if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 993). St. Louis: Mosby. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 928-929). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1320) The nurse is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the client with seizures. Which of the following solutions will the nurse plan to use to dilute this medication? a. Dextrose 5% b. Normal saline solution c. Lactated Ringer's solution d. Dextrose 5% and half-normal saline (0.45%) Source: Saunders 4th

ANS: B Rationale: Intravenous infusion of phenytoin should be administered by injection into a large vein. The medication may be diluted in normal saline solution; however, dextrose solution should be avoided because of medication precipitation. The medication is administered as intermittent doses. Continuous intravenous infusions should not be used. Infusion rates of more than 50 mg/min may cause hypotension or cardiac dysrhythmias, especially in older and debilitated clients. Strategy: Use the process of elimination. In most, but not all, situations, medications can be diluted in normal saline, so this would be the best option to select if you were unfamiliar with the intravenous administration of this medication. Review this procedure if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 intravenous medications (22nd ed., p. 993). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1649) A 1-year-old child is diagnosed with intussusception and the mother of the child asks the nurse to describe the disorder. The nurse tells the mother that this disorder is: a. An acute bowel obstruction. b. A condition when a proximal segment of the bowel prolapses into a distal segment of the bowel. c. A condition when a distal segment of the bowel prolapses into a proximal segment of the bowel. d. A condition that causes an acute inflammatory process in the bowel. Source: Saunders 4th

ANS: B Rationale: Intussusception occurs when a proximal segment of the bowel prolapses into a distal segment of the bowel. It is a common cause of acute bowel obstruction in infants and young children. It is not an inflammatory process. Strategy: Use the process of elimination. Recalling that this condition it a telescoping of the bowel will assist in eliminating options 1 and 4. Use the principles of gravity to assist in directing you to the correct option. Review this disorder if you had difficulty with this question. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 882). St. Louis: Mosby. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1140). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

1058) A client has been taking isoniazid (INH) for 1½ months. The client complains to a nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing: a. Hypercalcemia b. Peripheral neuritis c. Small blood vessel spasm d. Impaired peripheral circulation Source: Saunders 4th

ANS: B Rationale: Isoniazid (INH) is an antitubercular medication. A common side effect of isoniazid is peripheral neuritis, manifested by numbness, tingling, and paresthesias in the extremities. This can be minimized with pyridoxine (vitamin B₆) intake. Options 1, 3, and 4 are incorrect. Strategy: Use the process of elimination. Options 3 and 4 would not cause the symptoms presented in the question but instead would cause pallor and coolness. From the remaining options, you should know that peripheral neuritis is a side effect of the medication or that these signs and symptoms do not correlate with hypercalcemia. Review the side effects associated with isoniazid if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 643). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1059) A client is to begin a 6-month course of therapy with isoniazid (INH). A nurse plans to teach the client to: a. Use alcohol in small amounts only. b. Report yellow eyes or skin immediately. c. Increase intake of Swiss or aged cheeses. d. Avoid vitamin supplements during therapy. Source: Saunders 4th

ANS: B Rationale: Isoniazid (INH) is hepatotoxic, and therefore the client is taught to report signs and symptoms of hepatitis immediately, which include yellow skin and sclera. For the same reason, alcohol should be avoided during therapy. The client should avoid intake of Swiss cheese, fish such as tuna, and foods containing tyramine because they may cause a reaction characterized by redness and itching of the skin, flushing, sweating, tachycardia, headache, or light-headedness. The client can avoid developing peripheral neuritis by increasing the intake of pyridoxine (vitamin B₆) during the course of isoniazid therapy. Strategy: Use the process of elimination. Because alcohol intake is prohibited with the use of many medications, eliminate option 1 first. Because the client receiving this medication typically is given supplements of vitamin B₆, option 4 is incorrect and is eliminated next. Recalling that the medication is hepatotoxic will direct you to option 2. If you had difficulty with this question, review this medication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 643). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1063) A client with tuberculosis is being started on antituberculosis therapy with isoniazid (INH). Before giving the client the first dose, a nurse ensures that which of the following baseline studies has been completed? a. Electrolyte levels b. Liver enzyme levels c. Serum creatinine level d. Coagulation times Source: Saunders 4th

ANS: B Rationale: Isoniazid (INH) therapy can cause an elevation of hepatic enzyme levels and hepatitis. Therefore, liver enzyme levels are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is older than 50 or abuses alcohol. The laboratory tests in options 1, 3, and 4 are not necessary. Strategy: Use the process of elimination. Recalling that this medication can be toxic to the liver will direct you to the correct option. Review the adverse effects of the various antituberculosis medications if this is an area that is unfamiliar to you. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 643). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1932) A cystectomy is performed in a client with a diagnosis of bladder cancer, and a Kock pouch is created for a urinary diversion. In preparing a discharge teaching plan for the client, the nurse will include: a. External pouch and application care b. Technique of catheterization c. Proper administration of prophylactic antibiotics d. Dietary restrictions Source: Saunders 4th

ANS: B Rationale: Kock's pouch is a continent internal ileal reservoir. The nurse instructs the client about the technique of catheterization. There is no external pouch. Antibiotics are not required unless an infection is present and are prescribed by the physician. Dietary restriction are not required. Strategy: Use the process of elimination. Recalling the physiology associated with creation of a Kock's pouch will direct you to option 2. Review the characteristics of this form of urinary diversion if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1702, 1704). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1687) A client arrives at the clinic complaining of fatigue, lack of energy, constipation, and depression. Following diagnostic studies, hypothyroidism is diagnosed and levothyroxine (Synthroid) is prescribed. The nurse instructs the client that the expected outcome of the medication is to: a. Increase energy levels. b. Achieve normal thyroid hormone levels. c. Increase blood glucose levels. d. Alleviate depression. Source: Saunders 4th

ANS: B Rationale: Laboratory determinations of serum thyroid stimulating hormone (TSH) level are an important means of evaluation. Successful therapy will cause elevated TSH levels to fall. These levels will begin their decline within hours of the onset of therapy and will continue to drop as plasma levels of thyroid hormone build up. If an adequate dosage is administered, TSH levels will remain suppressed for the duration of therapy. Strategy: Use the process of elimination. Note the strategic words expected outcome. Relate the diagnosis hypothyroidism with thyroid hormone levels in the correct option. If you had difficulty with this question, review the therapeutic effects of levothyroxine (Synthroid). Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 687). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., pp. 493-495). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2542) Lactulose (Chronulac) is prescribed for a client with a diagnosis of hepatic encephalopathy. The nurse would determine that this medication has had a therapeutic effect if assessment reveals which of the following? a. Increased red blood cell count b. Decreased serum ammonia level c. Increased protein level d. Decreased white blood cell count Source: Saunders 4th

ANS: B Rationale: Lactulose is prescribed for the client with hepatic encephalopathy to reduce bacterial breakdown of protein in the bowel. The medication creates an acidic environment in the bowel and causes the ammonia to leave the bloodstream and enter the colon. Ammonia then becomes trapped in the bowel. Lactulose also has a laxative effect that allows for the elimination of the ammonia. Strategy: Use the process of elimination. Focusing on the client's diagnosis will assist in eliminating options 1 and 4. From the remaining options, noting the subject, therapeutic effect, will direct you to option 2. Review the action of lactulose if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1357). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1859) A nurse is reviewing the record of a client who arrives at the health care clinic. The nurse notes that the client is taking letrozole (Femara). The nurse should suspect that the client has which of the following disorders? a. Diabetes mellitus b. Advanced breast cancer c. Chronic renal failure d. Endometriosis Source: Saunders 4th

ANS: B Rationale: Letrozole is used in the palliative treatment for advanced breast cancer in the postmenopausal woman with disease progression after treatment with antiestrogen therapy. Options 1, 3, and 4 are incorrect. Strategy: Knowledge regarding the action of letrozole is required to answer this question. The prefix fem- in the trade name may suggest that the medication is used for females, which points to option 2. If you are unfamiliar with this medication, review its action and use. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 676). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1554) Levothyroxine (Synthroid) is prescribed for a client diagnosed with hypothyroidism. The nurse reviews the client's record and notes that the client is presently taking warfarin (Coumadin). The nurse contacts the physician, anticipating that the physician will prescribe which of the following? a. An increased dosage of Coumadin b. A decreased dosage of Coumadin c. An increased dosage of Synthroid d. A decreased dosage of Synthroid Source: Saunders 4th

ANS: B Rationale: Levothyroxine (Synthroid) accelerates the degradation of vitamin K-dependent clotting factors. As a result, the effects of warfarin (Coumadin) are enhanced. Therefore, if thyroid hormone replacement therapy is instituted in a client who has been taking warfarin, the dosage of warfarin should be reduced. Strategy: Use the process of elimination. Recalling that levothyroxine enhances the effects of warfarin will direct you to the correct option. Review these medication interactions if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 597, 603). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1983) A client is prescribed a liquid iron preparation that has the potential to stain the teeth. The nurse instructs the client to: a. Brush the teeth before drinking the iron. b. Dilute the iron in juice, drink it through a straw, and rinse the mouth afterwards. c. Dilute more than the amount prescribed to obtain the correct dosage. d. Drink the iron undiluted for maximal effect. Source: Saunders 4th

ANS: B Rationale: Liquid iron preparations will stain the teeth. The best advice for the client who needs liquid iron is to dilute the iron in juice or water, drink it through a straw, and rinse the mouth well after taking. Brushing before taking the liquid iron would not be of any benefit. The nurse would not instruct a client to take more than the prescribed amount. Strategy: Use the process of elimination. Option 3 can be eliminated first because the nurse would not instruct a client to take more than the prescribed amount of a medication. Recalling that iron stains the teeth will assist in eliminating options 1 and 4. Review client teaching regarding the administration of oral iron if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 634). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

72) A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis Source: Saunders 4th

ANS: B Rationale: Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. Options 1, 3, and 4 are incorrect. Strategy: Remembering that a client receiving nasogastric suction loses hydrochloric acid will direct you to the option identifying an alkalotic condition. Because the question addresses a situation other than a respiratory one, the acid-base disorder would be a metabolic condition. If you had difficulty with this question, review the causes of metabolic alkalosis. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 288-289). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1145). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1358) A client is complaining of low back pain that radiates down the left posterior thigh. The nurse further assesses the client to see if the pain is worsened or aggravated by: a. Bed rest b. Bending or lifting c. Ibuprofen (Motrin) d. Application of heat Source: Saunders 4th

ANS: B Rationale: Low back pain that radiates into one leg (sciatica) is consistent with herniated lumbar disk. The nurse assesses the client to see whether the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, and coughing, or by lifting the leg straight up while supine (straight leg raising test). Strategy: Use the process of elimination. Recall that bed rest, heat (or sometimes ice), and nonsteroidal anti-inflammatory agents usually relieve back pain, whereas bending, lifting, and straining aggravate it. Review the causes of back pain and the factors that alleviate or aggravate pain if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 978). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2346) A client with a head injury is experiencing signs of increased intracranial pressure, and mannitol (Osmitrol) is prescribed. The nurse administering this medication understands that which of the following is not an effect of this medication? a. Reduced tubular reabsorption of water and solutes b. Reabsorption of sodium and water in the loop of Henle c. Diuresis d. Increased osmotic pressure of glomerular filtrate Source: Saunders 4th

ANS: B Rationale: Mannitol is an osmotic diuretic that induces diuresis by raising the osmotic pressure of glomerular filtrate, thereby inhibiting tubular reabsorption of water and solutes. It is used to reduce intracranial pressure in the client with head trauma. Option 2 would cause fluid retention, thereby increasing the intracranial pressure. Strategy: Note the strategic word not in the question. Read the question carefully, noting that it describes a client with increased intracranial pressure. The only option that suggests a medication action that will increase intracranial pressure is option 2. If you had difficulty with this question, review the action of mannitol. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 720-721). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1876) A nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which of the following data if noted on the client's record would alert the nurse that the client is at risk for a spontaneous abortion? a. Age of 35 years b. History of syphilis c. History of genital herpes d. History of diabetes mellitus Source: Saunders 4th

ANS: B Rationale: Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion. There is no evidence that genital herpes is a causative agent in abortion although the presence of active lesions at the time of birth presents concerns. Maternal age over 40 and diabetes mellitus are considered high-risk factors in a pregnancy but are related to an increased risk of congenital malformations. Strategy: Focus on the subject of the question, risk factors associated with spontaneous abortion. Use the process of elimination and knowledge regarding the risks associated with each of the items in the options to assist in directing you to option 2. Review the risk factors associated with spontaneous abortion if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 619). St. Louis: W.B. Saunders. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 625). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1179) The nurse is reviewing the client's record and notes that the physician has documented that the client has a renal disorder. On review of the laboratory results, the nurse most likely would expect to note which of the following? a. Decreased hemoglobin level b. Elevated blood urea nitrogen level c. Decreased red blood cell count d. Decreased white blood cell count Source: Saunders 4th

ANS: B Rationale: Measuring the blood urea nitrogen level is a frequently used laboratory test to determine renal function. The blood urea nitrogen level starts to rise when the glomerular filtration rate falls below 40% to 60%. A decreased hemoglobin level and red blood cell count may be noted if bleeding from the urinary tract occurs or if erythropoietic function by the kidney is impaired. An increased white blood cell count is most likely to be noted in renal disease. Strategy: Use the process of elimination. Recalling the relationship between the blood urea nitrogen level and renal function will direct you to option 2. Review significant laboratory tests related to renal function if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1701). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2673) A client has been told by the physician to take psyllium (Metamucil) daily. The nurse teaches the client to take this medication with: a. Gelatin, applesauce, or pudding b. A total of two glasses of liquid c. A multivitamin and mineral supplement d. A dose of antacid Source: Saunders 4th

ANS: B Rationale: Metamucil is a bulk-forming laxative that should be taken with a full glass of water or juice, followed by another glass of liquid. This will help prevent impaction of the medication in the stomach or small intestine. The other options are incorrect. Strategy: Use the process of elimination. Recalling that most medications should not be taken with an antacid because of interactive effects will assist in eliminating option 4. Regarding the remaining options, recalling that psyllium is a bulk-forming laxative will direct you to option 2. Review the procedure for the administration of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 987). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 734). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2247) Methenamine (Mandelamine) is prescribed for the client with a chronic urinary tract infection (UTI). The nurse understands that the mechanism of action of this medication is which of the following? a. Inhibits the replication of bacterial DNA b. Decomposes into ammonia and formaldehyde and denatures bacterial proteins c. Decreases bladder muscle spasms d. Relaxes smooth muscles of the urinary tract Source: Saunders 4th

ANS: B Rationale: Methenamine, under acidic conditions, decomposes into ammonia and formaldehyde. The formaldehyde denatures bacterial proteins, causing death of the organism. Nalidixic acid (NegGram) is a medication that inhibits the replication of bacterial DNA. Antispasmodics relax smooth muscle of the urinary tract and decrease bladder muscle spasms. Strategy: Use the process of elimination. Eliminate options 3 and 4 because they are comparative or alike. Regarding the remaining options, it is necessary to know the action of this medication. If you had difficulty with this question, review this content. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 486). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2511) A client admitted to the medical nursing unit has a diagnosis of gastroesophageal reflux disease (GERD). Metoclopramide (Reglan) has been prescribed four times a day. The nurse should schedule administration of the medication for which of the following times? a. 8 <SC>AM</SC>, 2 <SC>PM</SC>, 8 <SC>PM</SC>, 2 <SC>AM</SC> b. 30 minutes before meals and at bedtime c. With meals and at bedtime d. 1 hour after meals and at bedtime Source: Saunders 4th

ANS: B Rationale: Metoclopramide is a gastrointestinal stimulant. Administration should be scheduled 30 minutes before meals and at bedtime to allow the medication time to begin working before food intake and digestion. The other options are incorrect. Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they are comparative or alike in relation to timing and food intake. From the remaining options, recalling that the medication must be taken before meals will direct you to option 2. Review the points related to the administration of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 554). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2669) A client with constipation has been directed to take oral bisacodyl (Dulcolax). The nurse instructs the client on how to receive the most rapid effect from the medication. The client demonstrates understanding of use of this medication by stating the recommendation to take it: a. With a large meal b. On an empty stomach c. At bedtime d. With two glasses of milk Source: Saunders 4th

ANS: B Rationale: Most rapid results from bisacodyl occur when it is taken on an empty stomach. It will not have a rapid effect if taken with a large meal or with two glasses of milk. If it is taken at bedtime, the client will have a bowel movement in the morning. Strategy: Use principles of digestion and knowledge of the medication to answer this question. Focusing on the subject, the most rapid effect, will direct you to option 2. Review the method of administration of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 103). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1085) A nurse notices frequent artifact on the electrocardiographic monitor for a client whose leads are connected by cable to a console at the bedside. The nurse examines the client to determine the cause. Which of the following items is unlikely to be responsible for the artifact? a. Frequent movement of the client b. Tightly secured cable connections c. Leads applied over hairy areas d. Leads applied to the limbs Source: Saunders 4th

ANS: B Rationale: Motion artifact, or "noise," can be caused by frequent client movement, electrode placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy areas of the skin. Electrode placement over bony prominences also should be avoided. Signal interference also can occur with electrode removal and cable disconnection. Strategy: Use the process of elimination, focusing on the subject, artifact and note the strategic word unlikely. Recalling the causes of artifact will direct you to option 2. Review these causes if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 710-711, 714). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1269) The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? a. Sternal rub b. Nail bed pressure c. Pressure on the orbital rim d. Squeezing of the sternocleidomastoid muscle Source: Saunders 4th

ANS: B Rationale: Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle. Strategy: Note the strategic words peripheral response. The nail beds are the most distal of all the options and are therefore the most peripheral. Each of the other options may elicit a generalized response, but not a localized one. Review the process of peripheral testing if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 571, 2031). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 938). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1290) A client receives a dose of edrophonium (Tensilon) intravenously. The client shows improvement in muscle strength for a period of time following the injection. The nurse interprets that this finding is compatible with: a. Multiple sclerosis b. Myasthenia gravis c. Muscular dystrophy d. Amyotrophic lateral sclerosis Source: Saunders 4th

ANS: B Rationale: Myasthenia gravis often can be diagnosed based on clinical signs and symptoms. The diagnosis can be confirmed by injecting the client with a dose of edrophonium (Tensilon). This medication inhibits the breakdown of an enzyme in the neuromuscular junction, so more acetylcholine binds onto receptors. If the muscle is strengthened for 3 to 5 minutes after this injection, it confirms a diagnosis of myasthenia gravis. Another medication, neostigmine (Prostigmin) also may be used because the effect lasts for 1 to 2 hours, giving a better analysis. For either medication, atropine sulfate should be available as the antidote. Strategy: Use the process of elimination. Knowledge of the purpose and expected findings of the Tensilon test is required to answer this question. Remember that an increase in muscle strength after the injection confirms the diagnosis of myasthenia gravis. Review the Tensilon test if you are unfamiliar with it. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., pp. 1035-1036). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1014). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1220) Mycophenolate mofetil (CellCept) is prescribed for a client for prophylaxis of organ rejection following allogeneic renal transplantation. Which instruction would a nurse provide to the client regarding administration of this medication? a. Administer following meals. b. Contact the physician if a sore throat occurs. c. Take the medication with a magnesium-type antacid. d. Open the capsule and mix with food for administration. Source: Saunders 4th

ANS: B Rationale: Mycophenolate mofetil (CellCept) should be administered on an empty stomach. The capsules should not be opened or crushed. The client should contact the physician if unusual bleeding or bruising, sore throat, mouth sores, abdominal pain, or fever occurs. Antacids containing magnesium and aluminum may decrease the absorption of the medication and therefore should not be taken with the medication. The medication is given with corticosteroids and cyclosporine. Strategy: Use the process of elimination. Recalling that neutropenia can occur with the use of this medication will direct you to option 2. Review this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 592). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2054) A nurse is performing an assessment on a client with a diagnosis of myxedema (hypothyroidism). Which of the following assessment findings would the nurse expect to note in this client? a. Thin, silky hair b. Dry skin c. Fine muscle tremors d. Bulging eyeballs Source: Saunders 4th

ANS: B Rationale: Myxedema is a deficiency of thyroid hormone. The client will present with a puffy edematous face, especially around the eyes (periorbital edema), along with coarse facial features, dry skin, and dry coarse hair and eyebrows. Options 1, 3, and 4 are noted in the client with hyperthyroidism. Strategy: Use the process of elimination. Recalling the function of thyroid hormone and that a deficiency of thyroid hormone occurs in this condition will direct you to option 2. Review the clinical manifestations of myxedema if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1488). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

1742) Laboratory analysis of a urine for culture and sensitivity reveals a gram-negative bacterial infection. The client is treated with nalidixic acid (NegGram). Which of the following existing disorders in the client would alert the nurse to question the prescription for this medication? a. Diabetes mellitus b. Seizure disorder c. Coronary artery disease d. Peptic ulcer disease Source: Saunders 4th

ANS: B Rationale: Nalidixic acid (NegGram) is used for acute and chronic urinary tract infections, especially gram-negative bacterial infections. The medication is contraindicated in clients with a history of seizures. It is used with caution in clients with liver or renal disorders. It is not contraindicated in the disorders in options 1, 3, or 4. Strategy: Use the process of elimination and knowledge regarding the contraindications associated with this medication to answer the question. Remember that the medication is contraindicated in clients with a history of seizures. Review this medication if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 487). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2447) A nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The nurse will direct the assessment to look for which of the following as a hallmark sign of this disorder? a. Severe abdominal pain relieved by vomiting b. Severe abdominal pain that is unrelieved by vomiting c. Hypothermia d. Epigastric pain radiating to the neck area Source: Saunders 4th

ANS: B Rationale: Nausea and vomiting are common presenting manifestations of acute pancreatitis. A hallmark symptom is severe abdominal pain that is not relieved by vomiting. The vomitus characteristically consists of gastric and duodenal contents. Fever also is a common sign but usually is mild, with temperatures less than 39° C. Epigastric pain radiating to the neck area is not a characteristic symptom. Strategy: Focus on the anatomical location of the pancreas to assist in eliminating options 3 and 4. Regarding the remaining options, it is necessary to know that pain is not relieved by vomiting. If you had difficulty with this question, review the signs associated with acute pancreatitis. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1405-1407). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2541) Oral neomycin has been prescribed for a client with a diagnosis of portosystemic encephalopathy. The nurse reviews the physician's order and determines that this medication has been prescribed to: a. Prevent infection b. Destroy normal bacteria found in the bowel c. Prevent restlessness in the client d. Prevent fluid retention and ascites Source: Saunders 4th

ANS: B Rationale: Neomycin may be prescribed for the client with portosystemic encephalopathy. It is a broad-spectrum antibiotic that destroys normal bacteria found in the bowel, thereby decreasing protein breakdown and ammonia production. Options 1, 3, and 4 are not actions of this medication for this client. Strategy: Focus on the diagnosis of the client and the pathophysiologic changes associated with this disorder to answer this question. Recalling the relationship among bacteria in the bowel, protein breakdown, and ammonia production will direct you to option 2. Review the purpose of this medication if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1357-1358). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1221) The nurse receives a call from a client concerned about eliminating brown-colored urine after taking nitrofurantoin (Furadantin) for a urinary tract infection. Which of the following is the appropriate response from the nurse? a. "Discontinue taking the medication and make an appointment for a urine culture." b. "Continue taking the medication because the urine is discolored from the medication." c. "Decrease your medication to half the dose because your urine is too concentrated." d. "Take magnesium hydroxide (Maalox) with your medication to lighten the urine color." Source: Saunders 4th

ANS: B Rationale: Nitrofurantoin (Furadantin) produce a harmless brown color to the urine and the medication should not be discontinued until the client's symptoms are alleviated or the prescribed dose is completed. Magnesium hydroxide (Maalox) will not affect urine color. Additionally, antacids should be avoided because they interfere with medication effectiveness. Strategy: Use the process of elimination. Option 1 can be eliminated because the client should not need a urine culture at this time. These are done before treatment is initiated, if treatment is ineffective, and during follow-up appointment. Option 3 can be eliminated, because the nurse cannot change a medication dosage without a physician's order. Additionally, there is no data in the question to indicate that the urine is concentrated. Option 4 can be eliminated because antacids should be avoided as a result of their interference with the effectiveness of nitrofurantoin. Additionally, magnesium hydroxide will not have an effect on urine color. Review the effects of nitrofurantoin if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 1012). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1791) A nursing student is caring for a client who has been admitted to the hospital with malnutrition. The student is reviewing the results of the various laboratory tests performed on the client with the nursing instructor. Which statement, if made by the nursing student, indicates an understanding of the interpretation of the results? a. "An elevated creatinine level indicates respiratory problems." b. "A normal hemoglobin level indicates that iron and protein intake are sufficient." c. "An elevated albumin level indicates a definite dehydration." d. "A normal red blood cell level indicates adequate vitamin B₆ intake." Source: Saunders 4th

ANS: B Rationale: Normal hemoglobin levels indicate that iron and protein intake is sufficient. Elevated creatinine levels indicate kidney problems, which is not considered a nutritional disorder. Elevated albumin levels may falsely indicate dehydration. Normal red blood cell levels indicate adequate vitamin B₁₂ intake. Strategy: Knowledge regarding the interpretation of common laboratory test findings is required to answer this question. Remember that normal hemoglobin levels indicate that iron and protein intake is sufficient. Review these common laboratory tests if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1426-1428). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1115) A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following assessment findings by the nurse is probably unrelated to the aneurysm? a. Pulsatile abdominal mass b. Hyperactive bowel sounds in the area c. Systolic bruit over the area of the mass d. Subjective sensation of "heart beating" in the abdomen Source: Saunders 4th

ANS: B Rationale: Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the "heart beating" in the abdomen when supine or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm. Strategy: Use the process of elimination and note the strategic word unrelated. Note that options 1, 3, and 4 are comparative or alike in that they identify a circulatory component. Review the signs of abdominal aortic aneurysm if you had difficulty with this question. Reference: Ignatavicius, D. & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 806-807). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1282) The nurse is caring for the client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? a. Loosening restrictive clothing b. Restraining the client's limbs c. Removing the pillow and raising padded side rails d. Positioning the client to the side, if possible, with the head flexed forward Source: Saunders 4th

ANS: B Rationale: Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed. Strategy: Use the process of elimination and note the strategic word contraindicated. Evaluate this question from the perspective of causing possible harm. No harm can come to the client from any of the options except for restraining the limbs. Remember, avoid restraints. Review care of a client during a seizure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 953). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1098) A nurse is evaluating a client's response to cardioversion. Which of the following observations would be of highest priority to the nurse? a. Blood pressure b. Status of airway c. Oxygen flow rate d. Level of consciousness Source: Saunders 4th

ANS: B Rationale: Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Strategy: Use the process of elimination, noting the strategic words highest priority. Use the ABCs—airway, breathing, and circulation—to direct you to option 2. Review care of the client following cardioversion if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 742). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

2660) A client has been taking omeprazole (Prilosec) for 4 weeks. The ambulatory care nurse evaluates medication effectiveness by asking the client about whether relief was obtained from which of the following symptoms? a. Flatulence b. Heartburn c. Constipation d. Diarrhea Source: Saunders 4th

ANS: B Rationale: Omeprazole is a proton pump inhibitor and is classified as an antiulcer agent. The medication relieves pain from gastric irritation, which often is experienced as "heartburn" by clients. The medication does not relieve the symptoms identified in options 1, 3, and 4. Strategy: Use the process of elimination. Recalling that omeprazole is an antiulcer agent will direct you to option 2. If you are unfamiliar with the action and use of this medication, review its action and use. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 868). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

982) The client has been taking omeprazole (Prilosec) for 4 weeks. The ambulatory care nurse evaluates that the client is receiving optimal intended effect of the medication if the client reports the absence of which symptom? a. Diarrhea b. Heartburn c. Flatulence d. Constipation Source: Saunders 4th

ANS: B Rationale: Omeprazole is a proton pump inhibitor classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often called heartburn by clients. Omeprazole is not used to treat the conditions identified in options 1, 3, and 4. Strategy: Use the process of elimination. Recalling that this medication is a proton pump inhibitor will direct you to option 2. Review the action of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 868). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2011) A nurse is preparing to assist a physician with the removal of a client's chest tube. The nurse gathers items that will be needed for this procedure. Which of the following items are unnecessary for removal of the chest tube? a. Petrolatum gauze dressing b. Telfa dressing c. A sterile 4 × 4 gauze d. Adhesive tape Source: Saunders 4th

ANS: B Rationale: On removal of a chest tube, a sterile petrolatum gauze dressing is applied to the chest tube insertion site, followed by a sterile gauze pad and adhesive tape. The entire dressing is securely taped to ensure that it remains occlusive. The petrolatum dressing is the key element for an airtight seal at the chest tube insertion site. A Telfa dressing is not used and is not indicated for this procedure. Although this is the usual procedure, somewhat different procedures may be used in accordance with physician preferences and agency protocols. Strategy: Use the process of elimination. Recalling that an occlusive seal is needed after the removal of a chest tube will direct you to option 2. If you had difficulty with this question, review the procedure for chest tube removal. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1866). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2497) A physician tells the nurse that a client's chest tube is to be removed. The nurse brings which of the following dressing materials to the bedside for the physician's use? a. Telfa dressing and neosporin ointment b. Petrolatum gauze and sterile 4 × 4 gauze c. Sterile 4 × 4 gauze, Neosporin ointment, and tape d. Benzoin spray and a hydrocolloid dressing Source: Saunders 4th

ANS: B Rationale: On removal of the chest tube, a sterile petrolatum gauze and a sterile 4 × 4 gauze is placed at the insertion site. The entire dressing is securely taped to make sure it is occlusive. The use of Telfa, Neosporin ointment, hydrocolloid dressing, and benzoin spray is not indicated. Elastoplast tape may be used at the discretion of the physician as the tape of choice to make the dressing occlusive. Strategy: Use the process of elimination and focus on the subject, removal of the chest tube. Remembering that an occlusive dressing is needed to cover the site will direct you to the correct option. Review care of a client when a chest tube is removed if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1866). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1069) A client with myocardial infarction has been transferred from a coronary care unit to a general medical unit with cardiac monitoring via telemetry. A nurse plans to allow for which of the following client activities? a. Strict bed rest for 24 hours after transfer b. Bathroom privileges and self-care activities c. Ad lib activities because the client is monitored d. Unsupervised hallway ambulation with distances under 200 feet Source: Saunders 4th

ANS: B Rationale: On transfer from the coronary care unit, the client is allowed self-care activities and bathroom privileges. Supervised ambulation in the hall for brief distances is encouraged, with distances gradually increased (50, 100, 200 feet). Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they are excessive, given that the client has just been transferred from the coronary care unit. Option 1 is not appropriate because the client would be doing less activity than in the coronary care unit before transfer. Review activity prescriptions for the client with a myocardial infarction if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 178). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 851). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1200) The client at a follow-up clinic visit after experiencing a urinary diversion with an ileal conduit is concerned about the strong urine odor from the urine collection pouch over the abdominal stoma. Which of the following is an appropriate nursing action for this client? a. Encourage increased vegetables and decreased protein in the diet. b. Teach the client to avoid foods such as onions, fish, eggs, and cheese. c. Check the client's serum creatinine, blood urea nitrogen, and potassium levels. d. Perform a dipstick urinalysis on the urine that has settled in the collection pouch. Source: Saunders 4th

ANS: B Rationale: Onions, fish, eggs, and cheese are odor-producing foods. A client with an ileal conduit should be taught to avoid these foods. Protein is usually limited for clients with renal failure, although the question does not state that the client has renal failure; protein is needed for wound healing. Although the serum creatinine, blood urea nitrogen (BUN), and potassium levels are important to monitor for clients with renal problems, the question does not provide evidence that the client is experiencing problems with elimination other than odor. Urinalysis should be done using a fresh urine sample. Strategy: Use the process of elimination. Applying knowledge about foods that increase urine odor should direct you to option 2. Option 1 can be eliminated because the client should be increasing protein for wound healing. Protein is limited for clients with renal failure, though the situation does not state the client has renal failure. Option 3 can be eliminated because even though serum creatinine, blood urea nitrogen (BUN), and potassium levels are important to monitor for clients with renal problems, the question does not provide evidence that the client is experiencing problems with elimination other than odor. Option 4 can be eliminated because urinalysis should be done with a fresh urine sample. Review the normal expected findings following urinary diversion with an ileal conduit if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., and Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1205). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1258) The nurse is caring for a client with glaucoma. Which of the following medications, if prescribed for the client, would the nurse question? a. Carbachol (Carboptic) b. Atropine sulfate (Isopto Atropine) c. Pilocarpine (Ocusert Pilo-20, Ocusert Pilo-40) d. Pilocarpine hydrochloride (Isopto Carpine) Source: Saunders 4th

ANS: B Rationale: Options 1, 3, and 4 are miotic agents used to treat glaucoma. Option 2 is a mydriatic and cycloplegic medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye. Strategy: Use the process of elimination. Knowledge regarding the classifications of the medications identified in the options will assist in answering the question. Remember that mydriatics dilate and that these medications are contraindicated in glaucoma. Review the contraindications related to medications for the client with glaucoma if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 734-735). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

993) A nurse is caring for a client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed: a. 1 L/min b. 2 L/min c. 6 L/min d. 10 L/min Source: Saunders 4th

ANS: B Rationale: Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system. Strategy: Use the process of elimination, focusing on the client's diagnosis. Recalling that in the client with emphysema, respiratory drive is triggered by low oxygen levels will direct you to option 2. If you are unfamiliar with this important concept, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 600). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

126) A nurse is caring for a group of adult clients on an acute care medical-surgical nursing unit. The nurse understands that which of the following clients would be the least likely candidate for parenteral nutrition (PN)? a. A 66-year-old client with extensive burns b. A 42-year-old client who has had an open cholecystectomy c. A 27-year-old client with severe exacerbation of Crohn's disease d. A 35-year-old client with persistent nausea and vomiting from chemotherapy Source: Saunders 4th

ANS: B Rationale: Parenteral nutrition is indicated in clients whose gastrointestinal tracts are not functional or who cannot take in a diet enterally for extended periods. Examples of these conditions include those of the clients identified in options 1, 3, and 4. Other clients would be those who have had extensive surgery, have multiple fractures, are septic, or have advanced cancer or acquired immunodeficiency syndrome. The client with the open cholecystectomy is not a candidate because this client would resume a regular diet within a few days following surgery. Strategy: Note the strategic words least likely, which tell you that the correct option is the client who does not require this type of nutritional support. Use nursing knowledge of these various conditions and baseline knowledge of the purposes of PN to make your selection. Review the indications for PN if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 820). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1400). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1793) The nurse is performing an admission assessment on a child with a seizure disorder. The nurse is interviewing the child's parents to determine their adjustment to caring for their child, who has a chronic illness. Which statement, if made by the parents, would indicate a need for teaching? a. "Our child is involved in a swim program with neighbors and friends." b. "Our child sleeps in our bedroom at night." c. "Our babysitter just completed cardiopulmonary resuscitation (CPR) training." d. "We worry about injuries when our child has a seizure." Source: Saunders 4th

ANS: B Rationale: Parents are especially concerned about seizures that might go undetected during the night. The nurse needs to decrease parental overprotection and should suggest the use of a baby monitor at night. Options 1 and 3 identify parental understanding of the disorder. Option 4 is a common concern. The parents need to be reminded that, as the child grows, they cannot always observe their child, but that their knowledge of seizure activity and care are appropriate to minimize complications. Strategy: Note the strategic words need for further teaching. These words indicate a negative event query and ask you to select an option that is incorrect. Use the process of elimination, recalling that parental overprotection needs to be discouraged. Option 2 identifies a need to provide the parents with an alternate manner to monitor for night seizures. Review parental home care instructions for the child with a seizure disorder. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1520). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

1388) A client with pemphigus is being seen in the clinic regularly. The nurse plans care based on which of the following descriptions of this condition? a. The presence of tiny red vesicles b. An autoimmune disease that causes blistering in the epidermis c. The presence of skin vesicles found along the nerve caused by a virus d. The presence of red, raised papules and large plaques covered by silvery scales Source: Saunders 4th

ANS: B Rationale: Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters. Option 1 describes eczema, option 3 describes herpes zoster, and option 4 describes psoriasis. Strategy: Use the process of elimination. Recalling that pemphigus vulgaris is an autoimmune disorder will direct you easily to option 2. If you had difficulty with this question, review the characteristics of this disorder. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1418). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1613). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1737) The nurse is caring for a client who is on strict bed rest. The nurse develops a plan of care and develops goals related to the prevention of deep vein thrombosis (DVT) and pulmonary emboli. Which of the following nursing actions would be most helpful to prevent these disorders from developing? a. Applying a heating pad to the lower extremities b. Encouraging active range-of-motion (ROM) exercises c. Placing a pillow under the knees d. Restricting fluids Source: Saunders 4th

ANS: B Rationale: Persons at greatest risk for pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat should not be applied without a physician's prescription. Strategy: Use the process of elimination and basic principles related to the care of the immobile client to answer this question. If you are unfamiliar with these basic measures, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 650). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1427). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2380) A client in shock is receiving dopamine hydrochloride by intravenous (IV) infusion. The nurse should have which of the following medications available for local injection if IV infiltration and medication extravasation occur? a. Vitamin K b. Phentolamine c. Atropine sulfate d. Protamine sulfate Source: Saunders 4th

ANS: B Rationale: Phentolamine is an α-adrenergic blocking agent that prevents dermal necrosis and sloughing after infiltration of norepinephrine or dopamine. Vitamin K is the antidote for warfarin (Coumadin). Atropine sulfate is the antidote for cholinergic crisis. Protamine sulfate is the antidote for heparin. Strategy: Note the strategic words local injection. Alternatively, if you knew the medication classifications for the medications in options 1, 3, and 4 and their uses as antidotes, by the process of elimination you would choose correctly. If you are unfamiliar with these medications, review this content. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 437). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2349) A pregnant client is receiving pitocin (Oxytocin) for the induction of labor. The nurse should immediately discontinue the pitocin infusion if which of the following is noted in the client? a. Early decelerations of the fetal heart rate b. Uterine hyperstimulation c. Severe drowsiness d. Uterine atony Source: Saunders 4th

ANS: B Rationale: Pitocin is a synthetic hormone that stimulates uterine contractions and commonly is used to induce labor. A major danger associated with oxytocin induction of labor is hyperstimulation of uterine contractions, which can cause fetal distress as a result of decreased placental perfusion. Therefore, oxytocin infusion must be stopped when any signs of uterine hyperstimulation are observed. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress. Options 3 and 4 do not indicate a need to discontinue the infusion. Strategy: Knowing that induction of labor stimulates uterine contractions will help to answer this question. Recall the effect of uterine contractions on uteroplacental circulation and remember that hyperstimulation of contractions would compromise fetal oxygenation, a primary physiological need. If you had difficulty with this question, review the nursing implications associated with the administration of this medication. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 832). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1289) The client with diplopia has been taught to use an eye patch to promote better vision and prevent injury. The nurse determines that the client has correct understanding of the use of the patch if the client states that he or she will: a. Wear the patch for 1 hour at a time. b. Wear the patch continuously, alternating eyes each day. c. Wear the patch continuously, alternating eyes each week. d. Use the patch only when vision is especially troublesome. Source: Saunders 4th

ANS: B Rationale: Placing an eye patch over one eye in the client with diplopia removes the second image and restores more normal vision. The patch is alternated each day to maintain the strength of the extraocular muscles of the eyes. Strategy: Use the process of elimination. Knowing that an eye patch will help diplopia only while it is worn will assist you in eliminating options 1 and 4. Recalling that the extraocular muscles weaken with eye patch use will direct you to option 2. Review instructions for the client with diplopia if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2028). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1016-1017, 1041). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1542). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1732) The nurse is preparing to care for a client who will be weaned from a tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which of the following nursing interventions are required prior to plugging the tube? a. Place the inner cannula into the tube. b. Deflate the cuff on the tube. c. Ensure that the client is able to swallow. d. Ensure that the client is able to speak. Source: Saunders 4th

ANS: B Rationale: Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug (decannulation stopper) into the opening of the outer cannula. This closes off the tracheostomy, and airflow and respiration occur normally through the nose and mouth. When plugging a cuffed tracheostomy tube, the cuff must be deflated. If it remains inflated, ventilation cannot occur and respiratory arrest could result. The ability to swallow or speak is unrelated to weaning and plugging the tube. Strategy: Note the strategic word required in the question. This should assist in directing you to the option that addresses a priority physiological need. Use the process of elimination to direct you to option 2, because an inflated cuff would cause airway obstruction. Review this procedure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 558). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 576). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1114). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1182) A client is admitted to the hospital with a diagnosis of early-stage chronic renal failure. Which of the following should the nurse expect to note on client assessment? a. Anuria b. Polyuria c. Oliguria d. Polydypsia Source: Saunders 4th

ANS: B Rationale: Polyuria occurs early in chronic renal failure and, if untreated, can cause severe dehydration. Polyuria progresses to anuria, and the client loses all normal kidney functions. Oliguria and anuria are not early signs, and polydipsia is unrelated to chronic renal failure. Strategy: Use the process of elimination and note the strategic word early in the question. Eliminate options 1 and 3 because they are comparative or alike. From the remaining options, select option 2 because this option relates to renal function. Review the early and late signs of chronic renal failure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1740). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1748) The client with acute pancreatitis is experiencing severe pain from the disorder. The nurse would teach the client to avoid which of the following positions that could aggravate the pain? a. Sitting up b. Lying flat c. Leaning forward d. Flexing the left leg Source: Saunders 4th

ANS: B Rationale: Positions such as sitting up, leaning forward, and flexing the legs (especially the left leg) may alleviate some of the pain associated with pancreatitis. The pain is aggravated by lying supine or walking. This is because the pancreas is located retroperitoneally, and the edema and inflammation intensify the irritation of the posterior peritoneal wall with these positions. Strategy: Note the strategic word avoid. Use the process of elimination and your critical thinking skills to visualize the pancreas and the potential effects from stretching associated with the various positions listed. Remember also that options that are comparative or alike are not likely to be correct. This will help you eliminate options 1 and 3. Review pain reduction measures for the client with pancreatitis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1405). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1138). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1643) The nurse is assessing the client for signs of postpartum depression. Which of the following, if noted in the new mother, would indicate the need for further assessment related to this form of depression? a. The mother is caring for the infant in a loving manner. b. The mother constantly complains of tiredness and fatigue. c. The mother demonstrates an interest in the surroundings. d. The mother looks forward to visits from the father of the newborn. Source: Saunders 4th

ANS: B Rationale: Postpartum depression is not the normal depression that many new mothers experience from time to time. The woman experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The woman is also unable to show pleasure or love, and may have intense feelings of unworthiness, guilt, and shame. The woman often expresses a sense of loss of self. Generalized fatigue, complaints of ill health, and difficulty in concentrating are also present. The mother would have little interest in food and experience sleep disturbances. Strategy: Focus on the subject of the question to assist in answering. Note the strategic words need for further assessment. Use the process of elimination, noting that options 1, 3, and 4 identify positive maternal behaviors. If you had difficulty with this question, review the clinical manifestations of postpartum depression. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 754). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

49) A nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because the client: a. Has renal failure. b. Requires nasogastric suction. c. Has a history of Addison's disease. d. Is taking a potassium-sparing diuretic. Source: Saunders 4th

ANS: B Rationale: Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with renal failure or Addison's disease and the client taking a potassium-sparing diuretic are at risk for hyperkalemia. Strategy: Use the process of elimination. Note that the subject of the question is a potassium deficit. Option 2 is the only option that identifies a loss of body fluid. If you had difficulty with this question, review the causes of hypokalemia. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 226-227). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1141-1142). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2258) A nurse is monitoring a client receiving muromonab-CD3 (Orthoclone OKT3). Which of the following is a priority assessment required in monitoring for adverse effects of the medication? a. Assessing pedal pulses b. Assessing lung sounds c. Assessing for positive bowel sounds d. Assessing for Homans' sign Source: Saunders 4th

ANS: B Rationale: Potentially fatal anaphylactic reactions can occur with this medication. Manifestations include pulmonary edema, cardiovascular collapse, and cardiac or respiratory arrest. Assessing lung sounds is a priority. Strategy: Note the strategic word priority in the question. Use the ABCs—airway, breathing, and circulation. Remember that airway is the first priority. Review this medication if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 799). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 591). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1379) Following diagnosis of stage I Lyme disease, the nurse would anticipate that which of the following will be part of the treatment plan for the client? a. No treatment unless symptoms develop b. A 3-week course of oral antibiotic therapy c. Daily oatmeal baths for 2 weeks d. Treatment with intravenously administered antibiotics Source: Saunders 4th

ANS: B Rationale: Prevention, public education, and early diagnosis are vital to the control and treatment of Lyme disease. A 3-week course of oral antibiotic therapy is recommended during stage I. Later stages of Lyme disease may require therapy with intravenously administered antibiotics, such as penicillin G. Options 1 and 3 are incorrect. Strategy: Use the process of elimination. Note that the question addresses stage I. Eliminate option 4 because intravenous antibiotics will not be administered in this stage. Eliminate option 3, because although oatmeal baths may be helpful for pruritus, they would not be helpful for a systemic disorder. Waiting for symptoms to develop is an incorrect option. Review the treatment associated with Lyme disease if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 418). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

2267) A nurse has obtained a personal and family history from a client with a neurological disorder. Which of the following factors in the client's history is not associated with added risk for neurological problems? a. Previous back injury b. Allergy to pollen c. History of hypertension d. History of headaches Source: Saunders 4th

ANS: B Rationale: Previous neurological problems such as headaches or back injuries place the client at greater risk for development of a neurological disorder. Chronic diseases such as hypertension and diabetes mellitus also place the client at greater risk. Assessment for allergies is a routine part of the health history, regardless of the nature of the client's problem. Strategy: Use the process of elimination. Note the strategic words is not. Each of the incorrect options has an actual or a potential neurological association. Allergies indicate a disturbance of the immune system. Review the risks associated with neurological problems if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 933). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1454) A male client with delirium becomes disoriented and confused in his room at night. The best initial nursing intervention is to: a. Move the client next to the nurse's station. b. Use an indirect light source and turn off the television. c. Keep the television and a soft light on during the night. d. Play soft music during the night, and maintain a well-lit room. Source: Saunders 4th

ANS: B Rationale: Provision of a consistent daily routine and a low stimulating environment is important when the client is disorientated. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station is not the initial action. Strategy: Use the process of elimination and note the strategic word initial in the question. Eliminate options 3 and 4 first because they are comparative or alike. Focusing on the strategic word will direct you easily to option 2. Review measures related to the client who is disoriented and confused if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 330). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 430). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2656) Fluoxetine hydrochloride (Prozac) is prescribed for the client. The nurse who is teaching the client about the medication tells the client to take the prescribed dose: a. At noon with an antacid b. In the morning on first arising c. Just before bedtime d. With the evening meal Source: Saunders 4th

ANS: B Rationale: Prozac is administered in the early morning. The other options are incorrect. Strategy: Use the process of elimination. Eliminate options 1 and 4 first because they are comparative or alike in indicating administration of the medication with another item (antacid or food). From the remaining options, focus on the action and use of the medication to direct you to option 2. If you are unfamiliar with the use of this medication and its associated client teaching points, review this content. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 351). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 367). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2113) A nurse is caring for a client with an intracranial aneurysm who was previously alert. Which of the following assessments would not be an early indication that the level of consciousness (LOC) is deteriorating? a. Slight slurring of speech b. Ptosis of the left eyelid c. Mild drowsiness d. Less frequent spontaneous speech Source: Saunders 4th

ANS: B Rationale: Ptosis of the eyelid is due to pressure on and dysfunction of cranial nerve III. This condition, once it occurs, is ongoing; it does not relate to LOC. Early changes in LOC relate to alertness and verbal responsiveness. Less frequent speech, slight slurring of speech, and mild drowsiness are early signs of decreasing LOC. Strategy: Use the process of elimination, noting the strategic word not. Recalling that LOC includes orientation, awareness, and verbal responsiveness will direct you to option 2. Review the early signs of decreasing LOC if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2023-2025). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 939, 1049). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1075) A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which of the following would the nurse anticipate when auscultating the client's breath sounds? a. Stridor b. Crackles c. Scattered rhonchi d. Diminished breath sounds Source: Saunders 4th

ANS: B Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway. Strategy: Use the process of elimination. Recalling that fluid produces sounds that are called crackles will assist you in eliminating options 1, 3, and 4. If you had difficulty with this question, review the manifestations found in pulmonary edema. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 760, 853). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2687) A client has been taking pyrazinamide for 6 months. The nurse interprets that the medication is effective if which of the following cultures gives a negative result? a. Blood b. Sputum c. Urine d. Wound Source: Saunders 4th

ANS: B Rationale: Pyrazinamide is an antituberculosis medication that is given in conjunction with other antituberculosis medications. Its use may be discontinued by the prescriber if sputum cultures become negative. Options 1, 3, and 4 are incorrect. Strategy: Recalling that this medication is an antituberculosis medication will easily direct you to option 2. If this question was difficult, review the classification and use of this medication. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 735). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2643) Quinupristin-dalfopristin (Synercid) is prescribed as an intermittent intravenous (IV) infusion for a client with a skin infection. The nurse adjusts the drip rate so that the dose is administered over: a. 4 hours b. 1 hour c. 30 minutes d. 15 minutes Source: Saunders 4th

ANS: B Rationale: Quinupristin-dalfopristin is an antimicrobial medication used to treat endocarditis, bacteremia, and infections of the skin. It also is used to treat infections of the urinary tract, central catheter infections, and bone, joint, and respiratory system infections. For intermittent IV infusion (piggyback), the medication should be infused over a 1-hour period. Strategy: Use the process of elimination. Options 1 and 4 can be eliminated first because they are both extreme (too long and too short) time lengths. Regarding the remaining options, it is necessary to know that this medication should be infused over 1 hour. Review the concepts related to IV administration of this medication if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 1064). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1590) A 6-year-old child has just been diagnosed with localized Hodgkin's disease and chemotherapy is planned to begin immediately. The mother of the child asks the nurse why radiation therapy was not prescribed as a part of the treatment. The appropriate and supportive response to the mother is: a. "I'm not sure. I'll discuss it with the physician." b. "The child is too young to have radiation therapy." c. "It's very costly, and chemotherapy works just as well." d. "The physician would prefer that you discuss treatment options with the oncologist." Source: Saunders 4th

ANS: B Rationale: Radiation therapy is usually delayed until a child is 8 years of age, whenever possible, to prevent retardation of bone growth and soft tissue development. Options 1, 3, and 4 are inappropriate responses to the mother. Strategy: Note the age of the child in the question. Additionally, use therapeutic communication techniques and knowledge regarding the effects of radiation to answer this question. Options 1 and 4 are nontherapeutic and place the mother's inquiry on hold. From the remaining options, use the child's age as a guide in directing you to option 2. Review the effects of radiation therapy if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1335). St. Louis: W.B. Saunders. Reference: Wong, D., Perry, S., Hockenberry, M., et al. (2006). Maternal child nursing care (3rd ed., p. 1631). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Child Health Alternate Question Types -> Multiple Choice

1107) A nurse has given instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further reinforcement of teaching if the client states which of the following? a. "Smoking cessation is important." b. "Moving to a warmer climate is needed." c. "Sources of caffeine should be eliminated from the diet." d. "Taking nifedipine (Procardia) as prescribed will decrease vessel spasm." Source: Saunders 4th

ANS: B Rationale: Raynaud's disease responds favorably to eliminating caffeine from the diet and cessation of smoking. Medications may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is important. However, moving to a warmer climate may not necessarily be beneficial because the symptoms still could occur with the use of air conditioning and during periods of cooler weather. Strategy: Note the strategic words needs further reinforcement. These words indicate a negative event query and ask you to select an option that is incorrect. Think about the measures used to treat the disease to direct you to option 2. Also, relocation is the least favorable of all the options from the viewpoints of practicality and encountering new environmental concerns. Review the teaching points related to this disorder if this question was difficult. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 811). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1463) When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. The appropriate maintenance goal should focus on which of the following? a. Ignoring feelings of anxiety b. Identifying anxiety-producing situations c. Continued contact with a crisis counselor d. Eliminating all anxiety from daily situations Source: Saunders 4th

ANS: B Rationale: Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Ignoring feelings will not resolve anxiety. Elimination of all anxiety from life is impossible. Strategy: Use the process of elimination. Eliminate option 4 first because of the word all. Eliminate option 1 next, because feelings should not be ignored. From the remaining options, select option 2 because this option is more client-centered and helps prepare the client to deal with anxiety should it occur. Review home care planning for the client with chronic anxiety if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 184, 190-191). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2127) A client is complaining of knee pain. The knee is swollen, reddened, and warm to the touch. The nurse interprets that the client's signs and symptoms are not compatible with: a. Inflammation b. Degenerative disease c. Infection d. Recent injury Source: Saunders 4th

ANS: B Rationale: Redness and heat are associated with musculoskeletal inflammation, infection, or a recent injury. Degenerative disease is accompanied by pain, but there is no redness. Swelling may or may not occur. Strategy: Use the process of elimination and note the strategic words not compatible. Recalling that swelling, redness, and warmth are signs of inflammation and that the body's inflammatory response is triggered by inflammation, infection, and injury will direct you to option 2. Review the signs of inflammation if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 402, 406). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 362-364). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2196) A young male client tentatively diagnosed with a borderline personality disorder says to the nurse, "I don't know why I got my tattoo, it was for me. OK? Sometimes I do these things to get my parents mad and sometimes I do them because I'm bored. That's what happened the night I crashed the family car. I wasn't drunk or suicidal or anything like the police thought. It was just for kicks!" Which of the following is the appropriate nursing response? a. "Next time, pick less dangerous and expensive ways to explode." b. "It is scary when you feel out of control with such feelings of emptiness and anger that you can't stop yourself." c. "It's a good thing that you don't abuse substances or you might be dead due to your reckless disregard." d. "What can you do to stop your behavior when it gets to that point the next time?" Source: Saunders 4th

ANS: B Rationale: Reflection, a technique that prompts the client by repeating the major theme in the client's process, is a therapeutic communication technique. In option 1, the nurse inappropriately uses a sardonic response, which is nontherapeutic, because it gives advice. In option 3, the nurse is nontherapeutic because it starts by agreeing and ends up bordering on being slightly threatening. Option 4 is not the most therapeutic response because it is premature in the therapy. Strategy: Use the process of elimination and therapeutic communication techniques. Option 2 is the only option that identifies the use of a therapeutic technique. Review therapeutic communication techniques if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-35, 436-438). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1919) A nursing assistant collects a urine specimen from a client and is planning to deliver the specimen to the laboratory after completing morning care for other assigned clients. The registered nurse instructs the nursing assistant to place the collected specimen in the unit laboratory refrigerator. The nursing assistant asks the registered nurse about the reason that the urine needs refrigeration. The registered nurse bases the response on the fact that when urine is allowed to stand unrefrigerated: a. The urine becomes more acidic. b. Bacteria and white blood cells (WBCs) decompose. c. The urine clumps. d. The pH decreases. Source: Saunders 4th

ANS: B Rationale: Refrigeration preserves the elements of urine. If the specimen stands at room temperature, the warmth causes bacteria and WBCs to decompose. Also, when urine is allowed to stand unrefrigerated, the urea breaks down to ammonia and becomes more alkaline. The pH decreases in an acidic condition. Strategy: Use the process of elimination. Careful reading will assist in eliminating option 3. Eliminate options 1 and 4 next because they are comparative or alike. Recall that the pH decreases in acidic conditions. Review the procedures related to collecting urine specimens if you had difficulty with this question. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., pp. 965-967). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2083) A client with renal cancer is to undergo preoperative renal artery embolization. The nurse reinforces the primary benefit of this procedure by explaining to the client that: a. This will prevent the risk of pulmonary embolism, by occluding the renal artery and its branches. b. This will decrease the size of the tumor, because its blood supply will be removed after placement of an absorbable gelatin sponge. c. The procedure will reduce the time needed for surgery by at least half because it provides hemostasis. d. This will cause the tumor to become tougher and easier to resect in surgery with the scalpel. Source: Saunders 4th

ANS: B Rationale: Renal artery embolization may be done instead of radiation therapy to shrink the kidney tumor by cutting off its blood supply and impairing its overall vascularity. A secondary benefit is that it reduces the risk of hemorrhage during surgery. This procedure can be accomplished in a number of ways, including placement of an absorbable gelatin sponge (Gelfoam), barium, a balloon, metal coil, or any of various other substances. Strategy: Use the process of elimination. Eliminate option 1 first, considering normal anatomy and physiology. Option 4 is eliminated next because there is no basis for determining that this procedure would make a tumor tougher. Regarding the remaining options, note the strategic words by at least half in option 3. Although renal artery embolization does help with hemostasis, it is not guaranteed to have this much of an effect on the operative time. Review the characteristics of this procedure if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 924). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2302) A teenager diagnosed with active tuberculosis has been prescribed a combination of isoniazid (INH) and rifampin (Rifadin) for treatment. The nurse teaches the teenager: a. To report any change in urine color b. To take both medications together once a day c. That both medications should be taken with food d. To expect to take the medication for 2 to 3 weeks Source: Saunders 4th

ANS: B Rationale: Rifampin in combination with isoniazid prevents the emergence of drug-resistant organisms. This combination taken together daily eliminates the tubercle bacilli from the sputum and improves clinical status. Rifampin produces a harmless red-orange color in all body fluids and should be taken along with the isoniazid 1 hour before or 2 hours after eating to maximize absorption. The treatment regimen is maintained for at least 6 months for effectiveness and the therapeutic effect may be evident in 2 to 3 weeks. Strategy: Knowledge regarding the administration of these medications is required to answer this question. Remember that the medications should be taken together every day. Review these medications if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1848). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., pp. 1027-1028). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1821) The rubella vaccine has been prescribed for a new mother. Which of the following statements should the postpartum nurse make when providing information about the vaccine to the client? a. "You must sign an informed consent because anaphylactic reactions can occur with the administration of this vaccine." b. "You should not become pregnant for 2 to 3 months following administration of the vaccine." c. "You should avoid sexual intercourse for 2 weeks following administration of the vaccine." d. "You should avoid heat and extreme temperature changes for 1 week following administration of the vaccine." Source: Saunders 4th

ANS: B Rationale: Rubella vaccine is a live attenuated virus that provides immunity for 15 years. Because rubella is a live vaccine, it will act as a virus and is potentially harmful to the organogenesis phase of fetal development. The client should be informed about the potential effects of this vaccine and the need to avoid becoming pregnant for 2 to 3 months after administration of the vaccine. Abstinence from sexual intercourse is unnecessary. The vaccine is not known to cause anaphylactic reactions. Warmth and temperature or extreme changes in temperature have no effect on the person who has been vaccinated. Strategy: Use the process of elimination. Recalling that most vaccines are either contraindicated or administered with caution during pregnancy or recalling that viruses can cross the placental barrier will direct you to option 2. If you had difficulty with this question, review the potential risks associated with administration of rubella vaccine. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 406). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

943) The client with ulcerative colitis has an order to begin a salicylate medication to reduce inflammation. What instruction should the nurse give the client regarding when to take this medication? a. On arising b. After meals c. On an empty stomach d. 30 minutes before meals Source: Saunders 4th

ANS: B Rationale: Salicylate compounds such as sulfasalazine (Azulfidine) act by inhibiting prostaglandin synthesis and reducing inflammation. The nurse teaches the client to take the medication with a full glass of water and to increase fluid intake throughout the day. The medication needs to be taken after meals to reduce gastrointestinal irritation. The other options are incorrect. Strategy: Use the process of elimination. Eliminate options 1, 3, and 4 because they are comparative or alike and indicate taking the medication on an empty stomach. Review the administration of salicylate medications if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1348). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1045) A nurse has an order to give a client metaprotenerol (Alupent), two puffs, and beclomethasone dipropionate (Qvar), two puffs, by metered-dose inhaler. The nurse administers the medication by giving the: a. Beclomethasone first and then the salmeterol b. Salmeterol first and then the beclomethasone c. Alternating a single puff of each, beginning with the salmeterol. d. Alternating a single puff of each, beginning with the beclomethasone Source: Saunders 4th

ANS: B Rationale: Salmeterol (Serevent) is an adrenergic type of bronchodilator and beclomethasone dipropionate is a glucocorticoid. Bronchodilators are always administered before glucocorticoids when both are to be given on the same time schedule. This allows for widening of the air passages by the bronchodilator, which then makes the glucocorticoid more effective. Strategy: To answer this question correctly, you must know two different things. First, you must know that a bronchodilator is always given before a glucocorticoid. This would allow you to eliminate options 3 and 4 because you would not alternate the medications. To select between options 1 and 2, you must know that salmeterol is a bronchodilator, whereas beclomethasone is a glucocorticoid. Review these medications if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 590-592). Philadelphia: W.B. Saunders. Reference: Mosby. (2007). 2007 Mosby's nursing drug reference (20th ed., p. 172). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1596) Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. The home care nurse provides instructions to the client regarding the use of the medication. Which client statement indicates an accurate understanding of the use of this medication? a. "I will apply the ointment once a day and leave it open to the air." b. "I will apply the ointment once a day and cover it with a sterile dressing." c. "I will apply the ointment twice a day and leave it open to the air." d. "I will apply the ointment at bedtime and in the morning, and cover it with a sterile dressing." Source: Saunders 4th

ANS: B Rationale: Santyl is used to promote débridement of dermal lesions and severe burns. It is applied once daily and covered with a sterile dressing. Options 1, 3, and 4 are incorrect. Strategy: Use the process of elimination. Note the strategic words indicates an accurate understanding the question. Eliminate options 3 and 4 first because they are comparative or alike. Recalling that the client with a burn is at risk for infection will direct you to option 2, the option that indicates covering the wound. Review this medication if you are unfamiliar with it. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1644). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1281) The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which of the following measures would the nurse avoid in planning for the client's safety? a. Padding the side rails of the bed b. Putting a padded tongue blade at the head of the bed c. Placing an airway, oxygen, and suction equipment at the bedside d. Having intravenous equipment ready for insertion of an intravenous catheter Source: Saunders 4th

ANS: B Rationale: Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if anticonvulsant medications must be administered. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins. Strategy: Use the process of elimination noting the strategic word avoid. Evaluate this question from the perspective of causing possible harm. No harm can come to the client from any of the options, except for the tongue blade. Review seizure precautions if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 953). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1523) The client's medication sheet contains an order for sertraline hydrochloride (Zoloft). To ensure safe administration of the medication, the nurse would administer the dose: a. On an empty stomach b. At the same time each evening c. Evenly spaced around the clock d. As needed when the client complains of depression Source: Saunders 4th

ANS: B Rationale: Sertraline hydrochloride (Zoloft) is classified as an antidepressant. Sertraline generally is administered once every 24 hours. It may be administered in the morning or evening, but evening administration may be preferable, because drowsiness is a side effect. The medication may be administered without food or with food if gastrointestinal distress occurs. Sertraline is not ordered for use as needed. Strategy: Use the process of elimination. Recalling that this medication is an antidepressant administered daily will direct you to option 2. Review this medication if you had difficulty with this question. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., pp. 164, 166). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1755) The client is receiving baclofen (Lioresal) for muscle spasms because of a spinal cord injury. The nurse monitors the client for which side effect related to this medication? a. Photosensitivity b. Slurred speech c. Hypertension d. Muscle pain Source: Saunders 4th

ANS: B Rationale: Side effects of baclofen include drowsiness, dizziness, weakness, and nausea. Occasional side effects include headache, paresthesias of the hands and feet, constipation or diarrhea, anorexia, hypotension, confusion, and nasal congestion. Paradoxical central nervous system excitement and restlessness can occur, along with slurred speech, tremor, dry mouth, nocturia, and impotence. Strategy: Use the process of elimination. Option 2 is the option that is most closely associated with a neurological disorder. If you had difficulty with this question, review the side effects related to baclofen. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 120). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2558) The clinic nurse is providing instructions to a client regarding the side effects of chlorpromazine (Thorazine). The nurse instructs the client that which of the following may occur with the use of this medication? a. Increased urinary output b. Dry mouth c. Hand tremors d. Lip smacking Source: Saunders 4th

ANS: B Rationale: Side effects of chlorpromazine can include hypotension, dizziness, and fainting, especially with parenteral use. Additional side effects include drowsiness, blurred vision, dry mouth, lethargy, constipation or diarrhea, nasal congestion, peripheral edema, and urinary retention. Strategy: Recalling that chlorpromazine is a phenothiazine will assist in directing you to option 2. Review the side effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 242). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2569) The home care nurse is visiting a mother 1 week after she gave birth to an infant who is at risk for developing neonatal congenital syphilis. After teaching the mother about the signs and symptoms of this disorder, the nurse instructs the mother to monitor the infant for which of the following? a. Loose stools b. A copper-colored skin rash c. High-pitched cry d. Vigorous feeding habits Source: Saunders 4th

ANS: B Rationale: Signs and symptoms of congenital neonatal syphilis may be nonspecific initially, including poor feedings, slight hyperthermia, and "snuffles." By the end of the first week of life, a copper-colored maculopapular dermal rash typically is observed on the palms of the hands, soles of the feet, and diaper area and around the mouth and anus. Options 1, 3, and 4 are not associated signs of this disorder. Strategy: Knowledge regarding the signs and symptoms of congenital syphilis is required to answer this question. Remember a copper-colored skin rash is characteristic of congenital neonatal syphilis. If you are unfamiliar with the manifestations of this disorder, review this content. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., p. 414). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

2244) A client with suspected opioid overdose has received a dose of naloxone hydrochloride (Narcan). The client subsequently becomes restless, starts to vomit, and complains of abdominal cramping. The blood pressure increases from 110/72 mm Hg to 160/86 mm Hg. The nurse provides emotional support and reassurance while administering care to the client, knowing that: a. These effects will last only a few moments. b. These are signs of opioid withdrawal. c. The client may otherwise sign out against medical advice. d. The client may next become suicidal. Source: Saunders 4th

ANS: B Rationale: Signs of opioid withdrawal include increased temperature and blood pressure, abdominal cramping, vomiting, and restlessness. Time of onset may be anywhere from a few minutes to a few hours after administration of naloxone hydrochloride, depending on the opioid involved, the degree of dependence, and the dose of naloxone. Options 1, 3, and 4 are incorrect. Strategy: Use the process of elimination. Eliminate option 1 first because the signs and symptoms identified in the question are not likely to disappear in a few moments. Option 4 is eliminated next, because no supporting information is provided in the question. Regarding the remaining options, recalling that the client with opioid overdose may well have a history of prior chronic use will direct you to option 2. Review the effects of this medication in opioid overdose if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 599). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1084) A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/min. The PR interval is 0.14 second, the QRS complex measures 0.08 second, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm? a. Sinus arrhythmia b. Sinus tachycardia c. Sinus bradycardia d. Normal sinus rhythm Source: Saunders 4th

ANS: B Rationale: Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are higher than 100 beats/min. Strategy: Use the process of elimination. Eliminate options 3 and 4 because they do not meet the rate criteria (ventricular rate is 110 beats/min). Eliminate option 1 because sinus arrhythmia is an irregular rhythm, with changing PP and RR intervals. Review the characteristics of sinus tachycardia if you had difficulty with this question. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., p. 680). St. Louis: Mosby. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 716, 718). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

162) A client has an order to receive a unit of packed red blood cells. The nurse should obtain which of the following intravenous (IV) solutions from the IV storage area to hang with the blood product at the client's bedside? a. Lactated Ringer's b. 0.9% sodium chloride c. 5% dextrose in 0.9% sodium chloride d. 5% dextrose in 0.45% sodium chloride Source: Saunders 4th

ANS: B Rationale: Sodium chloride 0.9% (normal saline) is a standard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells. Lactated Ringer's is not the solution of choice with this procedure. Strategy: Use the process of elimination and eliminate options 3 and 4 first because they are comparative or alike in that both solutions contain dextrose. From the remaining options, remember that normal saline is the solution compatible with red blood cells. If this question was difficult, review the procedures related to the administration of blood. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 913). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1333) A client is treated in a physician's office for a sprained ankle after a fall. Radiographic examination has ruled out a fracture. Before sending the client home, the nurse plans to teach the client to avoid which of the following in the next 24 hours? a. Resting the foot b. Applying a heating pad c. Applying an elastic compression bandage d. Elevating the ankle on a pillow while sitting or lying down Source: Saunders 4th

ANS: B Rationale: Soft tissue injuries such as sprains are treated by RICE ( <b>r</b> est, <b>i</b> ce, <b>c</b> ompression, and <b>e</b> levation) for the first 24 hours after the injury. Ice is applied intermittently for 20 to 30 minutes at a time. Heat is not used in the first 24 hours because it could increase venous congestion, which would increase edema and pain. Strategy: Use the process of elimination. Note the strategic word avoid. Sprains should be rested and elevated, so eliminate options 1 and 4. Use of an elastic compression wrap is also helpful in reducing the pain and swelling, so eliminate option 3. Review treatment measures for a sprain if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1226). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1468) The nurse is planning activities for a client who has bipolar disorder with aggressive social behavior. Which of the following activities would be most appropriate for this client? a. Chess b. Writing c. Ping pong d. Basketball Source: Saunders 4th

ANS: B Rationale: Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. Competitive games should be avoided because they can stimulate aggression and increase psychomotor activity. Strategy: Use the process of elimination. Options 1, 3, and 4 are comparative or alike in that they are activities that the client cannot do alone. Option 2 identifies a solitary activity. Review care of the client with aggressive behavior if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 220-221, 225, 450). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 355). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1178) The hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse assesses this client for which of the following manifestations? a. Warmth, redness, and pain in the left hand b. Pallor, diminished pulse, and pain in the left hand c. Edema and reddish discoloration of the left arm d. Aching pain, pallor, and edema of the left arm Source: Saunders 4th

ANS: B Rationale: Steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and a diminished pulse distal to the fistula. The client also complains of pain distal to the fistula, caused by tissue ischemia. Warmth, redness, and pain probably would characterize a problem with infection. The manifestations described in options 3 and 4 are incorrect. Strategy: You must understand steal syndrome and know the signs and symptoms to answer this question. Recalling that steal syndrome results from vascular insufficiency after creation of a fistula will direct you to option 2. Review this syndrome and associated signs and symptoms if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1755). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1602) A prenatal client with a history of heart disease has been instructed on care at home. Which statement, if made by the client, would indicate that the client understands her needs? a. "There is no restriction on people who visit me." b. "I should avoid stressful situations." c. "My weight gain is not important." d. "I should rest on my right side." Source: Saunders 4th

ANS: B Rationale: Stress causes increased heart workload and the client should be instructed to avoid stress. To avoid infections, individuals with active infections should not be allowed to visit the client. Otherwise, restrictions are not required. Too much weight gain can place further demands on the heart. Resting should be on the left side to promote blood return. Strategy: Use the process of elimination. Note the strategic words heart disease and the client understands her needs in the question. Using principles related to the therapeutic management of cardiac disease in general will assist in directing you to option 2. If you had difficulty with this question, review the measures for the pregnant client with cardiac disease. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 676). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

2509) A client has an order for sucralfate (Carafate), 1 g four times daily. The nurse writes which of the following schedules for this medication on the Medication Administration Record? a. 8 <SC>AM</SC>, 2 <SC>PM</SC>, 8 <SC>PM</SC>, 2 <SC>AM</SC> b. 1 hour before meals and at bedtime c. With meals and at bedtime d. 1 hour after meals and at bedtime Source: Saunders 4th

ANS: B Rationale: Sucralfate is prescribed to treat gastric ulcers. It should be scheduled for administration 1 hour before meals and at bedtime to allow it to form a protective coating over the gastric ulcer to prevent irritation by food, gastric acid, and mechanical movement of the stomach. The other options are incorrect. Strategy: Knowledge about the action of sucralfate is needed to answer this question. Recalling that it is used to treat a gastric ulcer will direct you to option 2. Review the administration schedule for this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1082). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2456) A nurse is reviewing the discharge instructions for the client who had a skin biopsy. Which of the following statements, if made by the client, would indicate a need for further instruction? a. "I will watch for any drainage from the wound." b. "I will return tomorrow to have the sutures removed." c. "I will use the antibiotic ointment as prescribed." d. "I will keep the dressing dry." Source: Saunders 4th

ANS: B Rationale: Sutures usually are removed 7 to 10 days after a skin biopsy, depending on physician preference. After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for a minimum of 8 hours. After the dressing is removed, the site is cleaned once a day with tap water or saline to remove any dry blood or crusts. The physician may prescribe an antibiotic ointment to minimize local bacterial colonization. The nurse instructs the client to report any redness or excessive drainage at the site. Strategy: Note the strategic words need for further instruction in the question. These words indicate a negative event query and the need to select an incorrect statement. General principles related to surgical incisions and suture removal will direct you to option 2. Review postprocedure instructions for a skin biopsy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1388). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1573). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

1826) A nurse is performing an assessment on a client admitted to the hospital who was diagnosed with toxic shock syndrome (TSS). Which of the following assessment questions would assist in eliciting more specific data regarding the cause of this syndrome? a. "Have your menstrual periods been irregular?" b. "Do you use tampons during your menstrual period?" c. "Have you been consuming a high intake of green leafy vegetables?" d. "Did you start your menses at an early age?" Source: Saunders 4th

ANS: B Rationale: TSS is caused by infection and is often associated with tampon use. Disseminated intravascular coagulation is a complication of TSS. Options 1, 3, and 4 are unrelated to the etiology of TSS. Strategy: Use the process of elimination. Focusing on the name of the disorder will assist in eliminating options 1, 3, and 4. Review the etiology of TSS if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1082). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1534) The nurse notes that a client diagnosed with schizophrenia is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing: a. Torticollis b. Tardive dyskinesia c. Hypertensive crisis d. Neuroleptic malignant syndrome Source: Saunders 4th

ANS: B Rationale: Tardive dyskinesia is an adverse reaction that can occur from antipsychotic medication. It is characterized by uncontrollable involuntary movements of the body and extremities, particularly the tongue. Torticollis refers to an extrapyramidal side effect involving the upper body. Hypertensive crisis can occur from the use of monoamine oxidase inhibitors and is characterized by hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, and vomiting. Neuroleptic malignant syndrome is a potentially fatal syndrome that may occur at any time during therapy with neuroleptic (antipsychotic) medications. It is characterized by dyspnea or tachypnea, tachycardia or irregular pulse rate, fever, blood pressure changes, increased sweating, loss of bladder control, and skeletal muscle rigidity. Strategy: Focus on the data in the question. Remember that tardive dyskinesia is characterized by uncontrollable involuntary movements of the body and extremities, particularly the tongue. Review the side effects and extrapyramidal side effects of antipsychotic medications if you had difficulty with this question. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., p. 222). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1429) The nurse is preparing the client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task appropriate for this phase? a. Planning short-term goals b. Making appropriate referrals c. Developing realistic solutions d. Identifying expected outcomes Source: Saunders 4th

ANS: B Rationale: Tasks of the termination phase include evaluating client performance, evaluating achievement of expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with termination. Options 1, 3, and 4 identify the tasks of the working phase of the relationship. Strategy: Use the process of elimination. Noting the strategic words termination phase should direct you easily to option 2. If you are unfamiliar with the appropriate tasks of the phases of the nurse-client relationship, review this content. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 431-437). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 23). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1543) The client is brought into the emergency room in ventricular fibrillation (VF). The advanced cardiac life support (ACLS) nurse prepares to defibrillate by placing conductive gel pads on which part of the chest? a. The upper and lower halves of the sternum b. The right of the sternum, just below the clavicle and to the left of the precordium c. The right shoulder and the back of the left shoulder d. Parallel between the umbilicus and the right nipple Source: Saunders 4th

ANS: B Rationale: The ACLS nurse would place one gel pad to the right of the sternum just below the clavicle and the other gel pad to the left of the precordium. The nurse would then place the electrode paddles over the pads. Options 1, 3, and 4 identify incorrect positions. Strategy: Use the process of elimination, considering the anatomical location of the heart. This will easily assist in eliminating options 1, 3, and 4. If you had difficulty with this question, review the correct placement of pads for defibrillation. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 742). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 875). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

132) The nurse is assessing the IV dressing of a client with a peripheral intravenous infusion running. The date on the dressing is 7/25 (July 25). The nurse documents on the client's record that the dressing should be changed on which of the following dates? a. 7/26 b. 7/28 c. 7/30 d. 8/1 Source: Saunders 4th

ANS: B Rationale: The IV site dressing should be changed every 48 to 72 hours, which is every 2 to 3 days. With an insertion date of 7/25, the due date for change, depending on agency policy, would be 7/27 or 7/28. It would be unnecessary, uncomfortable, and not cost-effective to change the site dressing daily (option 1). Changing the site dressing every 5 or 7 days (options 3 and 4) would place the client at higher risk for infection or other catheter complications. Strategy: Use the process of elimination. Recalling that the IV site dressing should be changed every 48 to 72 hours will direct you to option 2. Review the standard accepted guidelines for intravenous site maintenance if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 256). Philadelphia: W.B. Saunders. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., p. 925). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1187). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Communication and Documentation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

987) An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed? a. Face tent b. Venturi mask c. Aerosol mask d. Tracheostomy collar Source: Saunders 4th

ANS: B Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity. Strategy: Use the process of elimination and note the strategic words precise oxygen concentration. Eliminate options 1, 3, and 4 because they are comparative or alike in that they are used to provide high humidity. Review the various types of oxygen delivery systems if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 600). Philadelphia: W.B. Saunders. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills and techniques (6th ed., pp. 766-768). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2289) A nurse is administering medications to a client with trigeminal neuralgia. The nurse brings which of the following prescribed medications to the client for pain relief? a. Meperidine hydrochloride (Demerol) and hydroxyzine (Vistaril) b. Carbamazepine (Tegretol) and phenytoin (Dilantin) c. Acetaminophen (Tylenol) and codeine sulfate (Codeine) d. Oxycodone plus aspirin (Percodan) Source: Saunders 4th

ANS: B Rationale: The anticonvulsant medications carbamazepine and phenytoin help relieve the pain in many clients with trigeminal neuralgia. They act by inhibiting the reactivity of neurons in the trigeminal nerve. Opioid analgesics (meperidine hydrochloride, codeine sulfate, oxycodone) are not very effective in controlling pain due to trigeminal neuralgia. Strategy: Use the process of elimination. Note the similarity of the incorrect options. They each have an opioid analgesic as part of the option. In this case, looking for the option that is different will direct you to option 2. Review the actions and purposes of these medications if you are unfamiliar with this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 183-184). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1023). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 223). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1651) The nurse is teaching the client who has had a laryngectomy for laryngeal cancer how to use an artificial larynx. The nurse tells the client to: a. Insert the device into the tracheostomy. b. Hold the device alongside the neck. c. Hold the device over the upper portion of the sternum. d. Swallow air into the esophagus to make speech. Source: Saunders 4th

ANS: B Rationale: The artificial larynx is an electronic device that assists the client after laryngectomy to produce speech. There are two types—one is held at the side of the neck and the other is inserted into the mouth. The vibration produces a mechanical sounding speech that is monotone in quality but is intelligible. Strategy: Use the process of elimination. Focus on the strategic words artificial larynx. Remember that there are two types of devices—one is held at the side of the neck and the other is inserted into the mouth. Review the available devices that assist with speech if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 589). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Communication and Documentation Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

1869) A pregnant client in the prenatal clinic is scheduled for a biophysical profile. The client asks the nurse what this test involves. The appropriate nursing response is which of the following? a. "This test only measures the amount of amniotic fluid present in the uterus." b. "This test measures amniotic fluid volume and fetal activity." c. "This test measures your ability to tolerate the pregnancy." d. "This test measures your cardiac status and ability to tolerate labor." Source: Saunders 4th

ANS: B Rationale: The biophysical profile assesses five parameters of fetal activity: fetal heart rate (FHR), fetal breathing movements, gross fetal movements, fetal tone, and amniotic fluid volume. In a biophysical profile, each of the five parameters contributes 0 to 2 points, with a score of 8 being considered normal and a score of 10 perfect. Results are available immediately. Options 1, 3, and 4 are incorrect. Strategy: Focus on the subject and use the process of elimination. Option 2 is the only option that addresses both the mother and fetus and is the likely option. Review this test if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., pp. 333-334). St. Louis: Mosby. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., pp. 217-218). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1815) A nurse is instructing a client who had a stroke how to ambulate with the use of a cane. Which of the following instructions should the nurse provide to the client? a. To hold the cane on the affected (weak) side b. To hold the cane on the unaffected (strong) side c. To move the cane forward first along with the unaffected (strong) leg d. In going down stairs, to move the cane and the unaffected (strong) leg down first Source: Saunders 4th

ANS: B Rationale: The cane is kept on the strong side of the body. It would be hard to hold the cane on the side with a weak arm. The cane is assisting the weakened leg, so the weakened leg moves with the cane, or right after it, in ambulating or in going down stairs. Strategy: Use the process of elimination. Visualize each of the options. Recalling that a cane would be difficult to hold with a weak hand and that the cane is assisting the weakened leg will assist in directing you to option 2. Review client teaching points in the use of a cane if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2131). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 948-949). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

47) A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for excess fluid volume? a. The client taking diuretics b. The client with renal failure c. The client with an ileostomy d. The client who requires gastrointestinal suctioning Source: Saunders 4th

ANS: B Rationale: The causes of excess fluid volume include decreased kidney function, congestive heart failure, the use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for deficient fluid volume. Strategy: Use the process of elimination and focus on the subject, excess fluid volume. Read each option and think about the fluid imbalance that can occur in each. The clients presented in options 1, 3, and 4 lose fluid. The only condition that can cause an excess is the condition noted in option 2. If you had difficulty with this question, review the causes of excess fluid volume. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1144). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2293) A client has a cerebellar lesion. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which of the following items? a. Adaptive eating utensils b. Walker c. Raised toilet seat d. Slider board Source: Saunders 4th

ANS: B Rationale: The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. Adaptive eating utensils may be beneficial when the client has partial paralysis of the hand. A raised toilet seat is useful when the client does not have the mobility or ability to flex the hips. A slider board is used in transferring a client from a bed to stretcher or wheelchair. Strategy: Use the process of elimination. Recall that the cerebellum controls balance and coordination. This would assist in eliminating options 3 and 4. To choose between options 1 and 2, remember that adaptive eating utensils are used with loss of fine motor coordination, such as with a cerebrovascular accident. The walker would help the client maintain balance. Review the effects of a cerebellar lesion if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1065). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1610) The nurse is reviewing the record of a pregnant client and notes that the physician has documented the presence of Chadwick's sign. The nurse understands that the hormone responsible for the development of this sign is which of the following? a. Human chorionic gonadotropin (hCG) b. Estrogen c. Progesterone d. Prolactin Source: Saunders 4th

ANS: B Rationale: The cervix undergoes significant changes following conception. The most obvious changes occur in color and consistency. In response to the increasing levels of estrogen, the cervix becomes congested with blood, resulting in the characteristic bluish color that extends to include the vagina and labia. This discoloration, referred to as Chadwick's sign, is one of the earliest signs of pregnancy. Strategy: Use the process of elimination. Knowledge regarding physiological changes and the hormones responsible for these changes is required to answer this question. Remember that the cervix becomes congested with blood in response to the increasing levels of estrogen. If you are unfamiliar with the physiological changes, review this content. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 111). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1149) A client is receiving thrombolytic therapy with a continuous infusion of streptokinase (Streptase). The client suddenly becomes extremely anxious and complains of itching. A nurse hears stridor and on examination of the client notes generalized urticaria and hypotension. Which of the following should be the priority action of the nurse? a. Administer oxygen and protamine sulfate. b. Stop the infusion and call the physician. c. Cut the infusion rate in half and sit the client up in bed. d. Administer diphenhydramine (Benadryl) and continue the infusion. Source: Saunders 4th

ANS: B Rationale: The client is experiencing an anaphylactic reaction to streptokinase, which is allergenic. The infusion should be stopped, the physician notified, and the client treated with epinephrine, antihistamines, and corticosteroids. Strategy: Recall that an allergic reaction and possible anaphylaxis are risks associated with streptokinase therapy. Also, focusing on the signs and symptoms in the question will assist in answering the question. When a severe allergic reaction occurs, the offending substance should be stopped, and lifesaving treatment should begin. Review the adverse effects of this medication if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 876). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2312) A client who has undergone radical neck dissection is experiencing impaired verbal communication related to postoperative hoarseness. The nurse formulates which of the following as the appropriate goal for this nursing diagnosis? a. Uses nonverbal communication only b. Incorporates nonverbal forms of communication as needed c. Describes that hoarseness will be permanent d. Initiates communication only when necessary Source: Saunders 4th

ANS: B Rationale: The client may experience temporary hoarseness after neck dissection. Goals for the client include using nonverbal forms of communication as needed, expressing willingness to ring the call bell for assistance, and using services of a speech pathologist if prescribed. Options 1, 3, and 4 are incorrect. Strategy: Use the process of elimination. Begin by eliminating options 1 and 4. The use of the word only in these options makes them incorrect. Because hoarseness is a temporary postoperative effect, eliminate option 3. Review communication measures for the client after radical neck dissection if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 576). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Communication and Documentation Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

1003) A client with tuberculosis is being treated with isoniazid (INH) and rifampin (Rifadin). A nurse is preparing instructions for the client regarding these medications and includes which statement in the plan? a. "You must take the medication with meals." b. "The entire year-long course of the medication needs to be completed." c. "You must discontinue the medication if gastrointestinal irritation occurs." d. "Fluids must be increased while taking this medication to prevent renal failure." Source: Saunders 4th

ANS: B Rationale: The client needs to be instructed that the entire year-long course of the medication needs to be completed. The preferable method of administration is for the client to take the medication 1 hour before or 2 hours after meals. If gastrointestinal irritation occurs, the medication should not be discontinued and, in this situation a small amount of food may be taken to reduce the irritation. Increasing fluid intake during this medication therapy is not necessary. Strategy: Use the process of elimination. Note that options 1, 3, and 4 contain the close-ended word must. Review the client teaching points related to these medications if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1847-1848). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 643-644). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

125) A client has been discharged to home on parenteral nutrition (PN). With each visit, a home care nurse assesses which of the following parameters most closely in monitoring this therapy? a. Pulse and weight b. Temperature and weight c. Pulse and blood pressure d. Temperature and blood pressure Source: Saunders 4th

ANS: B Rationale: The client receiving parenteral nutrition (PN) at home should have her or his temperature monitored as a means of detecting infection, which is a potential complication of this therapy. An infection also could result in sepsis because the catheter is in a blood vessel. The client's weight is monitored as a measure of the effectiveness of this nutritional therapy and to detect hypervolemia. The pulse and blood pressure are important parameters to assess, but they do not relate specifically to the effects of PN. Strategy: Note the strategic words most closely, which tell you that more than one or all the options may be partially or totally correct. Remember also that when there are multiple parts to an option, all the parts must be correct for that option to be correct. Recalling that infection and hypervolemia are complications of PN and that weight is monitored as a measure of the effectiveness of this nutritional therapy will direct you to option 2. Review these important assessments if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 707-708). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1433). Philadelphia: W.B. Saunders. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., p. 1055). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2459) A home care nurse visits an older client who was discharged from the hospital after diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which of the following measures should the nurse recommend for the client to alleviate this discomfort? a. Take baths twice daily using a dilute solution of vinegar and water. b. Avoid the use of astringents on the skin. c. Avoid the use of emollients on the skin. d. Purchase a dehumidifier for the home. Source: Saunders 4th

ANS: B Rationale: The client should be instructed to avoid applying rubbing alcohol, astringents, or other drying agents to the skin. One bath or one shower per day for 15 to 20 minutes with warm water and a mild soap should be immediately followed by the application of an emollient to prevent evaporation of water from the hydrated epidermis. A bath using a dilute vinegar solution should not be a component of the instructions because it will cause further drying of the skin. The client should avoid using a dehumidifier because this will further dry room air. Strategy: Use the process of elimination and focus on the subject of the question, chronic dry skin and pruritus. Eliminate options 1, 3, and 4 because these actions will not alleviate the client's skin problem. If you had difficulty with this question, review client teaching points related to dry skin and pruritus. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1576). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

2304) Which of the following should the nurse include in a postoperative teaching plan for a client with Harrington rod fusion who will be wearing a brace? a. Instruct the client to tighten the brace during meals and loosen for the first 30 minutes after each meal. b. Tell the client to inspect the environment for safety hazards. c. Inform the client that lotions and body powders can be used for skin breakdown. d. Reassure the client that she may ambulate to the bathroom to urinate or defecate. Source: Saunders 4th

ANS: B Rationale: The client should be taught to loosen the brace during meals and for 30 minutes after each meal. The client may have difficulty eating if the brace is too tight. Loosening the brace after each meal will allow adequate nutritional intake and promote comfort. The client needs to inspect the environment for safety hazards. Powders and lotions should not be used because they may irritate the skin. The client is not permitted to ambulate and should be encouraged to use a fracture pan. This allows minimal misalignment of the spine and thus ensures comfort when the client must urinate or defecate. Strategy: Use the process of elimination, focusing on the client's diagnosis. Also, note that option 2 addresses safety and is the umbrella option. Review Harrington rod fusion and the use of a brace if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 981-983). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1829) A home health care nurse is providing instructions to a client after a radical vulvectomy. Which of the following instructions should the nurse provide to the client? a. "You can engage in sexual activity in 2 weeks." b. "Resume activities slowly keeping in mind that walking is a beneficial activity." c. "It is important to rest and sit in a chair with your legs elevated as much as possible." d. "It is all right to begin to drive a car as long as you do not drive long distances." Source: Saunders 4th

ANS: B Rationale: The client should resume activities slowly, and walking is a beneficial activity. The client should not be instructed to sit in a chair as much as possible because pressure on the surgical site could lead to complications related to the surgery. Activities to be avoided include driving, heavy housework, wearing tight clothing, crossing the legs, and prolonged sitting and standing. Sexual activity is prohibited for 4 to 6 weeks after surgery. Strategy: Use the process of elimination. Look at each option and evaluate the option in regard to the potential stress or harm to the perineal area. This will direct you to option 2. Review teaching points for the client with a radical vulvectomy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1087). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

1546) The client is preparing for discharge from the hospital after radical vulvectomy. The nurse plans to teach this client that which of the following activities is acceptable after discharge because it will not precipitate complications? a. Sexual activity b. Walking c. Sitting for lengthy periods d. Driving a car Source: Saunders 4th

ANS: B Rationale: The client should resume activity slowly, but walking is a beneficial activity. The client should know to rest when fatigued. Activities to be avoided include driving, heavy housework, wearing tight clothing, crossing the legs, and prolonged standing or sitting. Sexual activity is prohibited for 4 to 6 weeks after surgery. Strategy: Use the process of elimination. Note the strategic words not precipitate complications. With this in mind, evaluate each option in terms of the stress or harm it could cause to the perineal area. Review home care measures following vulvectomy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1087). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

1065) A home care nurse has observed a client self-administer a dose of an adrenergic bronchodilator via metered-dose inhaler. Within a short time, the client begins to wheeze loudly. The nurse interprets that this is the result of: a. Insufficient dosage of the medication, which needs to be increased b. Paradoxical bronchospasm, which must be reported to the physician c. Probable interaction of this medication with an over-the-counter cold remedy d. Tolerance to the medication, indicating a need for a stronger type of bronchodilator Source: Saunders 4th

ANS: B Rationale: The client taking adrenergic bronchodilators may experience paradoxical bronchospasm, which is evidenced by the client's wheezing. This can occur with excessive use of inhalers. Further medication should be withheld, and the physician should be notified. Options 1, 3, and 4 are incorrect interpretations. Strategy: Use the process of elimination. Eliminate option 1 first because the client began wheezing after the medication was administered and not before. Option 4 may be eliminated next because tolerance generally does not occur. From the remaining options, knowing that wheezing is associated with bronchospasm will direct you to option 2. Review the side effects associated with the use of inhaled bronchodilators if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 743). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2297) A nurse is preparing a client who is scheduled to have a cerebral angiography performed. The nurse should assess the client for: a. Allergy to salmon b. Allergy to iodine or shellfish c. Claustrophobia d. Excessive weight Source: Saunders 4th

ANS: B Rationale: The client undergoing cerebral angiography is assessed for possible allergy to the contrast dye, which can be determined by questioning the client about allergies to iodine or shellfish. Salmon is irrelevant to the question. Claustrophobia and excessive weight are areas of concern with magnetic resonance imaging (MRI). Strategy: Use the process of elimination. Recalling that a contrast dye is used in this procedure will direct you to option 2. Review preparation for this test if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 341). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2589) A nurse is caring for a client who sustained a thermal burn caused by the inhalation of steam 24 hours ago. The nurse determines that the priority nursing action is to assess which of the following? a. Ability to swallow b. Pain level c. Lung sounds d. Laboratory results Source: Saunders 4th

ANS: C Rationale: Thermal burns to the lower airways can occur with the inhalation of steam or explosive gases or with the aspiration of scalding liquids. Thermal burns to the upper airways are more common and cause erythema and edema of the airways and mucosal blisters or ulcerations. The mucosal edema can lead to upper airway obstruction, particularly during the first 24 to 48 hours after burn injury. The priority nursing action would be to assess lung sounds. Strategy: Focus on the strategic words inhalation of steam. Use the process of elimination and the ABCs—airway, breathing, and circulation. Although options 1, 2, and 4 will be components of the assessment, option 3 is the only one that specifically addresses airway. Review care of the client who has sustained an inhalation burn if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1437). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1628). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

1135) A nurse is planning to administer hydrochlorothiazide (HydroDIURIL) to a client. The nurse understands that which of the following are concerns related to the administration of this medication? a. Hypouricemia, hyperkalemia b. Increased risk of osteoporosis c. Hypokalemia, hyperglycemia, sulfa allergy d. Hyperkalemia, hypoglycemia, penicillin allergy Source: Saunders 4th

ANS: C Rationale: Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia. Strategy: Use the process of elimination. Recalling that thiazide diuretics carry a sulfa ring will direct you to option 3. Review the nursing considerations related to administering this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 578). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 419). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1743) A client comes to the emergency room following an assault and is extremely agitated, trembling, and hyperventilating. The appropriate initial nursing action would be to: a. Encourage the client to discuss the assault. b. Place the client in a quiet room alone to decrease stimulation. c. Remain with the client until the anxiety decreases. d. Begin to teach relaxation techniques. Source: Saunders 4th

ANS: C Rationale: This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is critical for the nurse to remain with the client. Processing the anxiety at this point will further increase the client's level of anxiety. The client in a severe state of anxiety would not be able to learn relaxation techniques. Strategy: Use the process of elimination and note the strategic words appropriate initial. The best action in this situation is to remain with the client. If you are unfamiliar with the symptoms of the different levels of anxiety and the interventions that are indicated, review this information. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 379). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1485) The client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed room. A newly admitted client will be assigned to this client's room. Which of the following clients would be an appropriate choice as this client's roommate? a. A client with pneumonia b. A client receiving diagnostic tests c. A client who thrives on managing others d. A client who could benefit from the client's assistance at mealtime Source: Saunders 4th

ANS: B Rationale: The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia nervosa is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which the client can focus on the nutritional needs of others or being managed by others because this may contribute to sublimation and suppression of personal hunger. Strategy: Use the process of elimination and note the strategic words, in a state of starvation. Recalling the characteristics associated with anorexia nervosa will direct you to option 2. Review care of the client with anorexia nervosa if you have difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 311). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 521). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 303-304). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

979) The client who chronically uses nonsteroidal anti-inflammatory drugs has been taking misoprostol (Cytotec). The nurse determines that the medication is having the intended therapeutic effect if the client does not experience which sign or symptom? a. Diarrhea b. Epigastric pain c. Decreased platelet count d. Decreased white blood cell count Source: Saunders 4th

ANS: B Rationale: The client who chronically uses nonsteroidal anti-inflammatory drugs (NSAIDs) is prone to gastric mucosal injury. Misoprostol is a gastric protectant and is given specifically to prevent this occurrence. Diarrhea can be a side effect of the medication but is not an intended effect. Options 3 and 4 are incorrect. Strategy: The strategic words in this question are intended therapeutic effect and does not experience. This tells you that the medication is being given to prevent the occurrence of specific symptoms. Recalling that NSAIDs can cause gastric mucosal injury will direct you to option 2. Review this medication and the side effects of NSAIDs if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 783). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2091) A client is being transferred to the nursing unit after receiving a radium implant for bladder cancer. The nurse should take which priority action in the care of this client? a. Encourage the client to take frequent rest periods. b. Assign the client to a private room. c. Encourage the family to visit. d. Place the client on reverse isolation. Source: Saunders 4th

ANS: B Rationale: The client who has a radiation implant is placed in a private room and has limited visitors. This reduces the exposure of others to the radiation. Frequent rest periods are a helpful general intervention but are not a priority for the client in this situation. Reverse isolation is unnecessary. Strategy: Use the process of elimination. Note the strategic words priority action. Focus on the subject and eliminate option 4 as an unnecessary action. Option 1 is helpful but is not considered a priority and is eliminated next. Regarding the remaining options, recall that other people should have limited exposure to clients with radium implants. Review care of the client with a radium implant if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 363). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1750) A woman comes into the emergency room following an assault. She presents with hyperventilation, pacing, rapid speech, and headache. The nurse assesses the level of anxiety to be: a. Panic. b. Severe. c. Moderate. d. Psychotic. Source: Saunders 4th

ANS: B Rationale: The client who has severe anxiety has significant somatic complaints, ineffective functioning, loud or rapid speech, and purposeless activity. The client symptoms in the question do not relate to options 1, 3, and 4. Strategy: Use the process of elimination. Note the client's symptoms in the question to answer the question correctly. Review the signs and symptoms associated with each level of anxiety if you had difficulty with this question. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 214-216). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2313) An emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the physician's orders and plans to question an order for which of the following? a. Nothing by mouth (NPO) status b. Gastric lavage c. Intravenous fluid therapy d. Preparation for barium swallow Source: Saunders 4th

ANS: B Rationale: The client who has sustained chemical burns to the esophagus is placed on NPO status, is given intravenous (IV) fluids for replacement and treatment of possible shock, and is prepared for esophagoscopy and barium swallow to determine the extent of damage. A nasogastric tube may be inserted, but gastric lavage and emesis are avoided to prevent further erosion of the mucosa by the irritating substances. Strategy: Use the process of elimination, noting the strategic words question an order. Focusing on the subject, chemical burns to the esophagus, will direct you to option 2. Review care of the client after burns due to the ingestion of chemicals if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1437, 1446, 1448). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

1154) A client is admitted with pulmonary embolism and is to be treated with streptokinase (Streptase). A nurse would report which of the following assessments to the physician before initiating this therapy? a. Adventitious breath sounds b. Temperature of 99.4° F orally c. Blood pressure of 198/110 mm Hg d. Respiratory rate of 28 breaths/min Source: Saunders 4th

ANS: C Rationale: Thrombolytic therapy is contraindicated in a number of preexisting conditions in which there is a risk of uncontrolled bleeding, similar to the case in anticoagulant therapy. Thrombolytic therapy also is contraindicated in severe uncontrolled hypertension because of the risk of cerebral hemorrhage. Therefore, the nurse would report the results of the blood pressure to the physician before initiating therapy. Strategy: Use the process of elimination and focus on the client's diagnosis. Options 1, 2, and 4 may be present in the client with pulmonary embolism but are not necessarily signs that warrant reporting before this therapy is initiated. Review the contraindications associated with the administration of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1080). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1848) A nurse is supervising a nursing assistant performing mouth care in an unconscious client. The nurse should intervene if the nursing assistant is observed doing which of the following? a. Turning the client's head to one side b. Using a gloved finger to open the client's mouth c. Placing an emesis basin under the client's mouth d. Using small volumes of fluid to rinse the mouth Source: Saunders 4th

ANS: B Rationale: The client who is unconscious is at great risk for aspiration. The nursing assistant turns the client's head to the side and places an emesis basin underneath the mouth. A bite stick or a padded tongue blade is used to open the mouth, not a gloved finger, to prevent injury to the caregiver. Small volumes of fluids are used to rinse the mouth. Strategy: Use the process of elimination to assist in answering the question. Note the strategic word intervene. Attempt to visualize the procedure for providing mouth care for an unconscious client. This will direct you to option 2. If you had difficulty with this question, review mouth care for the client who is unconscious. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2060-2061). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1044-1045). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1080) A client who had cardiac surgery 24 hours ago has a urine output averaging 20 mL/hr for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL and the serum creatinine level is 2.2 mg/dL. Based on these findings, the nurse would anticipate that the client is at risk for which of the following? a. Hypovolemia b. Acute renal failure c. Glomerulonephritis d. Urinary tract infection Source: Saunders 4th

ANS: B Rationale: The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal insult is signaled by decreased urine output and increased blood urea nitrogen and creatinine levels. The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, urinary tract infection, or glomerulonephritis. Strategy: Use the process of elimination. Eliminate options 3 and 4 first because no data indicate infection or inflammation. Noting that the urine output is inadequate will assist you in eliminating option 1. Review the complications associated with cardiac surgery if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 914-916, 1642). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 860, 1663-1664, 1732). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1963) A nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which of the following laboratory findings would the nurse expect to note in this client? a. A blood glucose level of 110 mg/dL b. A potassium (K⁺) level of 5.5 mEq/L c. A white blood cell (WBC) count of 6,000/μL d. A platelet count of 200,000/μL Source: Saunders 4th

ANS: B Rationale: The client with Cushing's syndrome experiences hyperkalemia, hyperglycemia, an elevated WBC count, and an elevated plasma cortisol and ACTH levels. These abnormalities are due the effects of excess glucocorticoids and mineralocorticoids in the body. The laboratory values noted in options 1, 3, and 4 would not be noted in the client with Cushing's syndrome. Strategy: To answer this question correctly, it is necessary to have a basic understanding of this disorder and the effects of the excesses on the body. Use the process of elimination and eliminate options 1, 3, and 4 because they are within normal levels. This will assist in directing you to option 2. If you had difficulty with this question, review the manifestations of Cushing's syndrome. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 887). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1474-1475). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

2326) A nurse provides instructions to a client after a total laryngectomy. Which statement by the client indicates a need for further instruction? a. "Soaps should be avoided near the stoma." b. "I should use diluted alcohol on the stoma to clean it." c. "I should apply a thin layer of petroleum to the skin surrounding the stoma." d. "I need to protect the stoma from water." Source: Saunders 4th

ANS: B Rationale: The client with a stoma should be instructed to wash the stoma daily with a wash cloth. Soaps, cotton swabs, or tissues should be avoided because their particles may enter and obstruct the airway. The client should be instructed to avoid applying diluted alcohol to a stoma because it is both drying and irritating. A thin layer of petroleum applied to the skin around the stoma helps to prevent cracking. The client is instructed to protect the stoma from water. Strategy: Note the strategic words need for further instruction in the question. This phrasing indicates a negative event query and asks you to select an incorrect statement. Use the process of elimination, thinking about the measures that will irritate the stoma. This will direct you to option 2. If you had difficulty with this question, review these measures. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1792). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 575). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1934) A nurse is caring for the client with acute glomerulonephritis. The nurse instructs the nursing assistant to do which of the following in the care of the client? a. Monitor the client's temperature every 2 hours. b. Remove the water pitcher from the bedside. c. Ambulate the client frequently. d. Encourage a diet that is high in protein. Source: Saunders 4th

ANS: B Rationale: The client with acute glomerulonephritis commonly experiences fluid volume excess and fatigue. Interventions include fluid restriction, as well as monitoring weight, intake, and output. The client is placed on bedrest, or at least encouraged to rest, because there is a direct correlation between proteinuria and hematuria and increased activity levels. The diet is high in calories but low in protein. It is unnecessary to monitor the temperature as frequently as every 2 hours. Strategy: Use the process of elimination and focus on the client's diagnosis. Recalling that the client experiences a fluid volume excess will direct you to option 2. Review treatment for the client with glomerulonephritis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 930). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1785) The nurse is teaching the postgastrectomy client about measures to prevent dumping syndrome. Which statement by the client indicates a need for further teaching? a. "I need to lie down after eating." b. "I need to drink liquids with meals." c. "I need to eat small meals six times daily." d. "I need to avoid concentrated sweets." Source: Saunders 4th

ANS: B Rationale: The client with dumping syndrome should be placed on a high-protein, moderate-fat, and high-calorie diet. The client should lie down after eating and should avoid drinking liquids with meals. Frequent small meals are encouraged and the client should avoid concentrated sweets. Strategy: Note the strategic words need for further teaching in the question. These words indicate a negative event query and ask you to select an option that is incorrect. Think about this disorder and use the process of elimination selecting option 2 as the item that will contribute to the problems associated with dumping syndrome. If you had difficulty with this question, review the diet associated with this syndrome. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 759). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1156) The client with acute renal failure has a serum potassium level of 6.0 mEq/L. The nurse would plan which of the following as a priority action? a. Check the sodium level. b. Place the client on a cardiac monitor. c. Encourage increased vegetables in the diet. d. Allow an extra 500 mL of fluid intake to dilute the electrolyte concentration. Source: Saunders 4th

ANS: B Rationale: The client with hyperkalemia is at risk of developing cardiac dysrhythmias and cardiac arrest. Because of this, the client should be placed on a cardiac monitor. Fluid intake is not increased because it contributes to fluid overload and would not affect the serum potassium level significantly. Vegetables are a natural source of potassium in the diet, and their use would not be increased. The nurse also may assess the sodium level because sodium is another electrolyte commonly measured with the potassium level. However, this is not a priority action of the nurse. Strategy: First, note that the potassium level is elevated. Next, use the ABCs—airway, breathing, and circulation—to direct you to option 2. Review care of the client with hyperkalemia if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 233, 1740). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1024) A nurse is caring for a client diagnosed with tuberculosis. Which assessment, if made by the nurse, is inconsistent with the usual clinical presentation of tuberculosis and may indicate the development of a concurrent problem? a. Cough b. High-grade fever c. Chills and night sweats d. Anorexia and weight loss Source: Saunders 4th

ANS: B Rationale: The client with tuberculosis usually experiences cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever. Strategy: Use the process of elimination. Eliminate options 1 and 4 first because they are symptoms that are common in the client with tuberculosis. From the remaining options, you need to know that the client may get night sweats or that the fever is low grade. Review the clinical manifestations associated with tuberculosis if you had difficulty with this question. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., p. 774). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1164) The client who has a history of gout also is diagnosed with urolithiasis and the stones are determined to be of uric acid type. The nurse gives the client instructions in which foods to limit, including: a. Milk b. Liver c. Apples d. Carrots Source: Saunders 4th

ANS: B Rationale: The client with uric acid stones should avoid foods containing high amounts of purines. This includes limiting or avoiding organ meats such as liver, brain, heart, kidney, and sweetbreads. Other foods to avoid include herring, sardines, anchovies, meat extracts, consommés, and gravies. Foods that are low in purines include all fruits, many vegetables, milk, cheese, eggs, refined cereals, sugars and sweets, coffee, tea, chocolate, and carbonated beverages. Strategy: Use the process of elimination. Begin by examining the options and classifying the types of food sources they represent. Options 3 and 4 represent foods that are grown, whereas options 1 and 2 represent foods derived from animal sources. Because purines are end products of protein metabolism, you would eliminate options 3 and 4 first. From the remaining options, recall that organ meats such as liver provide more protein than milk. Review foods high in purines if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1701). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1566) The nurse has admitted a client to the clinical nursing unit following a modified right radical mastectomy for the treatment of breast cancer. The nurse plans to place the right arm in which of the following positions? a. Elevated above shoulder level b. Elevated on a pillow c. Level with the right atrium d. Dependent to the right atrium Source: Saunders 4th

ANS: B Rationale: The client's operative arm should be positioned so that it is elevated on a pillow, and not exceeding shoulder elevation. This promotes optimal drainage from the limb, without impairing the circulation to the arm. If the arm is positioned flat (option 3) or dependent (option 4), this could increase the edema in the arm, which is contraindicated because of lymphatic disruption caused by surgery. Strategy: Use the process of elimination. Read each option carefully and attempt to visualize the position identified in the option. Using the principles of circulation and gravity will easily direct you to option 2. Option 2 is the option that avoids the two extremes of height in positioning the limb affected by surgery. Review care of the client following mastectomy if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1805). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

135) A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 3 <sc>PM</sc>. The nurse making rounds at 3:45 <sc>PM</sc> finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which of the following actions first? a. Call the physician. b. Slow the IV infusion. c. Sit the client up in bed. d. Remove the IV catheter. Source: Saunders 4th

ANS: B Rationale: The client's symptoms are compatible with circulatory overload. This may be verified by noting that 600 mL has infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other actions may follow in rapid sequence. The nurse may elevate the head of the bed to aid the client's breathing, if necessary. The nurse also notifies the physician immediately. The IV catheter is not removed; it may be needed once the complication has been resolved. Strategy: Use the process of elimination and note the strategic word first. This tells you that more than one or all of the options are likely to be correct actions, and the nurse needs to prioritize them according to a time sequence. You must be able to recognize the signs of circulatory overload. From this point, select the option that provides the intervention specific to circulatory overload. Review nursing actions related to this complication if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 262). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1173). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

1753) The clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which of the following describes the accurate procedure to perform this test? a. The examiner and client cover the same eyes and stare at each other's uncovered eye, and a small object is brought into the visual field. b. The examiner and client cover the eyes directly opposite to one another and stare at each other's uncovered eye, and a small object is brought into the visual field. c. The client is asked to discriminate numbers from a chart composed of colored dots. d. The room is darkened and the client is asked to identify colored blocks and shapes when they appear in the visual field. Source: Saunders 4th

ANS: B Rationale: The confrontational method assumes that the examiner has normal peripheral vision. The client sits facing the examiner, approximately 2 feet away. The eyes of the client and the examiner should be at the same level. Both the examiner and client cover their eyes directly opposite each other and stare at each other's uncovered eye. A small object is brought from the peripheral visual field and tests the superior, temporal, inferior, and nasal field. The client states when he or she sees the object. Strategy: Use the process of elimination. Eliminate option 3 because this option describes the test for color vision. Option 4 does not describe a confrontational test and addresses testing color. Visualize the process of testing as you read through options 1 and 2. This may assist you in selecting the correct option. If you had difficulty with this question, review this assessment test. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., p. 308). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1000) A nurse is caring for a client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client? a. Pallor b. Low arterial Pa<SC>O</SC> ₂ c. Elevated arterial Pa<SC>O</SC> ₂ d. Decreased respiratory rate Source: Saunders 4th

ANS: B Rationale: The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a Pa<SC>O</SC> ₂ lower than 60 mm Hg. Strategy: Use the process of elimination. Note that options 2 and 3 relate to the same subject but present opposite conditions. This may provide you with the clue that one of these options is correct. Considering the diagnosis of the client, the best choice is option 2. Review the clinical manifestations associated with acute respiratory distress syndrome if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 655, 2183). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1355) A nurse has conducted teaching with a client in an arm cast about signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which of the following early symptoms of compartment syndrome? a. Cold, bluish-colored fingers b. Numbness and tingling in the fingers c. Pain that increases when the arm is dependent d. Pain relieved only by oxycodone and aspirin (Percodan) Source: Saunders 4th

ANS: B Rationale: The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by narcotics, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign. Strategy: Use the process of elimination. Note the strategic word early. Knowing that compartment syndrome is characterized by insufficient circulation and ischemia caused by pressure will direct you to option 2. Review the early signs of compartment syndrome if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1191-1192). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1713) The nurse has administered approximately half of an enema solution when the client complains of pain and cramping. Which nursing action is the most appropriate? a. Raise the enema bag so that the solution can be instilled quickly. b. Clamp the tubing for 30 seconds and restart the flow at a slower rate. c. Reassure the client and continue the flow. d. Discontinue the enema and notify the physician. Source: Saunders 4th

ANS: B Rationale: The enema fluid should be administered slowly. If the client complains of fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate. Slow enema administration and stopping the flow temporarily, if necessary, will decrease the likelihood of intestinal spasm and premature ejection of the solution. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum. There is no need to discontinue the enema and notify the physician at this time. Although client reassurance is important, continuing the flow is inappropriate. Strategy: Use the process of elimination. Eliminate options 1 and 3 first because they are comparative or alike. From the remaining options, focusing on the subject will direct you to option 2. Review the procedure for administering an enema if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1401-1402). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2139) A client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse should plan to provide which type of wound care to the fasciotomy site? a. Dry sterile dressings b. Moist sterile saline dressings c. Hydrocolloid dressings d. One-half strength povidone-iodine (Betadine) dressings Source: Saunders 4th

ANS: B Rationale: The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with moist sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. Strategy: Use the process of elimination. Recalling that with a fasciotomy, the skin is left open and remembering that moist tissue needs to remain moist will direct you to option 2. A hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so povidone-iodine should not be required. Also, this agent is irritating to tissues. Review care to a fasciotomy site if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 629). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1401) The client is diagnosed with stage I Lyme disease. The nurse assesses the client for which characteristic of this stage? a. Arthralgias b. Flu-like symptoms c. Enlarged and inflamed joints d. Signs of neurological disorders Source: Saunders 4th

ANS: B Rationale: The hallmark of stage I Lyme disease is the development of a rash within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a bull's-eye appearance. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons develop flu-like symptoms that last 7 to 10 days; these symptoms may reoccur later. Neurological deficits occur in stage II. Arthralgias and joint enlargements are most likely to occur in stage III. Strategy: Use the process of elimination and eliminate options 1 and 3 first because they are comparative or alike. Next, note that the question asks for the characteristic of stage I. From the remaining two options, select the least serious one because the subject of the question relates to stage I. Expect neurological disorders to occur with progression of the disease. If you had difficulty with this question, review the stages of Lyme disease. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 418). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1311) The nurse has completed discharge instructions for the client with application of a halo device. The nurse determines that the client needs further clarification of the instructions if the client states that he or she will: a. Use a straw for drinking. b. Drive only during the daytime. c. Use caution because the device alters balance. d. Wash the skin daily under the lamb's wool liner of the vest. Source: Saunders 4th

ANS: B Rationale: The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should use powder or lotions sparingly, or not at all. The wool liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client may not drive because the device impairs the range of vision. Strategy: Use the process of elimination and note the strategic words needs further clarification. These words indicate a negative event query and ask you to select an option that is incorrect. Visualize this device to answer correctly. The inability to turn the head without turning the torso would contraindicate driving. Review client education points related to a halo device if you had difficulty with this question. Reference: Ignatavicius, D. & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 994). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1274) The nurse is positioning the client with increased intracranial pressure. Which of the following positions would the nurse avoid? a. Head midline b. Head turned to the side c. Neck in neutral position d. Head of bed elevated 30 to 45 degrees Source: Saunders 4th

ANS: B Rationale: The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client's neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down. Strategy: Use the process of elimination, noting the strategic word avoid. Select the position that interferes with arterial circulation to the brain or with venous drainage from the brain. The only position that meets one of those criteria is option 2. Review positioning of the client with increased intracranial pressure if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2201). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1051). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1816) The home care nurse visits a client at home who has been experiencing increased weakness. The client tells the nurse that he is using a cane that was purchased at a local pharmacy. The home care nurse assesses the client's use of the cane and determines that the cane is sized correctly if: a. The handle of the cane is even with the client's waist. b. The client's elbow is flexed at a 15- to 30-degree angle when ambulating with the cane. c. The client's elbow is flexed at a 50- to 75-degree angle when ambulating with the cane. d. The client's elbow is straight when ambulating with the cane. Source: Saunders 4th

ANS: B Rationale: The height of a cane should be even with the greater trochanter. This allows the elbow to be held at approximately 15 to 30 degrees of flexion. The flexion is necessary to allow the client to push off without bending over when ambulating. Options 1, 3, and 4 are incorrect. Strategy: Use the process of elimination. Attempting to visualize the use of the cane will assist in directing you to the correct option. If you had difficulty with this question or are unfamiliar with the appropriate use of a cane, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 124-125). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 948-949). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1503) The police arrive at the emergency room with a client who has seriously lacerated both wrists. The initial nursing action is to: a. Administer an antianxiety agent. b. Examine and treat the wound sites. c. Secure and record a detailed history. d. Encourage and assist the client to ventilate feelings. Source: Saunders 4th

ANS: B Rationale: The initial nursing action is to assess and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions may follow after the client has been treated medically. Strategy: Use Maslow's Hierarchy of Needs theory to prioritize. Physiological needs come first. Option 2 addresses the physiological need. Review care of the client who attempted suicide if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 229, 367, 375-376). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

1660) To perform cardiopulmonary resuscitation (CPR), the nurse would use the method shown in the Figure to open the airway in which of the following situations? a. In all situations requiring CPR b. If neck trauma is suspected c. If the client is unconscious d. If the client has a history of headaches Source: Saunders 4th

ANS: B Rationale: The jaw thrust without the head tilt maneuver is used when head and/or neck trauma is suspected. This maneuver opens the airway while maintaining proper head and neck alignment, thus reducing the risk of further damage to the neck. Option 1 is incorrect. In situations requiring CPR, the client will be unconscious. Option 4 is also incorrect. Additionally, it is unlikely that the nurse will be able to obtain these data. Strategy: Focus on the data in the question. Eliminate option 1 because of the close-ended word all. Noting that the client requires CPR will assist in eliminating options 3 and 4. Review CPR guidelines and the various test-taking strategies if you had difficulty with this question. Reference: Harkreader, H., & Hogan, M.A. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed., p. 909). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Mulitiple Choice Image

1303) The client has a neurological deficit involving the limbic system. Specific to this type of deficit, the nurse would document which of the following information related to the client's behavior? a. Is disoriented to person, place, and time b. Affect is flat, with periods of emotional lability c. Cannot recall what was eaten for breakfast today d. Demonstrates inability to add and subtract; does not know who is president Source: Saunders 4th

ANS: B Rationale: The limbic system is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current events relates to function of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus. Strategy: Use the process of elimination. Recall that the limbic system is responsible for feelings and emotions to direct you to option 2. Review the function of the limbic system if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2001). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2372) A client with squamous cell carcinoma is receiving bleomycin (Blenoxane). To determine whether adverse effects of this medication are occurring, the nurse should carefully assess which of the following? a. Blood pressure b. Lung sounds c. White blood cell count d. Platelet count Source: Saunders 4th

ANS: B Rationale: The major form of dose-limiting toxicity with bleomycin is injury to the lungs. It manifests initially as pneumonitis but can progress to severe pulmonary fibrosis and death. In addition to auscultation of lung sounds, pulmonary function studies should be monitored. Bleomycin is discontinued at the first sign of these adverse changes. Nausea and vomiting usually are mild with the use of this medication, and unlike most other anticancer agents, bleomycin exerts minimal toxicity to bone marrow. It does not directly affect the blood pressure. Strategy: Use the process of elimination. Recalling that the medication causes injury to the lungs will direct you to the correct option. If you are unfamiliar with the adverse effects of this medication, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 148). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1531) The nurse is teaching a client who is being started on imipramine hydrochloride (Tofranil) about the medication. The nurse informs the client that the maximum desired effects may _____ of administration. a. Start during the first week b. Not occur for 2 to 3 weeks c. Start during the second week d. Not occur until after 2 months Source: Saunders 4th

ANS: B Rationale: The maximum therapeutic effects of imipramine hydrochloride (Tofranil) may not occur for 2 to 3 weeks after the antidepressant therapy has been initiated. Therefore, options 1, 3, and 4 are incorrect. Strategy: Focus on the strategic word maximum. Recalling that it takes 2 to 3 weeks for a maximum therapeutic effect to occur with most antidepressants will direct you to option 2. Review this medication if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 472). St. Louis: Mosby. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., p. 151). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2685) A client with a gastric ulcer is being discharged from the hospital with a prescription for sucralfate (Carafate) 1 g by mouth four times daily. The nurse teaches the client to take the medication: a. With meals and at bedtime b. 1 hour before meals and at bedtime c. Every 6 hours around the clock d. 1 hour after meals and at bedtime Source: Saunders 4th

ANS: B Rationale: The medication should be taken 1 hour before meals and at bedtime to allow it to form a protective coating over the ulcer to prevent irritation from food, gastric acid, and mechanical movement. The other options are incorrect. Strategy: Use the process of elimination and focus on the subject, the timing of the medication. Recalling that the medication provides a protective coating will direct you to the correct option. Review the method of administration of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1082). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1217) A nurse is monitoring a client receiving cyclosporine (Sandimmune). Which sign or symptom would indicate to the nurse that the client is experiencing an adverse effect from this medication? a. Nausea b. Tremors c. Alopecia d. Hypotension Source: Saunders 4th

ANS: B Rationale: The most common adverse effects of cyclosporine are nephrotoxicity, infection, hypertension, tremors, and hirsutism. Of these, nephrotoxicity and infection are the most serious. Strategy: Knowledge regarding the adverse effects associated with cyclosporine is required to answer this question. Remember that tremors are an indication of an adverse effect. If you are unfamiliar with these effects, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 303). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1667) Metformin (Glucophage) is prescribed for the client with type 2 diabetes mellitus. The nurse tells the client that the most common side effect of the medication is: a. Hypoglycemia b. Gastrointestinal (GI) disturbances c. Weight gain d. Flushing and palpitations Source: Saunders 4th

ANS: B Rationale: The most common side effect of metformin (Glucophage) is GI disturbances, including decreased appetite, nausea, and diarrhea. These generally subside over time. This medication does not cause weight gain; in fact, clients lose an average of 7 to 8 lb because the medication causes nausea and decreased appetite. Although hypoglycemia can occur, it is not the most common side effect. Strategy: Use the process of elimination, noting the strategic words most common side effect. Remember that the most common side effect of metformin is GI disturbances. Review these side effects if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 745-746). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1514) The nurse is performing a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine (Prozac). What information would be important for the nurse to obtain during this client visit regarding the side effects of the medication? a. Cardiovascular symptoms b. Gastrointestinal dysfunctions c. Problems with mouth dryness d. Problems with excessive sweating Source: Saunders 4th

ANS: B Rationale: The most common side effects related to this medication include central nervous system and gastrointestinal system dysfunction. Fluoxetine (Prozac) affects the gastrointestinal system by causing nausea and vomiting, cramping, and diarrhea. Excessive sweating, dry mouth, and cardiovascular symptoms are not side effects associated with this medication. Strategy: Use the process of elimination. Recalling that this medication causes gastrointestinal problems will direct you to option 2. Review the side effects related to this medication if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 470). St. Louis: Mosby. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., pp. 163-164, 656). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1477) The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse would be: a. "Why don't you tell your husband about this?" b. "What do you find difficult about this situation?" c. "This is not the best time to make that decision." d. "I agree with you. You should get out of this situation." Source: Saunders 4th

ANS: B Rationale: The most helpful response is one that encourages the client to solve problems. Giving advice implies that the nurse knows what is best and also can foster dependency. The nurse should not agree with the client, nor should the nurse request that the client provide explanations. Strategy: Use therapeutic communication techniques. Eliminate option 1 because of the word why, which should be avoided in communication. Eliminate option 4 because the nurse is agreeing with the client. Eliminate option 3 because this option places the client's feelings on hold. Option 2 is the only option that addresses the client's feelings. Review therapeutic communication techniques if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 125, 316-319, 322). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-34). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

79) A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to: a. 3 mg/dL b. 15 mg/dL c. 29 mg/dL d. 35 mg/dL Source: Saunders 4th

ANS: B Rationale: The normal blood urea nitrogen level is 8 to 25 mg/dL. Values such as those in options 3 and 4 reflect continued dehydration. Option 1 reflects a lower than normal value, which may occur with fluid volume overload, among other conditions. Strategy: Use the process of elimination and knowledge of the normal blood urea nitrogen level to answer the question. Option 2 is the only option that identifies a normal value. Review this laboratory test if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 1111). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2483) A female client is at risk for developing disseminated intravascular coagulopathy (DIC). On reviewing the laboratory test results for this client, the nurse determines that the fibrinogen level is normal if which of the following values is noted on the laboratory report? a. 180 mg/dL b. 400 mg/dL c. 480 mg/dL d. 500 mg/dL Source: Saunders 4th

ANS: B Rationale: The normal fibrinogen level is 180 to 340 mg/dL for males and 190 to 420 mg/dL for females. A critical value is one that is less than 100 mg/dL. With DIC, the fibrinogen level drops because fibrinogen is used up in the clotting process. Option 2 is the only option that identifies a normal level. Strategy: Knowledge of the normal fibrinogen level is required to answer this question. Review this normal value and the manifestations of DIC if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 546). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2477) A clinic nurse is reviewing the laboratory test results for an adult male client seen in the health care clinic. The nurse determines that the hematocrit level is normal if which of the following values is noted on the laboratory report? a. 56% b. 48% c. 39% d. 34% Source: Saunders 4th

ANS: B Rationale: The normal hematocrit level for an adult male is 42% to 52%. Option 1 indicates a high level, whereas options 3 and 4 are low hematocrit levels. Strategy: Knowledge of the normal hematocrit level is needed to answer this question. Review this laboratory test if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 635). Philadelphia: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 511). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1780) The adult male client admitted to the hospital with shock has received fluid volume replacement. The nurse evaluates that the client has had adequate fluid resuscitation if the client's repeat hematocrit level has decreased to which of the following values in the normal range? a. 56% b. 48% c. 39% d. 34% Source: Saunders 4th

ANS: B Rationale: The normal hematocrit level for an adult male is 42% to 52%. The client who is in shock has an elevated level because of hemoconcentration. The client's level may be expected to drift back down to within the normal range once fluid volume has been adequately restored. Thus, option 2 is the only correct choice. Option 1 is too high and options 3 and 4 are low. Strategy: Use the process of elimination. Recalling that the normal hematocrit level is 42% to 52% will direct you to option 2. Because this is a very common laboratory study, it would be useful to memorize this one. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2263). Philadelphia: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 511). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2476) A nurse is reviewing the laboratory test results for an adult female client seen in the health care clinic. The nurse determines that the hemoglobin level is normal if which of the following values is noted on the laboratory report? a. 8 g/dL b. 14 g/dL c. 22 g/dL d. 32 g/dL Source: Saunders 4th

ANS: B Rationale: The normal hemoglobin level for an adult female is 12 to 15 g/dL. Option 1 indicates a low hemoglobin level. Options 3 and 4 identify elevated hemoglobin levels. Strategy: Knowledge of the normal hemoglobin level is required to answer this question. Review this laboratory test if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 637). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

70) A nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, P<sc>CO</sc>₂ of 30 mm Hg, and HCO₃^- of 22 mEq/L. The nurse analyzes these results as indicating which condition? a. Metabolic acidosis, compensated b. Respiratory alkalosis, compensated c. Metabolic alkalosis, uncompensated d. Respiratory acidosis, uncompensated Source: Saunders 4th

ANS: B Rationale: The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the P<sc>CO</sc>₂. In this situation, the pH is at the high end of the normal value and the P<sc>CO</sc>₂ is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the question indicate a respiratory alkalosis. Compensation occurs when the pH returns to a normal value. Because the pH is in the normal range at the high end, compensation has occurred. Strategy: Remember that in a respiratory imbalance you will find an opposite response between the pH and the P<sc>CO</sc>₂ as indicated in the question. Therefore, you can eliminate options 1 and 3. Also, remember that the pH increases in an alkalotic condition and compensation occurs, as evidenced by a normal pH. Option 2 reflects a respiratory alkalotic condition and compensation and describes the blood gas values as indicated in the question. Review the steps related to reading blood gas values if you had difficulty with this question. Reference: McLean, B. (2005). Acid-base imbalances. In Baird MS, Keen JH, Swearingen PL (Eds.): Manual of critical care nursing (5th ed., pp. 566-581). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1145). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

84) A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium (Coumadin) has a prothrombin time of 35 seconds. Based on the prothrombin time, the nurse anticipates which of the following orders? a. Adding a dose of heparin sodium b. Holding the next dose of warfarin c. Increasing the next dose of warfarin d. Administering the next dose of warfarin Source: Saunders 4th

ANS: B Rationale: The normal prothrombin time (PT) is 9.6 to 11.8 seconds (male adult) or 9.5 to 11.3 seconds (female adult). A therapeutic PT level is 1.5 to 2.0 times higher than the normal level. Because the value of 35 seconds is high (and perhaps near the critical range), the nurse should anticipate that the client would not receive further doses at this time. Strategy: Use the process of elimination, recalling that the normal PT is 9.6 to 11.8 seconds (male adult) or 9.5 to 11.3 seconds (female adult) and that a therapeutic PT level is 1.5 to 2.0 times higher than the normal level. If this question was difficult, review this laboratory test and the expected level if the client is receiving warfarin sodium. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 920). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1820) A nurse in the newborn nursery is performing admission vital signs on a newborn infant. The nurse notes that the respiratory rate of the newborn is 50 breaths/min. Which of the following is the appropriate nursing action? a. Contact the physician. b. Document the findings. c. Apply an oxygen mask to the newborn infant. d. Cover the newborn infant with blankets and reassess the respiratory rate in 15 minutes. Source: Saunders 4th

ANS: B Rationale: The normal respiratory rate for a normal newborn in 30 to 60 breaths/min. On assessment, if the nurse noted a respiratory rate of 50 breaths/min, the nurse should document these findings since these findings are normal. Options 1, 3, and 4 are inappropriate or unnecessary nursing actions. Strategy: Use the process of elimination. Recall that the normal respiratory rate in a newborn is 30 to 60 breaths/min. This will help you eliminate each of the incorrect options. Review the normal ranges for newborn vital signs if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 478). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

1778) The adult client with hepatic encephalopathy has a serum ammonia level of 95 µg/dL, and receives treatment with lactulose (Chronulac). The nurse would evaluate that the client had the best and most realistic response if the serum ammonia level changed to which of the following after medication administration? a. 80 µg/dL b. 40 µg/dL c. 10 µg/dL d. 5 µg/dL Source: Saunders 4th

ANS: B Rationale: The normal serum ammonia level is 35 to 65 mcg/dL. In the client with hepatic encephalopathy, the serum level is not likely to drop below normal, nor is it likely to drop into the low-normal range. The most optimal but realistic change would be to 40 mcg/dL, which falls into the high-normal range. A level of 80 mcg/dL represents insufficient effect of the medication. Strategy: Use the process of elimination and knowledge of the normal serum ammonia level. Option 2 is the only option that identifies a normal ammonia level. Review this test and the desirable effects of this medication if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1369). Philadelphia: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 52). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2462) A nurse is reviewing the laboratory test results for an adult client admitted to the hospital with acute abdominal pain. The nurse would determine that the serum amylase level is normal if which of the following values was noted? a. 10 Somogyi units/dL b. 100 Somogyi units/dL c. 300 Somogyi units/dL d. 500 Somogyi units/dL Source: Saunders 4th

ANS: B Rationale: The normal serum amylase level ranges from 53 to 123 Somogyi units/dL in the adult, depending on the laboratory running the test. Options 1, 3 and 4 are not normal values of the serum amylase levels. Strategy: Knowledge of the normal serum amylase level is needed to answer this question. Remember that the normal level ranges from 53 to 123 Somogyi units/dL in the adult. Review this normal level if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 172). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2475) A nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the serum lipase level is normal if which of the following values is noted on the laboratory report? a. 20 U/L b. 80 U/L c. 200 U/L d. 350 U/L Source: Saunders 4th

ANS: B Rationale: The normal serum lipase level is 10 to 140 U/L. Option 1 identifies a low serum lipase level. Options 3 and 4 identify elevated serum lipase levels. Strategy: Knowledge of the normal serum lipase level is needed to answer this question. Review this laboratory test if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 724). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2471) A nurse is reviewing the results of the electrolyte panel for a client seen in the health care clinic. The nurse determines that the client's potassium level is normal if which of the following values is noted? a. 3.0 mEq/L b. 4.0 mEq/L c. 5.8 mEq/L d. 6.0 mEq/L Source: Saunders 4th

ANS: B Rationale: The normal serum potassium level in the adult is 3.5 to 5.1 mEq/L. Option 1 identifies a low level. Options 3 and 4 identify elevated levels. Strategy: Focus on the subject, a normal potassium level. Recalling that this level is 3.5 to 5.1 mEq/L will direct you to option 2. Review this level if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 887). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2470) A nurse is reviewing the results of the electrolyte panel for a client seen in the health care clinic. The nurse determines that the client's sodium level is normal if which of the following values is noted? a. 120 mEq/L b. 142 mEq/L c. 148 mEq/L d. 152 mEq/L Source: Saunders 4th

ANS: B Rationale: The normal serum sodium level is 135 to 145 mEq/L. Option 1 identifies a low sodium level. Options 3 and 4 identify elevated sodium levels. Strategy: Focus on the subject, a normal sodium level. Recalling that this level is 135 to 145 mEq/L will direct you to option 2. Review this level if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 1008). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1779) The client who has suffered a crush injury to the leg has a highly positive urine myoglobin level. The nurse assesses this particular client carefully for signs of: a. Brain attack (stroke) b. Acute tubular necrosis c. Respiratory failure d. Myocardial infarction Source: Saunders 4th

ANS: B Rationale: The normal urine myoglobin level is negative. After extensive muscle destruction or damage, myoglobin is released into the bloodstream, where it is cleared from the body by the kidneys. When there is a large amount of myoglobin being cleared from the body, there is a risk of the renal tubules being clogged with myoglobin, causing acute tubular necrosis. This is one form of acute renal failure. Strategy: Use the process of elimination. Note the relationship of the words urine in the question and acute tubular necrosis in the correct option. Review the significance of myoglobin in the urine if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1580). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1192). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1248) A client with Ménière's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? a. Increase sodium in the diet. b. Avoid sudden head movements. c. Lie still and watch the television. d. Increase fluid intake to 3000 mL a day. Source: Saunders 4th

ANS: B Rationale: The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Lying still and watching television will not control vertigo. Strategy: Use the process of elimination. Identify the subject, vertigo. Note the relationship between vertigo and avoiding sudden head movements in the correct option. If you had difficulty with this question, review the measures that will reduce vertigo in the client with Ménière's disease. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1132-1133). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

1141) A nurse has admitted a client who has a diagnosis of syncope to a medical unit. The client is taking enalapril (Vasotec), atenolol (Tenormin), and acetylsalicylic acid (aspirin) daily. The client admits that the medications were prescribed by different physicians. The admitting physician has written in the client's order sheet, "Administer medications as taken at home." Which of the following is the appropriate action for the nurse to take? a. Administer the medications as ordered by the physician. b. Call the physician, describe the medications, and request order clarification. c. Refuse to give any medications, and wait until the physician makes rounds to clarify the orders. d. Send the client's medication bottles to the pharmacy for identification and then administer the medications as ordered. Source: Saunders 4th

ANS: B Rationale: The nurse is responsible for administering the correct medication. When medication orders are vague, the nurse must call the physician to clarify the orders before administering the medication. Waiting for the physician to make rounds delays needed treatment. Strategy: Use the process of elimination. Options 1 and 4 are comparative or alike in that they indicate administering the medication and are eliminated first. Eliminate option 3 next because it is not appropriate to wait to clarify an unclear physician's order. Review the procedures related to clarifying a physician's orders if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 32-33). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 419, 838, 843). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1521) The hospitalized client has begun taking bupropion (Wellbutrin) as an antidepressant agent. The nurse monitors this client for which adverse effect indicating that the client is taking an excessive amount of medication? a. Constipation b. Seizure activity c. Increased weight d. Dizziness when getting upright Source: Saunders 4th

ANS: B Rationale: The nurse monitors for signs of toxicity. Seizure activity is common in bupropion dosages higher than 450 mg daily. This medication does not cause significant orthostatic blood pressure changes. Weight gain is an occasional side effect, whereas constipation is a common side effect of this medication. Strategy: Use the process of elimination and note the strategic words adverse effect and excessive amount. These strategic words will direct you to option 2. Review this medication if you had difficulty with this question. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., p. 169). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1538) The registered nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? a. A client with bladder cancer who will be receiving chemotherapy b. A client on bed rest who requires range-of-motion (ROM) exercises every 4 hours c. A new diabetes mellitus client scheduled for discharge d. A client scheduled to receive a blood transfusion Source: Saunders 4th

ANS: B Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a nursing assistant would be to care for a client on bed rest who requires range-of-motion (ROM) exercises. The nursing assistant is trained in this procedure. The client receiving chemotherapy and the client receiving a blood transfusion require the assessment skills that a licensed nurse can perform. The client with diabetes mellitus who is being discharged will require predischarge review of diabetic management instructions and potentially coordination of necessary home care services. Strategy: Note the strategic words most appropriate in the question. Use the process of elimination and recall the principles of delegation and supervision of the work of others in answering the question. Work that is delegated to others must be done consistent with the individual&#39;s level of expertise and licensure or lack of licensure. Review the principles of delegation if you had difficulty with this question. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., pp. 551-552). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

161) The nurse has just received an order to transfuse a unit of packed red blood cells for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring? a. 5 minutes b. 15 minutes c. 30 minutes d. 45 minutes Source: Saunders 4th

ANS: B Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, which is usually when a transfusion reaction may occur. This enables the nurse to detect a reaction and intervene quickly. The nurse engages in safe nursing practice by obtaining coverage for the other assigned clients during this time. Options 1, 3, and 4 are incorrect. Strategy: Use the process of elimination and knowledge regarding blood transfusion procedures to answer this question. Remember, the client must be monitored directly for the first 15 minutes of the transfusion. Review the nursing responsibilities involved in beginning a blood transfusion if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 914). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1191). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

174) A nurse is preparing to initiate an intravenous line containing a high dose of potassium chloride and plans to use an intravenous infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. Which of the following is the appropriate nursing action? a. Initiate the intravenous line without the use of a pump. b. Contact the electrical maintenance department for assistance. c. Plug in the pump cord in the available plug above the room sink. d. Use an extension cord from the nurses' lounge for the pump plug. Source: Saunders 4th

ANS: B Rationale: The nurse needs to use hospital resources for assistance. A regular extension cord should not be used because it poses the risk of fire. The use of electrical appliances near a sink also presents a hazard. An intravenous line that contains a high dose of potassium chloride should be administered by the use of a pump. Strategy: Use the process of elimination. Noting the strategic words high dose in the question will assist in eliminating option 1. Recalling safety issues related to electrical hazards will assist in eliminating options 3 and 4. If you had difficulty with this question, review the interventions related to electrical safety. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 992-993). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2321) A client is seen in the health care clinic and a diagnosis of acute sinusitis is made. The nurse provides home care instructions to the client regarding measures that will promote sinus drainage and comfort. Which statement by the client indicates a need for further instruction? a. "I should apply heat, such as a wet pack, over the sinuses." b. "I should use a warm mist vaporizer to liquify secretions." c. "I should drink large amounts of fluids." d. "I should try to sleep with the head of the bed elevated." Source: Saunders 4th

ANS: B Rationale: The nurse provides instructions to the client regarding measures to promote sinus drainage, comfort, and resolution of the infection. The nurse instructs the client to apply heat in the form of wet packs over the affected sinuses to promote comfort and help resolve the infection. The client should be instructed to use a cool mist vaporizer to help liquify secretions and promote drainage. Consumption of large amounts of fluids is important to help liquify secretions. Sleeping with the head of the bed elevated to a 45-degree angle will assist in promoting drainage. Strategy: Note the strategic words indicates a need for further instruction and promote sinus drainage and comfort. Use the process of elimination, recalling that a cool mist will assist in liquifying secretions. If you had difficulty with this question, review client teaching points related to acute sinusitis. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 629). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

78) A 22-year-old adult has a cholesterol blood test done at a screening clinic sponsored by a local health club. The nurse volunteering at the screening teaches the client that diet and exercise should be used as health measures to keep the total cholesterol level below: a. 80 mg/dL b. 200 mg/dL c. 250 mg/dL d. 300 mg/dL Source: Saunders 4th

ANS: B Rationale: The nurse should counsel the client to keep the total cholesterol level under 200 mg/dL. This will aid in the prevention of atherosclerosis, which can lead to a number of cardiovascular disorders later in life. Options 3 and 4 are elevated values and place the client at risk for cardiovascular disease. Although option 1 is a low cholesterol level, option 2 identifies the realistic value to assist in preventing cardiovascular disease. Strategy: Recalling that the normal cholesterol level ranges from 140 to 199 mg/dL and noting the subject of the question will direct you to option 2. Because of the importance of the health problems caused by atherosclerosis and cardiovascular disease, review this laboratory test. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 369). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

113) A nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of the solution. The nurse takes which of the following actions? a. Rolls the bottle of solution gently b. Obtains a different bottle of solution c. Shakes the bottle of solution vigorously d. Runs the bottle of solution under warm water Source: Saunders 4th

ANS: B Rationale: The nurse should examine the bottle of fat emulsion for separation of emulsion into layers or fat globules or for the accumulation of froth. The nurse should not hang a fat emulsion if any of these are observed and should return the solution to the pharmacy. Options 1, 3, and 4 are inappropriate actions. Strategy: Use the process of elimination. Remember that options that are comparative or alike are not likely to be correct. With this in mind, eliminate options 1 and 3 first. Select between the remaining options by recalling the significance of fat globules in the solution. Also, think about the potential adverse effect of fat globules entering the client's bloodstream. Review the procedure for administering fat emulsion if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 intravenous medications (22nd ed., p. 540). St. Louis: Mosby. Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed., p. 863). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 989). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1943) A nurse is preparing to suction a client with a tracheostomy tube and gathers the supplies needed for the procedure. Which of the following is the initial nursing action? a. Set the suction pressure range at 150 mm Hg. b. Hyperoxygenate the client. c. Place the catheter into the tracheostomy tube. d. Apply suction on the catheter and insert it into the tracheostomy tube. Source: Saunders 4th

ANS: B Rationale: The nurse should hyperoxygenate the client both before and after suctioning. This would be the initial nursing action. The safe suction range for an adult client is 100 to 120 mm Hg. When the nurse advances the catheter into the tracheostomy tube, suction is not applied because applying suction at that time will cause mucosal trauma and aspiration of the client's oxygen. Strategy: Note the strategic word initial in the question. Attempt to visualize the suctioning procedure to assist in directing you to the correct option. Recalling that suctioning will remove oxygen from the client will assist in directing you to option 2. Also use the ABCs—airway, breathing, and circulation—to direct you to option 2. Review suctioning procedures if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 556-557). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1098, 1101-1108). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1431) The nurse is providing care to a client admitted to the hospital with a diagnosis of acute anxiety disorder. While conversing with the client, the client says to the nurse, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" The appropriate nursing response is which of the following? a. "No, I won't tell anyone." b. "I cannot promise to keep a secret." c. "If you tell me the secret, I will tell it to your doctor." d. "If you tell me the secret, I will need to document it in your record." Source: Saunders 4th

ANS: B Rationale: The nurse should never promise to keep a secret. Secrets are appropriate in a social relationship but not in a therapeutic one. The nurse needs to be honest with the client and tell the client that a promise cannot be made to keep the secret. Options 1, 3, and 4 are inappropriate responses. Strategy: Use the process of elimination. Option 1 can be eliminated easily because it is inappropriate. Options 3 and 4 are not only inappropriate but are also somewhat threatening and may even block further communication. Review therapeutic communication techniques and the nurse-client relationship if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 125, 130). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-34, 275). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1942) A nurse has assisted the physician and the anesthesiologist with placement of an endotracheal (ET) tube in a client in respiratory distress. Which of the following is the initial nursing action to evaluate proper ET tube placement? a. Ask the radiology department to obtain a stat portable radiograph at the client's bedside. b. Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds. c. Tape the ET tube in place and note the centimeter marking at the lip line. d. Attach the ET tube to the ventilator and determine if the client is able to tolerate the tidal volume prescribed. Source: Saunders 4th

ANS: B Rationale: The nurse verifies the placement of an ET tube immediately by ventilating the client using an Ambu bag and by auscultating for breath sounds bilaterally, which ensures ventilation of both lungs. After this initial assessment, placement is then checked radiographically. The nurse marks the ET tube at the point where it enters the nose or mouth for ongoing monitoring of correct placement, but this will not determine initial adequate placement of the ET tube. Noting the tidal volume and the client's toleration of the tidal volume prescribed is not a measure of appropriate ET tube placement. Strategy: Note the strategic word initial in the question. Use the process of elimination, visualizing each of the options to assist in determining the correct option. Also, use the ABCs—airway, breathing, and circulation—to assist in directing you to option 2. If you had difficulty with this question, review care of the client after ET tube placement. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1883). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1027) A nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which of the following items when performing this care? a. Surgical mask and gloves b. Particulate respirator, gown, and gloves c. Particulate respirator and protective eyewear d. Surgical mask, gown, and protective eyewear Source: Saunders 4th

ANS: B Rationale: The nurse who is in contact with a client with tuberculosis should wear an individually fitted particulate respirator. The nurse also would wear gloves as per standard precautions. The nurse wears a gown when the possibility exists that the clothing could become contaminated, such as when giving a bed bath. Strategy: Use the process of elimination. Knowing that the nurse should wear a particulate respirator eliminates options 1 and 4. Knowledge of basic standard precautions directs you to option 2 from the remaining options. Review precautions related to the care of a client with tuberculosis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 644). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1645) The nurse instructs the client in breast self-examination (BSE). The nurse tells the client to lie down and to examine the left breast. The nurse instructs the client that while examining the left breast, she should place a pillow under the: a. Right shoulder. b. Left shoulder. c. Small of the back. d. Right scapula. Source: Saunders 4th

ANS: B Rationale: The nurse would instruct the client to lie down and place a towel or pillow under the shoulder on the side of the breast to be examined. If the left breast is to be examined, the pillow would be placed under the left shoulder. Strategy: Use the process of elimination. Attempt to visualize this procedure to select the correct option. Remember to examine the left breast, the pillow is placed under the left breast; to examine the right breast, the pillow is placed under the right breast. If you are unfamiliar with the procedure for performing breast self-examination (BSE), review this important self-examination. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1797-1798). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 736-737). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

935) The client has been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse is assessing the client's pain. What type of pain is consistent with this diagnosis? a. Burning and aching, located in the left lower quadrant and radiating to the hip b. Severe and unrelenting, located in the epigastric area and radiating to the back c. Burning and aching, located in the epigastric area and radiating to the umbilicus d. Severe and unrelenting, located in the left lower quadrant and radiating to the groin Source: Saunders 4th

ANS: B Rationale: The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back. The other options are incorrect. Strategy: Use the process of elimination. Noting the strategic word acute will assist in eliminating options 1 and 3. From the remaining options, recalling the anatomical location of the pancreas will direct you to option 2. Review the manifestations in acute pancreatitis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1405). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1838) A nurse is performing an assessment on a client with acute pancreatitis who was admitted to the hospital. Which of the following assessment questions would most specifically elicit information regarding the pain that is associated with acute pancreatitis? a. "Does the pain in your lower abdomen radiate to your groin?" b. "Does the pain in your stomach radiate to the back?" c. "Does the pain in your stomach radiate to your lower middle abdomen?" d. "Does the pain in your lower abdomen radiate to the hip?" Source: Saunders 4th

ANS: B Rationale: The pain that is associated with acute pancreatitis is often severe and is located in the epigastric region and radiates to the back. Options 1, 3, and 4 are incorrect because they are not specific for the pain experienced by the client with pancreatitis. Strategy: Use the process of elimination. Think about the anatomical location of the pancreas and recall that this type of pain radiates to the back. This will direct you to option 2. This characteristic also makes it easier to distinguish this pain from other gastrointestinal disorders. If you had difficulty with this question, review the manifestations of acute pancreatitis. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1405). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1294) The client with Parkinson's disease has a nursing diagnosis of Falls, Risk for related to an abnormal gait documented in the nursing care plan. The nurse assesses the client, expecting to observe which type of gait? a. Unsteady and staggering b. Shuffling and propulsive c. Broad-based and waddling d. Accelerating with walking on the toes Source: Saunders 4th

ANS: B Rationale: The parkinsonian gait is characterized by short, accelerating, shuffling steps. The client leans forward with the head, hips, and knees flexed, and has difficulty starting and stopping. A dystrophic gait is broad-based and waddling. A festinating gait is accelerating with walking on the toes. An ataxic gait is staggering and unsteady. Strategy: Use the process of elimination. Recall that the client has difficulty in initiating movement and bradykinesia. The gait is difficult to start, but it accelerates once it has begun. This will assist in eliminating options 1 and 3. From the remaining options, recall that the client with Parkinson's disease shuffles but does not walk on the toes. Review the characteristics associated with Parkinson's disease if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2172). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 960). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2583) A nurse is performing a neurological assessment on a client with a head injury. The nurse should assess the plantar reflex by: a. Using a tongue depressor and stimulating the back of the throat b. Stroking the foot from the heel to the toe c. Directing a flashlight onto the pupils of the eyes d. Gently inserting a gloved finger in the rectum Source: Saunders 4th

ANS: B Rationale: The plantar reflex is assessed by stroking the outer plantar surface of the foot from the heel to the toe. The pharyngeal (gag) reflex is tested by touching the back of the throat with an object such as a tongue depressor. Pupillary response is tested using a flashlight. The anal reflex is assessed by stimulating the perianal area or by gently inserting a gloved finger in the rectum. A positive response to each of these reflexes is considered normal. Strategy: Use the process of elimination. Focus on the strategic word plantar in the question. Recall the anatomical location of the plantar surface to direct you to option 2. Review this reflex if you are unfamiliar with this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2034). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2403) A nurse is writing out discharge instructions for the parents of a child diagnosed with celiac disease. The nurse should focus primarily on which of the following aspects of care? a. Restricting activity b. Following a gluten-free diet c. Following a lactose-free diet d. Giving medication to manage the condition Source: Saunders 4th

ANS: B Rationale: The primary nursing consideration in the care of a child with celiac disease is to instruct the child and parents regarding proper dietary management. Although medications may be prescribed for the client with celiac disease, treatment focuses primarily on maintaining a gluten-free diet. Options 1, 3, and 4 are not directly related to the care of a child with celiac disease. Strategy: Focus on the subject of the question, celiac disease. Recalling the relationship between celiac disease and dietary gluten will direct you to option 2. Review this disorder if you had difficulty with this question. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., p. 1422). St. Louis: Mosby. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 886). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

958) A client with Crohn's disease is scheduled to receive an infusion of infliximab (Remicade). What intervention by the nurse will determine the effectiveness of treatment? a. Carrying out a Hematest on gastric fluids after the infusion is completed b. Checking the frequency and consistency of bowel movements c. Monitoring the leukocyte count for 2 days after the infusion d. Checking serum liver enzyme levels before and after the infusion Source: Saunders 4th

ANS: B Rationale: The principle manifestations of Crohn's disease are diarrhea and abdominal pain. Infliximab (Remicade) is an immunomodulator that reduces the degree of inflammation in the colon, thereby reducing the diarrhea. Options 1, 3, and 4 are unrelated to this medication. Strategy: Focus on the client's diagnosis, Crohn's disease. Eliminate option 1 because gastric bleeding is not a characteristic of Crohn's disease. Monitoring the leukocyte count and liver enzyme levels is appropriate when infliximab (Remicade) is given but not to evaluate the effectiveness of treatment, eliminating options 3 and 4. Review the manifestations of Crohn's disease and the actions of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 618-619). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1506) A client is admitted to the hospital with a nursing diagnosis of Grieving, dysfunctional related to the loss of a spouse. The client progresses well and is approaching discharge. Which of the following is an appropriate outcome for this nursing diagnosis? a. The client reports three additional coping strategies. b. The client verbalizes stages of grief and plans to attend a community grief group. c. The client verbalizes connections between significant losses and low self-esteem. d. The client verbalizes decreased desire for self-harm and discusses two alternatives to suicide. Source: Saunders 4th

ANS: B Rationale: The question is focused on the nursing diagnosis of Grieving, dysfunctional. The only option that deals with grief is option 2. Options 1, 3, and 4 are unrelated to this nursing diagnosis. Strategy: When presented with a question that identifies a nursing diagnosis, use the information in the question to assist in directing you to the correct option. Option 2 is the only option that is focused on the nursing diagnosis of Grieving, dysfunctional. Additionally, note the word grieving in the question and the word grief in the correct option. Review expected outcomes for the client experiencing dysfunctional grieving if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 331, 786-787). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

175) A nurse obtains an order from a physician to restrain a client by using a jacket restraint and instructs a nursing assistant to apply the restraint to the client. Which observation by the nurse indicates inappropriate application of the restraint by the nursing assistant? a. A safety knot in the restraint straps b. Restraint straps that are safely secured to the side rails c. Jacket restraint straps that do not tighten when force is applied against them d. Jacket restraint secured so that two fingers can slide easily between the restraint and the client's skin Source: Saunders 4th

ANS: B Rationale: The restraint straps are secured to the bed frame and never to the side rail to avoid accidental injury in the event that the side rail is released. A half-bow or safety knot should be used for applying a restraint because it does not tighten when force is applied against it and it allows quick and easy removal of the restraint in case of an emergency. The jacket restraint should be secure, and one to two fingers should slide easily between the restraint and the client's skin. Strategy: Use the process of elimination and note the strategic words indicates inappropriate application. These words indicate a negative event query and ask you to select an option that is an incorrect observation. This indicates that you are looking for an option that identifies an inaccurate measure related to the application of restraints. Read each option carefully. The words secured to the side rails in option 2 should direct your attention to this as an inappropriate action. Review guidelines related to the application of restraints if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 44-45). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1398) The home care nurse is assigned to visit a client who has returned home from the emergency room following treatment for a sprained ankle. The nurse notes that the client was sent home with crutches that have rubber axillary pads and needs instructions regarding crutch walking. On admission assessment, the nurse discovers that the client has an allergy to latex. Before providing instructions regarding crutch walking, the nurse should: a. Contact the physician. b. Cover the crutch pads with cloth. c. Call the local medical supply store and ask for a cane to be delivered. d. Tell the client that the crutches must be removed from the house immediately. Source: Saunders 4th

ANS: B Rationale: The rubber pads used on crutches may contain latex. If the client requires the use of crutches, the nurse can cover the pads with a cloth to prevent cutaneous contact. Option 4 is inappropriate and may alarm the client. The nurse cannot order a cane for a client. Additionally, this type of assistive device may not be appropriate, considering this client's injury. No reason exists to contact the physician at this time. Strategy: Use the process of elimination and knowledge about alternative resources for a client with a latex allergy. No data in the question support the need to contact the physician. The nurse should not prescribe assistive devices for the client. Option 4 is not a therapeutic action. Review care of the client with a latex allergy if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills and techniques (6th ed., pp. 218, 291). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1622). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

2157) A client has just had a cast removed, and the underlying skin is yellow-brown and crusted. The nurse gives the client instructions for skin care. The nurse determines that the client has misunderstood the directions if the client states to: a. Soak the skin and wash it gently. b. Scrub the skin vigorously with soap and water. c. Apply an emollient lotion to enhance softening. d. Use a sunscreen on the skin if exposed to the sun for a period of time. Source: Saunders 4th

ANS: B Rationale: The skin under a casted area may be discolored and crusted with dead skin layers. The client should gently soak and wash the skin for the first few days. The skin should be patted dry, and a lubricating lotion should be applied. Clients often want to scrub the dead skin away, which irritates the skin. The client should avoid overexposing the skin to the sunlight. Strategy: Use the process of elimination and note the strategic word misunderstood. The word vigorously in option 2 should direct you to this option as the answer to this question. Review client instructions regarding skin care after removal of a cast if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1205). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

120) A nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition (PN) bag of an assigned client is empty. Which of the following solutions readily available on the nursing unit should the nurse hang until another PN solution is mixed and delivered to the nursing unit? a. 5% dextrose in water b. 10% dextrose in water c. 5% dextrose in Ringer's lactate d. 5% dextrose in 0.9% sodium chloride Source: Saunders 4th

ANS: B Rationale: The solution containing the highest amount of glucose should be hung until the new PN solution becomes available. Because PN solutions contain high glucose concentrations, the 10% dextrose in water solution is the best of the choices presented. The solution selected should be one that minimizes the risk of hypoglycemia. Options 1, 3, and 4 will not be as effective in minimizing the risk of hypoglycemia. Strategy: Use the process of elimination, recalling that this particular client is at risk for hypoglycemia. With this in mind, you would then select the solution that minimizes this risk to the client. Also, remember that options that are comparative or alike are not likely to be correct. Each of the incorrect options represents a solution that contains 5% dextrose. Review the nursing actions to prevent hypoglycemia in the client receiving PN if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 intravenous medications (22nd ed., p. 1056). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1949) A clinic nurse is performing an assessment on a client who is complaining of shortness of breath. The client tells the nurse that he is a cigarette smoker and admits to smoking one pack of cigarettes per day for the past 10 years. The nurse determines that the client has a smoking history of how many pack-years? a. 7.5 b. 10 c. 15 d. 20 Source: Saunders 4th

ANS: B Rationale: The standard method for quantifying the smoking history is to multiply the number of packs smoked per day by the number of years of smoking. The number is then recorded as the number of pack-years. The calculation for the number of pack-years for the client in this question who smokes 1 pack per day for 10 years is 1 pack × 10 years = 10 pack-years. Strategy: Knowledge regarding history taking related to smoking and knowledge of the formula for determining the pack-years is required to answer this question. Remember to multiply the number of packs smoked per day by the number of years of smoking. Review this formula if you are unfamiliar with it. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 524). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2383) A nurse notes that a newly determined phenytoin level for a client receiving phenytoin (Dilantin) is 7 mcg/mL. The nurse makes which of the following interpretations regarding this laboratory result? a. The level is within the expected therapeutic range. b. The level is lower than the expected therapeutic range. c. The level is higher than the expected therapeutic range. d. The level indicates the medication should be stopped. Source: Saunders 4th

ANS: B Rationale: The target range for a therapeutic serum level of phenytoin is between 10 and 20 mcg/mL. Levels below 10 mcg/mL are too low to control seizures. At levels above 20 mcg/mL, signs of toxicity begin to appear. This client has a low serum level, and the dosage is likely to be increased. Strategy: Knowing that the therapeutic medication range of phenytoin is between 10 and 20 mcg/mL will assist in directing you to the correct option. If you are unfamiliar with this medication and the therapeutic phenytoin level, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 930). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1147) A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin sodium (Coumadin). The client's prothrombin time is 20 seconds, with a control of 11 seconds. How would the nurse interpret these results? a. Client needs to have test repeated. b. Client results are within the therapeutic range. c. Client results are higher than the therapeutic range. d. Client results are lower than the needed therapeutic level. Source: Saunders 4th

ANS: B Rationale: The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at high risk for thrombus. Based on the client's control value, the therapeutic range for this individual would be 16.5 to 22 seconds. Therefore the result is within the therapeutic range. Strategy: Use the process of elimination. Look at the control value. Remembering that the purpose of anticoagulant therapy is to prolong clotting times will assist in eliminating options 3 and 4. Eliminate option 1, because there is no basis for repeating the test. Because the prothrombin value identified in the question is not even double the control, select option 2 from the remaining options. Review the therapeutic prothrombin level for a client at risk for pulmonary embolism if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 920). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1319) The client is taking phenytoin (Dilantin) for seizure control. A sample is drawn to determine the serum drug level, and the nurse reviews the results. Which of the following would indicate a therapeutic serum drug range? a. 5 to 10 mcg/mL b. 10 to 20 mcg/mL c. 20 to 30 mcg/mL d. 30 to 40 mcg/mL Source: Saunders 4th

ANS: B Rationale: The therapeutic serum drug level range for phenytoin is 10 to 20 mcg/mL. Strategy: Use the process of elimination. A helpful Pyramid Point is to remember that the theophylline therapeutic range and the acetaminophen therapeutic range are the same as the phenytoin therapeutic range. Remembering this may assist you when answering questions related to these three medications. Review this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 930). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2125) A nurse is planning to administer furosemide (Lasix) 40 mg by IVP (intravenous push) through an existing line. In order to deliver this medication safely, the nurse must: a. Pinch the IV tubing below the injection port and inject slowly over 1 to 2 minutes. b. Pinch the tubing above the injection port and inject slowly over 1 to 2 minutes. c. Give the medication rapidly over 10 seconds. d. Give the medication slowly diluted in 100 mL of 5% dextrose in water. Source: Saunders 4th

ANS: B Rationale: The tubing must be pinched above the injection port so that the medication does not go back up the tubing. Most IVP medications should be injected slowly. Considering the need for and action of the medication, it is not diluted unless prescribed. Strategy: Use the process of elimination. Eliminate option 3 because of the word rapidly. Eliminate option 4, considering the action of the medication. It does not make sense to add additional fluid when a diuretic is administered. Regarding the remaining options, visualize the administration of the medication through the IV tubing. Pinching the tubing below the injection port would prevent the medication reaching the client and instead force it back up the tubing. Review the procedure for administering furosemide by IVP if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., pp. 588-589). St. Louis: Mosby. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 920). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 440). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

154) The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with: a. An air vent. b. An in-line filter. c. A microdrip chamber. d. Tinted tubing to protect the blood from light. Source: Saunders 4th

ANS: B Rationale: The tubing used for blood administration has an in-line filter. The filter helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the client. The tubing should be macrodrip, not microdrip, to allow blood to flow freely through the drip chamber. An air vent is unnecessary because the blood bag is not made of glass. Option 4 is incorrect and, in addition, blood does not need to be protected from light. Strategy: Use the process of elimination. Read each option carefully and visualize the process of blood administration. Remember that tubing used for blood administration has an in-line filter. Review concepts related to tubing used for blood administration if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 913-914). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1191). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1939) A client with chronic renal failure is about to begin hemodialysis therapy. The client asks the nurse about the frequency and scheduling of hemodialysis treatments. The nurse's response is based on an understanding that the typical schedule is: a. 5 hours of treatment 2 days per week b. 3 to 4 hours of treatment 3 days per week c. 2 to 3 hours of treatment 5 days per week d. 2 hours of treatment 6 days per week Source: Saunders 4th

ANS: B Rationale: The typical schedule for hemodialysis is 3 to 4 hours of treatment three days per week. Individual adjustments may be made according to variables such as the size of the client, type of dialyzer, the rate of blood flow, personal client preferences, and others. Strategy: Knowledge regarding the typical schedule for hemodialysis is required to answer this question. Remember that the typical schedule if 3 to 4 hours of treatment 3 days per week. If you are unfamiliar with this procedure, review this information. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 961). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1984) Ticlopidine (Ticlid) is prescribed for a client. The nurse plans to take which of the following actions before implementing this medication therapy? a. Taking the client's blood pressure b. Obtaining a prothrombin time (PT) c. Reviewing the results of the complete blood cell (CBC) count d. Taking the client's apical heart rate Source: Saunders 4th

ANS: C Rationale: Ticlopidine (Ticlid) is an antiplatelet that is used for the prevention of thrombotic stroke. Ticlopidine's effects last for the life of the platelet, 7 to 10 days. Ticlopidine also can cause neutropenia, which is an abnormally small number of mature white blood cell (WBCs). Baseline data from a CBC are necessary before implementation of therapy, and the nurse should monitor for neutropenia during this medication therapy. If this adverse effect does occur, therapy should be ceased. The effects of neutropenia are reversible within 1 to 3 weeks. Options 1, 2, and 4 are actions that are not specific to this medication therapy. Strategy: Use the process of elimination. Recalling that this medication is an antiplatelet and affects the WBCs will direct you to option 3. Review the action and effects of this medication if you are unfamiliar with this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1130). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2299) A nurse is administering mouth care to an unconscious client. The nurse should avoid doing which of the following? a. Positioning the client on the side b. Using products that contain lemon or alcohol c. Cleansing the mucous membranes with soft sponges d. Brushing the teeth with a small toothbrush Source: Saunders 4th

ANS: B Rationale: The unconscious client is positioned on the side during mouth care to prevent aspiration. The teeth are brushed at least twice daily using a small toothbrush. The gums, tongue, roof of the mouth, and oral mucous membranes are cleansed with soft sponges to avoid encrustation and infection. The lips are coated with water-soluble lubricant to prevent drying, cracking, and encrustation. The use of products with lemon or alcohol should be avoided because they have a drying effect. Strategy: Use the process of elimination and note the strategic word avoid. This indicates a negative event query and asks you to select an incorrect action. Standard mouth care procedures include use of a toothbrush and soft sponges, so these may eliminated first. Knowing that the unconscious client is at risk of aspiration tells you that option 1 also is correct. This leaves option 2 as incorrect, because repeated use of these products could dry and crack the oral mucous membranes. Review the procedure for administering mouth care to an unconscious client if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2060). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1795) The nursing student is asked to describe the corpus of the uterus. Which of the following responses, if made by the student, indicates an understanding of the anatomy of the uterus? a. "It is the lower portion of the uterus." b. "It is the uppermost part of the uterus." c. "It is the area where the cervix meets the external os." d. "It is the area where the vagina meets the uterus." Source: Saunders 4th

ANS: B Rationale: The uterus has three divisions, the corpus, isthmus, and cervix. The upper division is the corpus or body of the uterus. The uppermost part of the uterine corpus, above the area where the fallopian tubes enter the uterus, is the fundus of the uterus. Options 1, 3, and 4 are incorrect. Strategy: Use the process of elimination. Knowledge regarding the divisions of the uterus is required to answer this question. Remember that the upper division is the corpus or body of the uterus. If you had difficulty with this question, review the anatomical structure of the uterus. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 58). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

985) An emergency room nurse is assessing a client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? a. A low respiratory rate b. Diminished breath sounds c. The presence of a barrel chest d. A sucking sound at the site of injury Source: Saunders 4th

ANS: B Rationale: This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury. Strategy: Use the process of elimination and note the strategic word blunt in the question. This will assist in eliminating option 4, sucking chest wound injury. Knowing that in a respiratory injury increased respirations will occur will assist you in eliminating option 1. Option 3 can be eliminated because a barrel chest is a characteristic finding in a client with chronic obstructive pulmonary disease. Review the signs of pneumothorax if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 670-671). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1133) A client is admitted to a medical unit with nausea and bradycardia. The family hands a nurse a small white envelope labeled "heart pill." The envelope is sent to the pharmacy and it is found to be digoxin (Lanoxin). A family member states, "That doctor doesn't know how to take care of my family." Which of the following statements would convey a therapeutic response by the nurse? a. "Don't worry about this. I'll take care of everything." b. "You are concerned your loved one receives the best care." c. "You're right! I've never seen a doctor put pills in an envelope." d. "I think you're wrong. That physician has been in practice over 30 years." Source: Saunders 4th

ANS: B Rationale: This is a therapeutic, nonjudgmental response. The statement reflects the family's concern but remains nonjudgmental. Option 1 dismisses the family's concerns and disempowers the family. Option 3 creates doubt about the physician's practice without actually knowing the circumstances. Option 4 is argumentative and nontherapeutic. Strategy: Use therapeutic communication techniques. Reflection of the client's or family's concerns is the most therapeutic. Review these techniques if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 356-357). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 437). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2605) A client with acquired immunodeficiency syndrome (AIDS) is receiving didanosine (Videx). The nurse reviewing the client's laboratory test results should most closely monitor serum levels of: a. Cholesterol b. Amylase c. Glucose d. Protein Source: Saunders 4th

ANS: B Rationale: This medication is toxic to both the pancreas and the liver. A serum amylase level that is increased 1.5 to 2 times normal may signify pancreatitis and may be potentially fatal in the client with AIDS. Therefore, the nurse monitors the results of amylase and liver function studies closely. Options 1, 3, and 4 are unrelated to this medication. Strategy: Use the process of elimination. Recalling that this medication affects the pancreas and liver will easily direct you to option 2. Review the adverse affects of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 264). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1153) A client is admitted to a hospital with acute myocardial infarction and is started on tissue plasminogen activator (tPA, Activase) by infusion. Of the following parameters, which one would a nurse determine requires the least frequent assessment to detect complications of therapy with tissue plasminogen activator? a. Neurological signs b. Presence of bowel sounds c. Blood pressure and pulse d. Complaints of abdominal and back pain Source: Saunders 4th

ANS: B Rationale: Thrombolytic agents dissolve existing clots, and bleeding can occur anywhere in the body. The nurse monitors for any obvious signs of bleeding and also for occult signs of bleeding, which would include hemoglobin and hematocrit values, blood pressure and pulse, neurological signs, assessment of abdominal and back pain, and the presence of blood in the urine or stool. Strategy: Note the strategic words least frequent assessment. Remember that bleeding is the primary complication of thrombolytic therapy. Therefore, look for the option that is not related to bleeding. A change in neurological signs could indicate cerebral bleeding, abdominal and back pain could indicate abdominal bleeding, and change in blood pressure and pulse could be general indicators of hemorrhage. The presence of bowel sounds is unrelated to this medication. Review nursing considerations for the client receiving tissue plasminogen activator if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 850). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

1985) Ticlopidine (Ticlid) has been prescribed for a client with a diagnosis of thrombotic stroke. The nurse provides instructions to the client and spouse regarding the medication. Which of the following statements if made by the client indicates that the client understands the use of this medication? a. "If I have any gastrointestinal (GI) side effects, I should call the doctor." b. "I'll take the medicine with meals." c. "I won't have another stroke if I take this medicine faithfully." d. "If I do not feel well, I should skip the medication." Source: Saunders 4th

ANS: B Rationale: Ticlopidine is an antiplatelet that is used to assist in preventing a thrombotic stroke. Ticlopidine is best tolerated when taken with meals. The most common adverse effects are GI disturbances. Taking ticlopidine with meals tends to lessen those effects. It is not necessary to contact the physician if GI upset occurs. The medication is used to prevent strokes but does not guarantee that a stroke will not occur. The client should not skip medications. Strategy: Use the process of elimination. Eliminate options 3 and 4 first, knowing that the medication will not guarantee that a stroke will not occur and knowing that the client should not skip medications. Recalling that GI upset can occur with many medications and is lessened if taken with meals will assist in directing you to option 2 from the remaining options. Review this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1130). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1131) A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase (Activase, tPA). Which of the following is a priority nursing intervention? a. Monitor for renal failure. b. Monitor psychosocial status. c. Monitor for signs of bleeding. d. Have heparin sodium available. Source: Saunders 4th

ANS: C Rationale: Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding. Monitoring for renal failure and monitoring the client's psychosocial status are important but are not the most critical interventions. Heparin is given after thrombolytic therapy, but the question is not asking about follow-up medications. Strategy: Use the process of elimination and note the strategic word priority. Remember, bleeding is a priority. Review care of the client on tissue plasminogen activator if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 31). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

2453) A nurse is reviewing the ventilator settings on a client with an endotracheal tube attached to mechanical ventilation. The nurse notes that the tidal volume is set at 700 mL and determines that the tidal volume indicates: a. The number of breaths that the client will receive per minute by the ventilator b. The amount of air delivered with each set breath c. The fraction of inspired oxygen (F<SC>IO</SC> ₂) that is delivered to the client through the ventilator d. A breath that has a greater volume than the preset tidal volume Source: Saunders 4th

ANS: B Rationale: Tidal volume is the amount of air delivered with each set breath on the mechanical ventilator. The respiratory rate is the number of breaths to be delivered by the ventilator. The fraction of inspired oxygen delivered to the client is indicated by the F<SC>IO</SC> ₂ indicator on the ventilator. A sigh is a breath that has a greater volume than the preset tidal volume. Strategy: Use the process of elimination and focus on the subject, tidal volume. Recalling the definition of this basic respiratory concept will direct you to option 2. If you had difficulty with this question, review the description of tidal volume. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 664). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1226) The client is diagnosed with a disorder involving the inner ear. Which of the following is the most common client complaint associated with a disorder involving this part of the ear? a. Pruritus b. Tinnitus c. Hearing loss d. Burning in the ear Source: Saunders 4th

ANS: B Rationale: Tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client's thinking process and attention span. Options 1, 3, and 4 are not associated specifically with disorders of the inner ear. Strategy: Use the process of elimination. Recalling the function of the inner ear will direct you to option 2. Review the manifestations associated with an inner ear disorder if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1973-1974). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

1607) The nurse is assigned to care for a client who is in traction. The nurse prepares a plan of care for the client and includes which nursing action in the plan? a. Monitor the weights to be sure that they are resting on a firm surface. b. Check the weights to be sure that they are off of the floor. c. Make sure that the knots are at the pulleys. d. Make sure the head of the bed is kept at a 45- to 90-degree angle Source: Saunders 4th

ANS: B Rationale: To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. Weights are not to be kept resting on a firm surface. The head of the bed is usually kept low to provide countertraction. Strategy: Use the process of elimination. Attempt to visualize the traction, recalling that there must be weight to exert the pull from the traction setup. This concept will assist in eliminating options 1 and 3. Recalling that countertraction is needed will assist in eliminating option 4. Review care of the client in traction if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 637). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1201). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1890) A nursing student is assigned to care for a client in the postpartum unit. The coassigned nurse asks the student to identify the most objective method to assess the amount of lochial flow in the client. Which of the following statements if made by the student indicates an understanding of this method? a. "I can estimate the amount of blood loss by gauging the amount of staining on a perineal pad." b. "I should weigh the perineal pad before and after use and note the amount of time between each pad change." c. " I should ask the client to keep a record and to document every time the perineal pad is changed." d. "I can look at the perineal pad and gauge the amount of staining and relate it to the amount of time between pad changes." Source: Saunders 4th

ANS: B Rationale: To gather accurate data for comparison, the perineal pads must be weighed both before and after use. Once these weights are gathered, the amount of lochia flow can be accurately determined. Noting the time frame between pad changes also is an important factor. Gauging the amount of staining does not provide accurate data. Asking the client to obtain the data also may not provide accurate data. Strategy: Use the process of elimination. Focus on the strategic words most objective method. Eliminate option 3 first because this option relies on the client's interpretation of the amount of lochial flow. Next, eliminate options 1 and 4 because gauging an amount of lochial flow does not provide accurate data. Review postpartum assessment of lochial flow if you had difficulty with this question. Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & woman's health care (8th ed., p. 619) St. Louis: Mosby. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 395). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

1132) A home health nurse instructs a client about the use of a nitrate patch. The nurse tells the client that which of the following will prevent client tolerance to nitrates? a. "Do not remove the patches." b. "Have a 12-hour 'no-nitrate' time." c. "Have a 24-hour 'no-nitrate' time." d. "Keep nitrates on 24 hours, then off 24 hours." Source: Saunders 4th

ANS: B Rationale: To help prevent tolerance, clients need a 12-hour "no-nitrate" time, sometimes referred to as a pharmacological vacation away from the medication. Options 1, 3, and 4 are incorrect. Strategy: Use the process of elimination, focusing on the subject, preventing tolerance to nitrates. This subject and knowledge regarding administering this medication will direct you to option 2. Review the administration of nitrate patches if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 842). Philadelphia: W.B. Saunders. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 613). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2112) A nurse is teaching a paraplegic client measures to maintain skin integrity. Which of the following instructions will be least helpful to the client? a. Shifting weight every 2 hours while in a wheelchair b. Using a mirror to inspect for redness and breakdown twice a week c. Checking the bottom sheet for wetness and wrinkles d. Using a pressure relief pad while in a wheelchair Source: Saunders 4th

ANS: B Rationale: To maintain skin integrity, the paraplegic client should shift weight in the wheelchair every 2 hours and use a pressure relief pad. While the client is in bed, the bottom sheet should be free of wrinkles and wetness. The client should use a mirror to inspect the skin twice a day (morning and evening) to assess for redness, edema, and breakdown. General additional measures include a nutritious diet and meticulous skin care. Strategy: Use the process of elimination, noting the strategic words least helpful. Note that the time frame for inspecting the skin is much too infrequent, making this the correct option to the question as stated. Review care of the paraplegic client if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2224). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1005) A nurse is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate obtaining the specimen? a. Limiting fluids b. Having the client take three deep breaths c. Asking the client to spit into the collection container d. Asking the client to obtain the specimen after eating Source: Saunders 4th

ANS: B Rationale: To obtain a sputum specimen, the client should rinse the mouth to reduce contamination, breathe deeply, and then cough into a sputum specimen container. The client should be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning. Strategy: Use the process of elimination. Option 1 can be eliminated first because general principles indicate that fluids assist in loosening or thinning secretions. Eliminate option 3 because of the word spit. Spit is different from sputum. Next, eliminate option 4 because of the words after eating. Review this procedure if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., pp. 1018-1019). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1729) A sexually active 20-year-old client has developed viral hepatitis. Which of the following statements, if made by the client, would indicate a need for further teaching? a. "A condom should be used for sexual intercourse." b. "I can never drink alcohol again." c. "I won't go back to work right away." d. "My close friends should get the vaccine." Source: Saunders 4th

ANS: B Rationale: To prevent transmission of hepatitis, a condom is advised during sexual intercourse, as well as vaccination of the partner. Alcohol should be avoided for 1 year because it is detoxified in the liver and may interfere with recovery. Rest is especially important until laboratory studies show that liver function has returned to normal. The client's activity is increased gradually. Strategy: Use the process of elimination, focusing on the strategic words need for further teaching. These words indicate a negative event query and ask you to select an option that is incorrect. Noting the strategic word never in option 2 will direct you to this option. Review client instructions regarding hepatitis if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1114). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1253) Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse analyzes the test results as documented in the client's chart and understands that normal intraocular pressure is: a. 2 to 7 mm Hg b. 10 to 21 mm Hg c. 22 to 30 mm Hg d. 31 to 35 mm Hg Source: Saunders 4th

ANS: B Rationale: Tonometry is the method of measuring intraocular fluid pressure using a calibrated instrument that indents or flattens the corneal apex. Pressures between 10 and 21 mm Hg are considered within the normal range. Strategy: Use the process of elimination and knowledge regarding normal intraocular pressure to answer this question. Remember that normal intraocular pressure is between 10 and 21 mm Hg. If you had difficulty with this question, learn this normal value. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1080-1081). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1193) The client with benign prostatic hyperplasia undergoes a transurethral resection of the prostate. Postoperatively, the client is receiving continuous bladder irrigations. The nurse assesses the client for signs of transurethral resection syndrome. Which of the following assessment data would indicate the onset of this syndrome? a. Tachycardia and diarrhea b. Bradycardia and confusion c. Increased urinary output and anemia d. Decreased urinary output and bladder spasms Source: Saunders 4th

ANS: B Rationale: Transurethral resection syndrome is caused by increased absorption of nonelectrolyte irrigating fluid used during surgery. The client may show signs of cerebral edema and increased intracranial pressure, such as increased blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual disturbances, and nausea and vomiting. Strategy: Use the process of elimination. Recalling that increased intracranial pressure is the concern in this syndrome will direct you to option 2. Review the clinical manifestations of this disorder if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1020). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1237) The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention is initiated immediately? a. Notify the physician. b. Apply ice to the affected eye. c. Irrigate the eye with cool water. d. Accompany the client to the emergency room. Source: Saunders 4th

ANS: B Rationale: Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by a physician and receive a thorough eye examination to rule out the presence of other eye injuries. Strategy: Use the process of elimination. Focus on the strategic word immediately. Recalling the principles related to initial treatment of injuries will direct you to option 2. Review emergency treatment of eye injuries if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1105). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

2179) A client is taking trihexyphenidyl (Artane) for the treatment of Parkinson's disease. The nurse should assess for which of the following as an adverse effect of this medication? a. Urinary incontinence b. Urinary retention c. Diarrhea d. Excessive perspiration Source: Saunders 4th

ANS: B Rationale: Trihexyphenidyl is an anticholinergic medication. Thus, it can cause urinary hesitancy and retention, constipation, dry mouth, and decreased sweating. Strategy: The key to answering this question lies in knowing that this medication has an anticholinergic action. Recalling the effects of an anticholinergic will direct you to option 2. Review the adverse effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1179). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1204) Trimethoprim-sulfamethoxazole (TMP-SMZ; Bactrim) is prescribed to be administered by intravenous infusion to a client with a recurrent urinary tract infection. A nurse would administer this medication: a. Over 30 minutes b. Over 60 to 90 minutes c. Piggybacked into the peripheral line containing parenteral nutrition d. Piggybacked into the existing infusion of normal saline and potassium chloride Source: Saunders 4th

ANS: B Rationale: Trimethoprim (TMP)-sulfamethoxazole (SMX) (Bactrim) may be administered by intravenous infusion but should not be mixed with any other medications or solutions. Trimethoprim-sulfamethoxazole is infused over 60 to 90 minutes, and bolus infusions or rapid infusions must be avoided. Strategy: Use the process of elimination. Eliminate options 3 and 4 because they address the issue of mixing the trimethoprim-sulfamethoxazole with other solutions. From the remaining options, option 2 identifies the longer time frame and is the safe and correct choice. Review administration of this medication by intravenous infusion if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 intravenous medications (22nd ed., p. 1136). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1727) The client with tuberculosis (TB) asks the nurse about precautions to take after discharge to prevent infection of others. The nurse develops a response to the client's question based on the understanding that: a. The client should maintain enteric precautions only. b. The disease is transmitted by droplet nuclei. c. Clothing and sheets should be bleached after each use. d. Deep pile carpet should be removed from the home. Source: Saunders 4th

ANS: B Rationale: Tuberculosis (TB) is spread by droplet nuclei or the airborne route. The disease is not carried on objects such as clothing, eating utensils, linens, or furniture. Bleaching of clothing and linens is unnecessary, although the client and family members should use good hand washing technique. It is unnecessary to remove carpeting from the home. Strategy: Knowing that TB is not carried on inanimate objects helps you eliminate options 3 and 4 first. To select between options 1 and 2, recall that the disease is transmitted by the airborne route. If you had difficulty with this question, review the transmission mode of TB. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 644). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

992) A nursing instructor asks a nursing student to describe the route of transmission of tuberculosis. The instructor concludes that the student understands this information if the student states that tuberculosis is transmitted by: a. Hand to mouth b. The airborne route c. The fecal-oral route d. Blood and body fluids Source: Saunders 4th

ANS: B Rationale: Tuberculosis is an infectious disease caused by the bacillus Mycobacterium tuberculosis and is spread primarily by the airborne route. Options 1, 3, and 4 are incorrect. Strategy: Focus on the disorder. Recalling that tuberculosis is a respiratory disease will direct you easily to option 2. If you had difficulty with this question, review the transmission of this disease. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 644). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

991) A nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse reviews the results of which diagnostic test that will confirm this diagnosis? a. Bronchoscopy b. Sputum culture c. Chest x-ray d. Tuberculin skin test Source: Saunders 4th

ANS: B Rationale: Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy. Strategy: Note the strategic word confirm in the question. Confirmation is made by identifying M. tuberculosis. If you had difficulty with this question, review the diagnostic procedures related to tuberculosis. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 641-642). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1315) The nurse has given medication instructions to the client receiving phenytoin (Dilantin). The nurse determines that the client has an adequate understanding if the client states that: a. "Alcohol is not contraindicated while taking this medication." b. "Good oral hygiene is needed, including brushing and flossing." c. "The medication dose may be self-adjusted, depending on side effects." d. "The morning dose of the medication should be taken before a serum drug level is drawn." Source: Saunders 4th

ANS: B Rationale: Typical anticonvulsant medication instructions include taking the prescribed daily dosage to keep the blood level of the drug constant and having a sample drawn for serum drug level before taking the morning dose. The client is taught not to stop the medication abruptly, to avoid alcohol, check with the physician before taking over-the-counter medications, avoid activities where alertness and coordination are required until medication effects are known, provide good oral hygiene, and obtain regular dental care. The client should also wear a Medic-Alert bracelet. Strategy: Use the process of elimination. Using knowledge of general principles related to the medication administration will assist you in eliminating options 1 and 3. From the remaining options, recall that medications generally are not taken just before drawing therapeutic serum levels because the results would be artificially high. This leaves oral hygiene as the correct option because of the risk of gingival hyperplasia. Review client education related to phenytoin (Dilantin) if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 951-952). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 691). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1287) A nursing student is caring for a client with a brain attack (stroke) who is experiencing unilateral neglect. The nurse would intervene if the student plans to use which of the following strategies to help the client adapt to this deficit? a. Tells the client to scan the environment b. Approaches the client from the unaffected side c. Places the bedside articles on the affected side d. Moves the commode and chair to the affected side Source: Saunders 4th

ANS: B Rationale: Unilateral neglect is an unawareness of the paralyzed side of the body, which increases the client's risk for injury. The nurse's role is to refocus the client's attention to the affected side. The nurse moves personal care items and belongings to the affected side, as well as the bedside chair and commode. The nurse teaches the client to scan the environment to become aware of that half of the body and approaches the client from the affected side to increase awareness further. Strategy: Use the process of elimination, noting the strategic word intervene. Recall that with unilateral neglect, the client loses awareness of the affected side. If you know that the client needs to be trained to attend to that side, you can eliminate each of the incorrect options. Review care of the client with unilateral neglect if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2131). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1041-1042). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Leadership and Management Alternate Question Types -> Multiple Choice

1163) The client with urolithiasis has a history of chronic urinary tract infections. The nurse plans teaching the client to avoid which of the following? a. Long-term use of antibiotics b. Wearing synthetic underwear and pantyhose c. High-phosphate foods, such as dairy products d. Foods that make the urine more acidic, such as cranberries Source: Saunders 4th

ANS: B Rationale: Urolithiasis (struvite stones) can result from chronic infections. They form in urine that is alkaline and rich in ammonia, such as with a urinary tract infection. Teaching should focus on prevention of infections and ingesting foods to make the urine more acidic. The client should wear cotton (not synthetic) underclothing to prevent the accumulation of moisture and to prevent irritation of the perineal area, which can lead to infection. Strategy: Use the process of elimination and note the strategic word avoid. Focus on the data in the question. Noting that the client has urolithiasis and a history of chronic urinary tract infections will direct you to option 2, thus eliminating options 1, 3, and 4. Review the causes of the various types of stones and interventions if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1696). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1120) A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often at rest in the absence of precipitating factors. How would the nurse best describe this type of anginal pain? a. Stable angina b. Variant angina c. Unstable angina d. Nonanginal pain Source: Saunders 4th

ANS: B Rationale: Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at rest. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower and lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction. Strategy: Use the process of elimination, focusing on the data in the question. Noting the strategic words at rest will direct you to option 2. If you had difficulty with this question, review the characteristics of the various types of angina. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: critical thinking for collaborative care (5th ed., p. 840). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

98) The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse plans to provide dietary teaching focusing on foods high in which vitamin that may be lacking in a vegan diet? a. Vitamin A b. Vitamin B₁₂ c. Vitamin C d. Vitamin E Source: Saunders 4th

ANS: B Rationale: Vegans do not consume any animal products. Vitamin B₁₂ is found in animal products and therefore would most likely be lacking in a vegan diet. Vitamins A, C, and E are found in fresh fruits and vegetables, which are consumed in a vegan diet. Strategy: Focus on the subject, a vegan diet. Recalling the food items eaten and restricted in this diet will direct you to the correct option. Review vegan diets and sources of vitamins if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 972). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2398) A nurse is caring for a client in the postpartum period immediately after delivery. The nurse performs an assessment on the client and prepares to assess uterine involution by: a. Auscultating the bowel sounds b. Assessing the amount of drainage on the peripad c. Palpating the uterine fundus d. Monitoring the vital signs Source: Saunders 4th

ANS: C Rationale: To assess uterine involution, the nurse would palpate the fundal height. Fundal height is measured in fingerbreadths or centimeters in relation to the umbilicus, and this measurement is used to assess the rate of uterine involution. Vital signs and the amount of drainage on the peripad do not indicate uterine involution. Bowel sounds, although they may be diminished in the postpartum period, are not helpful in assessing uterine involution. Strategy: Note the strategic word uterine in the question and in the correct option. Use the process of elimination and knowledge regarding assessment techniques in the postpartum period to assist in directing you to option 3. If you had difficulty with this question, review postpartum assessment. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 394). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

2631) A nurse has a new order to administer verapamil (Calan) 5 mg by the intravenous (IV) route. In administering this medication, a critical nursing action is monitoring the client's response to the medication using: a. A noninvasive blood pressure monitor b. A cardiac monitor c. A pulse oximeter d. Supplemental oxygen Source: Saunders 4th

ANS: B Rationale: Verapamil is a calcium channel-blocking agent that may be used to treat rapid-rate supraventricular tachydysrhythmias such as atrial flutter or atrial fibrillation. A cardiac monitor is used to determine the client's response to the medication. A noninvasive blood pressure monitor also is helpful, but is not as essential or critical as the cardiac monitor. A pulse oximeter and oxygen are related to respiratory care and may be other useful adjuncts to care, but they are not directly related to the use of this medication. Strategy: Use the process of elimination. Note the strategic word critical. Eliminate options 3 and 4 first because the question contains no information about respiratory difficulty. Regarding the remaining options, recalling that this medication is a calcium channel blocker will direct you to option 2. Review nursing interventions related to the administration of this medication if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 1227). St. Louis: Mosby. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1205). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1578) A 7-year-old child is diagnosed with viral conjunctivitis. Antibiotic eye drops are prescribed for the child. The mother asks the nurse when the child can return to school. The appropriate response is: a. "The child can return to school immediately." b. "The child should be kept home until the antibiotic eye drops have been administered for 24 hours." c. "The child should be kept home until the antibiotic eye drops have been administered for 72 hours." d. "The child cannot return to school until seen by the physician in 1 week." Source: Saunders 4th

ANS: B Rationale: Viral conjunctivitis is extremely contagious. The child should be kept home from school or day care until the child has received antibiotic eye drops for 24 hours. Strategy: Use the process of elimination. Recalling that viral conjunctivitis is highly contagious will assist in eliminating option 1. Eliminate option 4 next because this time frame is rather lengthy. From the remaining options, knowledge regarding the action of antibiotics will assist in directing you to option 2. Review infection control measures related to viral conjunctivitis if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1588). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

1623) A client is seen in the health care clinic and a vitamin K deficiency is suspected. On assessment of the client, the nurse would expect to note which of the following if this vitamin deficiency were present? a. Client complaints of night blindness b. Signs of clotting problems c. Scaly skin d. Client complaints of skeletal pain Source: Saunders 4th

ANS: B Rationale: Vitamin K is associated with the production of prothrombin, which helps the blood properly clot. Vitamin A deficiency is associated with night blindness. Vitamin B₂ (riboflavin) deficiency is associated with scaly skin. Vitamin D deficiency can cause skeletal pain. Strategy: Knowledge regarding the clinical manifestations associated with a Vitamin K deficiency is required to answer this question. Recalling that Vitamin K is the antidote for warfarin (Coumadin), an anticoagulant medication, will assist in directing you to option 2. Review the clinical manifestations associated with vitamin K deficiency if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1149). Philadelphia: W.B. Saunders. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 227). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

114) A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hr. A nurse anticipates that which of the following orders regarding the PN solution will accompany the diet order? a. Discontinue the PN. b. Decrease PN rate to 50 mL/hr. c. Hang 1000 mL 0.9% normal saline. d. Continue current infusion rate orders for PN. Source: Saunders 4th

ANS: B Rationale: When a client begins eating a regular diet after a period of receiving parenteral nutrition, the PN is decreased gradually. Parenteral nutrition that is discontinued abruptly can cause hypoglycemia. Clients often have anorexia after being without food for some time, and the digestive tract also is not used to producing the digestive enzymes that will be needed. Gradually decreasing the infusion rate allows the client to remain adequately nourished during the transition to a normal diet and prevents the occurrence of hypoglycemia. Even before clients are started on a solid diet, they are given clear liquids followed by full liquids to further ease the transition. A solution of normal saline will not provide the glucose needed during the transition of discontinuing the PN and also could cause the client to experience hypoglycemia. Strategy: Use the process of elimination and note the strategic word weaned in the question. Recalling the effects of PN and the complications that occur will direct you to option 2. If you had difficulty with this question, review the concepts related to discontinuing PN solution. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 990). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2062) A neighborhood nurse is attending a soccer game at a local middle school. One of the students falls off the bleachers and sustains an injury to the left arm. The nurse quickly attends to the child and suspects that the child's arm may be broken. Which nursing action would be of highest priority before transferring the child to the hospital emergency department? a. Tell the child that the arm probably is fractured but not to worry because permanent damage to the arm will not occur. b. Immobilize the arm. c. Ask for the name of the child's pediatrician or family physician so that he or she can be contacted. d. Have someone call the radiology department of the local hospital to let staff know that the child will be arriving. Source: Saunders 4th

ANS: B Rationale: When a fracture is suspected, it is imperative that the area be splinted and immobilized before the injured person is transferred or moved. The nurse should remain with the child and provide realistic reassurance. The child would not be told that permanent damage will not occur. It is not necessary to notify the radiology department because this would be the responsibility of the emergency department staff when the child arrives, and if it had been determined that the child needs a radiograph. Although it may be necessary to contact the child's pediatrician, this is not the highest priority. Strategy: Note the strategic words highest priority in the question. Use Maslow's Hierarchy of Needs theory and knowledge regarding emergency care when a fracture is suspected to assist in directing you to option 2. If you had difficulty with this question, review emergency care of a child suspected of having a fracture. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., p. 1752). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Child Health Alternate Question Types -> Multiple Choice

2551) A nurse is performing an admission assessment on a client at high risk for suicide. The nurse should prepare to ask the client which assessment question to elicit data related to this risk? a. "Why were your attempts at suicide unsuccessful in the past?" b. "Do you have a plan to commit suicide?" c. "How many times have you attempted suicide in the past?" d. "What are you are feeling right now?" Source: Saunders 4th

ANS: B Rationale: When assessing for suicide risk, the nurse must determine if the client has a suicide plan. Clients who have a definitive plan pose a greater risk for suicide. Although options 1, 3, and 4 are questions that may provide information that will be helpful in planning care for the client, these questions will not provide information regarding the risk of suicide. Strategy: Focus on the subject, high risk for suicide. Use the process of elimination, noting that option 2 is the only option that specifically addresses the risk. Review the components of a suicide assessment if you had difficulty with this question. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 477-478). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2042) A nurse is developing a plan of care for the client with a diagnosis of paranoia. The nurse avoids including which intervention in the plan of care? a. Eliminate any physical contact with the client. b. Provide a warm approach to the client. c. Use simple and clear language when communicating with the client. d. Diffuse any anger or verbal attacks with a nondefensive stance. Source: Saunders 4th

ANS: B Rationale: When caring for a client with paranoia, the nurse must eliminate any physical contact and not touch the client. The nurse should ask permission if touch is necessary because touch may be interpreted as a sexual or physical assault. The nurse should avoid a warm approach because warmth can be frightening to a person who needs emotional distance. Simple and clear language should be used in speaking to the client to prevent misinterpretation and to clarify the nurse's intent and action. The anger that a paranoid client expresses often is displaced, and when a staff member becomes defensive, both client and staff anger may escalate. Strategy: Note the strategic word avoids in the question. This indicates a negative event query and directs you to select an incorrect intervention. Use the process of elimination, focusing on the diagnosis of the client to assist in directing you to option 2. If you had difficulty with this question, review care of the client with paranoia. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 288). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2230) A nurse is monitoring the function of a client's chest tube that is attached to a Pleur-Evac drainage system. The nurse notes that the fluid in the water seal chamber rises with inspiration and falls with expiration. The nurse interprets that: a. The client has residual pneumothorax. b. The system is patent. c. Suction should be added to the system. d. There is a leak in the system. Source: Saunders 4th

ANS: B Rationale: When the chest tube is patent, the fluid in the water seal chamber rises with inspiration and falls with expiration. This is referred to as "tidaling" and indicates proper function of the system. Options 1, 3, and 4 are inaccurate interpretations. Strategy: Use the process of elimination. Recalling that negative pressure (pulling pressure) develops with inspiration, it is natural that the fluid level in the water seal chamber would rise on inspiration. Consequently, with expiration, the opposite naturally would be true. This makes options 3 and 4 incorrect. Select option 2 over option 1 because the question makes no mention of bubbling in the water seal chamber, which would occur if the client had pneumothorax. Review care of a client with a chest tube if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1863). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1478) The home health nurse visits a client at home and determines that the client is dependent on drugs. Which of the following assessment questions would assist the nurse to provide appropriate nursing care? a. "Why did you get started on these drugs?" b. "How much do you use and what effect does it have on you?" c. "How long did you think you could take these drugs without someone finding out?" d. The nurse does not ask any questions for fear that the client is in denial and will throw the nurse out of the home. Source: Saunders 4th

ANS: B Rationale: Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental and off focus and reflects the nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention. Strategy: Use the process of elimination and therapeutic communication techniques to answer the question. Also, focus on the subject, provide appropriate nursing care. Review assessment of a client who is a substance abuser if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 311-313). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1331) The nurse is caring for a client with severe back pain. Codeine sulfate has been prescribed for the client. Which of the following does the nurse specifically include in the plan of care while the client is taking this medication? a. Monitor fluid balance. b. Monitor bowel activity. c. Monitor peripheral pulses. d. Monitor for hypertension. Source: Saunders 4th

ANS: B Rationale: While the client is taking codeine sulfate, the nurse would monitor vital signs and assess for hypotension. The nurse also should increase fluid intake, palpate the bladder for urinary retention, auscultate bowel sounds, and monitor the pattern of daily bowel activity and stool consistency. The nurse should monitor respiratory status and initiate deep-breathing and coughing exercises. Additionally, the nurse monitors the effectiveness of the pain medication. Strategy: Use the process of elimination. Note the strategic word specifically and recall that codeine sulfate can cause constipation. If you had difficulty with this question, review nursing measures related to the administration of codeine sulfate. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 218). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1577) A pregnant woman has a positive history of genital herpes but has not had lesions during this pregnancy. The nurse should plan to provide which of the following information to the client? a. "You will be isolated from your newborn infant following delivery." b. "You will be evaluated at the time of delivery for herpetic genital tract lesions and, if present, a cesarean delivery will be needed." c. "There is little risk to your newborn infant during this pregnancy, birth, and following delivery." d. "Vaginal deliveries can reduce neonatal infection risks, even if you have an active lesion at birth." Source: Saunders 4th

ANS: B Rationale: With active herpetic genital lesions, cesarean delivery can reduce neonatal infection risks. In the absence of active genital lesions, vaginal delivery is indicated unless there are other indications for cesarean delivery. Maternal isolation is not necessary, but potentially exposed newborn infants should be cultured on the day of delivery. Strategy: Use the process of elimination. Knowledge regarding the transmission of genital herpes to the newborn infant is required to answer this question. Remember that with active herpetic genital lesions, cesarean delivery can reduce neonatal infection risks. If you had difficulty with this question, review this content area. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 687). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

2316) A nurse is caring for an infant after repair of an inguinal hernia. Which of these assessment findings indicate that the surgical repair was effective? a. Abdominal distention b. Absence of inguinal swelling with crying c. A clean, dry incision d. An adequate flow of urine Source: Saunders 4th

ANS: B Rationale: With an inguinal hernia, inguinal swelling occurs when the infant cries or strains. Absence of this swelling would indicate resolution of this problem. Abdominal distention indicates a continuing gastrointestinal problem. A clean, dry incision refers to absence of wound infection after surgery. The flow of urine is not specific to an inguinal hernia. Strategy: Use the process of elimination, focusing on the subject, effective inguinal hernia repair. The only option that addresses this subject is option 2. Also, note the same word, inguinal, in the question and in the correct option. Review care of the infant after inguinal hernia repair if you had difficulty with this question. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., pp. 482-483). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Child Health Alternate Question Types -> Multiple Choice

1332) A client is receiving meperidine hydrochloride (Demerol) for pain. Select the side effects of this medication. Select all that apply. a. Diarrhea b. Tremors c. Drowsiness d. Hypotension e. Urinary frequency f. Increased respiratory rate Source: Saunders 4th

ANS: B ANS: C ANS: D Rationale: Meperidine hydrochloride is an opioid analgesic. Side effects include respiratory depression, drowsiness, hypotension, constipation, urinary retention, nausea, vomiting, and tremors. Strategy: Focus on the name of the medication. Recalling that this medication is an opioid analgesic and recalling the effects of an opioid analgesic will assist in identifying the side effects. Review the side effects of this medication if you had difficulty with this question. Reference: Mosby. (2005). Mosby's 2005 drug consult for nurses (p. 812). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Multiple

1201) The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Select all nursing actions in this situation that apply. a. Contact the physician. b. Check the level of the drainage bag. c. Reposition the client to his or her side. d. Place the client in good body alignment. e. Check the peritoneal dialysis system for kinks. f. Increase the flow rate of the peritoneal dialysis solution. Source: Saunders 4th

ANS: B ANS: C ANS: D ANS: E Rationale: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. The connecting tubing and peritoneal dialysis system are also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. There is no reason to contact the physician. Increasing the flow rate is an inappropriate action and is not associated with the amount of outflow solution. Strategy: Use the principles related to gravity flow and preventing obstruction to flow to answer this question. This will assist in determining the correct interventions. Review the nursing interventions related to insufficient flow of dialysate if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1759). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Multiple

16) Which of the following are low-risk therapies? Select all that apply. a. Herbs b. Prayer c. Touch d. Massage e. Relaxation f. Acupuncture Source: Saunders 4th

ANS: B ANS: C ANS: D ANS: E Rationale: Low-risk therapies include meditation, relaxation techniques, imagery, music therapy, massage, touch, laughter and humor, and spiritual measures, such as prayer. The other options are not considered low-risk therapies. Strategy: Use knowledge of low-risk complementary and alternative therapies. Focusing on the strategic words low-risk will direct you to the correct options. Review complementary and alternative medicine (CAM) and low-risk therapies if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 97-108). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Multiple

1412) Ketoconazole (Nizoral) is prescribed for a client with a diagnosis of candidiasis. Select the interventions that the nurse includes when administering this medication. Select all that apply. a. Restrict fluid intake. b. Instruct the client to avoid alcohol. c. Monitor liver function studies. d. Administer the medication with an antacid. e. Instruct the client to avoid exposure to the sun. f. Administer the medication on an empty stomach. Source: Saunders 4th

ANS: B ANS: C ANS: E Rationale: Ketoconazole (Nizoral) is an antifungal medication. It is administered with food (not on an empty stomach) and antacids are avoided for 2 hours after taking the medication to ensure absorption. The medication is hepatotoxic and the nurse monitors liver function studies. The client is instructed to avoid exposure to the sun because the medication increases photosensitivity. The client is also instructed to avoid alcohol. There is no reason for the client to restrict fluid intake. In fact, this could be harmful to the client. Strategy: Use general medication guidelines to assist in selecting the correct interventions. Also, remember that this medication is administered with food and that it is hepatotoxic. Review this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 654). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Multiple

176) A community health nurse is providing a teaching session about terrorism to members of the community and is discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted by which route(s)? Select all that apply. a. Bites from ticks or deer flies b. Inhalation of bacterial spores c. Through a cut or abrasion in the skin d. Direct contact with an infected individual e. Sexual contact with an infected individual f. Ingestion of contaminated undercooked meat Source: Saunders 4th

ANS: B ANS: C ANS: F Rationale: Anthrax is caused by Bacillus anthracis and can be contracted through the digestive system, abrasions in the skin, or inhaled through the lungs. It cannot be spread from person to person or animal to person and it is not contracted via bites from ticks or deer flies. Strategy: Knowledge regarding the methods of contracting anthrax is needed to answer this question. Remember that it is not spread by person-to-person contact or contracted via tick or deer fly bites. Review information related to this infection if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 519). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Multiple

932) The nurse is doing preoperative teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which statement? a. "I will be able to pass stool by the rectum eventually." b. "The drainage from this type of ostomy will be formed." c. "I will need to drain the pouch regularly with a catheter." d. "I will need to wear a drainage bag for the rest of my life." Source: Saunders 4th

ANS: C Rationale: A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the client drains it every 3 to 4 hours and then decreases the draining to about three times a day, or as needed when full. The client does not need to wear a drainage bag but should wear an absorbent dressing to absorb mucous drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool only from the rectum if an ileal-anal pouch or anastomosis were created. This type of operation is a two-stage procedure. Strategy: Use the process of elimination. Focusing on the strategic word pouch will assist in directing you to option 3. If this question was difficult, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1704). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2414) A nurse has been caring for a client with a Sengstaken-Blakemore tube. The physician arrives on the nursing unit and deflates the esophageal balloon. After deflation of the balloon, the nurse should monitor the client most closely for which of the following? a. Swelling of the abdomen b. Bloody diarrhea c. Hematemesis d. An elevated temperature and a rise in blood pressure Source: Saunders 4th

ANS: C Rationale: A Sengstaken-Blakemore tube may be inserted in a client with a diagnosis of cirrhosis and ruptured esophageal varices. It has both an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices, manifested as vomiting of blood (hematemesis). Strategy: Use the process of elimination. Recalling that the esophageal balloon exerts pressure on the ruptured esophageal varices to stop the bleeding will direct you to option 3. Review care of the client with a Sengstaken-Blakemore tube if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1379). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2379) A nurse who is caring for a client with myasthenia gravis has an order to perform a Tensilon test. After obtaining edrophonium (Tensilon), the nurse should be certain that which of the following also is available at the bedside? a. Protamine sulfate b. Magnesium sulfate c. Atropine sulfate d. Calcium gluconate Source: Saunders 4th

ANS: C Rationale: A Tensilon test is performed to distinguish between myasthenic and cholinergic crisis. After administration of the Tensilon, if symptoms intensify, the crisis is cholinergic. Because the symptoms of cholinergic crisis will worsen with the administration of Tensilon, atropine sulfate should be available because it is the antidote. Strategy: Use the process of elimination. Recalling the purpose of the Tensilon test and that atropine sulfate is an anticholinergic medication will direct you to option 3. If you are unfamiliar with the Tensilon test and the associated nursing interventions, review this content. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 1036). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 303). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2207) A nurse is scheduling diagnostic tests for a client. If all of the following diagnostic tests are ordered, which should be performed last? a. Gallbladder series b. Barium enema c. Barium swallow d. Oral cholecystogram Source: Saunders 4th

ANS: C Rationale: A barium swallow should be done after a barium enema or gallbladder series to prevent the contrast used in the barium swallow from obstructing the view of other organs. It takes several days for swallowed barium to pass completely out of the gastrointestinal tract. Strategy: Use the process of elimination. Eliminate options 1 and 4 first because a gallbladder series is the same procedure as an oral cholecystogram. Regarding the remaining options, think about the use of barium and its effect in blocking the visualization of organs. This should direct you to option 3. Review the effects of this diagnostic study if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 684). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1845) A client arrives in the hospital emergency department in an unconscious state. As reported by the spouse, the client has diabetes mellitus and began to show symptoms of hypoglycemia. A blood glucose level is obtained for the client and the result is 40 mg/dL. Which of the following medications should the nurse anticipate to be prescribed for the client? a. NPH insulin b. Regular insulin c. Glucagon d. Glyburide (Diabeta) Source: Saunders 4th

ANS: C Rationale: A blood glucose lower that 50 mg/dL is considered to be critically low. Glucagon is used to treat hypoglycemia because it increases blood glucose levels. Glyburide is an oral hypoglycemic agent used to treat diabetes mellitus type 2 and would not be given to a client with hypoglycemia. Additionally, an oral medication would not be administered to an unconscious client. Regular insulin and NPH insulin would also lower the client's blood glucose and would not be an appropriate treatment for hypoglycemia. Strategy: Focus on the subject of the question, hypoglycemia. Knowing that Regular insulin, NPH insulin, and glyburide are used to treat hyperglycemia will assist in directing you to the correct option. If you are unfamiliar with these medications and their actions, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1451, 1499, 1539, 1541). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

1675) The client with type 1 diabetes mellitus is to begin an exercise program and the nurse is providing instructions to the client regarding the program. Which of the following does the nurse include in the teaching plan? a. Exercise is best performed during peak times of insulin. b. Administer insulin after exercising. c. Take a blood glucose test before exercising. d. Try to exercise prior to mealtime. Source: Saunders 4th

ANS: C Rationale: A blood glucose test performed before exercising provides the client with information regarding the need to consume a snack prior to exercising. Exercising during the peak times of insulin or prior to mealtime places the client at risk for hypoglycemia. Insulin should be administered as prescribed. Strategy: Focus on the subject, the occurrence of a hypoglycemia reaction. Use the process of elimination, keeping this subject in mind and the action of insulin to eliminate options 1, 2, and 4. Review client instructions for implementing an exercise program if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1530-1531, 1542). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

1110) A client is scheduled for a cardiac catheterization using a radiopaque dye. Which of the following assessments is most critical before the procedure? a. Intake and output b. Height and weight c. Allergy to iodine or shellfish d. Baseline peripheral pulse rates Source: Saunders 4th

ANS: C Rationale: A cardiac catheterization requires an informed consent because it involves injection of a radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is a concern and the presence of allergies must be assessed before the procedure. Although options 1, 2, and 4 are accurate, they are not the most critical preprocedure assessments. Strategy: Use the process of elimination and note the strategic words most critical. Recalling the concern related to allergy to the dye and the risk of anaphylaxis makes option 3 correct. Review preprocedure interventions for a cardiac catheterization if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 103). Philadelphia: W.B. Saunders. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 327). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 697). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

2424) A client in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week; however, he is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern that he will not be able to continue the tube feedings at home. Which of the following nursing responses is appropriate at this time? a. "Do you want to stay here in this facility a few more days?" b. "Have you discussed your feelings with your doctor?" c. "Tell me more about your concerns with your diet after going home." d. "You need to talk to your doctor about these findings." Source: Saunders 4th

ANS: C Rationale: A client often has fears about leaving the secure, cared-for environment of the health care facility. This client has a fear about not being able to care for himself at home and of not being able to handle the tube feedings at home. A therapeutic communication statement such as "Tell me more about..." often leads to valuable information about the client and the client's concerns. Options 1, 2, and 4 are nontherapeutic statements. Strategy: Use therapeutic communication techniques. Focus on the client's feelings. Options 2 and 4 place the client's feelings on hold. Option 1 is a close-ended statement. Option 3 focuses on the client's feelings. Remember to address the client's feelings first. Review therapeutic communication techniques if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 193). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 437). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2663) A client who has been chronically taking acetylsalicylic acid (aspirin) for arthritis has been given a prescription for misoprostol (Cytotec). The nurse evaluates that the new medication is effective if the client states relief from which of the following signs and symptoms? a. Bleeding b. Joint aches c. Epigastric pain d. Diarrhea Source: Saunders 4th

ANS: C Rationale: A client who chronically uses aspirin is prone to gastric mucosal injury, which causes epigastric pain as a symptom. Misoprostol is specifically given to prevent this occurrence. Diarrhea can be a side effect of the medication but is not an intended effect. Bleeding and joint aches are not relieved by misoprostol. Strategy: Use the process of elimination. The strategic words in this question, aspirin and relief, tell you that the medication is being given to treat or prevent the occurrence of a specific symptom. Recalling that aspirin is irritating to the gastric mucosa will direct you to option 3. Review the action and indications for use of misoprostol if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 783). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1345) A nurse is caring for a client who had skeletal traction applied to the left leg. The client is complaining of severe left leg pain. Which of the following actions should the nurse take first? a. Provide pin care. b. Call the physician. c. Check the client's alignment in bed. d. Medicate the client with an analgesic. Source: Saunders 4th

ANS: C Rationale: A client who complains of severe pain may need realignment or may have traction weights ordered that are too heavy. The nurse realigns the client and, if that is ineffective, then calls the physician. Severe leg pain, once traction has been established, indicates a problem. Medicating the client should be done after one has tried to determine and treat the cause of the pain. Providing pin care is unrelated to the problem as described. Strategy: Use the process of elimination. Note the strategic word first. Use the steps of the nursing process to direct you to option 3. This is the only option that addresses assessment. Review care of the client in traction if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1201). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

1937) A client with a bladder injury has had surgical repair of the injured area with placement of a suprapubic catheter. The nurse plans to do which of the following to prevent complications of this procedure? a. Monitor urine output every shift. b. Encourage a high intake of oral fluids. c. Ensure that the catheter tubing is not kinked. d. Measure specific gravity once a shift. Source: Saunders 4th

ANS: C Rationale: A complication after surgical repair of the bladder is disruption of sutures caused by tension on them from urine buildup. The nurse prevents this from happening by ensuring that the catheter is able to drain freely. This involves basic catheter care including keeping the tubing free from kinks, maintaining the tubing at a level below the bladder, and monitoring the flow of urine frequently. Measurement of urine specific gravity and a high intake of oral fluids do not prevent complications of bladder surgery. Monitoring of urine output every shift is insufficient to detect decreased flow from catheter kinking. Strategy: Use the process of elimination. Noting that the client has a suprapubic catheter will assist in directing you to option 3. Also, focus on the subject, preventing complications. Keeping this subject in mind as you read each option also will assist you in answering correctly. Review care of the client after surgical bladder repair if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1704, 1863). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2089) A female client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing: a. Extreme stress due to the diagnosis of cancer b. Altered perineal sensation as a side effect of radiation therapy c. The development of a vesicovaginal fistula d. Rupture of the bladder Source: Saunders 4th

ANS: C Rationale: A complication of radiation therapy for bladder cancer is fistula formation. In women, this frequently is manifested as a vesicovaginal fistula, which is an opening between the bladder and the vagina. With this complication, the client senses that urine is flowing out of the vagina. In men, a colovesical fistula may develop, which is an opening between the bladder and the colon. This is manifested as voiding urine that contains fecal material. Strategy: Use the process of elimination. Focus on the strategic words voiding through the vagina. Note the relationship between these words and option 3. Review the complications of radiation therapy for bladder cancer if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 870). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1214) A nurse is providing dietary instructions to a client who has been prescribed cyclosporine (Sandimmune). Which food item would the nurse instruct the client to avoid? a. Red meats b. Orange juice c. Grapefruit juice d. Green leafy vegetables Source: Saunders 4th

ANS: C Rationale: A compound present in grapefruit juice inhibits metabolism of cyclosporine. As a result, consumption of grapefruit juice can raise cyclosporine levels by 50% to 100%, thereby greatly increasing the risk of toxicity. Strategy: Use the process of elimination, noting the strategic word avoid. Use of general pharmacology guidelines will direct you to option 3. If you had difficulty with this question, review this medication and the client instructions regarding its use. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 303). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1613) A contraction stress test is scheduled for the pregnant client and the client asks the nurse about the test. The nurse tells the client that: a. Small amounts of oxytocin (Pitocin) are administered during internal fetal monitoring to stimulate uterine contractions. b. An external fetal monitor is attached and the woman ambulates on a treadmill until contractions begin. c. The uterus is stimulated to contract by small amounts of oxytocin (Pitocin) or nipple stimulation. d. Uterine contractions are stimulated by Leopold's maneuvers. Source: Saunders 4th

ANS: C Rationale: A contraction stress test assesses placental oxygenation and function, determines fetal ability to tolerate labor, determines fetal well-being, and is performed if the nonstress test is abnormal. The fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. An external fetal monitor is applied to the mother and a 20- to 30-minute baseline strip is recorded. The uterus is stimulated to contract by the administration of a dilute dose of oxytocin (Pitocin) or by having the mother use nipple stimulation until three palpable contractions of 40 seconds or longer in a 10-minute period have occurred. Frequent maternal blood pressure readings are done and the client is monitored closely while increasing doses of oxytocin are given. Options 1, 2, and 4 are inaccurate. Strategy: Use the process of elimination. Eliminate option 1 because of the words internal fetal monitoring. Eliminate option 2 because a treadmill is not used to stimulate contractions. From the remaining options, recalling that the uterus is stimulated to contract by small amounts of oxytocin or by nipple stimulation will direct you to option 3. If you had difficulty answering this question, review the contraction stress test. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., pp. 215-217). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1466) A client is admitted to a medical nursing unit with a diagnosis of acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car accident, when a family of three was killed. The nurse suspects that the client may be experiencing: a. Psychosis b. Repression c. Conversion disorder d. Dissociative disorder Source: Saunders 4th

ANS: C Rationale: A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. A conversion disorder is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the person's ability to deal with life's demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness. Strategy: Use the process of elimination. The key to the correct option lies in the fact that the client presents no organic reason to account for the blindness—hence, a conversion disorder. If you had difficulty with this question, review defense mechanisms and the concepts associated with a conversion disorder. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 183). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 254, 259) Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1470) In planning activities for the depressed client, especially during the early stages of hospitalization, which of the following plans is best? a. Plan nothing until the client asks to participate in milieu. b. Offer the client a menu of daily activities and insist the client participate in all of them. c. Provide a structured daily program of activities and encourage the client to participate. d. Provide an activity that is quiet and solitary to avoid increased fatigue, such as working on a puzzle or reading a book. Source: Saunders 4th

ANS: C Rationale: A depressed person experiences a depressed mood and often is withdrawn. The person also experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. Options 1 and 4 provide little or no structure. Option 2 is a forceful and absolute approach. Strategy: Use the process of elimination. Recall that the depressed client requires a structured and stimulating program. Eliminate options 1 and 4 because these provide little or no structure and stimulation. Option 2 is eliminated because of the words insist and all. Review care of the client with depression if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 220-221, 225). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 338-339, 348). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

921) The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which symptom(s) of duodenal ulcer? a. Weight loss b. Nausea and vomiting c. Pain relieved by food intake d. Pain radiating down the right arm Source: Saunders 4th

ANS: C Rationale: A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the midepigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer. Strategy: Use the process of elimination. To answer this question accurately, you must be able to discriminate between symptoms of duodenal and gastric ulcer. This will allow you to eliminate options 1 and 2 first. Choose option 3 over option 4, knowing that the pain does not radiate down the right arm and that a pattern of pain-food-relief occurs with duodenal ulcer. Review the clinical manifestations of a duodenal ulcer if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 750). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1288-1289). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1584) The pediatric nurse assists the physician in performing a lumbar puncture on a 3-year-old child with leukemia suspected of central nervous system (CNS) metastasis. The nurse places the child in which position for this procedure? a. Prone, with the knees flexed to the abdomen, and the head bent, with the chin resting on the chest b. Modified Sims' position c. Lateral recumbent, with the knees flexed to the abdomen, and the head bent, with the chin resting on the chest d. Lithotomy position Source: Saunders 4th

ANS: C Rationale: A lateral recumbent position, with the knees flexed to the abdomen and the head bent with the chin resting on the chest, is assumed for a lumbar puncture. This position separates the spinal processes and facilitates needle insertion into the subarachnoid space. Options 1, 2, and 4 are incorrect positions. Strategy: Use the process of elimination. Note the strategic word lumbar in the question. Visualize each of the descriptions of positions described in the options and focus on the strategic word to direct you to option 3. Review this procedure if you are unfamiliar with it. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., pp. 741-742). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Child Health Alternate Question Types -> Multiple Choice

1629) A fasting blood glucose screening is performed on a pregnant client. The results indicate that the blood glucose level is 140 mg/dL. Which of the following would the nurse anticipate to be prescribed for the mother? a. An oral hypoglycemic agent b. NPH insulin on a daily basis c. A 3-hour glucose tolerance test d. A sliding scale Regular insulin dose Source: Saunders 4th

ANS: C Rationale: A maternal glucose level is determined to screen for gestational diabetes. A 50-g oral glucose load may be prescribed and is followed by a serum glucose determination 1 hour later. If the test is given without regard for fasting, 140 mg/dL is the upper limit of normal. If the test is given when the woman is fasting, the upper acceptable limit is 135 mg/dL. Clients exceeding these limits should be further evaluated with a 3-hour glucose tolerance test (GTT). Options 1, 2, and 4 would not be prescribed based solely on the maternal glucose levels. Further follow-up would be implemented. Strategy: Use the process of elimination. Eliminate options 1, 2, and 4 because they are comparative or alike in that they all identify the administration of medication to treat the elevated blood glucose level. Option 3 is the only option that identifies further evaluation of the client. Review measures to evaluate and treat elevated blood glucose levels in a pregnant client if you had difficulty with this question. Reference: Wong, D., Perry, S., Hockenberry, M., et al. (2006). Maternal child nursing care (3rd ed., p. 337). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

2473) A nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the client's platelet level is normal if which of the following values is noted? a. 80,000 cells/μL b. 100,000 cells/μL c. 160,000 cells/μL d. 500,000 cells/μL Source: Saunders 4th

ANS: C Rationale: A normal platelet count ranges from 150,000 to 400,000 cells/μL. Options 1 and 2 identify decreased values. Option 4 identifies an elevated value. Strategy: Focus on the subject, a normal platelet level. Recalling that this level is 150,000 to 400,000 cells/μL will direct you to option 3. Review normal values for this blood component if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 879). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1496) The nurse is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, the appropriate question to ask is: a. "With whom do you live?" b. "Who is available to help you?" c. "What leads you to seek help now?" d. "What do you usually do to feel better?" Source: Saunders 4th

ANS: C Rationale: A nurse's initial task when assessing a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. Option 3 will assist in determining data related to the precipitating event that led to the crisis. Options 1 and 2 assess situational supports. Option 4 assesses personal coping skills. Strategy: Use the process of elimination and note the strategic words precipitating event. Focus on these strategic words when selecting the correct option. Eliminate options 1 and 2 because these data will determine support systems. Eliminate option 4 because this question would be asked when determining coping skills. Review assessment techniques for the client in crisis if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 511). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 459). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1950) A nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets that this client has: a. Rhonchi b. Crackles c. Pleural friction rub d. Wheezes Source: Saunders 4th

ANS: C Rationale: A pleural friction rub is characterized by sounds that are described as creaking, groaning, or grating in quality. The sounds are localized over an area of inflammation on the pleura and may be heard in both the inspiratory and expiratory phases of the respiratory cycle. Crackles have the sound that is heard when a few strands of hair are rubbed together and indicate fluid in the alveoli. Rhonchi are usually heard on expiration when there is an excessive production of mucus that accumulates in the air passages. Wheezes are musical noises heard on inspiration, expiration, or both and are the result of narrowed airway passages. Strategy: Use knowledge of respiratory assessment data and breath sounds to answer this question. Focusing on the strategic words grating and creaking will direct you to option 3. If you are unfamiliar with the characteristics of the various breath sounds, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1756). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

57) A nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte results indicate a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L. Based on these laboratory findings, the nurse selects which solution to use for the nasogastric tube irrigation? a. Tap water b. Sterile water c. Sodium chloride d. Distilled water Source: Saunders 4th

ANS: C Rationale: A potassium level of 4.5 mEq/L is within normal range. A sodium level of 132 mEq/L is low, indicating hyponatremia. In clients with hyponatremia, sodium (isotonic) chloride should be used rather than water for gastrointestinal irrigations. Strategy: Use the process of elimination. Eliminate options 1, 2, and 4 because they are comparative or alike (sterile water, tap water, and distilled water). Also, recalling that the serum sodium level identified in the question indicates hyponatremia will direct you to option 3. If you had difficulty with this question, review the care of the client experiencing hyponatremia. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 235). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2236) A nurse is caring for a client with tuberculosis who is fearful of the disease and anxious about prognosis. In planning nursing care, the nurse should incorporate which of the following as the best strategy to assist the client in coping with the illness? a. Encourage the client to visit with the pastoral care department chaplain. b. Ask family members if they wish a psychiatric consult. c. Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease. d. Allow the client to deal with the disease in an individual fashion. Source: Saunders 4th

ANS: C Rationale: A primary role of the nurse in working with the client with tuberculosis is to teach the client about medication therapy. The anxious client may not absorb information optimally. The nurse continues to reinforce teaching using a variety of methods (repetition, teaching aids) and teaches the family about the medications as well. The most effective way of coping with the disease is to learn about the therapy, which will eradicate it. This gives the client a measure of power over the situation and outcome. Strategy: Note the subject, the best strategy for coping with anxiety about the disease and its prognosis. Options 2 and 4 are the least useful and may be eliminated first. Option 2 does not involve the client, and option 4 gives no active assistance to the client. Regarding the remaining options, recalling the importance of medication therapy will direct you to option 3. Review the psychosocial concerns related to tuberculosis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 644-645). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1618) The home care nurse is visiting a client who is in a body cast. The nurse is performing an assessment and is assessing the psychosocial adjustment of the client to the cast. The nurse would most appropriately assess the: a. Type of transportation available for follow-up care b. Ability to perform activities of daily living c. Need for sensory stimulation d. Amount of home care support available Source: Saunders 4th

ANS: C Rationale: A psychosocial assessment of the client who is immobilized would most appropriately include the need for sensory stimulation. This assessment should also include such factors as body image, past and present coping skills, and coping methods used during the period of immobilization. Although transportation, home care support, and the ability to perform activities of daily living are components of an assessment, they are not as specifically related to psychosocial adjustment as is the need for sensory stimulation. Strategy: Use the process of elimination and focus on the strategic words psychosocial and most appropriately. Option 2 can be eliminated first because it relates to physiological integrity rather than psychosocial integrity. Next, eliminate options 1 and 4 because they are most closely related to physical supports rather than psychosocial needs of the client. Review the components of a psychosocial assessment if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1442). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2455) An ambulatory care nurse is providing information to a client scheduled for a skin biopsy. The client asks the nurse how painful the procedure is. The appropriate response by the nurse is: a. "The procedure is painless." b. "An analgesic will be prescribed after the procedure." c. "The local anesthetic may cause a stinging sensation, but the surgeon will numb the area so that pain will not be felt." d. "A preoperative medication will put you to sleep." Source: Saunders 4th

ANS: C Rationale: A skin biopsy is not painless. The most common source of pain during a skin biopsy is the initial local anesthetic, which can produce a burning or stinging sensation. A preoperative medication that puts the client to sleep is not a component of this procedure. Analgesics may be prescribed after the procedure, but this option does not address the issue related to the amount or type of pain associated with the procedure itself. Strategy: Use the process of elimination. Eliminate option 1 first, because a skin biopsy is not painless. Eliminate option 2 next, because this option is concerned with the postprocedure period, which is not the issue of the client's question to the nurse. Eliminate option 4 because a preoperative medication that puts the client to sleep is not a part of the procedure for a skin biopsy. If you had difficulty with this question, review the procedure related to a skin biopsy. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 683). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1573). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

1953) A home care nurse instructs a client how to administer enoxaprin (Lovenox) subcutaneously. Which statement if made by the client indicates an understanding of how to administer this medication? a. "I need to massage the skin with the alcohol wipe after I give the injection." b. "I need to pull back on the syringe and aspirate before pushing the medication into my skin." c. "A syringe that has a small 5/8-inch needle is used to administer the injection." d. "I need to hold my skin flat before I put the needle into my skin." Source: Saunders 4th

ANS: C Rationale: A subcutaneous injection of enoxaprin is performed using the same technique as for a heparin injection. The client should use a 25- to 27-gauge, 5/8-inch needle to prevent hematoma formation at the injection site. The client should be taught to bunch the skin, rather than placing it flat. The client should not aspirate before injecting the medication and should not massage the area after injection. Strategy: Use the process of elimination and note the strategic words indicates an understanding. Recalling that the principles of the administration of enoxaprin are the same as for a heparin injection will assist in directing you to the correct option. If you had difficulty with this question, review the administration of enoxaprin. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 412). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 591). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2527) A nurse is preparing to perform a Weber test on a client. The nurse obtains which item needed to perform this test? a. A tongue blade b. A stethoscope c. A tuning fork d. A reflex hammer Source: Saunders 4th

ANS: C Rationale: A tuning fork is needed to perform the Weber test, during which the nurse places the vibrating tuning fork at the midline of the client's forehead or above the upper lip over the teeth. Normally, the sound is heard equally in both ears by bone conduction. If the client has a sensorineural hearing loss in one ear, the sound is heard in the other ear. If the client has a conductive hearing loss in one ear, the sound is heard in that ear. The items identified in options 1, 2, and 4 are not needed to perform the Weber test. Strategy: Use the process of elimination. Recalling that this test is a hearing test will direct you to option 3. Review this test if you had difficulty with this question. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., p. 353). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

906) A client with a peptic ulcer is scheduled for a vagotomy and the client asks the nurse about the purpose of this procedure. Which response by the nurse best describes the purpose of a vagotomy? a. Halts stress reactions b. Heals the gastric mucosa c. Reduces the stimulus to acid secretions d. Decreases food absorption in the stomach Source: Saunders 4th

ANS: C Rationale: A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion. Options 1, 2, and 4 are incorrect descriptions of a vagotomy. Strategy: Focus on the subject, the purpose of a vagotomy. Knowledge regarding the purpose of a vagotomy and noting the client's diagnosis will direct you to the correct option. If you are unfamiliar with this procedure, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1297). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2442) A nurse is providing instructions to the parents of a child with a hernia regarding measures that will promote reducing the hernia. The nurse determines that the parents understand appropriate care for their child if they state which of the following? a. "We will be sure to give our child a Fleet enema every day to prevent constipation." b. "We will make sure that our child participates in physical activity every day." c. "We will provide comfort measures to reduce any crying periods by our child." d. "We will encourage our child to cough every few hours on a daily basis." Source: Saunders 4th

ANS: C Rationale: A warm bath, avoidance of upright positioning, and other comfort measures to reduce crying are all simple measures to reduce a hernia. Coughing and crying increase the strain on the hernia. Likewise, physical activity and enemas of any type would increase the strain on the hernia. Strategy: Use the process of elimination and focus on the subject. The subject of the question is an appropriate action that will reduce a hernia. Options 1, 2, and 4 all increase pressure and strain on the hernia site. Review nursing measures for a hernia if you had difficulty with this question. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., p. 483). St. Louis: Mosby. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1115). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Child Health Alternate Question Types -> Multiple Choice

14) A nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care when a staff member asks the nurse educator to describe the concept of acculturation. The appropriate response is which of the following? a. "It is a subjective perspective of the person's heritage and a sense of belonging to a group." b. "It is a group of individuals in a society who are culturally distinct and have a unique identity." c. "It is a process of learning a different culture to adapt to a new or changing environment." d. "It is a group that shares some of the characteristics of the larger population group of which it is a part." Source: Saunders 4th

ANS: C Rationale: Acculturation is a process of learning a different culture to adapt to a new or changing environment. Option 1 describes ethnic identity. Option 2 describes an ethnic group. Option 4 describes a subculture. Strategy: Knowledge regarding the descriptions and definitions of the foundational concepts related to culture is required to answer this question. Focusing on the word acculturation and thinking about its definition will direct you to option 3. Review these concepts if you are unfamiliar with them. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 120). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2408) A home care nurse is visiting a client with glaucoma who is receiving acetazolamide (Diamox) daily. Which of the following would indicate to the nurse that the client is experiencing an adverse reaction related to the medication? a. Diarrhea b. Lacrimation c. Low back pain and dysuria d. Irritability Source: Saunders 4th

ANS: C Rationale: Acetazolamide is a carbonic anhydrase inhibitor with possible harmful effects on the liver and kidneys. Manifestations of toxicity include dark-colored urine and stools, pain in the lower back, jaundice, dysuria, crystalluria, renal colic, and calculi. Bone marrow depression also may occur. Strategy: Focus on the strategic words adverse reaction. Remembering that acetazolamide is nephrotoxic and hepatotoxic will assist in directing you to the correct option. Review the adverse effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 15). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

2420) A nurse is caring for a 14-year-old girl who is hospitalized and has been placed in traction using Crutchfield tongs. The child is having difficulty adjusting to the prolonged hospital confinement. Which nursing action would be appropriate to meet the child's needs? a. Allow the girl to have her hair dyed if the parent agrees. b. Allow the child to play loud music in the hospital room. c. Let the child wear her own clothing when friends visit. d. Allow the child to keep the shades closed and the room darkened at all times. Source: Saunders 4th

ANS: C Rationale: Adolescents need to identify with their peers and have a strong need to belong to a group. They prefer to dress like the group and wear similar hairstyles, which are different from their parents'. Because Crutchfield tongs require the use of skeletal pins, hair dye is not appropriate. The child should be allowed to wear her own clothes to feel a sense of belonging to the group. Loud music may disturb others in the hospital. The child's request for a darkened room may indicate a problem with depression that may need further evaluation and intervention. Strategy: Use the process of elimination and focus on the subjects, Crutchfield traction and a 14-year-old-child. Knowledge regarding Crutchfield traction and its limitations and growth and development concepts will direct you to option 3. Review child growth and development and care of the client in Crutchfield traction if you had difficulty with this question. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., pp. 1073-1074). St. Louis: Mosby. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 894). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Child Health Alternate Question Types -> Multiple Choice

2560) Tobramycin sulfate (Nebcin) is prescribed for a client with a diagnosis of cellulitis. The nurse is administering the medication by intermittent intravenous infusion every 8 hours. The nurse monitors the client for signs of an adverse reaction related to this medication. The nurse determines that which of the following if noted on assessment would indicate the presence of an adverse reaction? a. A blood urea nitrogen (BUN) of 10 mg/dL b. A white blood cell count of 6,000/μL c. Client complaint of ringing in the ears d. Client complaint of diarrhea Source: Saunders 4th

ANS: C Rationale: Adverse reactions or toxic effects of tobramycin sulfate include nephrotoxicity as evidenced by an increased BUN and serum creatinine; irreversible ototoxicity as evidenced by tinnitus, dizziness, ringing or roaring in the ears, and reduced hearing; and neurotoxicity as evidenced by headaches, dizziness, lethargy, tremors, and visual disturbances. A normal white blood cell count is 5,000 to 10,000/μL. The normal blood urea nitrogen (BUN) is 5 to 20 mg/dL. Option 3 is the only option that indicates an adverse reaction to this medication. Strategy: Use the process of elimination. Eliminate options 1 and 2 first because these laboratory values are within normal limits. Focusing on the subject of the question, adverse reaction, and recalling that ototoxicity is associated with the use of this medication will direct you to option 3. Review the adverse effects of tobramycin sulfate if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 1174). St. Louis: Mosby. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1146). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

2430) A client who sustained an inhalation injury arrives in the emergency department. On initial assessment, the nurse notes that the client is very confused and combative. The nurse determines that the client is experiencing: a. Anxiety b. Fear c. Hypoxia d. Pain Source: Saunders 4th

ANS: C Rationale: After a burn injury, clients normally are alert. If a client becomes confused or combative, hypoxia may be the cause. Hypoxia occurs after inhalation injury and also may occur after an electrical injury. Strategy: Use the process of elimination and knowledge regarding this type of burn injury to answer the question. Use the ABCs—airway, breathing, and circulation—to assist in directing you to option 3. If you had difficulty with this question, review assessment of the client with a burn injury. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1628). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 516). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

1709) The nurse is caring for a client with a nasogastric (NG) tube connected to continuous suction. During the assessment, the nurse observes that the client is mouth-breathing, has dry mucous membranes, and has a foul breath odor. In planning care, which of the following would be most appropriate to maintain the integrity of this client's oral mucosa? a. Offer small sips of water frequently. b. Encourage the client to suck on sour, hard candy. c. Brush teeth frequently; use mouthwash and water. d. Use lemon glycerin swabs to provide oral hygiene. Source: Saunders 4th

ANS: C Rationale: After a nasogastric tube is in place, mouth care is extremely important. With one nares occluded, the client tends to mouth-breathe, drying the mucous membranes. Small sips of water are contraindicated when the client is on gastric suction. Hard candy would increase the salivation, but would not be useful in cleaning the oral cavity. Lemon glycerin swabs have a drying and irritating effect on the mucous membranes. Strategy: Focus on the subject, maintaining the integrity of the oral mucosa. Options 1, 2, and 4 are unrelated to this subject and can be easily eliminated. Review the basic measures related to maintaining the integrity of oral mucosa if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1016). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2339) An ambulatory care nurse is providing home care instructions to the client after an arthroscopy of the knee. Which statement by the client indicates a need for further instruction? a. "I should avoid excessive use of the joint for several days." b. "I should elevate my knee while sitting." c. "I can apply heat to the site if it becomes uncomfortable." d. "I should return to the physician for suture removal in about 7 days." Source: Saunders 4th

ANS: C Rationale: After arthroscopy, the client is instructed to avoid excessive use of the joint for several days, to elevate the knee while sitting, to avoid twisting the knee, and to return for suture removal in about 7 days. Ice is applied to the affected joint for pain and swelling, and analgesics are administered as prescribed. Strategy: Note the strategic words need for further instruction. This phrasing indicates a negative event query and asks you to select an incorrect statement. Recalling the principles related to heat and cold will assist in directing you to option 3. If you are unfamiliar with the post-procedural instructions for arthroscopy, review this content. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 205). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1335) A nurse has given instructions to a client returning home after knee arthroscopy. The nurse determines that the client understands the instructions if the client states that he or she will: a. Resume regular exercise the following day. b. Stay off the leg entirely for the rest of the day. c. Report fever or site inflammation to the physician. d. Refrain from eating food for the remainder of the day. Source: Saunders 4th

ANS: C Rationale: After arthroscopy, the client usually can walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for at least a few days. The client may resume the usual diet. Signs and symptoms of infection should be reported to the physician. Strategy: Use the process of elimination. Recalling the general client teaching points related to surgical procedures will direct you to option 3. Review client teaching points following arthroscopy if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1153). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2500) A client has had an arterial blood gas sample drawn from the radial artery, and the nurse is asked to hold pressure on the site. The nurse should apply pressure for at least: a. 1 minute b. 2 minutes c. 5 minutes d. 10 minutes Source: Saunders 4th

ANS: C Rationale: After blood is drawn for arterial blood gas analysis, continuous pressure must be applied to the site. A radial artery site requires at least 5 minutes of pressure, whereas a femoral artery site requires 10 minutes. A small pressure dressing often is placed on the site after this time period. When the client is receiving anticoagulant therapy, application of pressure for a longer period of time may be needed. Strategy: To answer this question, use knowledge regarding the fundamental concepts related to the care of the client in whom arterial blood gas samples were drawn. Remembering that the needle puncture is made into an artery will direct you to option 3. Review this procedure if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 249). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2531) A nurse is providing discharge instructions to a client who had a fenestration procedure for the treatment of otosclerosis. The nurse instructs the client to: a. Drink liquids through a straw for the next 2 to 3 weeks. b. Shower daily to prevent infection. c. Avoid air travel. d. Resume all normal activities in 1 week. Source: Saunders 4th

ANS: C Rationale: After ear surgery, the client needs to be instructed to avoid air travel, avoid drinking through a straw for 2 to 3 weeks, and to avoid coughing excessively. In addition, the client should avoid straining when having a bowel movement, as well as washing the hair, getting the head wet, or showering for 1 week. The client also needs to avoid rapidly moving the head, bouncing, and bending over for 3 weeks. Strategy: Focus on the diagnosis and the procedure. Considering the anatomical area of the surgical procedure will direct you to option 3. Review home care measures after this procedure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1130). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

2317) After hydrostatic reduction for intussusception, the nurse should expect to observe which client response? a. Severe colicky-type pain with vomiting b. Currant jelly-like stools c. Passage of barium or water-soluble contrast with stools d. Severe abdominal distention Source: Saunders 4th

ANS: C Rationale: After hydrostatic reduction, the nurse observes for the passage of barium or water-soluble contrast material with stools. Options 1 and 2 are clinical indicators of intussusception. Option 4 is a sign of an unresolved gastrointestinal disorder. Strategy: Focus on the subject, hydrostatic reduction, and use the process of elimination to answer the question. Look for the option that indicates a positive response. Eliminate options 1 and 2 because they are clinical manifestations of intussusception. Eliminate option 4 because it is not a positive response. If you had difficulty with this question, review the expected findings after hydrostatic reduction. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., p. 1421). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Child Health Alternate Question Types -> Multiple Choice

1835) A nurse has provided discharge instructions to a client who underwent a right mastectomy with axillary lymph node dissection. Which of the following statements if made by the client indicates a need for further instruction regarding home care measures? a. "I must be sure to use thick pot holders when I am cooking." b. "I should inform all of my other health care providers that I have had this surgical procedure." c. "It is all right to use a straight razor to shave under my arms." d. "I must be sure not to have blood pressures taken or blood drawn from my right arm." Source: Saunders 4th

ANS: C Rationale: After mastectomy with axillary lymph node dissection, the client is at risk for arm edema and infection. The client should be instructed regarding home care measures to prevent these complications. The client should be told to avoid activities such as carrying heavy objects or having blood pressure measurements taken on the affected arm. The client also should be instructed in the techniques to avoid trauma to the affected arm, such as using an electric razor to shave under the arms, using gloves when working in the garden, and using or wearing thick pot holders when cooking. Strategy: Note the strategic words a need for further instruction. This phrasing indicates a negative event query and directs you to select an incorrect statement. The subject of the question relates to the prevention of complications following this type of surgery. Recall that edema and infection are concerns after this type of surgery to assist in directing you to option 3. If you had difficulty with this question, review postoperative teaching points after mastectomy. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1108). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1818-1819). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

2148) A client who has had spinal fusion and insertion of hardware is extremely concerned with the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to prior employment. The nurse understands that the client's needs could best be addressed by referral to: a. The surgeon b. A clinical nurse specialist c. A social worker d. The physical therapist Source: Saunders 4th

ANS: C Rationale: After spinal surgery, concerns about finances and employment are best handled by referral to a social worker. This professional has the most well-rounded information about resources available to the client. The physical therapist has the best knowledge of techniques for increasing mobility and endurance. The clinical nurse specialist and the surgeon do not have information related to financial resources. Strategy: Use the process of elimination. Focusing on the subject, concerns about finances, will direct you to option 3. Review the roles of various health care workers if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 120, 981-982). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2280) A nurse is caring for a client who has undergone craniotomy and has a supratentorial incision. The nurse should place the client in which of the following positions postoperatively? a. Head of bed flat, head and neck midline b. Head of bed flat, head turned to the nonoperative side c. Head of bed elevated 30 to 45 degrees, head and neck midline d. Head of bed elevated 30 to 45 degrees, head turned to the operative side Source: Saunders 4th

ANS: C Rationale: After supratentorial surgery, the head is kept at a 30- to 45-degree angle. The head and neck should not be angled either anteriorly or laterally but rather should be kept in a neutral (midline) position. This will promote venous return through the jugular veins, which will help prevent a rise in intracranial pressure. Strategy: This question tests knowledge of differences in positioning the craniotomy client with an infratentorial versus a supratentorial incision. Remember that with supratentorial surgery the head is kept up and with infratentorial surgery the head is kept down. Regarding the remaining options, recalling how to position the head for optimal venous drainage will help you to select option 3 over option 4. Review client positioning after craniotomy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2089). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1001) A client is receiving albuterol (Proventil) via a nebulizer. The nurse monitors the client for which side effect of this medication? a. Diarrhea b. Bradycardia c. Tachycardia d. Constipation Source: Saunders 4th

ANS: C Rationale: Albuterol is a sympathomimetic bronchodilator. Side effects that can occur from the use of this medication include tremors, nausea, nervousness, palpitations, tachycardia, and dryness of the mouth or throat. Strategy: Focus on the name of the medication. Recalling that this medication causes sympathomimetic stimulation will direct you to option 3. If you are unfamiliar with the side effects related to this medication, review this content. Reference: Kee, J. Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 592). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 646). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2545) A nurse is preparing to initiate an intravenous (IV) puncture on a client and obtains the prescribed solution of 1000 mL of normal saline for the infusion. The nurse sets up the IV infusion and checks which of the following before performing the venipuncture? a. The client's temperature b. The client's blood pressure c. The IV solution for particles or contamination d. The client's electrolyte values Source: Saunders 4th

ANS: C Rationale: All IV solutions should be free of particles or precipitates and should be assessed before initiation of an IV line. Although the client's vital signs and laboratory values may be assessed, these actions are unrelated to the subject of the question. Strategy: Focus on the subject of the question, the nursing action before initiating an intravenous line. Noting that the question contains information regarding an IV solution will assist in directing you to option 3. Review the nursing actions related to initiating an IV line if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1164). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1765) After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, the nurse documents that the bowel sounds are normal. Which of the following descriptions best describes "normal bowel sounds?" a. Waves of loud gurgles auscultated in all four quadrants b. Very high-pitched loud rushes auscultated especially in one or two quadrants c. Relatively high-pitched clicks or gurgles auscultated in all four quadrants d. Low-pitched swishing auscultated in one or two quadrants Source: Saunders 4th

ANS: C Rationale: Although frequency and intensity of bowel sounds will vary depending on the phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis. Bowel sounds will be more high-pitched and louder (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds. Strategy: Use the process of elimination. Normally, bowel sounds are audible in all four quadrants; therefore, options 2 and 4 can be eliminated. From the remaining options, use knowledge regarding normal findings to direct you to option 3. Review abdominal assessment if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 957). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1403) Amikacin (Amikin) is prescribed for a client with a bacterial infection. The nurse instructs the client to contact the physician immediately if which of the following occurs? a. Nausea b. Lethargy c. Hearing loss d. Muscle aches Source: Saunders 4th

ANS: C Rationale: Amikacin (Amikin) is an aminoglycoside. Adverse effects of aminoglycosides include ototoxicity (hearing problems) confusion, disorientation, gastrointestinal irritation, palpitations, blood pressure changes, nephrotoxicity, and hypersensitivity. The nurse instructs the client to report hearing loss to the physician immediately. Lethargy and muscle aches are not associated with the use of this medication. It is not necessary to contact the physician immediately if nausea occurs. If nausea persists or results in vomiting, the physician should be notified. Strategy: Note the strategic words contact the physician immediately. Recalling that this medication is an aminoglycoside (most aminoglycoside medication names end in the letters -cin) and that aminoglycosides are ototoxic will direct you to the correct option. Review the adverse effects of aminoglycosides if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 999). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

2635) A client is taking amiloride (Midamor) 10 mg PO daily. The nurse instructs the client to: a. Eat foods with extra sodium. b. Withhold the dose if the blood pressure is high. c. Take the dose in the morning. d. Take the dose without food. Source: Saunders 4th

ANS: C Rationale: Amiloride is a potassium-sparing diuretic used to treat edema or hypertension. The daily dose should be taken in the morning to avoid nocturia, and the medication should be taken with food to increase bioavailability. Sodium should be restricted or limited as prescribed. Increased blood pressure is not a reason to withhold the medication; rather, it may be an indication for its use. Strategy: Use the process of elimination. Recalling that the medication is a potassium-sparing diuretic will assist in eliminating options 1 and 2. Next, recalling the action of the medication will direct you to option 3. An important consideration is prevention of nocturia by taking the medication early in the day. Review the client teaching points related to this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 39). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2191) A client is being treated for depression with amitriptyline hydrochloride. During the initial phases of treatment, the most important nursing intervention is to: a. Provide the client a tyramine-free diet. b. Obtain frequent drug blood levels. c. Obtain postural blood pressures before the administration of each dose. d. Assess the client for anticholinergic effects. Source: Saunders 4th

ANS: C Rationale: Amitriptyline hydrochloride is a tricyclic antidepressant often used to treat depression. The client may experience some side effects, such as sedation, dry mouth, constipation, and blurred vision (anticholinergic). However, these effects are transient and will diminish as times goes on. A more common adverse effect is orthostatic blood pressure changes, which can produce hypotension and tachycardia. The tachycardia can be frightening to the client, and the hypotension is dangerous because it may result in dizziness and falling. The client must be instructed to move slowly from a lying to a sitting or standing position to avoid injury if these changes are experienced. A tyramine-free diet is initiated for a client on a monoamine oxidase inhibitor. Blood levels are required for the client taking lithium. Strategy: Use the process of elimination. Recalling that tricyclic antidepressants cause orthostatic hypotension will direct you to option 3. If you had difficulty with this question, review this medication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 62). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1519) The mental health clinic nurse is discussing the activities of the past week with a client receiving amitriptyline hydrochloride. The nurse evaluates that the medication is most effective for this client if the client reports which of the following? a. Decrease in appetite b. Sleeping 14 to 16 hours a day c. Ability to get to work on time each day d. Having difficulty concentrating on an activity Source: Saunders 4th

ANS: C Rationale: Amitriptyline hydrochloride is a tricyclic antidepressant. Depressed individuals sleep for extended periods, have a change in appetite, are unable to go to work, and have difficulty concentrating. They also may experience increased fatigue, feelings of guilt or worthlessness, loss of interest in activities, and possible suicidal tendencies. Once they have had some therapeutic effect from their medication, they will report resolution of many of these complaints and demonstrate an improvement in their appearance. Strategy: Use the process of elimination. Note the strategic words most effective. The symptoms stated in options 1, 2, and 4 are symptoms of depression. The ability to report to work indicates a therapeutic response to the medication. Review the action and expected effects of amitriptyline hydrochloride if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 468, 470). St. Louis: Mosby. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., pp. 148-149, 162). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1575) A client brought to the emergency room is dead on arrival (DOA). The family of the client tells the physician that the client had a terminal cancer. The emergency room physician examines the client and asks the nurse to contact the medical examiner regarding an autopsy. The family of the client tells the nurse that they do not want an autopsy performed. Which of the following responses to the family is appropriate? a. "It is required by federal law. Why don't we talk about it and why don't you tell me why you don't want the autopsy done?" b. "The decision is made by the medical examiner." c. "I will contact the medical examiner regarding your request." d. "An autopsy is mandatory for any client who is DOA." Source: Saunders 4th

ANS: C Rationale: An autopsy is required by state law in certain circumstances, including the sudden death of a client and a death that occurs under suspicious circumstances. A client may have provided oral or written instructions regarding an autopsy following death. If an autopsy is not required by law, these oral or written requests will be granted. If no oral or written instructions were provided, state law determines who has the authority to consent for an autopsy. Most often, the decision rests with the surviving relative or next of kin. Strategy: Use knowledge regarding the laws and issues surrounding autopsy and therapeutic communication techniques to answer the question. Eliminate options 1 and 4 because these statements are not completely accurate. From the remaining options, option 3 is the therapeutic and appropriate response to the family. Review the issues and laws surrounding autopsy if you had difficulty with this question. Reference: Lynch, V. (2006). Forensic nursing (pp. 354-355, 364). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1628) The nurse is assessing a client with a diagnosis of goiter. Which of the following would the nurse expect to note during the assessment of the client? a. Client complains of slow wound healing b. Client complains of chronic fatigue c. An enlarged thyroid gland d. The presence of heart damage Source: Saunders 4th

ANS: C Rationale: An enlarged thyroid gland develops in the client with goiter because an excessive amount of thyroxine occurs in the thyroid gland, causing it to enlarge. Slow wound healing occurs with zinc deficiency. Chronic fatigue occurs with iron deficiency. Heart damage occurs with selenium deficiency. Additionally, heart damage would not likely be noted during the nursing assessment. Further diagnostic tests in addition to the assessment would be necessary to determine heart damage. Strategy: Use the process of elimination. Thinking about the anatomical location of a goiter will easily direct you option 3. Review the manifestations associated with this disorder if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1191). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1483). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

133) The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client's intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which of the following complications has been experienced by the client? a. Infection b. Phlebitis c. Infiltration d. Thrombosis Source: Saunders 4th

ANS: C Rationale: An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling are the results of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line at another site. The other three options are likely to be accompanied by warmth at the site, not coolness. Strategy: Use the process of elimination, focusing on the clinical manifestations identified in the question. Noting the strategic word cool in the question will direct you to option 3. Review the signs of infiltration if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 259). Philadelphia: W.B. Saunders. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., pp. 918-919). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1173). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1706) The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which assessment data would alert the nurse to this occurrence? a. Firm, nontender mass palpable at the lower right costal margin b. Severe, constant pain with rapid onset c. Inability to pass flatus d. Loss of anal sphincter control Source: Saunders 4th

ANS: C Rationale: An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Option 1 is the description of the physical finding of liver enlargement. The liver is usually enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus or intestinal obstruction. Pain is associated with paralytic ileus, but the pain usually presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. Loss of sphincter control is not a sign of paralytic ileus. Strategy: Use the process of elimination. Noting the word paralytic will assist in directing you to option 3. Review the clinical manifestations of paralytic ileus if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1327). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2287) A nurse is planning to put aneurysm precautions in place for a client with a cerebral aneurysm. Which of the following nursing measures would be an inappropriate component of the precautions? a. Prevent pushing or straining activities. b. Maintain the head of bed at 15 degrees. c. Limit caffeinated coffee to one cup per day. d. Provide physical aspects of care. Source: Saunders 4th

ANS: C Rationale: Aneurysm precautions include placing the client on bedrest (as prescribed) in a quiet setting. Lights are kept dim to minimize environmental stimulation. Any activity that increases the blood pressure or impedes venous return from the brain is prohibited, such as pushing, pulling, sneezing, coughing, or straining. The nurse provides physical care to minimize increases in blood pressure. For the same reason, visitors, radio, television, and reading materials are prohibited or limited. Stimulants such as caffeine and nicotine are prohibited; decaffeinated coffee or tea may be used. Strategy: Use the process of elimination and note the strategic word inappropriate. Remember that a global principle in aneurysm precautions is to limit the amount of stimulation (in any form) that the client receives and to prevent increased intracranial pressure (ICP). Options 1 and 2 are effective in promoting venous drainage from the brain (to keep ICP down) and are part of the precautions. Option 4 limits the amount of stimulation and exertion by the client and also is part of the precautions. Caffeine must be completely eliminated. Review aneurysm precautions if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 546-547, 2095). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1171) The client with chlamydial infection has received instructions on self-care and prevention of further infection. The nurse determines that the client needs further reinforcement if the client states that he or she will: a. Use latex condoms to prevent disease transmission. b. Return to the clinic as requested for follow-up culture in 1 week. c. Use doxycycline prophylactically to prevent symptoms of chlamydia. d. Reduce the chance of reinfection by limiting the number of sexual partners. Source: Saunders 4th

ANS: C Rationale: Antibiotics are not taken prophylactically to prevent acquisition of urethritis from chlamydial infection. The risk of reinfection can be reduced by limiting the number of sexual partners and by the use of condoms. In some cases, follow-up culture is requested in 4 to 7 days to confirm a cure. Options 1, 2, and 4 are correct measures. Strategy: Use the process of elimination. Note the strategic words needs further reinforcement. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Knowing the basic principles of antibiotic therapy will direct you to option 3 because antibiotics are not used intermittently at will for prophylaxis of this infection. Review client teaching related to chlamydial infection if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1896). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

9) When communicating with a culturally diverse client who speaks a different language, the best practice for the nurse is to: a. Speak loudly and slowly. b. Stand close to the client and speak loudly. c. Arrange for an interpreter when communicating with the client. d. Speak to the client and family together to increase the chances that the topic will be understood. Source: Saunders 4th

ANS: C Rationale: Arranging for an interpreter would be the best practice when communicating with a client who speaks a different language. Options 1 and 2 are inappropriate and are ineffective ways in which to communicate. Option 4 is inappropriate because it violates privacy and does not ensure correct translation. Strategy: Note the strategic words best practice in the question. To begin answering this question, eliminate options 1 and 2 because they are nontherapeutic actions. From the remaining options, focus on the strategic word best to direct you to option 3. Review these communication techniques if you had difficulty with this question. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., p. 68). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 27). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2010) A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to touch. The nurse should document that these findings identify which type of ulcer? a. A vascular ulcer b. A venous stasis ulcer c. An arterial ulcer d. A stage 1 ulcer Source: Saunders 4th

ANS: C Rationale: Arterial ulcers have a pale, deep base and are surrounded by tissue that is cool with trophic changes such as dry, skin and loss of hair. Arterial ulcers are caused by tissue ischemia from inadequate arterial supply of oxygen and nutrients. A venous stasis ulcer is one that has a dark red base and is surrounded by brown skin with local edema. This type of ulcer is caused by the accumulation of waste products of metabolism that are not cleared, as a result of venous congestion. A stage 1 ulcer indicates a reddened area with an intact skin surface. Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are comparative or alike. Recalling that a stage 1 ulcer indicates the presence of reddened skin that is intact will assist in directing you to option 3. If you had difficulty with this question, review the different characteristics of stage 1, venous, and arterial ulcers. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 795). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Communication and Documentation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2357) A nurse is monitoring a client with acute lymphocytic leukemia for toxic effects of asparaginase (Elspar). The nurse should notify the physician if monitoring reveals: a. Oral ulcerations b. Alopecia c. Prolonged blood clotting times d. Decreased white blood cell count Source: Saunders 4th

ANS: C Rationale: Asparaginase can cause severe adverse effects; however, they often are different from those of other antineoplastic medications. By inhibiting protein synthesis, the medication can cause coagulation deficiencies and injury to the liver, pancreas, and kidneys. Signs and symptoms of central nervous system depression ranging from confusion to coma can occur. Nausea and vomiting can be intense and may limit the dose that can be tolerated. In contrast with most antineoplastic medications, asparaginase does not depress the bone marrow, nor does it cause alopecia, oral ulceration, or intestinal ulceration. Strategy: Recalling that the toxicity of this medication is different from that of most antineoplastic medications will assist in directing you to the correct option. If you had difficulty with this question, review the toxic effects associated with the administration of this medication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 92-93). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 1170). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1260) A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication would the nurse determine could be the cause of the client's complaint? a. Doxycycline (Vibramycin) b. Acetazolamide (Diamox) c. Acetylsalicylic acid (aspirin) d. Diltiazem hydrochloride (Cardizem) Source: Saunders 4th

ANS: C Rationale: Aspirin is contraindicated for gastrointestinal bleed and is potentially ototoxic. The client should be advised to notify the prescribing physician so the medication can be discontinued and/or a substitute that is less toxic to the ear can be taken instead. Options 1, 2, and 4 do not have side effects that are potentially associated with hearing difficulties. Strategy: Focus on the client's complaint. Review the classifications and/or therapeutic effects as well as the side effects of each medication in the options. Of the medications identified, only aspirin can cause ototoxicity. Additionally, it is contraindicated for GI bleed as well. Review medications that can cause ototoxicity if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 95). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

1951) A nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding would indicate the presence of this complication? a. A pulse rate of 60 beats/min b. Flat neck veins c. Muffled or distant heart sounds d. A blood pressure (BP) of 128/82 mm Hg Source: Saunders 4th

ANS: C Rationale: Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling blood pressure accompanied by pulsus paradoxus (a drop in inspiratory BP greater than 10 mm Hg). Bradycardia is not a sign of cardiac tamponade. Strategy: Knowledge regarding the signs of cardiac tamponade is required to answer this question. Recall that a falling BP is characteristic of this complication. Review the signs of cardiac tamponade if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1623). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

48) The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present? a. Weight loss b. Flat neck and hand veins c. An increase in blood pressure d. A decreased central venous pressure (CVP) Source: Saunders 4th

ANS: C Rationale: Assessment findings associated with excess fluid volume include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, an elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and a decreased hematocrit. Options 1, 2, and 4 identify signs noted in deficient fluid volume. Strategy: Use the process of elimination and knowledge regarding the assessment findings in excess fluid volume. Note that options 1, 2, and 4 are similar or alike in that each of these signs reflects a decrease. Option 3 reflects an increase. If you had difficulty with this question, review the assessment findings noted in excess fluid volume. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 339). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

917) The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? a. Dorsiflex the client's foot. b. Measure the abdominal girth. c. Ask the client to extend the arms. d. Instruct the client to lean forward. Source: Saunders 4th

ANS: C Rationale: Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing. Options 1, 2, and 4 are incorrect. Strategy: Use the process of elimination and knowledge regarding the procedure for this assessment to answer this question. Remember that asterixis is irregular flapping movements of the fingers and wrists. This will direct you to the correct option. Review this assessment procedure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1373). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2615) A client has a lithium level of 2.4 mEq/L. The nurse should immediately assess the client for which of the following signs or symptoms? a. Weakness b. Diarrhea c. Blurred vision d. An expected response, because this is within the therapeutic range Source: Saunders 4th

ANS: C Rationale: At lithium levels of 2.0 to 2.5 mEq/L, the client will experience blurred vision, muscle twitching, severe hypotension, and persistent nausea and vomiting. With levels between 1.5 and 2.0 mEq/L, the client experiences vomiting, diarrhea, muscle weakness, ataxia, dizziness, slurred speech, and confusion. At lithium levels of 2.5 to 3.0 mEq/L or higher, urinary and fecal incontinence occurs, as well as seizures, cardiac dysrhythmias, peripheral vascular collapse, and death. Strategy: Knowledge of the clinical manifestations associated with various lithium levels is needed to answer this question. If you are unfamiliar with these levels and the associated signs and symptoms, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 699). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2513) An ambulatory care nurse overhears the physician tell a client with rheumatoid arthritis that the condition needs to be treated with gold therapy. The nurse interprets that the physician is referring to which of the following medications? a. Prednisone (Deltasone) b. Pentostatin (Nipent) c. Auranofin (Ridaura) d. Fludarabine (Fludara) Source: Saunders 4th

ANS: C Rationale: Auranofin is a gold preparation used to manage rheumatoid arthritis in clients with insufficient therapeutic response to nonsteroidal anti-inflammatory drugs (NSAIDs). Prednisone is a corticosteroid. Fludarabine and pentostatin are antineoplastic agents. Strategy: Use the process of elimination. Eliminate options 2 and 4 first because they are comparative or alike and are both antineoplastic agents. Regarding the remaining options, recalling that prednisone is a corticosteroid will direct you to option 3. Review the medications identified in the options if you are unfamiliar with them. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 107-108). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2695) A client has been given a prescription for a course of azithromycin (Zithromax). The nurse teaches the client that this medication will relieve which of the following? a. Joint inflammation b. High blood pressure c. Signs and symptoms of infection d. Pain Source: Saunders 4th

ANS: C Rationale: Azithromycin is a macrolide antibiotic used to treat infection. It is not used to treat pain, joint inflammation, or blood pressure. Strategy: Recall the classification of this medication. Noting mycin in the name of the medication will assist in determining that the medication is an antibiotic and will direct you to option 3. Review the action and use of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 113). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1368) A nurse is monitoring a client receiving baclofen (Lioresal) for side effects related to the medication. Which of the following would indicate that the client is experiencing a side effect? a. Diarrhea b. Polyuria c. Drowsiness d. Muscular excitability Source: Saunders 4th

ANS: C Rationale: Baclofen is a skeletal muscle relaxant and frequently causes drowsiness, dizziness, weakness, and fatigue. Baclofen also can cause nausea, constipation, and urinary retention. Clients should be warned about the possible reactions. Options 1, 2, and 4 are not side effects. Strategy: Use the process of elimination. Recalling that baclofen is a skeletal muscle relaxant used to treat muscle spasticity will direct you easily to option 3. If you had difficulty with this question, review the side effects of this medication. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 240). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1788) The client with diabetes mellitus has been instructed in the dietary exchange system. The client asks the nurse if bacon is allowed in the diet. Which nursing response is appropriate? a. "Bacon is much too high in fat." b. "Bacon is not allowed." c. "One strip of bacon may be eaten if you eliminate 1 teaspoon of butter." d. "Bacon may be eaten if you eliminate one meat item from your diet." Source: Saunders 4th

ANS: C Rationale: Bacon is a component of the fat group in the exchange system. One teaspoon of butter is equal to 1 teaspoon of margarine, 1 teaspoon of any oil, 1 tablespoon of salad dressing, one strip of bacon, five large olives, or ten whole peanuts. Strategy: Use the process of elimination. Eliminate options 1 and 2 because they are comparative or alike. Select option 3 over option 4, knowing that bacon is an item of the fat group. Review foods in the exchange system if you had difficulty with this question. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed., pp. 565, 572). St. Louis: Mosby. Reference: Nix, S. (2005). Williams' basic nutrition and diet therapy (12th ed., p. 379). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

1586) The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching instructions should include which most important statement? a. "Your hair will need to be shaved." b. "Deep breathing and coughing will be needed after surgery." c. "Brushing your teeth will not be permitted for at least 2 weeks following surgery." d. "You will receive spinal anesthesia." Source: Saunders 4th

ANS: C Rationale: Based on the location of the surgical procedure, spinal anesthesia would not be used. Additionally, the hair would not be shaved. Although coughing and deep breathing are important, specific to this procedure is avoiding brushing the teeth to prevent disruption of the surgical site. Strategy: Consider the anatomical location and the surgical procedure itself to eliminate options 1 and 4. Although you may be tempted to select option 2, note the strategic words most important. Because of the anatomical location of the surgery, option 3 is most important. Review this surgical procedure if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1331). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

2692) A client is told by the physician to take aluminum hydroxide (Amphojel) as needed for heartburn. The nurse advises the client to watch for which common side effect of this medication? a. Muscle pain b. Dizziness c. Constipation d. Excitability Source: Saunders 4th

ANS: C Rationale: Because of the antacid's aluminum base, aluminum hydroxide causes constipation as a side effect. The other side effect is hypophosphatemia, which is noted by monitoring serum laboratory studies. The other options are not side effects of this medication. Strategy: Note the name of this medication and recall that this medication is an antacid to direct you to option 3. Review the common side effects this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 46). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

143) A client has just undergone insertion of a central venous catheter at the bedside. The nurse would be sure to check the results of which of the following before initiating the flow rate of the client's IV solution at 100 mL/hr? a. Serum osmolality b. Serum electrolyte levels c. Portable chest x-ray film d. Intake and output record Source: Saunders 4th

ANS: C Rationale: Before beginning administration of IV solution, the nurse should assess whether the chest radiograph reveals that the central catheter is in the proper place. This is necessary to prevent infusion of IV fluid into pulmonary or subcutaneous tissues. The other options represent items that are useful for the nurse to be aware of in the general care of this client, but they do not relate to this procedure. Strategy: Use the process of elimination and note the words central venous catheter at the bedside. Recalling the potential complications associated with the insertion of central venous catheters will direct you to option 3. Review the principles of care for a central venous catheter after insertion if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 250). Philadelphia. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 313). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2052) A nurse is performing an assessment on a client with a diagnosis of Bell's palsy. The nurse would expect to observe which of the following in the client? a. Twitching on the affected side of the face b. Ptosis of the eyelid c. Facial drooping d. Periorbital edema Source: Saunders 4th

ANS: C Rationale: Bell's palsy is a one-sided facial paralysis caused by the compression of the facial nerve (cranial nerve VII). Assessment findings would include facial droop from paralysis of the facial muscles, increased lacrimation, painful sensations in the eye, face, or behind the ear, and speech or chewing difficulty. Options 1, 2, and 4 are not associated findings in Bell's palsy. Strategy: Use the process of elimination. Recalling that Bell's palsy is a type of paralysis will direct you to option 3. If you had difficulty with this question, review the characteristics associated with Bell's palsy. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2154). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2595) The home care nurse is performing an assessment on a client with a diagnosis of Bell's palsy. Which of the following assessment questions will elicit the most specific information regarding this client's disorder? a. "Do you have any tingling sensations around your mouth?" b. "Do you have any spasms in your throat?" c. "Are you having any difficulty chewing food?" d. "Do your eyes feel dry?" Source: Saunders 4th

ANS: C Rationale: Bell's palsy is a one-sided facial paralysis due to compression of the facial nerve. Manifestations include facial droop from paralysis of the facial muscles, increased lacrimation, painful sensations in the eye, face, or behind the ear, and speech or chewing difficulties. Strategy: Use the process of elimination. Recalling that palsy is a type of paralysis will direct you to option 3. Review the manifestations associated with Bell's palsy if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1024). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1852) A male client is seen in the hospital emergency department after injury to the right ankle. The client tells the nurse that he twisted his ankle while playing volleyball. The physician has prescribed topical BenGay cream for the injury. The nurse providing instruction about the medication tells the client: a. To apply the medication three times a day and place a heating pad on top of the area b. To avoid hazardous activities while using the cream because it causes drowsiness c. That the medication contains a combination of an analgesic and menthol d. That the onset of headache indicates a systemic reaction and the physician needs to be notified Source: Saunders 4th

ANS: C Rationale: BenGay is one of many products that are used for the temporary relief of muscular aches, rheumatism, arthritis, sprains, and neuralgia. These types of products contain combinations of analgesics, menthol, local antiseptics, and counterirritants. Heat or a heating pad should never be applied because irritation or burning of the skin could occur. The medication does not act in a systemic manner, nor does the medication produce drowsiness. Strategy: Use the process of elimination. Recalling that heat applied to the medication site can cause burning and that the medication is applied to a local region will assist in eliminating options 1, 2, and 4. If you had difficulty with this question, review this medication. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1226). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2377) A nurse has an order to administer bethanechol chloride (Urecholine) subcutaneously. Before giving this medication, the nurse ensures that which of the following medications is available? a. AquaMEPHYTON b. Calcium chloride c. Atropine sulfate d. Protamine sulfate Source: Saunders 4th

ANS: C Rationale: Bethanechol chloride is a cholinergic medication, which is associated with a high incidence of side effects when given subcutaneously instead of orally. The medication can produce a cholinergic reaction, and the antidote for this type of reaction is atropine sulfate. The other options are incorrect. Strategy: Recalling that bethanechol chloride is a cholinergic medication will assist in directing you to choose an anticholinergic medication as the correct option. If you had difficulty with this question, review the adverse effects and antidote associated with the use of bethanechol chloride. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 135). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1165) The client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of: a. Pyelonephritis b. Glomerulonephritis c. Trauma to the bladder or abdomen d. Renal cancer in the client's family Source: Saunders 4th

ANS: C Rationale: Bladder trauma or injury should be considered or suspected in the client with low abdominal pain and hematuria. Glomerulonephritis and pyelonephritis would be accompanied by fever and are thus not applicable to the client in this question. Renal cancer would not cause pain that is felt in the low abdomen; rather pain would be in the flank area. Strategy: Use the process of elimination. Eliminate options 1 and 2, knowing that any inflammatory disease or infection is accompanied by fever. Because this client is afebrile, these are not possible options. Use knowledge of anatomy and pain assessment to select option 3. Pain from renal cancer is a later finding and is localized in the flank area. Review renal assessment techniques if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1704). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2319) A child's fasting blood glucose levels range between 100 and 150 mg/dL daily. The before-dinner blood glucose levels are between 120 and 130 mg/dL, with no reported episodes of hypoglycemia. Mixed insulin is administered before breakfast and before dinner. The nurse evaluates that for this child: a. Dietary needs are being met for adequate growth and development. b. Dietary intake should be increased to avoid hypoglycemic reactions. c. Insulin doses are appropriate for food ingested and activity level. d. Exercise should be increased to reduce blood glucose levels. Source: Saunders 4th

ANS: C Rationale: Blood glucose levels are a measure of the balance between diet, medication, and exercise. Options 2 and 4 imply that the data analyzed are abnormal. The question presents no data for determining growth and development status, such as height, weight, age, or behavior. Supporting normal growth and development is an important goal in managing diabetes in children, but that is not what is being evaluated here. Strategy: Use the process of elimination. Focusing on the subject will assist in eliminating option 1. Knowledge of the normal blood glucose levels and the basic components of management of diabetes mellitus will assist in eliminating options 2 and 4. Additionally, the only option that identifies all three components of diabetic management is option 3. Review management of the child with diabetes mellitus if you had difficulty with this question. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., p. 1711). St. Louis: Mosby. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1471). St. Louis: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 482). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Child Health Alternate Question Types -> Multiple Choice

1112) A nurse is assessing the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following? a. Seating the client with arm bared, supported, and at heart level b. Using a cuff with a rubber bladder that encircles at least 80% of the limb c. Taking the blood pressure within 15 minutes after nicotine or caffeine ingestion d. Measuring the blood pressure after the client has been seated quietly for 5 minutes Source: Saunders 4th

ANS: C Rationale: Blood pressure should be taken with the client seated with the arm bared, positioned with support and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should not have smoked tobacco or taken caffeine in the 30 minutes preceding the measurement. The client should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured. Finally, two or more BP readings should be averaged. Strategy: Use the process of elimination, noting the strategic word avoiding. Looking for the option that identifies variables that interfere with accuracy (caffeine and nicotine) will direct you to option 3. Review this skill and procedure if you had difficulty with this question. Reference: Ignatavicius, D. & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 682). Philadelphia: W.B. Saunders. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills and techniques (6th ed., pp. 522-523). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1344) A client has Buck's extension traction applied to the right leg. The nurse would plan which of the following interventions to prevent complications of the device? a. Give pin care once a shift. b. Massage the skin of the right leg with lotion every 8 hours. c. Inspect the skin on the right leg at least once every 8 hours. d. Release the weights on the right leg for daily range-of-motion exercises. Source: Saunders 4th

ANS: C Rationale: Buck's extension traction is a type of skin traction. The nurse inspects the skin of the limb in traction at least once every 8 hours for irritation or inflammation. Massaging the skin with lotion is not indicated. The nurse never releases the weights of traction unless specifically ordered by the physician. There are no pins to care for with skin traction. Strategy: Use the process of elimination and the steps of the nursing process to answer this question. Option 3 is the only option that relates to assessment. Review care of the client in Buck's traction if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1201). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1804) The physician has ordered a clear liquid diet for a postoperative client. The nurse prepares to deliver the lunch tray to the client and checks the food tray to be sure that: a. Sodium foods are restricted. b. All food items are lukewarm in temperature. c. All food items are liquid at body temperature. d. At least one serving of low-fat milk is served. Source: Saunders 4th

ANS: C Rationale: By definition, a clear liquid diet offers foods that are liquid at body temperature. Also, clear liquid diets prohibit milk of any nature because they are not clear liquids. Sodium intake is occasionally restricted if the client is on strict sodium regulation; however, owing to the short-term nature of a clear liquid diet in the postoperative client and the limited nutritional content of the diet, electrolytes and minerals generally are lacking. To offer the client some variety and to stimulate tastebuds, foods of different temperatures should be offered on a clear liquid diet, ranging from frozen (e.g., Popsicles) to warm (e.g., tea). Strategy: The subject of the question is a clear liquid diet. Eliminate option 1 first because sodium is not necessarily restricted on a clear liquid diet. Eliminate option 2 next because a variety of textures and temperatures aid in the psychological acceptance of a clear liquid diet. Eliminate option 4 because a clear liquid diet does not allow milk. Review the components of a clear liquid diet if you had difficulty with this question. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed., p. 415). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1298, 1640). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1929) A nurse instructs a client about continuous ambulatory peritoneal dialysis (CAPD). Which of the following statements if made by the client indicates an accurate understanding of CAPD? a. "A portable hemodialysis machine is used so that I will be able to ambulate during the treatment." b. "A cycling machine is used so the risk for infection is minimized." c. "No machinery is involved, and I can pursue my usual activities." d. "The drainage system can be used once during the day and a cycling machine for 3 cycles at night." Source: Saunders 4th

ANS: C Rationale: CAPD closely approximates normal renal function, and the client will need to infuse and drain the dialysis solution several times a day. No machinery is used, and CAPD is a manual procedure. Strategy: Use the process of elimination. Read the options carefully, noting that options 1, 2, and 4 address the use of a cycling machine. Option 3 is the option that is different and correctly describes the procedure for CAPD. Review CAPD if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1758). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2172) A client taking carbamazepine (Tegretol) asks the nurse what to do if a dose is inadvertently missed. The nurse responds that the carbamazepine should be: a. Withheld until the next scheduled dose, which should then be doubled b. Withheld until the next scheduled dose c. Taken so long as it is not just before the next dose d. Call the physician Source: Saunders 4th

ANS: C Rationale: Carbamazepine is an anticonvulsant that should be taken around the clock, precisely as directed. If a dose is omitted, the client should take the dose as soon as it is remembered, so long as it is not immediately before the next dose. The medication should not be double-dosed. If more than one dose is omitted, the client should call the physician. Strategy: Use the process of elimination. A general rule of client teaching with medication is that medications are not double-dosed if one dose is missed. Therefore, eliminate option 1. Regarding the remaining options, knowing that the medication is an anticonvulsant will direct you to option 3. Review the principles related to the administration of medications if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 183). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 137). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1029) A client experiencing confusion and tremors is admitted to a nursing unit. An initial arterial blood gas report indicates that the Pa<sc>CO</sc>₂ level is 72 mm Hg, whereas the Pa<sc>O</sc>₂ level is 64 mm Hg. A nurse interprets that the client is most likely experiencing: a. Metabolic acidosis b. Respiratory alkalosis c. Carbon dioxide narcosis d. Carbon monoxide poisoning Source: Saunders 4th

ANS: C Rationale: Carbon dioxide narcosis is a condition that results from extreme hypercapnia, with carbon dioxide levels in excess of 70 mm Hg. The client experiences symptoms such as confusion and tremors, which may progress to convulsions and possibly coma. Strategy: Use the process of elimination, focusing on the data in the question. Noting that the carbon dioxide (CO₂) level is elevated will direct you to the correct option, CO₂ narcosis. Review the clinical manifestations associated with CO₂ narcosis if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1877, 1882). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 669, 1833). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1686) The nurse is employed in a prenatal clinic and is performing prenatal assessments on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which of the following clients would be at the lowest risk for development of postpartum thromboembolitic disorders? a. A 39-year-old women who reports that she smokes b. A 37-year-old women in her fourth pregnancy who is overweight c. A 26-year-old women with a family history of thrombophlebitis d. A women who is 22 years old with a first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis Source: Saunders 4th

ANS: C Rationale: Certain factors create a risk for the development of thromboembolitic disorders. These include smoking, varicose veins, obesity, a history of thrombophlebitis, women older than 35 years or who have had more than three pregnancies, and women who have had a cesarean birth. From the options presented, a 26-year-old woman with a family history of thrombophlebitis is least likely to develop thromboembolitic disorders in the postpartum period. Strategy: Use the process of elimination. Note the strategic words least likely in the question. Knowing that a woman older than 35 years of age is at risk will assist in eliminating options 1 and 2. From the remaining options, select option 3, because the woman described in option 4 actually has a history of thrombophlebitis. If you had difficulty with this question, review the predisposing factors and risks associated with thromboembolitic disorders. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., pp. 742-743). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

1469) A client is admitted to the hospital with a diagnosis of major depression, severe, single episode. The nurse assesses the client and identifies a nursing diagnosis of nutrition: less than body requirements, imbalanced, related to poor nutritional intake. The appropriate nursing intervention related to this diagnosis is: a. Weigh the client three times per week before breakfast. b. Explain to the client the importance of a good nutritional intake. c. Schedule brief nursing interactions with the client during several meals in which small portions are offered. d. Report the nutritional concern to the psychiatrist and obtain a nutritional consultation as soon as possible. Source: Saunders 4th

ANS: C Rationale: Change in appetite is one of the major symptoms of depression. Other symptoms include a depressed mood, increased fatigue, feelings of worthlessness, diminished ability to think, or indecisiveness and psychomotor agitation or retardation. Option 2 is incorrect because the client is experiencing poor concentration; thus, even if the client does understand the rationale, the client still may not be able to complete tasks. Weighing the client does not address how to increase nutritional intake. Reporting to the psychiatrist and the nutritionist is to some degree correct but does not present a method to increase food intake. Strategy: Use the process of elimination, focusing on the subject, poor nutritional status. Option 3 is the only option that addresses the imbalanced nutrition concretely and designs a method in which the client feasibly will increase the nutritional intake. Review care of the client with depression if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 215). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 529-530). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 245, 336). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1676) The nursery room nurse is assessing a newborn infant who was born to a mother who abuses alcohol. Which of the following assessment findings would the nurse expect to note? a. Lethargy b. Higher than normal birth weight c. Irritability d. A greater than normal appetite when feeding Source: Saunders 4th

ANS: C Rationale: Characteristic behaviors of the newborn infant with fetal alcohol syndrome (FAS) are not unlike behaviors similar to those of the drug-exposed newborn infant. These behaviors include irritability, tremors, poor feeding, and hypersensitivity to stimuli. Newborn infants with FAS are smaller at birth and present with failure to thrive. Head circumference and weight are most affected. Strategy: Use the process of elimination. Recalling that the behaviors of the FAS newborn infant are not unlike behaviors similar to those of the drug-exposed newborn infant will assist in directing you to option 3. If you had difficulty with this question, review characteristics of the newborn infant with FAS. Reference: Wong, D., Perry, S., Hockenberry, M., et al. (2006). Maternal child nursing care (3rd ed., pp. 842-843). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

1067) A client with no history of cardiovascular disease comes to the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which of the following questions would best help a nurse discriminate pain caused by a noncardiac problem? a. "Can you describe the pain to me?" b. "Have you ever had this pain before?" c. "Does the pain get worse when you breathe in?" d. "Can you rate the pain on a scale of 1 to 10, with 10 being the worst?" Source: Saunders 4th

ANS: C Rationale: Chest pain is assessed by using the standard pain assessment parameters (e.g., characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms). Options 1, 2, and 4 may or may not help discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration. Strategy: Use the process of elimination, focusing on the subject, pain resulting from a noncardiac problem. The three incorrect options, although appropriate to use in practice, are general assessment questions only. Option 3 will discriminate between a cardiac and noncardiac cause of pain. Review pain assessment measures for the client with a cardiovascular problem if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 636, 844, 847). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2096) A male client who is admitted for an unrelated medical problem is diagnosed with urethritis due to chlamydial infection. The nursing assistant assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. The nurse tells the assistant that: a. Enteric precautions should be instituted for the client. b. Contact isolation should be initiated, because the disease is highly contagious. c. Standard precautions are quite sufficient, because the disease is transmitted sexually. d. Gloves and mask should be used by caregivers in the client's room. Source: Saunders 4th

ANS: C Rationale: Chlamydial infection is a sexually transmitted disease and frequently is called nongonococcal urethritis in the male client. It requires no special precautions in delivery of nursing care. Caregivers cannot acquire the disease during administration of care, and use of standard precautions is the only necessary measure. Strategy: Use the process of elimination. Recalling that chlamydial infection is a sexually transmitted disease will direct you to option 3. Review the risks of transmission associated with chlamydial infection if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1131). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 512-513, 1895-1896). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

957) The nurse has given instructions to a client who has just been prescribed cholestyramine (Questran). Which statement by the client indicates a need for further instructions? a. I will continue taking vitamin supplements. b. This medication will help lower my cholesterol. c. This medication should only be taken with water. d. A high-fiber diet is important while taking this medication. Source: Saunders 4th

ANS: C Rationale: Cholestyramine (Questran) is a bile acid sequestrant used to lower the cholesterol level and client compliance is a problem because of its taste and palatability. The use of flavored products or fruit juices can improve the taste. Some side effects of bile acid sequestrants include constipation and decreased vitamin absorption. Strategy: Use the process of elimination and note the strategic words need for further instructions. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Noting the close-ended word only in option 3 will direct you to this option. Review the action and side effects of this class of medications if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 675-678). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1642) The parents of a child with a cleft lip are concerned and ask the nurse when the lip will be repaired. The nurse supportively tells the parents that: a. Cleft lip repair is usually performed between 6 months and 2 years. b. Cleft lip repair is usually performed by 6 months of age. c. Cleft lip repair is usually performed during the first weeks of life. d. Cleft lip cannot be repaired. Source: Saunders 4th

ANS: C Rationale: Cleft lip repair is usually performed during the first few weeks of life. Early repair may improve bonding and makes feeding much easier. Revisions may be required at a later age. Options 1, 2, and 4 are incorrect Strategy: Use the process of elimination. Option 4 can be easily eliminated first. Eliminate options 1 and 2 next, because they are comparative or alike. Review the management of cleft lip repair if you had difficulty with this question. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 872). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Child Health Alternate Question Types -> Multiple Choice

2329) A nurse is providing information to a client scheduled for a lumbar puncture. Which information will the nurse provide to the client? a. Food and fluids will be restricted until after the test. b. Maintaining bedrest after the test will not be necessary. c. An informed consent form will be required. d. The test will probably take about 2 hours. Source: Saunders 4th

ANS: C Rationale: Client preparation for a lumbar puncture includes obtaining an informed consent from the client. No dietary restrictions are required before the test. The client is told that the test will take approximately 15 to 60 minutes. The nurse needs to inform the client about the need for bedrest after the test. Strategy: Use the process of elimination. Think about the anatomical location of the procedure. Also, recalling that an informed consent is required for any invasive procedure will direct you to option 3. If you had difficulty with this question, review client preparation for a lumbar puncture. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 739). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2653) A hospitalized client is receiving clozapine (Clozaril) for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which of the following laboratory studies? a. Cholesterol level b. Blood urea nitrogen (BUN) c. White blood cell (WBC) count d. Platelet count Source: Saunders 4th

ANS: C Rationale: Clients taking clozapine can experience hematological adverse reactions, including agranulocytosis and mild leukopenia. The WBC count should be assessed before initiation of treatment and should be monitored closely during the use of this medication. The client also should be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. Options 1, 2, and 4 are incorrect. Strategy: Specific knowledge of the adverse effects of clozapine is required to answer this question. Recalling that the medication causes agranulocytosis will direct you to option 3. If you are unfamiliar with these adverse reactions and the laboratory studies that must be closely monitored, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 279). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1460) The nurse is caring for a male client diagnosed with catatonic stupor. The client is lying on the bed with his body pulled into a fetal position. The appropriate nursing intervention is which of the following? a. Ask direct questions to encourage talking. b. Leave the client alone and intermittently check on him. c. Sit beside the client in silence with occasional open-ended questions. d. Take the client into the dayroom with other clients so that they can help watch him. Source: Saunders 4th

ANS: C Rationale: Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond. Strategy: Eliminate option 2 because the client would not be left alone. Option 4 relies on other clients to care for this client, which is an inappropriate expectation. Asking direct questions of this client is not therapeutic. Option 3 provides for client supervision and communication as appropriate. Review care of the client with catatonic stupor if this question was difficult. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 221). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 404). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 414). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1484) The nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by: a. Engaging in immoral acts b. Always reinforcing self-approval c. Observing rigid rules and regulations d. Having the need always to make the right decision Source: Saunders 4th

ANS: C Rationale: Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help the clients manage their anxiety. Strategy: Use the process of elimination and focus on the subject, managing anxiety. Eliminate options 2 and 4 because of the close-ended word always. Option 1 is not characteristic of the client with anorexia. Review the characteristics associated with this disorder if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 11, 376-377). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 307). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1288) The nurse is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client? a. Speaking to the client at a slower rate b. Allowing plenty of time for the client to respond c. Completing the sentences that the client cannot finish d. Looking directly at the client during attempts at speech Source: Saunders 4th

ANS: C Rationale: Clients with aphasia after brain attack (stroke) often fatigue easily and have a short attention span. General guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner. The nurse would avoid shouting (because the client is not deaf), appearing rushed for a response, and letting family members provide all the responses for the client. Strategy: Use the process of elimination, noting the strategic words least helpful. These words indicate a negative event query and ask you to select an option that is an incorrect action. This question tests a fundamental concept in communicating with the aphasic client. If this question was difficult, review these communication strategies. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2112-2113, 2129-2130). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1042). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2216) A client is hospitalized with a diagnosis of viral hepatitis. To detect any difficulty with coping with this disease, the nurse should ask which of the following questions? a. "Are you losing weight?" b. "Do you rest sometime during the day?" c. "Have you enjoyed having visitors?" d. "Do you have a fever?" Source: Saunders 4th

ANS: C Rationale: Clients with hepatitis may experience anxiety due to an anticipated change in lifestyle or fear of prognosis. They also may have a disturbance in body image related to the stigma of having a communicable disease or a change in appearance due to jaundice. Option 3 relates to the client's possible feelings of not wanting to be seen by others because of altered appearance. Remember that the client with hepatitis is jaundiced. Strategy: Focus on the subject, coping with the disease. Recalling the psychosocial concerns with the client with hepatitis and addressing client feelings will direct you to option 3. Review psychosocial concerns related to the client with hepatitis if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1331). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 437). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2344) A nurse has given instructions for taking codeine sulfate to a client with a severe headache. The nurse interprets that the client understands the information presented if the client identifies which of the following as an important measure in taking this medication? a. Avoid all exercise to prevent lightheadedness. b. Avoid the use of stool softeners to prevent diarrhea. c. Increase fluid intake. d. Maintain a low-fiber diet. Source: Saunders 4th

ANS: C Rationale: Codeine sulfate can cause constipation, so the client is instructed to increase fluid intake to prevent this occurrence. A high-fiber diet and stool softeners may be prescribed to prevent constipation. All exercise is not avoided. Strategy: Use the process of elimination to answer the question. Eliminate option 1 first because of the word all. Regarding the remaining options, recalling that constipation is a side effect will direct you to option 3. If you had difficulty with this question, review nursing measures related to the administration of codeine sulfate. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 336). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 279). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2632) A client has begun using a xanthine bronchodilator. The nurse plans to teach the client to avoid which of the following beverages while taking this medication? a. Orange juice b. Cranberry juice c. Coffee d. Mineral water Source: Saunders 4th

ANS: C Rationale: Cola, coffee, and chocolate contain xanthine and should be avoided by the client taking a xanthine bronchodilator. The additional xanthine could lead to increased incidence of cardiovascular and central nervous system side effects. Options 1, 2, and 4 identify fluids that are allowed. Strategy: Use the process of elimination. Recalling that coffee contains xanthine will direct you to option 3. Review client education points related to these medications if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 593). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 390). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1587) The nurse caring for a client with Addison's disease would expect to note which of the following on assessment of the client? a. Obesity b. Edema c. Hypotension d. Hirsutism Source: Saunders 4th

ANS: C Rationale: Common manifestations of Addison's disease include postural hypotension from fluid loss, syncope, muscle weakness, anorexia, nausea and vomiting, abdominal cramps, weight loss, depression, and irritability. Options 1, 2, and 4 are not specific to this disorder. Strategy: Use the process of elimination and knowledge regarding the clinical manifestations associated with Addison's disease to answer this question. If you had difficulty with this question, review the clinical manifestations of this disorder. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1471). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

1635) When counseling a female Amish client, the nurse should: a. Speak only to the husband. b. Use complex medical terminology. c. Avoid using scientific or medical jargon. d. Stand close to the client and speak loudly. Source: Saunders 4th

ANS: C Rationale: Complex scientific or medical terminology should be avoided when counseling an Amish client (or any client). Some Amish societies prohibit education after eighth grade. When counseling a female Amish client, most often the husband and wife will want to discuss health care options together. Standing close and speaking loudly is inappropriate in most counseling situations. Strategy: Use knowledge of the Amish society and therapeutic communication techniques to answer this question. Options 2 and 4 can be eliminated first because option 4 is inappropriate and option 2 is not a therapeutic intervention. Option 1 can then be eliminated because of Amish cultural habits. Review Amish society and cultural beliefs if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 28). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2578) A nurse is developing a plan of care for a client who is receiving parenteral nutrition (PN). The nurse identifies assessments to be made to help identify complications related to the infusion of the PN solution. The care plan will include monitoring of which of the following? a. Pulse oximetry b. Apical rate c. Blood glucose levels d. Hemoglobin and hematocrit Source: Saunders 4th

ANS: C Rationale: Complications associated with PN therapy include hypoglycemia or hyperglycemia, infection, fluid overload, air embolism, and electrolyte imbalance. It is standard care to monitor blood glucose levels at 6-hour intervals to assess for hyperglycemia. Strategy: Use the process of elimination, focusing on the subject, complications of PN. Recalling that hyperglycemia is a potential complication will direct you to option 3. Review the complications of PN if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1433). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1305) The nurse is testing the coordinated functioning of cranial nerves III, IV, and VI. To do this correctly, the nurse would test the: a. Corneal reflex b. Pupil response to light c. Six cardinal fields of gaze d. Pupil response to light and accommodation Source: Saunders 4th

ANS: C Rationale: Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) have only motor components and control, in a coordinated manner, the six cardinal fields of gaze. This is tested by moving an object in six directions (involving horizontal and diagonal movements). Corneal reflex is the function of the trigeminal nerve (cranial nerve V). Pupillary response and accommodation is the function of cranial nerve III (oculomotor) alone. Strategy: If you look at this question carefully, you will see that each of the incorrect options has to do with pupillary reactions of some type. The correct option is the one that is different from the others. Being able to move the eyes through the six cardinal fields of gaze is a coordinated effort of three cranial nerves. Review cranial nerve testing if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2028). Philadelphia: W.B. Saunders. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills and techniques (6th ed., pp. 591-592). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1510) The nurse is preparing a discharge plan for the client who attempted suicide. The plan of care should focus on which of the following? a. Follow-up appointments b. Providing the hospital telephone number c. Contracts and immediate available crisis resources d. Encouraging the family always to be with the client Source: Saunders 4th

ANS: C Rationale: Crisis times may occur between appointments. Contracts facilitate the client feeling a responsibility for keeping a promise. This gives the client control. Option 4 is unrealistic. Providing telephone numbers will not ensure available and immediate crisis intervention. Strategy: Use the process of elimination. The subject of the question relates to the availability of immediate resources for the client if needed. Eliminate option 4 first because this is unrealistic. Options 1 and 2 will not necessarily provide immediate resources. Also, note the word immediate in the correct option. Review care of the client who has attempted suicide if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing. (3rd ed., pp. 565-566). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 380). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1814) A nurse is caring for a client with impaired mobility that occurred as a result of a stroke. The client has right-sided arm and leg weakness. The nurse suggests that the client use which of the following assistive devices to provide the best stability for ambulating? a. Crutches b. Single straight-legged cane c. Quad cane d. Walker Source: Saunders 4th

ANS: C Rationale: Crutches and a walker can be difficult to maneuver for a client with weakness on one side. A cane is better suited for the client with weakness of the arm and leg on one side; however, the quad cane would provide the most stability because of the structure of the cane and because a quad cane has four legs. Strategy: Focus on the disability of the client and on the strategic words best stability. Eliminate options 1 and 4 first because a client with weakness on one side would not be able to manipulate these types of assistive devices. Regarding the remaining options, focusing on the strategic words will assist in directing you to option 3. Review the types of assistive devices and their uses if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 948-949). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1961) A nurse in the ambulatory care unit is providing home care instructions to a client after cryotherapy for the treatment of malignant skin lesions. Which of the following statements would be appropriate for the nurse to include in the home care instructions for this client? a. "Clean the site with alcohol three times daily." b. "Avoid showering or taking baths until seen by the physician in 1 week." c. "Apply a warm damp wash cloth if discomfort occurs." d. "Apply ice to the site to prevent swelling." Source: Saunders 4th

ANS: C Rationale: Cryotherapy involves the local application of liquid nitrogen to the lesion that causes cell death and tissue destruction. Tissue freezing is followed in 1 to 2 days by hemorrhagic blister formation. The nurse instructs the client to clean the site with hydrogen peroxide to prevent secondary infection. A topical antibiotic also may be prescribed. Alcohol would cause irritation to the skin. There is no reason for the client to avoid showering or bathing. The application of a warm, damp wash cloth intermittently to the site will provide relief of any discomfort. Ice is not applied to the site. Strategy: Use the process of elimination. Eliminate option 2 first because there is no reason for the client to avoid showers. Recalling that alcohol will cause irritation to the site will assist in eliminating option 1. Knowing that this treatment involves local freezing of the skin will assist in eliminating option 4. If you are unfamiliar with this procedure, review home care measures after cryotherapy. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1573). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

1986) A home care nurse is making a monthly visit to a client with a diagnosis of pernicious anemia who has been receiving a monthly injection of cyanocobalamin (vitamin B₁₂). Before administering the injection, the nurse evaluates the effects of the medication and determines that a therapeutic effect is occurring if the client makes which of the following statements? a. "I feel really light-headed." b. "I have not had any pain in a month." c. "I feel stronger and have a much better appetite." d. "I no longer have any nausea." Source: Saunders 4th

ANS: C Rationale: Cyanocobalamin is essential for DNA synthesis. It can take up to 3 years for the vitamin B₁₂ stores to be depleted and for symptoms of pernicious anemia to appear. Symptoms can include weakness, fatigue, anorexia, loss of taste, and diarrhea. To correct deficiencies, a crystalline form of vitamin B₁₂, cyanocobalamin, can be given intramuscularly. The client statements in options 1, 2, and 4 do not identify a therapeutic effect of the medication. Strategy: Note the strategic words therapeutic effect is occurring. This will assist in eliminating option 1. Regarding the remaining options, noting that the medication is a vitamin will direct you to option 3. If you had difficulty with this question, review the action and the therapeutic effects of this medication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 295). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2514) A client with tuberculosis receiving cycloserine (Seromycin Pulvules) 250 mg PO twice daily must have blood drawn in 1 week to measure the serum concentration of the medication. The nurse prepares the client for this test by telling the client to: a. Withhold the evening dose before the test and the dose scheduled for the morning of the test. b. Double the dose the evening before the test and withhold the morning dose on the day of the test. c. Take the morning dose and have the blood drawn 2 hours after taking the dose. d. Withhold the morning dose on the day of the scheduled blood test. Source: Saunders 4th

ANS: C Rationale: Cycloserine is an antituberculosis medication that requires weekly serum drug level determinations to monitor for neurotoxicity and other adverse effects. Peak concentrations are measured 2 hours after dosing and should be between 25 and 35 mcg/mL. Strategy: Use the process of elimination. First, apply general principles of medication administration to eliminate options 1 and 2. Regarding the remaining options, noting the strategic words measure the serum concentration will direct you to option 3. Review the actions, uses, and administration of this medication if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 1024). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2402) A nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which of the following as the best indicator? a. Urinary output b. IV fluid intake c. Daily weight d. NG tube intake Source: Saunders 4th

ANS: C Rationale: Daily weight is the best indicator of fluid balance. Options 1, 2, and 4 are related to intake or output but are incomplete indicators of fluid balance. Strategy: Remember that the best indicator of fluid balance is weight. Also, note that options 1, 2, and 4 are comparative or alike. These options represent measurements of intake or output. Review methods to monitor fluid balance if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 215). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1841) A nurse has provided dietary instructions to a client with a diagnosis of peptic ulcer disease. Which statement if made by the client indicates an understanding of the dietary measures to take? a. "Citrus fruits and raw vegetables need to be included in my daily diet." b. "I can drink beer so long as I consume only a moderate amount each day." c. "Baked foods such as chicken or fish are all right to eat." d. "I can drink coffee or tea so long as I limit the amount to two cups daily." Source: Saunders 4th

ANS: C Rationale: Dietary modifications for the client with peptic ulcer disease includes eliminating foods that can cause irritation to the gastrointestinal (GI) tract. Items that should be eliminated or avoided include highly spiced foods, alcohol, caffeine, chocolate, and citrus fruits. Other foods may be taken according to the client's level of tolerance for that food. Strategy: Use the process of elimination identifying those foods that would be most irritating to the GI mucosa. This will direct you to option 3. Review these foods if you had difficulty with this question Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1301, 1304). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2659) A client has received a dose of dimenhydrinate (Dramamine). The nurse evaluates the effect of the medication by noting whether the client obtained relief from which of the following? a. Headache b. Chills c. Nausea and vomiting d. Ringing in the ears Source: Saunders 4th

ANS: C Rationale: Dimenhydrinate is used to treat and prevent the symptoms and signs of dizziness, vertigo, and nausea and vomiting that accompany motion sickness. The other options are incorrect. Strategy: Focus on the name of the medication. Recalling that this medication is used to treat motion sickness will direct you to option 3. Review the action and use of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 272). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1712) The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric (NG) tube in place. The client has tolerated the tube being clamped every 2 hours for 1 hour. The physician has now ordered the NG tube to be removed. Prior to removing the tube, the nurse assesses for: a. Proper NG tube placement b. Normal serum electrolyte levels c. The presence of bowel sounds in all four quadrants d. Normal pH of the gastric aspirate Source: Saunders 4th

ANS: C Rationale: Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid from the stomach, thus relieving distention and vomiting. Bowel sounds return to normal as the obstruction is resolved and normal bowel function is restored. Discontinuing the nasogastric tube prior to normal bowel function may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, tube placement, and pH of the gastric aspirate are important assessments for the client with a nasogastric tube in place, but would not assist in determining the readiness for removing the nasogastric tube. Strategy: Use the process of elimination. Eliminate options 1 and 4 first because they are comparative or alike. Assessing the pH of the gastric aspirate is one method of assessing tube placement. From the remaining options, focus on the subject and the client's diagnosis to direct you to option 3. Review abdominal assessment in the client with an intestinal obstruction if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1329-1330). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1408). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1142) A 66-year-old client complaining of not feeling well is seen in a clinic. The client is taking several medications for the control of heart disease and hypertension. These medications include atenolol (Tenormin), digoxin (Lanoxin), and chlorothiazide (Diuril). A tentative diagnosis of digoxin toxicity is made. Which of the following assessment data would support this diagnosis? a. Dyspnea, edema, and palpitations b. Chest pain, hypotension, and paresthesia c. Double vision, loss of appetite, and nausea d. Constipation, dry mouth, and sleep disorder Source: Saunders 4th

ANS: C Rationale: Double vision, loss of appetite, and nausea are early signs of digoxin toxicity. Additional signs of digoxin toxicity include bradycardia, difficulty reading, visual alterations such as green and yellow vision or seeing spots or halos, confusion, vomiting, diarrhea, decreased libido, and impotence. Strategy: Use the process of elimination. Recalling that gastrointestinal and visual disturbances occur with digoxin toxicity will direct you to option 3. If you had difficulty with this question, review the signs of digoxin toxicity. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 608-609). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1008) A nurse is suctioning fluids from a client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which of the following is the appropriate nursing intervention? a. Continue to suction. b. Notify the physician immediately. c. Stop the procedure and reoxygenate the client. d. Ensure that the suction is limited to 15 seconds. Source: Saunders 4th

ANS: C Rationale: During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated. Strategy: Use the process of elimination, recalling that suctioning can cause cardiac irregularities. Noting the strategic words heart rate is decreasing should direct you to option 3. If you had difficulty with this question, review the complications and interventions associated with suctioning procedures. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1888, 1890). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1779). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2065) A nurse is performing a neurovascular assessment on a client with a cast on the left lower leg. The nurse notes the presence of edema in the foot below the cast. The nurse would interpret that this finding indicates: a. Impaired arterial circulation b. The presence of an infection c. Impaired venous return d. Arterial insufficiency Source: Saunders 4th

ANS: C Rationale: Edema in the extremity indicates impaired venous return. Signs of impaired arterial circulation in the limb include coolness and pallor of the skin and a diminished arterial pulse. Signs of infection under a cast area would include odor or purulent drainage from the cast and the presence of "hot spots," which are areas of the cast that feel warmer to the touch than the rest of the cast. Strategy: Use the process of elimination and focus on the subject of the question and the description of the client's problem. Eliminate options 1 and 4 first because they are comparative or alike. Regarding the remaining options, recalling that edema indicates diminished or impaired venous return will assist in directing you to option 3. If you had difficulty with this question, review assessment findings in the client with a casted extremity. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 633). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2175) A nurse is caring for a client with myasthenia gravis who has received edrophonium (Tensilon) by the intravenous (IV) route to test for myasthenic crisis. The client asks the nurse how long the improvement in muscle strength will last. The nurse's response is based on the understanding that the effects have a duration of approximately: a. 5 minutes b. 10 minutes c. 30 minutes d. 60 minutes Source: Saunders 4th

ANS: C Rationale: Edrophonium commonly is given to test for myasthenic crisis. If the client is in myasthenic crisis, muscle strength improves after administration of the medication, and the improvement lasts for about 30 minutes. Options 1, 2, and 4 are incorrect. Strategy: Specific knowledge about the effects of this medication is needed to answer this question. Remember that edrophonium increases muscle strength for about 30 minutes. Review the expected effects if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 469). St. Louis: Mosby. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 370). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 303). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

61) A nurse caring for a client with hypocalcemia would expect to note which of the following changes on the electrocardiogram? a. Widened T wave b. Prominent U wave c. Prolonged QT interval d. Shortened ST segment Source: Saunders 4th

ANS: C Rationale: Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A shortened ST segment and a widened T wave occur with hypercalcemia. Prominent U waves occur with hypokalemia. Strategy: Use knowledge regarding the electrocardiographic changes that occur in a calcium imbalance to answer the question. Remember that hypocalcemia causes a prolonged ST or QT interval. If you had difficulty with this question, review the electrocardiographic changes that occur in these conditions. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 696). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1650) A 3-year-old child is seen in the health care clinic and a diagnosis of encopresis is made. The nurse reviews the assessment findings, expecting to note documentation of which sign of this disorder? a. Nausea and vomiting b. Diarrhea c. Evidence of soiled clothing d. Malaise and anorexia Source: Saunders 4th

ANS: C Rationale: Encopresis is defined as fecal incontinence and is a major concern if the child is constipated. Signs include evidence of soiling clothing, scratching or rubbing the anal area because of irritation, fecal odor without apparent awareness by the child, and social withdrawal. Strategy: Use the process of elimination and knowledge regarding the definition of encopresis to direct you to option 3. Remember that encopresis is defined as fecal incontinence. Review the assessment findings in this disorder if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1122). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Child Health Alternate Question Types -> Multiple Choice

8) A nursing student is discussing cultural diversity issues in a clinical conference when a nursing instructor asks the student to describe ethnocentrism. Which statement by the student indicates a lack of understanding of the issue of ethnocentrism? a. "It is a tendency to view one's own ways as best." b. "It is acting in a manner that is superior to other cultures." c. "It is imposing one's beliefs on individuals from another culture." d. "It is believing that one's own way is the only acceptable way." Source: Saunders 4th

ANS: C Rationale: Ethnocentrism is a tendency to view one's own way of life as the most desirable, acceptable, or best and to act in a superior manner toward another culture. Cultural imposition is the tendency to impose one's own beliefs, values, and patterns of behavior on individuals from another culture. Strategy: Use the process of elimination and note the strategic words indicates a lack of understanding in the question. Also, note that options 1, 2, and 4 are comparative or alike. If you had difficulty with this question, review culturally related concepts. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., p. 40). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1475) The nurse is reviewing a nursing plan of care formulated by a nursing student for a hospitalized client with bulimia nervosa. The nurse would question which intervention listed in the plan? a. Monitoring electrolyte levels b. Monitoring intake and output c. Observing for excessive exercise d. Checking for the presence of laxatives and diuretics in the client's room Source: Saunders 4th

ANS: C Rationale: Excessive exercise is a characteristic of anorexia nervosa, not a characteristic of clients with bulimia. Frequent vomiting, in addition to laxative and diuretic abuse, may lead to dehydration and electrolyte imbalance. Assessing for dehydration and electrolyte imbalance are important nursing actions. Option 3 is the only option that is not a characteristic of bulimia. Strategy: Use the process of elimination. Note the strategic words the nurse would question in the question. Options 1, 2, and 4 are comparative or alike and directly or indirectly imply concern about fluid and electrolyte balance. Option 3 is different from the other options. Review the characteristics associated with bulimia nervosa if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 385). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006) Foundations of psychiatric mental health nursing (5th ed., p. 306). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2132) A nurse has suggested specific leg exercises for a client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further instruction if the nurse observes the client: a. Pulling up using the trapeze b. Flexing and extending the feet c. Performing active range of motion to the right ankle and knee d. Doing quadriceps-setting and gluteal-setting exercises Source: Saunders 4th

ANS: C Rationale: Exercise is indicated within therapeutic limits for the client in skeletal traction to maintain muscle strength and range of motion. The client may pull up using the trapeze, perform active range of motion with uninvolved joints, and do isometric muscle-setting exercises (such as quadriceps- and gluteal-setting exercises). The client also may flex and extend the feet. Strategy: Use the process of elimination. Note the strategic words needs further instruction. This phrasing indicates a negative event query and asks you to select an incorrect action. Visualizing each option will assist in eliminating options 1 and 4. Regarding the remaining options, imagine the lines of pull on the fracture site with the movements described. Although flexing and extending the feet do not disrupt the line of pull from the traction, performing active range of motion to the affected knee and ankle does. Review care of the client in traction if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 637). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1297) The nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs reinforcement of information if the client makes which of the following statements? a. "I will wash my face with cotton pads." b. "I'll have to start chewing on the unaffected side." c. "I'll try to eat my food either very warm or very cold." d. "I should rinse my mouth sometimes if toothbrushing is painful." Source: Saunders 4th

ANS: C Rationale: Facial pain can be minimized by using cotton pads to wash the face and using room temperature water. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If toothbrushing triggers pain, sometimes an oral rinse after meals is helpful instead. Strategy: Use the process of elimination, and note the strategic words needs reinforcement of information. These words indicate a negative event query and ask you to select an option that is incorrect. Recall that the pain of trigeminal neuralgia is triggered by mechanical or thermal stimuli. Very hot or cold foods are likely to trigger the pain, not relieve it. Review client education points if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2154). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1604). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2082) A client with renal cell carcinoma of the left kidney is scheduled for nephrectomy. The right kidney appears normal at this time. The client is anxious about whether dialysis will ultimately be a necessity. The nurse should plan to use which information in discussions with the client? a. There is absolutely no chance of needing dialysis, because of the nature of the surgery. b. Dialysis could become likely, but it depends on how well the client complies with fluid restriction after surgery. c. One kidney is adequate to meet the needs of the body so long as it has normal function. d. There is a strong likelihood that the client will need dialysis within 5 to 10 years. Source: Saunders 4th

ANS: C Rationale: Fears about having only one functioning kidney are common in clients who must undergo nephrectomy for renal cancer. These clients need emotional support and reassurance that the remaining kidney should be able to fully meet the body's metabolic needs, so long as it has normal function. Strategy: Use the process of elimination. Eliminate option 1, noting the words absolutely no chance. Knowing that fluid restriction is unnecessary with a functioning kidney guides you to eliminate option 2 next. Regarding the remaining options, recall that a person can donate a kidney without adverse consequences or the need for dialysis. Applying that knowledge to this question would guide you to choose option 3 over option 4. Review care of the client scheduled for nephrectomy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 922). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1592) The nurse is developing a postoperative plan of care for a 40-year-old male Filipino client scheduled for an appendectomy. Which of the following will the nurse most appropriately include in the plan of care? a. Inform the client the he will need to ask for pain medication when needed. b. Offer pain medication when nonverbal signs of discomfort are identified. c. Offer pain medication on a regular basis as prescribed. d. Allow the client to maintain control and request pain medication on his own. Source: Saunders 4th

ANS: C Rationale: Filipinos view pain as part of living an honorable life. The client may appear stoic and be tolerant of a high degree of pain. Health care providers need to offer, and in fact encourage, pain relief interventions for the Filipino client who does not complain of pain despite physiological indicators. Option 3 is the most appropriate intervention to include in the plan of care. Strategy: Note the strategic words most appropriately. Use the process of elimination and knowledge of cultural responses to pain in the Filipino client to answer this question. If you had difficulty with this question, review the characteristics of this culture. Reference: Giger, J., & Davidhizar, R. (2004). Transcultural nursing (5th ed., pp. 439, 448) St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1239). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1088) A nurse is viewing the cardiac monitor in a client's room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do which of the following? a. Immediately defibrillate. b. Prepare for pacemaker insertion. c. Administer amiodarone (Cordarone) intravenously. d. Administer epinephrine (Adrenalin) intravenously. Source: Saunders 4th

ANS: C Rationale: First-line treatment of ventricular tachycardia in a client who is hemodynamically stable is the use of antidysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Defibrillation is used with pulseless ventricular tachycardia. Epinephrine would stimulate an already excitable ventricle and is contraindicated. Strategy: Use the process of elimination. Eliminate option 2, recalling that pacemakers are used most often to treat bradycardia and heart block. Knowing that epinephrine is a sympathomimetic eliminates option 4. From the remaining options, noting that the client is awake and alert will direct you to option 3. Review treatment for ventricular tachycardia if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 729, 732). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1016) A client with chest injury has suffered flail chest. A nurse assesses the client for which most distinctive sign of flail chest? a. Cyanosis b. Hypotension c. Paradoxical chest movement d. Dyspnea, especially on exhalation Source: Saunders 4th

ANS: C Rationale: Flail chest results from fracture of two or more ribs in at least two places each. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a telltale sign of flail chest. Strategy: Use the process of elimination, focusing on the strategic words most distinctive. Cyanosis and hypotension occur with many different disorders, so eliminate options 1 and 2 first. From the remaining options, choose paradoxical chest movement over dyspnea on exhalation by remembering that a flail chest has broken rib segments that move independently of the rest of the rib cage. Review the assessment findings in flail chest if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1901-1902). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 670). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1247) The nurse has conducted discharge teaching for a client who has had a fenestration procedure for the treatment of otosclerosis. Which of the following, if stated by the client, would indicate that teaching was effective? a. "It is okay to take a shower and wash my hair." b. "I can resume my tennis lessons starting next week." c. "I will take stool softeners as prescribed by my doctor." d. "I should drink liquids through a straw for the next 2 to 3 weeks." Source: Saunders 4th

ANS: C Rationale: Following ear surgery, the client needs to avoid straining when having a bowel movement. The client needs to be instructed to avoid drinking with a straw for 2 to 3 weeks, air travel, and coughing excessively. The client needs to avoid getting his or her head wet, washing hair, showering for 1 week, and rapidly moving the head, bouncing, and bending over for 3 weeks. Strategy: Use the process of elimination and note the strategic words teaching was effective. Consider the anatomical area of the client's condition and the surgical procedure in eliminating the incorrect options. If you had difficulty with this question, review client instructions following ear surgery. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1130). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

1856) An emergency department nurse is preparing to administer fomepizole (Antizol) to a client suspected of having ethylene glycol (antifreeze) intoxication. The nurse should prepare to administer this medication by which of the following methods? a. Direct intravenous (IV) bolus b. Diluting the medication in 1000 mL of lactated Ringer's and administering over a 4-hour period c. Diluting the medication in 100 mL of 0.9% normal saline and administering over 30 minutes d. Administering the medication through a nasogastric tube, followed by activated charcoal Source: Saunders 4th

ANS: C Rationale: Fomepizole is used for the treatment of known or suspected ethylene glycol (antifreeze) intoxication. It is administered via the IV route, is not administered undiluted, and is not administered by rapid IV infusion. It is diluted in at least 100 mL of 0.9% normal saline or 5% dextrose in water and administered over a 30-minute period. Strategy: Knowledge regarding the administration of this medication is required to answer this question. Eliminate option 4 because the medication is administered via the IV route. Eliminate option 2 next because of the time frame 4-hour period. Regarding the remaining options, it is necessary to know that the medication is not administered via IV bolus. Review the administration of this medication if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., pp. 574-575). St. Louis: Mosby. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., pp. 1248-1249). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1874) A nurse has provided instructions to a pregnant client who is preparing to take iron supplements. The nurse determines that the client understands the instructions if the client states that she will take the supplements with which of the following? a. Milk b. Tea c. Orange juice d. Coffee Source: Saunders 4th

ANS: C Rationale: Foods containing ascorbic acid will increase the absorption of iron. Calcium and phosphorus in milk and tannin in tea decreases iron absorption. Coffee binds iron and prevents it from being fully absorbed. Orange juice is the only item that contains ascorbic acid and will increase the absorption of iron supplements. Strategy: Use the process of elimination. Recalling that ascorbic acid increases the absorption of iron and knowledge of the food items that contain ascorbic acid will direct you to option 3. Review client teaching points related to the administration of iron if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 181). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

2353) An older client with rheumatoid arthritis has been instructed by the physician to take ibuprofen (Motrin) 300 mg orally four times daily. A home care nurse reading the medication order interprets that the prescribed dosage is: a. Higher than the normal adult dose b. An unusual dosage for this diagnosis c. The normal adult dose d. Lower than the normal adult dose Source: Saunders 4th

ANS: C Rationale: For acute or chronic rheumatoid arthritis or osteoarthritis, the normal oral adult dose for an older client is 400 to 800 mg three to four times daily. The other options are incorrect. Strategy: Knowledge of the normal dosage for ibuprofen is required to answer this question. Noting the diagnosis of the client in the question will assist in directing you to the correct option. Review the normal dosage for this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 599). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2222) Oral dantrolene sodium (Dantrium) has been prescribed for a client for the treatment of spasticity. The nurse understands that the usual maintenance adult dosage of this medication is which of the following? a. 50 mg daily b. 100 mg daily c. 100 mg twice daily d. 200 mg four times daily Source: Saunders 4th

ANS: C Rationale: For treatment of spasticity, dantrolene is administered orally. The initial dosage in adults is 25 mg once daily. The usual maintenance dosage is 100 mg two to four times daily. If beneficial effects do not develop within 45 days, dantrolene therapy should be discontinued. Strategy: Knowledge of the adult oral dosage is required to answer this question. Recall that this dosage is 100 mg two to four times daily. If you are unfamiliar with the maintenance dosage of this medication, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 314). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1405) The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome who is receiving foscarnet (Foscavir), an antiviral. The nurse checks the latest results of which of the following laboratory studies while the client is taking this medication? a. CD4 cell count b. Serum albumin level c. Serum creatinine level d. Lymphocyte count Source: Saunders 4th

ANS: C Rationale: Foscarnet (Foscavir) is toxic to the kidneys. The serum creatinine level is monitored before therapy, two or three times per week during induction therapy, and at least weekly during maintenance therapy. Foscarnet also may cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus, these levels also are measured with the same frequency. Strategy: Use the process of elimination. Recalling that this medication is nephrotoxic will direct you easily to option 3. Review this medication if you are unfamiliar with it. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 516). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1190) The client returns to the nursing unit following a pyelolithotomy for removal of a kidney stone. A Penrose drain is in place. Which of the following actions would the nurse include in the client's postoperative plan of care? a. Positioning the client on the affected side b. Irrigating the Penrose drain using sterile procedure c. Changing dressings frequently around the Penrose drain d. Weighing dressings and adding the amount to the output Source: Saunders 4th

ANS: C Rationale: Frequent dressing changes around the Penrose drain are required to protect the skin against breakdown from the urinary drainage. If urinary drainage is excessive, an ostomy pouch may be placed over the drain to protect the skin. A Penrose drain is not irrigated. Weighing the dressings is not necessary. Placing the client on the affected side will prevent a free flow of urine through the drain. Strategy: Use the process of elimination. Identify the subject of the question, which relates to the Penrose drain. This should provide you with the clue that drainage is expected. Eliminate option 4 as the least likely answer. Eliminate option 2 because a Penrose drain is not irrigated. Visualize the effect that positioning on the affected side will have on the client. Review postoperative pyelolithotomy care if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1704). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

102) A nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and includes which food item on the list? a. Oranges b. Broccoli c. Cream cheese d. Broiled haddock Source: Saunders 4th

ANS: C Rationale: Fruits and vegetables tend to be lower in fat because they do not come from animal sources. Fish is also naturally lower in fat. Cream cheese is a high-fat food. Strategy: Use the process of elimination and focus on the subject of the question, the high-fat food. Options 1 and 2 (fruit and vegetable) can be eliminated first. From the remaining options, remember that cheese is high in fat content. Review foods that are high in fat content if you had difficulty with this question. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed., p. 123). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1789) The client with heart disease is provided instructions regarding a low-fat diet. The nurse determines that the client understands the diet if the client states that a food item to avoid is: a. Apples. b. Oranges. c. Avocado. d. Cherries. Source: Saunders 4th

ANS: C Rationale: Fruits and vegetables, except avocado, olives, and coconut, contain minimal amounts of fat. Strategy: Use the process of elimination. Options 1 and 2 can be easily eliminated based on general knowledge regarding nutrition. From the remaining two options, remember that avocado is high in fat content. Review the food items high in fat content if you had difficulty with this question. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed., pp. 134-135, 698). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

100) A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse would offer which full liquid item to the client? a. Tea b. Gelatin c. Custard d. Popsicle Source: Saunders 4th

ANS: C Rationale: Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, and strained vegetable juices. A clear liquid diet consists of foods that are relatively transparent. The food items in options 1, 2, and 4 are clear liquids. Strategy: Focus on the subject, a full liquid item. Remember that a clear liquid diet consists of foods that are relatively transparent. This will assist you in eliminating options 1, 2, and 4. Review food items allowed on a clear liquid diet and a full liquid diet if you had difficulty with this question. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed., p. 417). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2607) A client receiving ganciclovir (Cytovene) has acquired immunodeficiency syndrome (AIDS) and cytomegalovirus (CMV) retinitis. Which of the following nursing actions is appropriate during the time the client is taking this medication? a. Monitoring blood glucose levels for elevation b. Administering the medication on an empty stomach only c. Providing the client with a soft toothbrush and an electric razor d. Applying pressure to venipuncture sites for at least 2 minutes Source: Saunders 4th

ANS: C Rationale: Ganciclovir causes neutropenia and thrombocytopenia, and these are the most frequent side effects. For this reason, the nurse implements the same precautions that are used for a client receiving anticoagulant therapy. These include providing a soft toothbrush and an electric razor to minimize risk of trauma that could result in bleeding. Pressure on venipuncture sites should be held for approximately 10 minutes. The medication may cause hypoglycemia, but not hyperglycemia. The medication does not have to be taken on an empty stomach. Strategy: Use the process of elimination. Eliminate option 2 first because of the close-ended word only. Recalling that ganciclovir causes neutropenia and thrombocytopenia, which necessitate use of the same precautions as with anticoagulant therapy, will direct you to option 3. Review the adverse effects of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 392). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2015) A nurse is preparing to insert a nasogastric (NG) tube as prescribed for the purpose of stomach decompression. The nurse reviews the physician's orders and anticipates that the physician will prescribe which type of suction pressure and control? a. Low and continuous b. High and intermittent c. Low and intermittent d. High and continuous Source: Saunders 4th

ANS: C Rationale: Gastric mucosa can be traumatized and pulled into the tube if the suction pressure is placed on high or if the suction is continuous. The suction should be set on low pressure and intermittent suction control. Strategy: Use the process of elimination. Recall that when an option contains two parts, both parts must be correct for the option to be the correct one. Also recall that gastric mucosa can be traumatized and pulled into the tube if the suction is on high and is continuous. Eliminate options 1, 2, and 4 because each of these options identifies either high or continuous suction. Review nursing care for the client with an NG tube attached to suction if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 345). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1398, 1406). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2260) A client receiving nitrofurantoin (Macrodantin) calls the clinic complaining of side effects related to the medication. Which of the following side effects would indicate the need to stop the treatment with this medication? a. Anorexia b. Nausea c. Cough and chest pain d. Diarrhea Source: Saunders 4th

ANS: C Rationale: Gastrointestinal (GI) effects are the most frequent adverse reactions to this medication and can be minimized by administering the medication with milk or meals. Pulmonary reactions manifested as dyspnea, chest pain, chills, fever, cough, and the presence of alveolar infiltrates on radiography would indicate the need to stop the treatment. These abnormalities typically resolve in 2 to 4 days after discontinuation of this medication. Strategy: Use the process of elimination. Eliminate options 1, 2, and 4 because they are comparative or alike in that they all are GI side effects. Review the side effects of this medicine if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 842). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2385) A client is scheduled to begin medication therapy with valproic acid (Depakene). The nurse looks for the results of which of the following laboratory tests before administering the first dose? a. Renal function tests b. Pancreatic enzyme studies c. Liver function tests d. Pulmonary function test Source: Saunders 4th

ANS: C Rationale: Gastrointestinal effects from valproic acid are common and typically mild, but hepatotoxicity, although rare, is serious. To minimize the risk of fatal liver injury, liver function is evaluated before initiation of treatment and periodically thereafter. The other options are unrelated to the use of this medication. Strategy: Use the process of elimination, noting the strategic words before administering the first dose. Recalling that hepatotoxicity is associated with the use of valproic acid will direct you to the correct option. If you are unfamiliar with this medication, review its side effects and toxic effects. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1193). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1880) A nurse is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy may require: a. Increased caloric intake b. Decreased caloric intake c. Increased insulin d. Decreased insulin Source: Saunders 4th

ANS: C Rationale: Glucose crosses the placenta, but insulin does not. High fetal demands for glucose, combined with the insulin resistance caused by hormonal changes in the last half of pregnancy, can result in elevation of maternal blood glucose levels. This increases the mother's demand for insulin. This is referred to as the diabetogenic effect of pregnancy. Caloric intake is not affected by diabetes. Strategy: Use the process of elimination and knowledge regarding the pathophysiology associated with diabetes mellitus to assist in answering the question. Eliminate options 1 and 2 first because diabetes mellitus does not change caloric needs. Recalling that the need for insulin may decrease in the first half of pregnancy and increase in the second half of pregnancy will direct you to option 3. Review the effects of diabetes mellitus on pregnancy and insulin needs if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., pp. 667, 670). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1801) A nursing instructor is observing a student nurse donning a pair of sterile gloves and preparing a sterile field. Which of the following observations if made by the instructor indicates that the student is performing the procedure incorrectly? a. The student uses the inner wrapper of the gloves as a sterile field. b. The student touches a glove on the overbed table, removes both gloves, and dons another sterile pair. c. The student dons the sterile gloves without washing the hands. d. The student puts on the right glove and then the left glove. Source: Saunders 4th

ANS: C Rationale: Hands must always be washed (even though sterile gloves are used) to keep germs from spreading. The inside wrapper provides an excellent area for usage because it is sterile. If the gloves touch anything unsterile, they must be considered contaminated, and a new package of gloves must be obtained and used. The order of placing gloves on is up to the user, so long as sterile technique is not broken. Strategy: Note the strategic word incorrectly. This phrasing indicates a negative event query and directs you to select an incorrect statement. Read each option carefully and use the process of elimination. Visualize each of the options, keeping the principles of sterile technique in mind. If you had difficulty with this question, review sterile technique with donning gloves. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 802-803). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1502) A client is admitted to the mental health unit following a serious attempt of suicide by hanging. The nurse's most important aspect of care is to maintain client safety. This is accomplished best by: a. Requesting that a peer remain with the client at all times b. Removing the client's clothing and placing the client in a hospital gown c. Assigning a staff member to the client who will remain with the client at all times d. Admitting the client to a seclusion room where all potentially dangerous articles are removed Source: Saunders 4th

ANS: C Rationale: Hanging is a serious suicide attempt. The plan of care must reflect action that will ensure the client safety. Constant observation status (one to one) with a staff member who is never less than an arm's length away is the best selection. Seclusion should not be the initial intervention, and the least restrictive measure should be used. Placing the client in a hospital gown and requesting that a peer remain with the client will not ensure a safe environment. Strategy: Use the process of elimination. Eliminate option 4 because seclusion should not be the initial intervention. Eliminate option 1 next, because the responsibility to safeguard a client is not the peer's responsibility. Eliminate option 2, because removing one's clothing will not maximize all possible safety strategies. Review nursing interventions for the client at risk for suicide if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 379). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 481). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1073) A nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which of the following disorders reported by the client is unlikely to play a role in exacerbating the heart failure? a. Atrial fibrillation b. Nutritional anemia c. Peptic ulcer disease d. Recent upper respiratory infection Source: Saunders 4th

ANS: C Rationale: Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget's disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia. Strategy: Use the process of elimination and note the strategic word unlikely. Remembering that heart failure is exacerbated by factors that increase the workload of the heart will assist you in eliminating options 1, 2, and 4. Review the precipitating factors associated with heart failure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 752, 754). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2049) A nurse is developing a plan of care for a client with a brain attack (stroke). The nurse notes documentation in the client's record that the client has right homonymous hemianopsia. Which of the following should the nurse include in the plan of care for the client? a. Approach the client from the right field of vision. b. Place personal articles on the client's right side. c. Instruct the client to turn the head to scan the right visual field. d. Place an eye patch on the left eye. Source: Saunders 4th

ANS: C Rationale: Homonymous hemianopsia is a loss of half of the visual field. The client should have objects placed in the intact fields of vision and the nurse should approach the client from the intact side. The nurse instructs the client to scan the environment and stands within the client's intact field of vision. The nurse should not patch the eye because the client does not have double vision. Strategy: Use the process of elimination. Recalling that the client loses half of the visual field will assist in directing you to option 3. If you had difficulty with this question, review care of the client with homonymous hemianopsia. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2114-2115). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1634) Hydrocolloid gel (DuoDerm) is prescribed for a client with a leg ulcer. The home health nurse is preparing a plan of care for the client and appropriately documents to: a. Change the DuoDerm daily. b. Apply the DuoDerm over a dry sterile dressing. c. Change the DuoDerm weekly. d. Apply the DuoDerm over a normal saline-soaked dressing. Source: Saunders 4th

ANS: C Rationale: Hydrocolloid gel (DuoDerm) contains hydroactive particles embedded in a polymer base, which are softened by wound moisture and act as a protective gel over healing tissue. It is applied directly to the wound and can be left in place for up to 7 days. Strategy: Use the process of elimination. Recall the purpose of this type of dressing to assist in directing you to option 3. Review the nursing interventions associated with the use of a protective dressing if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1589). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

56) A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia were present? a. Dry skin b. Decreased urinary output c. Hyperactive bowel sounds d. Increased specific gravity of the urine Source: Saunders 4th

ANS: C Rationale: Hyperactive bowel sounds indicate hyponatremia. Options 1, 2, and 4 are signs of hypernatremia. In hyponatremia, increased urinary output and decreased specific gravity of the urine would be noted. Dry skin occurs in deficient fluid volume. Strategy: Focus on the data in the question and the subject of the question. Recalling the signs of hyponatremia will direct you to option 3. If you had difficulty with this question, review the assessment signs associated with hyponatremia and hypernatremia. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 234). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1141). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1972) A nurse is reviewing the laboratory test results for a client with bladder cancer and bone metastasis. Which finding would alert the nurse that physician notification is required? a. Potassium level of 3.8 mEq/L b. Platelet count of 200,000/μL c. Calcium level of 15 mg/dL d. White blood cell (WBC) count of 6,000/μL Source: Saunders 4th

ANS: C Rationale: Hypercalcemia is a serum calcium level greater than 10.0 mg/dL. It most often occurs in clients who have bone metastasis and is a late manifestation of extensive malignancy. The presence of cancer in the bone causes the bone to release calcium into the bloodstream. Hypercalcemia is an ontological emergency and the physician needs to be notified. Options 1, 2, and 4 indicate normal laboratory values. Strategy: Use the process of elimination, noting that option 3 is the only option that indicates an abnormal value. Review the normal calcium level and oncological emergencies if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 312). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1697, 1701). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

2549) A nurse is reviewing the laboratory results of a client who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 7 mEq/L. On the basis of this laboratory result, the nurse would expect to note which of the following in the client? a. No specific signs or symptoms because this value is a normal level b. Tremors c. Respiratory depression d. Hyperactive reflexes Source: Saunders 4th

ANS: C Rationale: Hypermagnesemia may be classified as mild (serum magnesia level of 3 to 5 mEq/L), moderate (6 to 7 mEq/L), severe (10 to 11 mEq/L), and emergency (12 to 15 mEq/L). A client with a mild degree of hypermagnesemia usually is asymptomatic. Neurological depression begins to occur at magnesium levels of 6 to 7 mEq/L and is manifested by drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia. Strategy: Use the process of elimination. Knowing that the level identified in the question is elevated will assist in eliminating option 1. Next, eliminate options 2 and 4 because they are comparative or alike. Review the normal magnesium level and the assessment findings with elevated levels if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 752). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1411) The nurse is caring for a post-renal transplantation client taking cyclosporin (Sandimmune, Gengraf, Neoral). The nurse notes an increase in one of the client's vital signs and the client is complaining of a headache. What is the vital sign that is most likely increased? a. Pulse b. Respirations c. Blood pressure d. Pulse oximetry Source: Saunders 4th

ANS: C Rationale: Hypertension can occur in a client taking cyclosporine (Sandimmune, Gengraf, Neoral) and, because this client is also complaining of a headache, the blood pressure is the vital sign to be monitoring most closely. Other adverse effects include infection, nephrotoxicity, and hirsutism. Options 1, 2, and 4 are unrelated to the use of this medication. Strategy: Focus on the name of the medication and recall that this medication can cause hypertension. Review the adverse effects of this medication if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., pp. 795-797). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

2581) A nurse is reviewing the record of a client admitted to the hospital with a diagnosis of pheochromocytoma. The nurse reads the assessment findings and expects to note documentation of which major symptom associated with this condition? a. Diaphoresis b. Weight loss c. Hypertension d. Glycosuria Source: Saunders 4th

ANS: C Rationale: Hypertension is the major symptom associated with pheochromocytoma. Glycosuria, weight loss, and diaphoresis also are clinical manifestations of pheochromocytoma; however, they are not major symptoms. Strategy: Use the process of elimination. Recalling the pathophysiology associated with pheochromocytoma will direct you to option 3. Review this disorder if you are unfamiliar with this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 784, 1478). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

1735) The client is diagnosed with glaucoma. Which of the following assessment data gathered by the nurse identifies a risk factor associated with this eye disorder? a. A history of migraine headaches b. Frequent urinary tract infections c. Cardiovascular disease d. Frequent upper respiratory infections Source: Saunders 4th

ANS: C Rationale: Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma. Options 1, 2, and 4 do not identify risk factors associated with this eye disorder. Strategy: Use the process of elimination. Focusing on the subject, a risk factor associated with glaucoma, will direct you to option 3. If you had difficulty with this question review the risk factors associated with this disorder. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1945). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1097-1098). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1696) A young male client with type 1 diabetes mellitus tells the nurse that he might lose his job because he has been having frequent hypoglycemic reactions. His boss thinks that he is drunk during these episodes, and that he has been drinking on the job. Which action by the nurse would best assist this client to meet his needs? a. Contact the local employment office to help him find another job. b. Ask the client if he indeed has been drinking at work. c. Examine factors with the client that may be causing frequent hypoglycemic episodes. d. Ask the client what he does to treat his hypoglycemia. Source: Saunders 4th

ANS: C Rationale: Hypoglycemic reactions present as adrenergic symptoms of tremor, shakiness and nervousness, which are comparative or alike to the signs of alcohol intoxication. The best strategy to assist the client to meet his needs is to decrease the episodes of hypoglycemia by first identifying and then eliminating those factors that precipitate this event. Options 1 and 2 are inappropriate. Option 4 is not directly related to the subject of the question. Strategy: Use the process of elimination and therapeutic communication techniques. Option 1 presumes that the problem is unavoidable and thus the client is at fault. Option 2 presumes that the client may be drinking, and option 4 avoids the subject of the question. Review therapeutic communication techniques if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1295). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

1143) A client is being treated for acute congestive heart failure with intravenously administered bumetanide (Bumex). The vital signs are as follows: blood pressure, 100/60 mm Hg; pulse, 96 beats/min; and respirations, 24 breaths/min. After the initial dose, which of the following is the priority assessment? a. Monitoring weight loss b. Monitoring urine output c. Monitoring blood pressure d. Monitoring potassium level Source: Saunders 4th

ANS: C Rationale: Hypotension is a common side effect associated with the use of this medication. Options 1, 2, and 4 also require assessment but are not the priority. Strategy: Use the process of elimination and note the strategic word priority. Also, note that blood pressure is mentioned in the question and in option 3. Use of the ABCs—airway, breathing, and circulation—also will direct you to option 3. Review care of the client receiving this medication by the intravenous route if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 intravenous medications (22nd ed., p. 195) St. Louis: Mosby. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 160). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

141) The nurse hears an attending physician asking an intern to prescribe a hypotonic intravenous (IV) solution for a client. Which of the following IV solutions would the nurse expect the intern to prescribe? a. 5% dextrose in water b. 10% dextrose in water c. 0.45% sodium chloride d. 5% dextrose in 0.9% sodium chloride Source: Saunders 4th

ANS: C Rationale: Hypotonic solutions contain a lower concentration of salt or more water than an isotonic solution. A solution of 0.45% sodium chloride is hypotonic. A solution of 5% dextrose in water (D₅W) is isotonic. Solutions of 10% dextrose in water (D₁₀W) and 5% dextrose in 0.9% sodium chloride are hypertonic solutions. Strategy: Use the process of elimination. Note that options 1, 2, and 4 are comparative or alike. All these solutions contain dextrose. Option 3 is different from the other options. If you had difficulty with this question, review the tonicity of the various IV solutions. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 213, 247). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1136, 1196). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1007) A nurse is suctioning fluids from a client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: a. 1 minute b. 5 seconds c. 10 seconds d. 30 seconds Source: Saunders 4th

ANS: C Rationale: Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds. Strategy: Use the process of elimination. Recall that during suctioning, the client's airway is blocked; therefore, you should be able to eliminate options 1 and 4 easily. From the remaining options, eliminate option 2 because of the short time frame. Five seconds does not seem reasonable to achieve removal of secretions. Review the procedure for suctioning if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 557). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 579). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1006) A nurse is caring for a client after a bronchoscopy and biopsy. Which of the following signs, if noted in the client, should be reported immediately to the physician? a. Dry cough b. Hematuria c. Bronchospasm d. Blood-streaked sputum Source: Saunders 4th

ANS: C Rationale: If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure. Strategy: Use the process of elimination. Eliminate option 2 first because it is unrelated to the procedure. Next, eliminate option 1 because a dry cough may be expected. Noting that a biopsy has been performed will assist in eliminating option 4, because blood-streaked sputum would be expected. Note that option 3, the correct option, relates to the airway. If you had difficulty with this question, review postprocedure care following bronchoscopy with biopsy. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 297). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

169) A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother immediately to: a. Induce vomiting. b. Call an ambulance. c. Call the Poison Control Center. d. Bring the child to the emergency department. Source: Saunders 4th

ANS: C Rationale: If a poisoning occurs, the Poison Control Center should be contacted immediately. Vomiting should not be induced if the victim is unconscious or if the substance ingested is a strong corrosive or petroleum product. Bringing the child to the emergency department or calling an ambulance would not be the initial action because this would delay treatment. The Poison Control Center may advise the mother to bring the child to the emergency department and, if this is the case, the mother should call an ambulance. Strategy: Use the process of elimination and note the strategic word immediately. Eliminate options 2 and 4 because these options will delay treatment. Recalling that vomiting should not be induced if a corrosive substance was ingested will assist in eliminating option 1. Review poison control measures if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 992). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

997) The low-pressure alarm sounds on a ventilator. A nurse assesses the client and then attempts to determine the cause of the alarm. The nurse is unsuccessful in determining the cause of the alarm and takes what initial action? a. Administers oxygen b. Checks the client's vital signs c. Ventilates the client manually d. Starts cardiopulmonary resuscitation Source: Saunders 4th

ANS: C Rationale: If at any time an alarm is sounding and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and manual resuscitation is used to support respirations until the problem can be corrected. No reason is given to begin cardiopulmonary resuscitation. Checking vital signs is not the initial action. Although oxygen is helpful, it will not provide ventilation to the client. Strategy: Use the process of elimination. Read the question carefully, and note that the subject relates to adequate ventilation of the client. Focusing on this subject will direct you easily to option 3. If you are unfamiliar with the management of ventilators and alarms, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 666-667). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

967) The nurse teaches the client taking metoclopramide (Reglan) to withhold the medication immediately and call the physician if which sign or symptom occurs with long-term use? a. Anxiety or irritability b. Excessive drowsiness or excitability c. Uncontrolled rhythmic movements of the face or limbs d. Dry mouth not relieved by sugar-free hard candy Source: Saunders 4th

ANS: C Rationale: If the client experiences tardive dyskinesia (rhythmic movements of the face or limbs), the client should stop the medication and call the physician. These side effects may be irreversible. Excitability is not a side effect of this medication. Anxiety, irritability, and dry mouth are side effects that are not so harmful to the client. Strategy: Use the process of elimination, focusing on the strategic words withhold the medication immediately. Select option 3 because these effects are most harmful to the client. Review the side effects and adverse effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 762). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1357) A nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. The nurse immediately: a. Calls the physician b. Applies ice to the site c. Rewraps the stump with an elastic compression bandage d. Applies a dry sterile dressing and elevates it on one pillow Source: Saunders 4th

ANS: C Rationale: If the client with an amputation has a cast or elastic compression bandage that slips off, the nurse must wrap the stump immediately with another elastic compression bandage. Otherwise, excessive edema will form rapidly, which could cause a significant delay in rehabilitation. If the client had a cast that slipped off, the nurse would have to call the physician so that a new one could be applied. Elevation on one pillow is not going to impede the development of edema greatly once compression is released. Ice would be of limited value in controlling edema from this cause. If the physician were called, the order likely would be to reapply the compression dressing anyway. Strategy: Use the process of elimination. Recalling that excessive edema can form rapidly will direct you to option 3. Review care of the client after amputation if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1221). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2359) A nurse transcribes a medication order for ifosfamide (Ifex) for a client with a diagnosis of germ cell cancer of the testes. The nurse looks for another order for which of the following medications, which usually is administered with the antineoplastic medication? a. Prednisone (Deltasone) b. Melphalan (Alkeran) c. Mesna (Mesnex) d. Bleomycin sulfate (Blenoxane) Source: Saunders 4th

ANS: C Rationale: Ifosfamide is used to treat refractory germ cell cancer of the testes. Concurrent therapy with mesna and at least 2 L of oral or intravenous fluid daily will limit the toxicity of this medication, evidenced by bone marrow depression and hemorrhagic cystitis. Mesna is a detoxifying agent used to inhibit the hemorrhagic cystitis induced by ifosfamide. The medications in options 1, 2, and 4 are not routinely administered with ifosfamide. Strategy: Knowledge regarding the toxic effects related to the administration of ifosfamide is required to answer this question. Remember that mesna is concurrently administered with ifosfamide. If you are unfamiliar with these toxic effects and the detoxifying agent used concurrently with this medication, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 603). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2226) A client is intubated with an endotracheal (ET) tube by the anesthesiologist. What is the responsibility of the nurse with regard to checking for tube placement immediately after tube insertion? a. It is not the responsibility of the nurse to check for tube placement. b. Arrange for a chest radiograph. c. Auscultate the lungs for the presence of bilateral breath sounds. d. Instill air into the ET tube and listen for its being forced into the lungs. Source: Saunders 4th

ANS: C Rationale: Immediately after an ET tube is inserted, tube placement is verified by both auscultation and chest radiography. Auscultating the lungs would be the immediate action, and the nurse would auscultate for bilateral breath sounds. Option 4 is an inappropriate action. Strategy: Use the process of elimination. Noting the strategic word immediately in the question will direct you to option 3. Although a nurse will prepare the client for a chest radiograph, the immediate action is to auscultate for bilateral breath sounds. Review the procedure for checking ET tube placement after insertion if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 661). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2228) A client with a tracheostomy tube on a ventilator is at risk for impaired gas exchange. The nurse should assess for which of the following items as the best indicator of adequate ongoing respiratory status? a. Moderate amounts of tracheobronchial secretions b. Small to moderate amounts of frank blood suctioned from the tube c. Respiratory rate of 16 breaths/min d. Oxygen saturation of 91% Source: Saunders 4th

ANS: C Rationale: Impaired gas exchange could occur after tracheostomy from excessive secretions, bleeding into the trachea, restricted lung expansion due to immobility, or concurrent respiratory conditions. An oxygen saturation of 91% is less than optimal. A respiratory rate of 16 breaths/min is in the normal range. Strategy: Focus on the subject, the best indication of normal respiratory status. An oxygen saturation of 91% is suboptimal and is eliminated first. Bloody secretions (option 2) also are abnormal, although secretions may be blood tinged for a few days after tracheostomy insertion. Although tracheobronchial secretions may be expected, they are not the best indication of respiratory adequacy, making option 3 correct. Review care of the client after creation of a tracheostomy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1781, 1783-1784). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

907) The nurse is caring for a client following a Billroth II procedure. Which postoperative order should the nurse question and verify? a. Leg exercises b. Early ambulation c. Irrigating the nasogastric tube d. Coughing and deep-breathing exercises Source: Saunders 4th

ANS: C Rationale: In a Billroth II procedure, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically ordered by the physician. In this situation, the nurse should clarify the order. Options 1, 2, and 4 are appropriate postoperative interventions. Strategy: Note the strategic words question and verify. Eliminate options 1, 2, and 4 because they are general postoperative measures. Consider the anatomical location of the surgical procedure to assist in directing you to option 3. Review postoperative measures following a Billroth II procedure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1298, 1303). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1266) Ear drops are prescribed for an infant with otitis media. The most appropriate method to administer the ear drops to the infant is to: a. Pull up and back on the pinna and direct the solution onto the eardrum. b. Pull down and back on the pinna and direct the solution onto the eardrum. c. Pull down and back on the pinna and direct the solution toward the wall of the canal. d. Pull up and back on the ear lobe and direct the solution toward the wall of the canal. Source: Saunders 4th

ANS: C Rationale: In a child younger than 3 years, the pinna is pulled down and straight back. The infant should be turned on the side with the affected ear uppermost. With the nondominant hand, the pinna is pulled down and back. The medication is administered by aiming it at the wall of the canal rather than directly onto the eardrum. The infant should remain with the affected ear uppermost for 10 to 15 minutes to retain the solution. In the adult or a child older than 3 years, the pinna is pulled up and back to straighten the auditory canal. Strategy: Use the process of elimination. Eliminate options 1 and 2 because you would not direct ear solution directly onto the eardrum. Remember that in a child younger than 3 years, pulling the pinna down and straight back is the correct procedure for administering ear medications. Review the procedure for the administration of ear medications if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 35). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

2435) A nurse has developed a nursing care plan for the client with a burn injury. The nursing diagnosis states deficient fluid volume. Which of the following nursing interventions will the nurse include in the plan of care as a priority intervention? a. Obtain and record weight every other day. b. Monitor intake and output every shift. c. Monitor mental status every hour. d. Monitor vital signs every 4 hours. Source: Saunders 4th

ANS: C Rationale: In a client with a nursing diagnosis of deficient fluid volume secondary to a burn injury, vital signs should be monitored every hour until the client is hemodynamically stable. The weight should be obtained and recorded daily or twice daily, and intake and output measurements should be recorded on an hourly basis. The nurse should monitor the mental status of the client every hour for the first 48 hours. Strategy: Note the strategic word priority. Also carefully note the time frames in each of the options to assist in the process of elimination. Option 3 is the only option that identifies an hourly assessment. If you had difficulty with this question, review care of the client with a burn injury who has a deficient fluid volume. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1448). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

1323) The client with trigeminal neuralgia tells the nurse that acetaminophen (Tylenol) is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication? a. Sodium level of 140 mEq/L b. Prothrombin time of 12 seconds c. Direct bilirubin level of 2 mg/dL d. Platelet count of 400,000/mm³ Source: Saunders 4th

ANS: C Rationale: In adults, overdose of acetaminophen causes liver damage. Option 3 is an indicator of liver function and is the only option that indicates an abnormal laboratory value. The normal direct bilirubin level is 0 to 0.3 mg/dL. The normal platelet count is 150,000 to 400,000/mm³. The normal prothrombin time is 10 to 13 seconds. The normal sodium level is 135 to 145 mEq/L. Strategy: Use the process of elimination. Knowledge that acetaminophen causes liver damage and knowledge of normal laboratory results will assist you in answering this question. Option 3 is the only abnormal value. Also, of all the options, the bilirubin level is the laboratory value most directly related to liver function. Review the effects of toxicity from acetaminophen and normal laboratory values if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 13). Philadelphia: W.B. Saunders. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 326-327). Philadelphia: W.B. Saunders. Reference: Mosby. (2007). 2007 Mosby's nursing drug reference (20th ed., p. 76). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2536) A nurse is performing the oculocephalic response (doll's eyes maneuver) test on an unconscious client. The nurse turns the client's head and notes movement of the eyes in the same direction as for the head. The nurse should appropriately document these findings as: a. Insignificant b. Normal c. Abnormal d. Inconclusive Source: Saunders 4th

ANS: C Rationale: In an unconscious client, eye movements are an indication of brain stem activity and are tested by the oculocephalic response. When the doll's eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brain stem. Strategy: Use the process of elimination. Eliminate options 1 and 4 first because they are comparative or alike. Regarding the remaining options, it is necessary to know that the assessment finding noted in the question is an abnormal response. Review the oculocephalic response if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2055-2056). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

998) A nurse reviews the arterial blood gas values and notes a pH of 7.50, a Pco₂ of 30 mm Hg, and an HCO₃^- of 25 mEq/L. The nurse interprets these values as indicating: a. Metabolic acidosis, uncompensated b. Respiratory acidosis, uncompensated c. Respiratory alkalosis, uncompensated d. Metabolic acidosis, partially compensated Source: Saunders 4th

ANS: C Rationale: In respiratory alkalosis, the pH will be higher than normal and the P<sc>co</sc>₂ will be low. The normal pH is 7.35 to 7.45. The normal P<sc>co</sc>₂ is 35 to 45 mm Hg. The only option that reflects these conditions is option 3. Strategy: Remember that when an alkalotic condition exists, the pH will be high. Next, recall that in a respiratory alkalotic condition, the P<sc>co</sc>₂ will move in the opposite direction from the pH. The only option that represents these conditions is option 3. Compensation can be identified if the pH is within normal limits. Review the process of blood gas analysis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 290). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

35) A new nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that planning care delivery will be based on which characteristic of this type of nursing model of practice? a. A task approach method is used to provide care to clients. b. Managed care concepts and tools are used in providing client care. c. An RN (registered nurse) leads nursing personnel in providing care to a group of clients. d. A single RN is responsible for providing nursing care to a group of clients. Source: Saunders 4th

ANS: C Rationale: In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 4 identifies primary nursing. Strategy: Note that the subject of the question relates to team nursing. Keep this subject in mind and use the process of elimination. Option 3 is the only option that identifies the concept of a team approach. Review the various types of nursing delivery systems if you had difficulty with this question. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., pp. 317, 322). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 373). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Leadership and Management Alternate Question Types -> Multiple Choice

1) A nurse in an ambulatory care clinic is performing an admission assessment for an African-American client scheduled for a cataract removal with an intraocular lens implant. Which question would be inappropriate for the nurse to ask on an initial assessment? a. &quot;Do you ever experience chest pain?&quot; b. &quot;Do you have any difficulty breathing?&quot; c. &quot;Do you have a close family relationship?&quot; d. &quot;Do you frequently have episodes of headache?&quot; Source: Saunders 4th

ANS: C Rationale: In the African-American culture, asking personal questions on the initial contact or meeting is considered intrusive. African Americans are highly verbal and express feelings openly to family or friends, but what transpires within the family is viewed as private. Cardiovascular, respiratory, and neurological assessments include physiological assessments, which are the priority assessments. Strategy: Use Maslow's Hierarchy of Needs theory to answer the question. Note the strategic words inappropriate and initial. Options 1, 2, and 4 address physiological needs. Option 3 addresses the psychosocial need. Review characteristics of the African-American culture if you had difficulty with this question. Reference: Potter, P. & Perry, A. (2005) Fundamentals of nursing (6th ed., p. 124). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1798) The nurse is providing care to a Cuban American client who is terminally ill. Numerous family members are present most of the time and many of the family members are very emotional. The appropriate action is to: a. Restrict the number of family members visiting at one time. b. Inform the family that emotional outbursts are to be avoided. c. Request permission to move the client to a private room and allow the family members to visit. d. Contact the physician to speak to the family regarding their behaviors. Source: Saunders 4th

ANS: C Rationale: In the Cuban American culture, loud crying and other physical manifestations of grief are considered socially acceptable. Of the options provided, option 3 is the only one that identifies a culturally sensitive approach on the part of the nurse. Options 1, 2, and 4 are inappropriate nursing interventions. Strategy: Focus on the client(s) of the question, the family members. Use the process of elimination and therapeutic nursing interventions, recalling the characteristics of the culture and the importance of cultural sensitivity. This will direct you to option 3. If you had difficulty with this question, review the characteristics of this culture. Reference: Giger, J., & Davidhizar, R. (2004). Transcultural nursing (5th ed., pp. 231-233). St. Louis: Mosby. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 56). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

4) Which of the following meal trays would be appropriate for the nurse to deliver to a client of Jewish faith who follows a kosher diet? a. Pork roast, rice, vegetables, mixed fruit, milk b. Crab salad on a croissant, vegetables with dip, potato salad, milk c. Sweet and sour chicken with rice and vegetables, mixed fruit, juice d. Fettucini Alfredo with shrimp and vegetables, salad, mixed fruit, iced tea Source: Saunders 4th

ANS: C Rationale: In the Jewish religion, those who are kosher believe that the dairy-meat combination is not acceptable. Pork and pork products are not allowed in the traditional Jewish religion. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven-hoofed, and ritually slaughtered. Strategy: Use the process of elimination, recalling that the dairy-meat combination is not acceptable in those in this religious group who follow the kosher tradition. Option 2 contains crab and milk, and option 1 contains pork roast and milk. Option 4 can be eliminated because it includes shrimp. Review the dietary rules of this religious group if you had difficulty with this question. Reference: Mahan, L.K., & Escott-Stump, S. (2004). Krause's food, nutrition, & diet therapy (11th ed., p. 385). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1242) During a hearing assessment, the nurse notes that the sound lateralizes to the client's left ear with the Weber test. The nurse analyzes these results as: a. A normal finding b. The presence of nystagmus c. A sensorineural or conductive loss d. A conductive hearing loss in the right ear Source: Saunders 4th

ANS: C Rationale: In the Weber tuning fork test, the nurse places the vibrating tuning fork in the middle of the client's head, at the midline of the forehead, or above the upper lip over the teeth. Normally, the sound is heard equally in both ears by bone conduction. If the client has a sensorineural hearing loss in one ear, the sound is heard in the other ear. If the client has a conductive hearing loss in one ear, the sound is heard in that ear. Strategy: This is a difficult question and knowledge regarding analyzing the results of the Weber tuning fork test is required to answer this question. If you had difficulty with this question, review this hearing test. Also, review the Rinne tuning fork test. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1118). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

1724) The client is returned to the nursing unit following thoracic surgery with chest tubes in place. During the first few hours postoperatively, the nurse assesses for drainage and expects to note that it is: a. Serous b. Serosanguineous c. Bloody d. Bloody, with frequent small clots Source: Saunders 4th

ANS: C Rationale: In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience frequent clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing. Strategy: Recall that following thoracic surgery, there may be considerable capillary oozing for some hours in the postoperative period. This would lead you to choose the bloody drainage over serous or serosanguineous. Knowing that patent chest tubes do not allow blood to collect in the pleural space eliminates the option of blood with clots. Review the assessment measures required for the care of a client with a chest tube if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 617). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1380) A Cub Scout leader, who is a nurse preparing a group of Cub Scouts for an overnight camping trip, instructs the scouts about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further instructions? a. "I need to bring a hat to wear during the trip." b. "I should wear long-sleeved tops and long pants." c. "I should not use insect repellents because it will attract the ticks." d. "I need to wear closed shoes and socks that can be pulled up over my pants." Source: Saunders 4th

ANS: C Rationale: In the prevention of Lyme disease, individuals need to be instructed to use an insect repellent on the skin and clothes when in an area where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. If possible, heavily wooded areas or areas with thick underbrush should be avoided. Socks can be pulled up and over the pant legs to the prevent ticks from entering under clothing. Strategy: Use the process of elimination and note the strategic words need for further instructions. These words indicate a negative event query and ask you to select an option that is incorrect. Note that option 3 uses the words should not. Reading carefully will assist in directing you to this option. If you had difficulty with this question, review the measures to prevent contact with ticks. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 418). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1443) A nurse employed in a mental health unit of a hospital is the leader of a group psychotherapy session. The nurse's role in the termination stage of group development is to: a. Encourage problem-solving. b. Encourage accomplishment of the group's work. c. Acknowledge the contributions of each group member. d. Encourage members to become acquainted with one another. Source: Saunders 4th

ANS: C Rationale: In the termination stage, the group leader's task is to acknowledge the contributions of each member and the experience of the group as a whole. In this stage, the group members prepare for separation and assist each other to prepare for the future. Options 1 and 2 identify the tasks of the working stage. Option 4 identifies the orientation stage. Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are comparative or alike. From the remaining options, note the relationship between the words termination stage in the question and option 3. Review the stages of group development if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 444). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 719). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1241) The nurse is performing a voice test to assess hearing. Which of the following describes the accurate procedure for performing this test? a. Whisper a statement while the client blocks both ears. b. Whisper a statement with the examiner's back facing the client. c. Whisper a statement and ask the client to repeat it while blocking one ear. d. Stand 4 feet away from the client to ensure that the client can hear at this distance. Source: Saunders 4th

ANS: C Rationale: In the voice test, the examiner stands 1 to 2 feet away from the client and asks the client to block one external ear canal. The nurse whispers a statement and asks the client to repeat it. Each ear is tested separately. Strategy: Use the process of elimination. Eliminate options 1 and 2 because they are not measures that would assess hearing effectively. Eliminate option 4 because distance hearing is not the subject of the question. Review the procedure for performing a voice test if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p 1118). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

1185) The nurse is reviewing the list of components contained in the peritoneal dialysis solution with the client. The client asks the nurse about the purpose of the glucose contained in the solution. The nurse bases the response on knowing that the glucose: a. Decreases the risk of peritonitis b. Prevents disequilibrium syndrome c. Increases osmotic pressure to produce ultrafiltration d. Prevents excess glucose from being removed from the client Source: Saunders 4th

ANS: C Rationale: Increasing the glucose concentration makes the solution more hypertonic. The more hypertonic the solution, the higher the osmotic pressure for ultrafiltration and thus the greater the amount of fluid removed from the client during an exchange. Options 1, 2, and 4 do not identify the purpose of the glucose. Strategy: Use the process of elimination. Knowledge regarding the principles related to ultrafiltration will direct you to option 3. If you had difficulty with this question, review dialysate solutions for peritoneal dialysis. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1758). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

901) The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client's record, would the nurse question? a. Digoxin (Lanoxin) b. Furosemide (Lasix) c. Indomethacin (Indocin) d. Propranolol hydrochloride (Inderal) Source: Saunders 4th

ANS: C Rationale: Indomethacin (Indocin) is a nonsteroidal anti-inflammatory drug and can cause ulceration of the esophagus, stomach, or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Furosemide (Lasix) is a loop diuretic. Digoxin is a cardiac medication. Propranolol (Inderal) is a β-adrenergic blocker. Furosemide, digoxin, and propranolol are not contraindicated in clients with gastric disorders. Strategy: Identify the classification of each of the medications listed. Use the process of elimination, selecting option 3 because this medication is the one that would affect the gastrointestinal tract. Review these medications if you are unfamiliar with them. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1285-1286). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., pp. 446-447). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1940) A client is about to begin hemodialysis. Which of the following measures should the nurse avoid in the care of the client? a. Giving the client a mask to wear during connection to the machine b. Wearing full protective clothing such as goggles, mask, gloves, and apron c. Covering the connection site with a bath blanket to enhance extremity warmth d. Using sterile technique for needle insertion Source: Saunders 4th

ANS: C Rationale: Infection is a major concern with hemodialysis. For that reason, the use of sterile technique and the application of a face mask for both nurse and client are extremely important. It also is imperative that standard precautions be followed, which includes the use of goggles, mask, gloves, and an apron. The connection site should not be covered; it should be visible so that the nurse can assess for bleeding, ischemia, and infection at the site during the hemodialysis procedure. Strategy: Use the process of elimination and note the strategic word avoid. Recalling the importance of both strict asepsis and standard precautions will direct you to option 3. Review care of the client receiving hemodialysis if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 967). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1019) A nurse is teaching a client with chronic respiratory failure how to use a metered-dose inhaler correctly. The nurse instructs the client to: a. Inhale quickly. b. Inhale through the nose. c. Hold the breath after inhalation. d. Take two inhalations during one breath. Source: Saunders 4th

ANS: C Rationale: Instructions for using a metered-dose inhaler include shaking the canister, holding it right side up, inhaling slowly and evenly through the mouth, delivering one spray per breath, and holding the breath after inhalation. Strategy: This question tests a fundamental concept of medication administration using inhalers. Visualize the procedure and use the process of elimination to direct you to option 3. If you selected the incorrect option, review the key principles of this medication therapy. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 593). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1690) The nurse is preparing to administer an IV insulin injection. The vial of Regular insulin has been refrigerated. On inspection of the vial, the nurse finds that the medication is frozen. The nurse should: a. Wait for the insulin to thaw at room temperature. b. Check the temperature settings of the refrigerator. c. Discard the insulin and obtain another vial. d. Rotate the vial between the hands until the medication becomes liquid. Source: Saunders 4th

ANS: C Rationale: Insulin should not be frozen. If the nurse notes that the vial of insulin is frozen, the insulin is discarded and a new vial is obtained. Options 1, 2, and 4 are incorrect actions. Strategy: Use the process of elimination. Eliminate options 1 and 4 because they are comparative or alike. From the remaining options, option 3 is most directly related to the subject of the question. Review insulin storage principles if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 778). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

1375) A nurse is administering an intravenous dose of methocarbamol (Robaxin) to a client with multiple sclerosis. For which of the following adverse effects would the nurse monitor? a. Tachycardia b. Rapid pulse c. Bradycardia d. Hypertension Source: Saunders 4th

ANS: C Rationale: Intravenous administration of methocarbamol can cause hypotension and bradycardia. The nurse needs to monitor for these side effects. Options 1, 2, and 4 are not a concern with administration of this medication. Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are comparative or alike. Knowledge about the specific side effects related to the intravenous use of this medication will direct you to option 3. Remember that hypotension and bradycardia can occur with intravenous administration of methocarbamol. Review this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 749). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2396) A client will be receiving ritodrine by the intravenous route to prevent preterm labor. The nurse places highest priority on which nursing diagnosis formulated for this particular client? a. Risk for hypoglycemia b. Risk for hypertension c. Risk for excess fluid volume d. Risk for deficient fluid volume Source: Saunders 4th

ANS: C Rationale: Intravenous ritodrine can cause pulmonary edema, and the client should be monitored for fluid overload. If pulmonary edema develops, the infusion should be discontinued and standard treatment implemented. The client also is at risk for hypotension and hyperglycemia during infusion of this medication. Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are not nursing diagnoses but rather are medical diagnoses. Regarding the remaining options, recalling the adverse effects of this medication will direct you to option 3. Review the action and effects of this medication if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 746). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1958) Isotretinoin (Accutane) has been prescribed for an adolescent with a diagnosis of severe cystic acne. The nurse provides instructions to the adolescent regarding the use of the medication. Which statement if made by the adolescent indicates a need for further instruction? a. "If my lips begin to burn, this is probably due to the medication." b. "My eyes may become dry and burn as a result of the medication." c. "I need to be sure to take my vitamin A supplement so that the treatment will work." d. "I will return to the clinic for blood tests." Source: Saunders 4th

ANS: C Rationale: Isotretinoin is used to inhibit inflammation in the client with severe cystic acne. Adverse effects include elevated triglycerides, skin dryness, and eye discomfort such as dryness and burning. Lip inflammation called cheilitis also can occur. Vitamin A supplements are stopped during this treatment because of their additive effects. Strategy: Use the process of elimination. Note the strategic words need for further instruction. This phrasing indicates a negative event query and directs you to select an incorrect statement. Recalling that vitamin A provides an additive effect will direct you to option 3. Review this medication and the client teaching points if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 647). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 647). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1569) The nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diabetic diet. Which statement, if made by the client, indicates a need for further teaching? a. "I need to drink diet soft drinks." b. "I&#39;ll eat a balanced meal plan." c. "I need to purchase special dietetic foods." d. "I&#39;ll snack on fruit instead of cake." Source: Saunders 4th

ANS: C Rationale: It is important to emphasize to the client and family that they are not eating a diabetic diet but rather a balanced meal plan. Adherence to nutrition principles is an important component of diabetic management and an individualized meal plan should be developed for the client. It is not necessary for the client to purchase special dietetic foods. Strategy: Use the process of elimination. Note the strategic words indicates a need for further teaching. These words indicate a negative event query and ask you to select an option that is incorrect. Careful reading of this question and the options will easily direct you to the correct option. Review dietary instructions for the client with diabetes mellitus if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1526-1529). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

2199) The mother of a teenage client with an anxiety disorder is concerned about her daughter's progress on discharge. She states that her daughter stashes food, eats all the foods that make her hyperactive, and hangs out with the "wrong crowd." In helping the mother prepare for her daughter's discharge, the nurse instructs her to: a. Restrict the daughter's socializing time with her friends. b. Consider taking time off from work to help her daughter readjust to the home environment. c. Restrict the amount of chocolate and caffeine products in the home. d. Keep her daughter out of school until she can adjust to the school environment. Source: Saunders 4th

ANS: C Rationale: It is recommended that clients with anxiety disorder abstain from or limit their intake of caffeine, chocolate, and alcohol. These products have the potential of increasing anxiety. Options 1 and 4 are unreasonable and are an unhealthy approach. It may not be realistic for a family member to take time off from work. Strategy: Use the process of elimination. Eliminate options 1, 2, and 4 because they are concerned with monitoring or curtailing the client's physical activities. Option 3 addresses preparation of the environment and also focuses on the concern or subject identified in the question. Review home care measures for a client with an anxiety disorder if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 266). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 247). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2327) Itraconazole (Sporanox) is prescribed for a client with a fungal infection of the hands. A nurse provides instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions? a. "I should take the medication on an empty stomach." b. "I should decrease my fluid intake while taking the medication." c. "If my urine becomes very dark in color, I should contact the physician." d. "I may become unusually fatigued while taking this medication." Source: Saunders 4th

ANS: C Rationale: Itraconazole is an antifungal medication. The client should be instructed to take the medication with food because it increases the absorption of the medication. Fluid should be increased to prevent constipation, which can occur as a side effect. Hepatitis is an adverse reaction associated with the medication, and if anorexia of any degree, abdominal pain, unusual tiredness or weakness, or jaundice develops, the physician should be notified. Strategy: Use the process of elimination, noting the strategic words indicates an understanding. Recalling that the presence of dark urine may indicate liver dysfunction will direct you to option 3. If you difficulty with this question, review client teaching points related to the administration of itraconazole. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 470). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

947) The nurse is caring for a Black client who has a diagnosis of acute viral hepatitis. The nurse assesses for jaundice by checking which specific area? a. Skin b. Nail beds c. Hard palate of the mouth d. Flexor surfaces of the extremities Source: Saunders 4th

ANS: C Rationale: Jaundice occurs in the skin and mucous membranes. In light-skinned persons, jaundice first is seen in the sclera of the eyes and later in the skin. In dark-skinned persons, jaundice is observed in the inner canthus of the eyes and hard palate of the mouth. Pallor is detected in the nail beds, and flushing associated with increased body temperature is best noted on the flexor surfaces of the extremities. Strategy: Use the process of elimination. Recalling that jaundice is not observed in the skin of a dark-skinned client will assist you in eliminating options 1 and 4. Knowing that pallor is assessed in the nail beds will direct you to option 3. Review assessment techniques if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 483). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1381) The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which of the following? a. Swelling in the genital area b. Swelling in the lower extremities c. Punch biopsy of the cutaneous lesions d. Appearance of reddish-blue lesions noted on the skin Source: Saunders 4th

ANS: C Rationale: Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions. Strategy: Use the process of elimination. Eliminate options 1 and 2 first because these symptoms occur late in the development of Kaposi's sarcoma. From the remaining options, note the strategic word confirmed. This strategic word will assist in directing you to the option that will confirm the diagnosis, the biopsy of the lesions. Review diagnostic measures for Kaposi's sarcoma if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2393). Philadelphia: W.B. Saunders. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., p. 1157). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

2485) A client with acquired immunodeficiency syndrome (AIDS) is suspected of having cutaneous Kaposi's sarcoma. The nurse prepares the client for which of the following tests to confirm the presence of this type of sarcoma? a. Sputum culture b. Liver biopsy c. Punch biopsy of the cutaneous lesions d. White blood cell count Source: Saunders 4th

ANS: C Rationale: Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis to the upper body then to the face and oral mucosa. The lymphatic system, lungs, and gastrointestinal (GI) tract can become involved as well. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is by punch biopsy of cutaneous lesions and biopsy of pulmonary and GI lesions. Options 1, 2, and 4 are incorrect. Strategy: Use the process of elimination. Note the strategic word confirm. Also, noting the relationship between the word cutaneous in the question and in the correct option will direct you to option 3. Review diagnosis of Kaposi's sarcoma if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 1387, 2393. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., p.1157). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1747) The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which of the following laboratory results would the nurse expect to note if the client does indeed have appendicitis? a. Leukopenia with a shift to the right b. Leukocytosis with a shift to the right c. Leukocytosis with a shift to the left d. Leukopenia with a shift to the left Source: Saunders 4th

ANS: C Rationale: Laboratory findings do not establish the diagnosis of appendicitis, but there is often a moderate elevation of the white blood cell (WBC) count (leukocytosis) to 10,000 to 18,000/mm³ with a shift to the left (an increased number of immature WBCs). Strategy: Use the process of elimination. Knowledge that an inflammatory process causes a rise in the WBC count will assist in eliminating options 1 and 4. From the remaining options, it is necessary to understand the significance of a shift to the left. If you are unfamiliar with the meaning of shift to the left, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1339). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2022) An ambulatory care nurse is providing instructions to a client who underwent a laser trabeculoplasty for the treatment of primary open-angle glaucoma. Which statement if made by the client would indicate an understanding of the post-procedure instructions? a. "I should resume the vision that I lost within 1 week." b. "I'm so glad that I had this type of surgery because I can resume all my activities immediately." c. "I need to avoid activities that cause straining." d. "I can lift objects as long as they do not weigh more than 35 pounds." Source: Saunders 4th

ANS: C Rationale: Laser trabeculoplasty is performed in an outpatient/ambulatory care department and takes about 30 minutes. The client may resume all normal activity including returning to work within 1 to 2 days as prescribed. The client should avoid activities that produce strain immediately after the procedure. This procedure can prevent further visual loss, but lost vision cannot be restored. The client should avoid lifting heavy objects because this will produce strain on the surgical site. Thirty-five pounds is an excessive amount of weight. Strategy: Use the process of elimination. Recall that in glaucoma, vision lost will not be regained. Eliminate option 2 because of the word immediately. Eliminate option 4 because 35 pounds is an excessive amount of weight and lifting objects of this weight can increase intraocular pressure. Review the purpose of and precautions with this procedure if you are unfamiliar with this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1099). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1688) A client diagnosed with hypothyroidism is taking levothyroxine (Synthroid). The client returns to the clinic 1 week after beginning the medication and tells the nurse that the medication has not helped. The appropriate nursing response to the client is based on which of the following? a. A higher dosage is required. b. The medication may need to be changed. c. Full therapeutic effect may take 1 to 3 weeks. d. Full therapeutic effect may take up to 4 months. Source: Saunders 4th

ANS: C Rationale: Levothyroxine (Synthroid) is used in the treatment of hypothyroidism. Although therapy with levothyroxine may begin with small doses that are gradually increased, the most appropriate response is to inform the client that the full therapeutic effect may take 1 to 3 weeks. Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are comparative or alike. Next, eliminate option 4 because the time frame is lengthy. If you had difficulty with this question, review the therapeutic effects of this medication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 688). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., pp. 493-495). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2192) A client who is on lithium carbonate (Eskalith) will be discharged at the end of the week. In formulating a discharge teaching plan, the nurse will include which of the following precautions? a. Avoid soy sauce, wine, and aged cheese. b. Take the medication only as prescribed because it can become addicting. c. Check with the psychiatrist before using any over-the-counter medications. d. Have the blood lithium level checked every 2 weeks. Source: Saunders 4th

ANS: C Rationale: Lithium is the medication of choice to treat bipolar disorder. Its exact mechanism of action remains speculative; however, an equilibrium of sodium and potassium must be maintained at the intracellular membrane to maintain therapeutic effects. Lithium competes with sodium in the cell. Many over-the-counter medications contain sodium, and often prescription medications (diuretics) change the sodium-potassium ratios of the cell, thereby affecting lithium concentrations, so that it is more difficult to achieve therapeutic levels of the medication. Food restriction (tyramine-restricted diet) is associated with monoamine oxidase inhibitors. Antianxiety agents (not lithium) generally are of an addictive nature. Lithium blood levels are recommended for the client taking lithium, but these tests generally are prescribed every 3 to 4 months. Strategy: Use the process of elimination. Recalling the general principles related to medication administration and the importance of teaching the client to avoid over-the-counter medications will direct you to option 3. Review client teaching points related to this medication if you had difficulty with this question. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 373). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 505). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

964) The client has a PRN order for loperamide hydrochloride (Imodium). For which condition should the nurse plan to administer this medication? a. Constipation b. Abdominal pain c. An episode of diarrhea d. Hematest-positive nasogastric tube drainage Source: Saunders 4th

ANS: C Rationale: Loperamide is an antidiarrheal agent. It is used to manage acute and also chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy. It is not used for the conditions in options 1, 2, and 4. Strategy: Focus on the name of the medication. Recalling that this medication is an antidiarrheal agent will direct you to option 3. Review the action of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 703-704). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2616) A client with anxiety is starting therapy with lorazepam (Ativan). The nurse who is preparing to administer the first dose reviews the client's medical record. Which of the following factors in the client's history would prompt the nurse to consult with the physician before administering the medication? a. Hypothyroidism b. Coronary artery disease c. Narrow angle glaucoma d. Diabetes mellitus Source: Saunders 4th

ANS: C Rationale: Lorazepam is contraindicated in hypersensitivity, cross-sensitivity with other benzodiazepines, comatose state, preexisting central nervous system depression, uncontrolled severe pain, and narrow angle glaucoma. It also is contraindicated in pregnancy and in women who are breast-feeding. Strategy: Knowledge of the contraindications to lorazepam use is required to answer this question. Remember that this medication is contraindicated in narrow-angle glaucoma. If you are unfamiliar with these contraindications, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 709). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2676) A client has an order for magnesium citrate to prevent constipation after undergoing barium studies of the gastrointestinal (GI) tract. The nurse administers the magnesium citrate: a. With a full glass of water b. With fruit juice only c. After it is chilled in the refrigerator d. At room temperature Source: Saunders 4th

ANS: C Rationale: Magnesium citrate is available as an oral solution and should be served chilled to make it more palatable. The other options are incorrect. Strategy: Use the process of elimination. Eliminate options 1 and 2 first knowing that magnesium citrate preparations already are in liquid form. Regarding the remaining options, it is necessary to know the medication should be given cold to enhance palatability. Review the method of administration of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 719). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1767) The nurse is assessing the child with a diagnosis of suspected appendicitis. In assessing the intensity and progression of the pain, the nurse palpates the child at McBurney's point. In performing this assessment, the nurse knows that McBurney's point is located midway between the: a. Right anterior inferior iliac crest and umbilicus. b. Left anterior superior iliac crest and umbilicus. c. Right anterior superior iliac crest and umbilicus. d. Left anterior superior iliac crest and umbilicus. Source: Saunders 4th

ANS: C Rationale: McBurney's point is midway between the right anterior superior iliac crest and the umbilicus. It is usually the location of greatest pain in the child with appendicitis. Strategy: Use the process of elimination. Knowledge that the appendix is located in the right side of the abdomen will assist in eliminating options 2 and 4. From this point, attempt to visualize this assessment procedure. This will assist in directing you to option 3. Review the location of McBurney's point if you had difficulty with this question. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 858). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Child Health Alternate Question Types -> Multiple Choice

2528) The home care nurse is visiting a client who was recently diagnosed with a hearing impairment. The nurse prepares to instruct the client's spouse in which measure that will facilitate communication? a. Speak frequently to the client to provide sensory stimulation. b. Speak loudly to the client to facilitate hearing. c. Speak in a normal tone and face the client when speaking. d. Speak directly into the impaired ear to facilitate hearing. Source: Saunders 4th

ANS: C Rationale: Measures that facilitate hearing in the client with a hearing impairment problem include speaking in a normal tone; avoiding shouting; talking directly to the client while facing the client; and speaking clearly. If the client does not seem to understand what is said, the statement should be expressed differently. Moving closer to the client and toward the better ear may facilitate communication, but talking directly into the impaired ear should be avoided. Strategy: Use the process of elimination. Read each option carefully and think about the action that will assist in facilitating communication. Review effective communication techniques for hearing-impaired persons if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1139). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Communication and Documentation Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

1924) A client with chronic renal failure who is receiving an antihypertensive medication is experiencing frequent hypotensive episodes. The nurse reviews the client's medication record, knowing that which of the following medications would have the greatest tendency to cause hypotension? a. Levothyroxine (Synthyroid) b. Epoetin alfa (Epogen, Procrit) c. Methyldopa (Aldomet) d. Calcium carbonate (OsCal) Source: Saunders 4th

ANS: C Rationale: Methyldopa is metabolized by the kidneys and requires careful dosage adjustment according to the client's renal function to prevent hypotension. Epoetin alfa is an erythropoietin and is more likely to cause hypertension. Levothyroxine does not cause hypotension. Calcium carbonate is used in the treatment of calcium deficiency and does not cause hypotension when administered via the oral route. Parenteral administration of calcium may cause hypotension. Strategy: Use the process of elimination and focus on the subject, hypotensive episodes. Eliminate options 1, 2, and 4 because they are not used to control blood pressure. Also, recalling that methyldopa is an antihypertensive medication will direct you to option 3. Review these medications if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 546). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1439) The client asks the nurse about milieu therapy. The nurse responds, knowing that the primary focus of milieu therapy can best be described as which of the following? a. A form of behavior modification therapy b. A cognitive approach to changing behavior c. A living, learning, or working environment d. A behavioral approach to changing behavior Source: Saunders 4th

ANS: C Rationale: Milieu therapy, or "therapeutic community," has as its focus a living, learning, or working environment. Such therapy may be based on any number of therapeutic modalities from structured behavioral therapy to spontaneous, humanistically oriented approaches. Although milieu may include behavioral approaches, option 3 describes its primary focus. Strategy: Use the process of elimination. Note that options 1, 2, and 4 are comparative or alike and that option 3 identifies a comprehensive description. Review milieu therapy if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 438). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 30-31). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1259) A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse tells the client that: a. "The medication will help dilate the eye to prevent pressure from occurring." b. "The medication will relax the muscles of the eyes and prevent blurred vision." c. "The medication causes the pupil to constrict and will lower the pressure in the eye." d. "The medication will help block the responses that are sent to the muscles in the eye." Source: Saunders 4th

ANS: C Rationale: Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork. Options 1, 2, and 4 are incorrect. Strategy: Use the process of elimination. Note that the client has glaucoma. Recall that prevention of increased intraocular pressure is the goal in the client with glaucoma. Options 1, 2, and 4 describe actions related to mydriatic medications, which primarily dilate the pupils and relax the ciliary muscles. Review the action of a miotic medication if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 728-729). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

2342) A client with cancer is receiving morphine sulfate 10 mg every 3 to 4 hours for pain. When writing the plan of care for this client, the nurse should include which of the following as a priority action? a. Monitor temperature. b. Monitor urine output. c. Monitor respiratory status. d. Encourage increased fluids. Source: Saunders 4th

ANS: C Rationale: Morphine sulfate depresses respirations. The nurse monitors the client's respiratory status closely. Although the incorrect options may be components of the plan of care, option 3 identifies the priority nursing action. Strategy: Use the process of elimination, noting the strategic words priority action. Use the ABCs—airway, breathing, and circulation—to guide you to the correct option. Review nursing care of the client receiving morphine sulfate if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 859). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1347) A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. The nurse interprets that this pain may be caused by: a. Infection under the cast b. The anxiety of the client c. Impaired tissue perfusion d. The recent occurrence of the fracture Source: Saunders 4th

ANS: C Rationale: Most pain associated with fractures can be minimized with rest, elevation, application of cold, and administration of analgesics. Pain that is not relieved by these measures should be reported to the physician because the pain unrelieved by medications and other measures may indicate neurovascular compromise. Because this is a new closed fracture and cast, infection would not have had time to set in. Strategy: Use the process of elimination. Focus on the issue, intense pain. Use of the ABCs—airway, breathing, and circulation—will direct you to option 3. Review care of the client with a fracture and new cast if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1667). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

962) The client taking bisacodyl (Dulcolax) wants to obtain a rapid effect from the medication. How should the nurse instruct the client to take the medication? a. At bedtime b. With a large meal c. On an empty stomach d. With two glasses of juice Source: Saunders 4th

ANS: C Rationale: Most rapid results from bisacodyl occur when it is taken on an empty stomach. Bisacodyl will not have a rapid effect if taken with a large meal. If bisacodyl is taken at bedtime, the client will have a bowel movement in the morning. Taking the medication with two glasses of juice will not add to its effect. Strategy: Use the process of elimination, noting the strategic words rapid effect. Remember that the most rapid results occur when taken on an empty stomach. Review the administration of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 140). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1292) The client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as: a. Getting too little exercise b. Taking excess medication c. Omitting doses of medication d. Increasing intake of fatty foods Source: Saunders 4th

ANS: C Rationale: Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications, such as neostigmine (Prostigmin) and pyridostigmine (Mestinon). Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Too little exercise and fatty food intake are incorrect. Overexertion and overeating possibly could trigger myasthenic crisis. Strategy: Use the process of elimination. Recalling that undermedication is a common cause of myasthenic crisis will direct you easily to option 3. Review the causes of myasthenic crisis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1015-1016). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2584) A nurse administers 20 units of NPH insulin to a hospitalized client with diabetes mellitus at 7:00 <SC>AM</SC>. The nurse should monitor the client most closely for a hypoglycemic reaction at: a. 9:00 <SC>AM</SC> b. 10:00 <SC>AM</SC> c. 4:00 <SC>PM</SC> d. 12:00 midnight Source: Saunders 4th

ANS: C Rationale: NPH is an intermediate-acting insulin with an onset of action in 3 to 4 hours, a peak action in 6 to 12 hours, and a duration of action of 18 to 28 hours. A hypoglycemic reaction is most likely to occur at peak time. Option 3 is the only option that represents a time frame within the peak hours after administration of the NPH insulin. Strategy: Note the strategic words NPH insulin and hypoglycemic reaction. Recalling that NPH is an intermediate-acting insulin and that hypoglycemic reactions are likely to occur during peak action time will direct you to option 3. Review NPH insulin if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 620-621). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1518). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

1570) The client received 20 units of NPH insulin subcutaneously at 8:00 <sc>AM</sc>. The nurse should assess the client for a hypoglycemic reaction at: a. 10:00 <sc>AM</sc> b. 11:00 <sc>AM</sc> c. 5:00 <sc>PM</sc> d. 11:00 <sc>PM</sc> Source: Saunders 4th

ANS: C Rationale: NPH is an intermediate-acting insulin. The onset of action is 3 to 4 hours, it peaks in 4 to 12 hours, and its duration of action is 16 to 20 hours. Hypoglycemic reactions most likely occur during peak time. Strategy: Use the process of elimination and knowledge regarding the onset, peak, and duration of action for NPH insulin. Recalling that peak action is between 4 to 12 hours will direct you to option 3. Review the characteristics of NPH insulin if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1519, 1539). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

2388) A nurse is caring for a client who is receiving morphine sulfate by the intravenous (IV) route for acute pain. The nurse ensures that which of the following medications is available in the event that the client's respiratory status and level of consciousness deteriorate? a. Promethazine (Phenergan) b. Protamine sulfate c. Naloxone (Narcan) d. Atropine sulfate Source: Saunders 4th

ANS: C Rationale: Naloxone is an opioid antagonist that is used to treat opioid overdose. Promethazine is an antiemetic medication, and protamine sulfate is the antidote for heparin. Atropine sulfate is an anticholinergic. Strategy: Use the process of elimination. Recalling that morphine sulfate depresses the respiratory rate will direct you to option 3. If you had difficulty with this question and are unfamiliar with the actions and uses of the medications identified in the options, review this content. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 860). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

12) A nurse is bathing a hospitalized Native American client of the Navajo culture and notes that the client avoids eye contact during the procedure. The nurse makes which interpretation about the client's behavior? a. The client is depressed. b. The client is displaying disrespectful mannerisms. c. The client is displaying behavior that is a common cultural action. d. The client is humiliated because of the need to be cared for by someone else. Source: Saunders 4th

ANS: C Rationale: Native American clients often avoid eye contact when being cared for by health care personnel. In this culture, eye contact is considered a sign of disrespect. Therefore, this client&#39;s action is culturally appropriate behavior. Options 1, 2, and 4 are inappropriate interpretations of the client&#39;s behavior. Strategy: Use the process of elimination and knowledge regarding the culturally appropriate behaviors of Navajo clients. Remember that, in this culture, eye contact is considered a sign of disrespect. If you had difficulty with this question, review the characteristics of this culture. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., pp. 68, 70). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1434) The nurse is caring for a Native-American client who says, "I don't want you to touch me. I'll take care of myself!" Which nursing response is therapeutic? a. "If you didn't want our care, why did you come here?" b. "Why are you being so difficult? I only want to help you." c. "It sounds as though you want to take care of yourself. Let's work together so you can do things for yourself." d. "Okay. If that's what you want. I'll just leave this cup for you to collect your urine in. After breakfast, I will take more blood from you." Source: Saunders 4th

ANS: C Rationale: Native Americans may view touch differently from other Americans. The therapeutic response is the one that reflects the client's feelings and empowers the client by offering self-control over one's own care. Option 1 is an aggressive and nontherapeutic communication technique. Option 2 labels the client's behavior and is likely to provoke anger from the client. In option 4, the nurse uses avoidance and provides information. Strategy: Use the process of elimination and knowledge regarding the use of therapeutic communication techniques. Focus on the client's cultural heritage and the client's feelings to direct you to option 3. Review therapeutic communication techniques and cultural considerations if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 76, 125). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 55-56). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-34, 431-432). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1213) Following kidney transplantation, cyclosporine (Sandimmune) is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication? a. Decreased creatinine level b. Decreased hemoglobin level c. Elevated blood urea nitrogen level d. Decreased white blood cell count Source: Saunders 4th

ANS: C Rationale: Nephrotoxicity can occur from the use of cyclosporine (Sandimmune). Nephrotoxicity is evaluated by monitoring for elevated blood urea nitrogen and serum creatinine levels. Cyclosporine does not depress the bone marrow. Strategy: Use the process of elimination. Eliminate options 2 and 4 first because they are unrelated to renal function. Next, eliminate option 1 because the creatinine level would be elevated, not decreased. Option 3 is the only option that indicates an increased level of a renal function test. Review the adverse effects related to this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 303). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1768) The nurse is caring for a client with a burn injury to the lower legs. Nitrofurazone (Furacin) is prescribed to be applied to the sites of injury. The nurse documents which of the following in the plan of care as the appropriate method for applying this medication? a. Apply saline-soaked dressings over the medication. b. Apply 1-inch film directly to the burn sites. c. Apply a 1/16-inch film directly to the burn sites. d. Apply a ½-inch film directly to the burn sites after cleansing the wounds. Source: Saunders 4th

ANS: C Rationale: Nitrofurazone (Furacin) is applied topically to the burn and has a broad spectrum of antibiotic activity. It is used for burns in which bacterial resistance to other agents is a real or potential problem. A {1/16}-inch film is applied directly to the burn. Saline-soaked dressings are not used. Strategy: Use the process of elimination. Option 1 can be eliminated because infection is a major concern with the burn client and a wet dressing can more easily harbor bacteria. Recalling that a very thin film is required will direct you to option 3. Review the use of this medication for burn therapy if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 749). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Communication and Documentation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2208) A client is scheduled for an oral cholecystogram. The nurse should plan to order what type of diet for the evening meal before the test? a. Low protein b. High carbohydrate c. Low fat d. Liquid Source: Saunders 4th

ANS: C Rationale: Normal dietary intake of fat should be maintained during the days preceding the test in order to empty bile from the gallbladder and a low-fat diet is ordered on the evening before the test. The low-fat diet prevents contraction of the gallbladder and allows accumulation of the contrast substance needed for x-ray visualization. Options 1, 2, and 4 are not required diets. Strategy: Recall that an oral cholecystogram is an x-ray study of the gallbladder. Thinking about the function of the gallbladder will direct you to option 3. Review pre-procedure dietary measures for this test if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 368). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1082) The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/min. Which of the following would be a correct interpretation based on these characteristics? a. Sinus bradycardia b. Sick sinus syndrome c. Normal sinus rhythm d. First-degree heart block Source: Saunders 4th

ANS: C Rationale: Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/min. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively. Strategy: A baseline knowledge of normal electrocardiographic measurements is needed to answer this question. Focusing on the data in the question and recalling the characteristics of normal sinus rhythm will direct you to option 3. Review this content if you are unfamiliar with it. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 716). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2245) Norfloxacin (Noroxin) is prescribed for a client with a Pseudomonas infection of the urinary tract. The nurse instructs the client to take the medication: a. With meals b. At bedtime c. 2 hours after meals d. With a snack in the late afternoon Source: Saunders 4th

ANS: C Rationale: Noroxin is administered 1 hour before or 2 hours after meals because food may hamper absorption. The normal dosage is 400 mg orally twice daily for 7 to 10 days for mild infections and for 10 to 21 days for severe infections. Strategy: Use the process of elimination. Eliminate options 1 and 4 first because they are comparative or alike. Regarding the remaining options, knowledge that this medication is administered more than once daily will direct you to option 3. Review the use of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 851). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

23) A nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. The appropriate initial action by the nurse is which of the following? a. Call security. b. Call the police. c. Call the nursing supervisor. d. Lock the co-worker in the medication room until help is obtained. Source: Saunders 4th

ANS: C Rationale: Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and therefore this is not the initial action. Option 4 is an inappropriate and unsafe action. Strategy: Note the strategic words initial action. Eliminate option 4 first because this is an inappropriate and unsafe action. Recall the lines of organizational structure to assist in directing you to option 3. If you had difficulty with this question, review the nurse's responsibilities when substance abuse is suspected or occurs in the workplace. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 93). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1877) A nurse is preparing to care for a client who is being admitted to the hospital with a possible diagnosis of ectopic pregnancy. The nurse develops a plan of care for the client and determines that which of the following nursing actions is the priority? a. Monitoring daily weight b. Assessing for edema c. Monitoring the apical pulse d. Monitoring the temperature Source: Saunders 4th

ANS: C Rationale: Nursing care for the client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of shock. Weight and edema are priority interventions for the client with preeclampsia, and an elevated temperature is an indicator of infection. Strategy: Focus on the diagnosis of the client and note the strategic word priority. Recall that bleeding and hypovolemic shock are concerns to assist in directing you to option 3, the only assessment associated with the presence of shock. Review care of the client with ectopic pregnancy if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 628). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

949) A client has just had a hemorrhoidectomy. What nursing intervention is appropriate for this client? a. Instruct the client to limit fluid intake to avoid urinary retention. b. Instruct the client to eat low-fiber foods to decrease the bulk of the stool. c. Apply and maintain ice packs over the dressing until the packing is removed. d. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding. Source: Saunders 4th

ANS: C Rationale: Nursing interventions after a hemorrhoidectomy are aimed at management of pain and avoidance of bleeding. An ice pack will increase comfort and decrease bleeding. Options 1, 2, and 4 are incorrect interventions. Strategy: Use the process of elimination. Decreasing fluid intake and avoiding high-fiber foods will cause difficulty with defecation because of hard stool, eliminating options 1 and 2. Fowler's position will increase pressure in the rectal area, causing increased bleeding and increased pain, eliminating option 4. Knowing that an ice pack will decrease swelling and cause vasoconstriction leads you to option 3. Review care of the client following hemorrhoidectomy if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1100). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2434) A nurse has developed a nursing diagnosis of ineffective airway clearance for a client who sustained an inhalation burn injury. Which of the following nursing interventions should the nurse include in the plan of care for this client? a. Monitor oxygen saturation levels every 4 hours. b. Encourage coughing and deep breathing every 4 hours. c. Elevate the head of the bed. d. Assess respiratory rate and breath sounds every 4 hours. Source: Saunders 4th

ANS: C Rationale: Nursing interventions for the client with an inhalation burn injury include assessing the respiratory rate every hour, monitoring oxygen saturation levels every hour, and assisting the client in coughing and deep breathing every hour. The head of the bed is elevated to facilitate lung expansion. Strategy: Use the process of elimination, noting the time frame in options 1, 2, and 4. This will assist in eliminating these options. If you had difficulty with this question, review care of the client experiencing ineffective airway clearance after a burn injury. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1448). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

2107) A nurse is providing care to a client with increased intracranial pressure (ICP). Which of the following approaches is least beneficial in controlling the client's ICP from an environmental viewpoint? a. Maintaining a calm atmosphere b. Reducing environmental noise c. Clustering nursing activities to be done all at one time d. Allowing the client uninterrupted time for sleep Source: Saunders 4th

ANS: C Rationale: Nursing interventions should be spaced out over the shift to minimize the risk of a sustained rise in ICP. If possible, activities known to raise the ICP should be avoided. Other interventions to control the ICP include maintaining a calm, quiet environment and avoiding emotional stress and interruption of sleep. Strategy: Use the process of elimination, noting the strategic words least beneficial. This question tests the concept that stimulation raises the ICP. If you know this, you will be able to eliminate each of the incorrect options. Review nursing care of the client with increased ICP if you had difficulty with this question. Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed., p. 1334). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1898) A nurse is using Nägele's rule to calculate a pregnant woman's estimated date of delivery. The woman tells the nurse that her last period began on June 17, 2008, and ended 6 days later. The nurse should compute the estimated date of delivery to be: a. March 10, 2008 b. March 15, 2008 c. March 24, 2009 d. March 29, 2009 Source: Saunders 4th

ANS: C Rationale: Nägele's rule is a noninvasive method for estimating the date of birth. The rule states the following: add 7 days to the first day of the last menstrual period, subtract 3 months, and add 1 year. This is based on the assumption that the cycle is 28 days. June 17, 2008, plus 7 days minus 3 months is March 24, 2008. Adding 1 year brings the delivery date to March 24, 2009. Strategy: Knowledge regarding Nägele's rule is required to answer this question. Application of the rule and performing math calculations carefully will direct you to the correct option. Review this rule for calculating the estimated date of delivery if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 131). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1896) A client in the prenatal clinic asks the nurse about the delivery date. The nurse notes that the client's record indicates that the client began her last menses on March 7, 2008, and ended the menses on March 14, 2008. Using Nägele's rule, the nurse should tell the client that the estimated date of birth is which of the following? a. January 14, 2009 b. December 21, 2008 c. December 14, 2008 d. January 21, 2009 Source: Saunders 4th

ANS: C Rationale: Nägele's rule is a noninvasive method for estimating the date of birth. The rule states the following: add 7 days to the first day of the last menstrual period, subtract 3 months, and add 1 year. This is based on the assumption that the cycle is 28 days. March 7, 2008, plus 7 days minus 3 months is December 14, 2007. Adding 1 year brings the delivery date to December 14, 2008. Strategy: Knowledge regarding Nägele's rule is required to answer this question. Application of the rule and using math calculations carefully will direct you to the correct option. Review this rule for calculating the estimated date of delivery if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 131). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

2100) A client with acute prostatitis has difficulty voiding, which is accompanied by pain. The client asks the nurse, "Can't you just put a catheter in so I won't be in this misery when I try to go?" The nurse's response is based on the understanding that catheterization: a. Will prolong the course of the inflammation b. Could result in obstruction from rebound edema once the catheter is removed c. Is avoided whenever possible to avoid pushing organisms up into the bladder d. Could result in puncture of the prostate gland because it is so inflamed Source: Saunders 4th

ANS: C Rationale: Occasionally, the client with acute prostatitis needs urinary catheterization if he cannot void at all. Otherwise, catheterization is avoided to prevent introducing bacteria into the bladder by pushing them up the urethra. Catheterization does not prolong the course of the inflammation, nor does it cause rebound edema when it is discontinued. Prostate gland puncture from this procedure is not likely, although the procedure may be painful. Strategy: Use the process of elimination and basic principles related to the transmission of infection to direct you to option 3. Review the complications associated with urinary catheterization if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1019). Philadelphia: W.B. Saunders. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills and techniques (6th ed., pp. 1167-1169). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1553) Octreotide acetate (Sandostatin) is prescribed for the client with acromegaly. The nurse monitors the client, knowing that which side effect is associated with the administration of this medication? a. Constipation b. Polyuria c. Abdominal pain d. Hypotension Source: Saunders 4th

ANS: C Rationale: Octreotide (Sandostatin) is used to reduce growth hormone levels in clients with acromegaly. The most common side effects of octreotide include diarrhea, nausea, gallstone formation, and abdominal discomfort. Hypertension, although rare, may occur. Polyuria is not associated with this medication. Strategy: Knowledge regarding the side effects associated with octreotide is required to answer the question. Remember that the most common side effects of octreotide include diarrhea, nausea, gallstone formation, and abdominal discomfort. Review these side effects if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 628). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1828) A home health care nurse is visiting a client who has undergone a mastectomy. The nurse determines that the client demonstrates greatest adjustment to the loss of the breast if which of the following behaviors is noted? a. The client performs the prescribed arm exercises. b. The client takes the pain medication as prescribed. c. The client looks at the surgical site. d. The client has read all of the postoperative materials provided by the hospital nurse. Source: Saunders 4th

ANS: C Rationale: Of the options provided, the client behavior in option 3 demonstrates the greatest adaptation or adjustment (looking at the surgical site). This indicates that the client has acknowledged and is beginning to cope with the loss of the breast. Reading postoperative care booklets and performing prescribed exercises indicates an interest in self-care and is a positive sign indicating adjustment. Taking pain medication is not related to adjustment to the loss of the breast. Strategy: Note the strategic words greatest adjustment and use the process of elimination. Option 2 can be eliminated because taking medication is not directly related to adjustment. Although options 1 and 4 are positive signs of adjustment, these are not the best indicators of adjustment to loss of the breast. Review positive psychosocial outcomes following a mastectomy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1106). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1804). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

2619) A nurse taking a medication history for a client who has been admitted to the nursing unit notes that the client is receiving olanzapine (Zyprexa). The nurse interprets that this client most likely has a history of which of the following disorders? a. Diabetes insipidus b. Hypertension c. Schizophrenia d. Diabetes mellitus Source: Saunders 4th

ANS: C Rationale: Olanzapine is an antipsychotic medication that targets both the positive and the negative symptoms of schizophrenia. The other options listed are not indications for use of this medication. Strategy: Use the process of elimination. Recalling that this medication is an antipsychotic will direct you to the correct option. If you are unfamiliar with the action and use of this medication, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 861). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2675) A client who is in the postanesthesia care unit (PACU) has received a dose of ondansetron (Zofran). The unit nurse evaluates that this medication was effective if relief was obtained from which of the following? a. Urinary retention b. Incisional pain c. Nausea and vomiting d. Paralytic ileus Source: Saunders 4th

ANS: C Rationale: Ondansetron is an antiemetic used for relief of postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy. This medication is not used to treat the other problems identified in options 1, 2, and 4. Strategy: Use the process of elimination. Noting that the setting is the PACU, eliminate options 1 and 4, because these problems would not be diagnosed so soon after surgery. Regarding the remaining options, it is necessary to recall that this medication is an antiemetic. Review the action of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 635). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2069) A nurse in the delivery room is performing an assessment on a newborn to determine the Apgar score. The nurse notes an Apgar score of 6. On the basis of this score, the nurse determines which of the following? a. The newborn is adjusting well to extrauterine life. b. The newborn is having some difficulty adjusting to extrauterine life. c. The newborn requires some resuscitative interventions. d. The newborn requires vigorous resuscitation. Source: Saunders 4th

ANS: C Rationale: One of the earliest indicators of successful adaptation of the newborn to extrauterine life is the Apgar score. Scoring ranges from 0 to 10. A score of 8 to 10 indicates that the newborn is adjusting well to extrauterine life. A score of 5 to 7 often indicates that the newborn requires some resuscitative interventions. Scores of less than 5 indicate that the newborn is having difficulty adjusting to extrauterine life and requires vigorous resuscitation. Strategy: Use the process of elimination. Recall that the Apgar score ranges from 0 to 10. Noting that the score is 6 will assist in directing you to option 3. If you had difficulty with this question, review the Apgar scoring system and the specific nursing interventions required. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 385). St. Louis: W.B. Saunders. Reference: Murray, S., & McKinney, E., (2006). Foundations of maternal-newborn nursing (4th ed., p. 298). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

1490) A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. The appropriate nursing response is which of the following? a. "You need to try to be realistic. The rape did not just occur." b. "It will take some time to get over these feelings about your rape." c. "Tell me more about the incident that causes you to feel like the rape just occurred." d. "What do you think that you can do to alleviate some of your fears about being raped again"? Source: Saunders 4th

ANS: C Rationale: Option 3 allows the client to express her ideas and feelings more fully, and portrays a nonhurried, nonjudgmental, supportive attitude on the part of the nurse. Clients need to be reassured that their feelings are normal and that they may express their concerns freely in a safe, caring environment. Option 4 places the problem solving totally on the client. Option 2 places the client's feelings on hold. Option 1 immediately blocks communication. Strategy: Use the process of elimination. Option 3 is the only option that addresses the client's feelings. Always address the client's feelings first. Review therapeutic communication techniques if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 546-547). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-31). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1863) A mother brings her 5-week-old infant to the health care clinic and tells the nurse that the child has been vomiting after meals. The mother reports that the vomiting is becoming more frequent and forceful. The nurse suspects pyloric stenosis and asks the mother which of the following assessment questions to elicit data specific to this condition? a. "Does the infant cry loudly and continuously during the evening hours but nurses or takes formula well?" b. "Does the infant suddenly become pale, begin to cry, and draw the legs up to the chest?" c. "Does the vomit contain sour undigested food without bile, and is the infant constipated?" d. "Are the stools ribbon-like and is the infant eating poorly?" Source: Saunders 4th

ANS: C Rationale: Option 3 are classic symptoms of pyloric stenosis. Crying during the evening hours, appearing to be in pain, eating well, and gaining weight are clinical manifestations of colic. An infant who suddenly becomes pale, cries out, and draws the legs up to chest is demonstrating physical signs of intussusception. Stools that are ribbon-like and eating poorly are signs of congenital megacolon (Hirschsprung's disease). Strategy: Knowledge of the clinical manifestations associated with pyloric stenosis is required to answer this question. Thinking about the pathophysiology associated with this disorder and noting the word vomit in option 3 will direct you to this option. If you are unfamiliar with this disorder, review these clinical manifestations. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., pp. 1418-1419). St. Louis: Mosby. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., pp. 880-881). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Child Health Alternate Question Types -> Multiple Choice

1987) A nurse is providing dietary instructions to the client with anemia. The client tells the nurse that the iron pills are very expensive and that it will be difficult to pay for the pills and buy the proper food. The appropriate nursing response is which of the following? a. "You will be fine as long as you take the iron pills." b. "You will have to find a way to afford both." c. "Would you like for me to check into some other options for you?" d. "Why don't you ask your family to help you out financially?" Source: Saunders 4th

ANS: C Rationale: Option 3 is correct because it validates the issue that the client has with income. The nurse offers help in a nonthreatening manner that will allow the client to accept or decline. Option 1 is incorrect because the client needs to consume a proper diet. Options 2 and 4 block the communication process and are nontherapeutic and nonhelpful statements. Strategy: Use knowledge regarding treatment measures for anemia to assist in eliminating option 1. Next, identify the use of therapeutic communication. Options 2 and 4 block further communication by placing the client's issues on hold. Additionally, option 4 is requesting an explanation "why?" Option 3 is the only helpful statement for the client. Review therapeutic communication techniques if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 894). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 437). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1417) An inebriated client is brought to the emergency department by the local police. The client is told that the physician will be in to see the client in about 30 minutes. The client becomes loud and offensive and wants to be seen by the physician immediately. The appropriate nursing intervention is which of the following? a. Watch the behavior escalate before intervening. b. Attempt to talk with the client to de-escalate behavior. c. Offer to take the client to an examination room until the client can be treated. d. Inform the client that the client will be asked to leave if the behavior continues. Source: Saunders 4th

ANS: C Rationale: Option 3 is in effect an isolation technique that allows for separation from others and provides a less stimulating environment where the client can maintain dignity. Safety of the client, other clients, and staff is of prime concern. Option 2 is not appropriate, given the fact that the client is inebriated and may not be able to be reasoned with. Option 1 is inaccurate because waiting to intervene could cause the client to become even more agitated and a threat to others. Option 4 would aggravate an already agitated individual further. Strategy: Focus on the subject, an inebriated client. Use this information and the process of elimination in selecting the correct option. Option 3 most directly addresses the situation and the behavior and feelings of the client. Review therapeutic communication techniques if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 22-23, 125). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-34). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1420) The community health nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse illustrates a therapeutic communication technique for this client? a. "Go on." b. "Sleeping?" c. "You're having difficulty sleeping?" d. "Sometimes, I have trouble sleeping too." Source: Saunders 4th

ANS: C Rationale: Option 3 uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the client's major theme, which assists the nurse to obtain a more specific perception of the problem from the client. Options 1, 2, and 4 are not therapeutic responses. Strategy: Use the process of elimination. Option 1 is a general lead and allows the client to direct the discussion. Option 2 uses reflection, which simply repeats the client's last words to prompt further discussion. Option 4 focuses on the nurse's problem. Option 3 will provide the perception of the problem from the client's perspective. Review therapeutic communication techniques if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 125). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-34, 288). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1693) The nurse is preparing to discharge a client who has had a parathyroidectomy. The discharge instructions include medication administration of oral calcium supplements that the client will need daily. Which statement by the nurse would be appropriate regarding the oral calcium supplement therapy? a. Store the tablets in the refrigerator to maintain potency. b. Check the pulse daily; if it is below 60 beats/min, do not take the tablets. c. Take the tablets following a meal. d. Avoid sunlight because the medication can cause skin color changes. Source: Saunders 4th

ANS: C Rationale: Oral calcium supplements need to be administered with food to enhance its absorption as well as decrease gastrointestinal irritation. Options 1, 2, and 4 are unrelated to oral calcium therapy. Strategy: Use the process of elimination, focusing on the medication being addressed in the question. Recalling that oral calcium supplements need to be administered with food will direct you to option 3. Review the administration of oral calcium supplements if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 172). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

1818) A client is taking large doses of acetylsalicylic acid (aspirin) for rheumatoid arthritis. Which of the following assessment findings would indicate that the client is experiencing ototoxicity as a result of the medication? a. Gastrointestinal (GI) upset and dizziness b. GI bleeding, ecchymosis, and dizziness c. Tinnitus, hearing loss, dizziness, and ataxia d. Dizziness, sore throat, and purpura Source: Saunders 4th

ANS: C Rationale: Ototoxicity can occur as a result of the administration of aspirin. Signs and symptoms of tinnitus, hearing loss, dizziness, and ataxia reflects damage to the eighth cranial nerve, the organ of hearing and balance. Purpura and ecchymosis are caused by prolonged bleeding, but not ototoxicity. GI bleeding and upset may be caused by acetylsalicylic acid (aspirin) irritation but are not symptoms of ototoxicity. Strategy: Focus on the subject of the question, ototoxicity. Remember that when an option contains more than one part, all parts of the option need to be correct for the option to be the answer to the question. If you are unfamiliar with the assessment findings in ototoxicity, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 95). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2144) A client who has had a total knee replacement (TKR) tells the nurse that there is pain with extension of the knee. The nurse should: a. Put the client's knee through full passive range of motion. b. Immobilize the knee temporarily. c. Administer an analgesic. d. Notify the physician. Source: Saunders 4th

ANS: C Rationale: Pain with knee extension is a common complaint of clients after knee replacement. This is because preoperatively, these clients placed the knee in flexion to reduce pain, and flexion contracture has resulted. The nurse should encourage the client to keep the knee extended and administer analgesics as needed. Strategy: Use the process of elimination. The question states that there is pain with extension. Immobilizing the knee will not help, so this option may be eliminated first. Putting the joint through full range of motion may be more than the client can tolerate; also, the client usually has a continuous passive motion machine in place that controls the amount of flexion and extension of the joint. Regarding the remaining options, recall that a flexion contracture can occur preoperatively, which would lead you to choose medicating the client rather than notifying the physician. Review expected findings after TKR if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 390). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

972) The client has begun medication therapy with pancrelipase (Pancrease). The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed? a. Weight loss b. Relief of heartburn c. Reduction of steatorrhea d. Absence of abdominal pain Source: Saunders 4th

ANS: C Rationale: Pancrelipase (Pancrease) is a pancreatic enzyme used in clients with pancreatitis as a digestive aid. The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could be improved nutritional status. It is not used to treat abdominal pain or heartburn. Its use could result in weight gain but should not result in weight loss if it is aiding in digestion. Strategy: Use the process of elimination and focus on the name of the medication. Use knowledge of physiology of the pancreas to assist in directing you to the correct option. Review this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 894). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1615) The physician prescribes "patching" for a child with strabismus of the right eye and the nurse instructs the mother regarding this procedure. Which of the following will the nurse include in the instructions? a. Place the patch on the right eye. b. Place the patch on both eyes. c. Place the patch on the left eye. d. Alternate the patch from the right to the left eye hourly. Source: Saunders 4th

ANS: C Rationale: Patching may be used in the treatment of strabismus to strengthen the weak eye. In this treatment, the "good" eye is patched. This encourages the child to use the weaker eye. It is most successful when done during the preschool years. The schedule for patching is individualized and is prescribed by the ophthalmologist. Strategy: Use the process of elimination. Remembering that this condition is a "lazy eye" will direct you to the correct option. It makes sense to patch the unaffected eye to strengthen the muscles in the affected eye. Review the procedure for patching if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1586). St. Louis: W.B. Saunders. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 150). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

1786) A client has been diagnosed with pernicious anemia. In planning care for the client, the nurse anticipates that the client will be treated with: a. Thiamine. b. Iron. c. Vitamin B₁₂. d. Folic acid. Source: Saunders 4th

ANS: C Rationale: Pernicious anemia is caused by a deficiency of vitamin B₁₂. Treatment consists of monthly injections of vitamin B₁₂. Thiamine is most often prescribed for the client with alcoholism. Iron is administered for iron deficiency anemia and folic acid for folic acid deficiency. Strategy: Knowledge regarding the relationship between pernicious anemia and vitamin B₁₂is required to answer this question. Remember that pernicious anemia is caused by a deficiency of vitamin B₁₂. Review the treatment for this disorder if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 894). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1041) A nurse working on a medical respiratory nursing unit is caring for several clients with respiratory disorders. The nurse would determine that which of the following clients on the nursing unit is at the lowest risk for infection with tuberculosis? a. An uninsured man who is homeless b. A newly immigrated woman from Korea c. A man who is an inspector for the U.S. Postal Service d. An older woman admitted from a long-term care facility Source: Saunders 4th

ANS: C Rationale: Persons at high risk for acquiring tuberculosis include immigrants from Asia, Africa, Latin America, and Oceania, medically underserved populations (ethnic minorities, homeless), those with human immunodeficiency virus infection or other immunosuppressive disorders, residents in group settings (long-term care, correctional facilities), and health care workers. Strategy: Use the process of elimination, noting the strategic words lowest risk. Begin to answer this question by eliminating options 1 and 2 because immigrants and the medically underserved more frequently are affected by the disease. From the remaining options, the postal inspector may or may not come into contact with many persons, depending on the job description. The client from the long-term care facility, however, lives in a group setting where a large number of persons share a common environment 24 hours a day. Review the risk factors associated with tuberculosis if you had difficulty with this question. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., p. 773). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1321) The home health nurse visits a client who is taking phenytoin (Dilantin) for control of seizures. During the assessment, the nurse notes that the client is taking birth control pills. Which of the following information should the nurse include in the teaching plan? a. Pregnancy should be avoided while taking phenytoin. b. The client may stop the medication if it is causing severe gastrointestinal effects. c. There is the potential of decreased effectiveness of birth control pills while taking phenytoin. d. There is the increased risk of thrombophlebitis while taking phenytoin and birth control pills together. Source: Saunders 4th

ANS: C Rationale: Phenytoin enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth control pills. Options 1, 2, and 4 are inappropriate instructions. Strategy: Use the process of elimination. Option 4 would cause anxiety in the client. A client should not be instructed to stop anticonvulsant medication, as indicated in option 2. Pregnancy does not need to be "avoided." Review medication interactions related to phenytoin if you had difficulty with this question. Reference: Clayton, B., and Stock, Y. (2004). Basic pharmacology for nurses (13th ed., p. 272). St. Louis: Mosby. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 347). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1992) A nurse is preparing a plan of care for a postpartum client who is at risk for endometritis. Which of the following nursing interventions will the nurse include in the plan of care to minimize this risk? a. Instruct the client in proper positioning of the newborn to facilitate breast-feeding. b. Encourage early ambulation. c. Review hand-washing techniques and pericare procedures with the client. d. Discuss the resumption of home care and other activities with the client. Source: Saunders 4th

ANS: C Rationale: Postpartum endometritis frequently is associated with the invasion of bacteria that may arise from the gastrointestinal tract or from the lower genital tract. Reviewing appropriate hand-washing techniques and pericare with clients during the postpartum period will reduce the risk of possible bacterial invasion. Options 1, 2, and 4 are unrelated to this postpartum complication. Strategy: Use the process of elimination. Options 2 and 4 can be eliminated first because they are comparative or alike. Regarding the remaining options, use medical terminology skills relating to the word endometritis to direct you to option 3. Review client teaching points related to the prevention of endometritis if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., pp. 420, 747-749, 771). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Planning Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

1196) The nurse is caring for the client who has undergone renal angiography using the left femoral artery for access. The nurse determines that the client is experiencing a complication of the procedure if which of the following is observed? a. Urine output, 50 mL/hr b. Blood pressure, 110/74 mm Hg c. Pallor and coolness of the left leg d. Absence of hematoma in the left groin Source: Saunders 4th

ANS: C Rationale: Potential complications after renal angiography include allergic reaction to the dye, renal damage from the dye, and vascular complications, which include hemorrhage, thrombosis, or embolism. The nurse detects these complications by noting signs and symptoms of allergic reaction, decreased urine output, hematoma or hemorrhage at the insertion site, and/or signs of decreased circulation to the affected leg. Strategy: Use the process of elimination, focusing on the subject, a complication. Eliminate options 1 and 2 because they are normal findings. Because a hematoma is abnormal, then "absence of hematoma" is a normal finding, which eliminates option 4 also. Review the signs of a complication following a renal angioplasty if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., pp. 958-959). Philadelphia: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 131). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2622) A client with depression has an order for sertraline (Zoloft). The nurse should withhold the medication and question the order if which of the following is documented in the client's record? a. History of irritable bowel syndrome b. History of diabetes mellitus c. Use of phenelzine sulfate (Nardil) d. History of myocardial infarction Source: Saunders 4th

ANS: C Rationale: Potentially fatal reactions may occur if sertraline is administered concurrently with phenelzine, a monoamine oxidase inhibitor (MAOI). MAOIs should be stopped at least 14 days before initiation of sertraline therapy. Likewise, sertraline should be stopped at least 14 days before initiation of MAOI therapy. The other options are incorrect. Strategy: Knowledge of the interactions of and contraindications to the use of sertraline is needed to answer this question. Remember, sertraline is contraindicated with the use of an MAOI. If you are unfamiliar with this medication, review its contraindications. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 782). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2530) A nursing student is caring for a client with a diagnosis of presbycusis. The nursing instructor asks the student to describe the physiology associated with this diagnosis. The nursing instructor determines that the student understands this condition if the student states that presbycusis is: a. A loss of vision associated with aging b. A loss of balance that occurs with aging c. A sensorineural hearing loss that occurs with aging d. A conductive hearing loss that occurs with aging Source: Saunders 4th

ANS: C Rationale: Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. Options 1, 2, and 4 are incorrect descriptions of this condition. Strategy: Use the process of elimination. Recalling that this condition relates to hearing loss and occurs in the aging process will assist in eliminating options 1 and 2. From this point it is necessary to know that this condition is a sensorineural hearing loss. Review the description of this disorder if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1971). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

2689) A client being admitted to the coronary care unit from the emergency department has a stat order to receive a dose of procainamide (Procanbid). The nurse interprets that the client has which of the following conditions if this medication is needed? a. Bradycardia b. Dyspnea c. Ventricular ectopy d. Hypertension Source: Saunders 4th

ANS: C Rationale: Procainamide is an antidysrhythmic medication used to treat ventricular dysrhythmias unresponsive to lidocaine. The other options are not indications for giving this medication. Strategy: Recalling that procainamide is an antidysrhythmic will direct you to option 3. Review the action and use of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 964). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

971) The nurse is administering a dose of prochlorperazine (Compazine) to a client for nausea and vomiting. The nurse should assess the client for which frequent side effect of this medication? a. Diarrhea b. Drooling c. Blurred vision d. Excessive lacrimation Source: Saunders 4th

ANS: C Rationale: Prochlorperazine is a phenothiazine-type antiemetic and antipsychotic. The nurse would assess the client for blurred vision as a frequent side effect of prochlorperazine. Other frequent side effects include dry eyes, dry mouth, and constipation. Strategy: Use the process of elimination. Recalling that this medication is a phenothiazine-type antiemetic and knowing the side effects of these medications will direct you to option 3. Review this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 969). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2454) A nurse is conducting a clinic screening program to identify clients at risk for an integumentary disorder. Which of the following clients seen at the clinic would be at the greatest risk for development of an integumentary disorder? a. An athlete b. An adolescent c. A client who tans in an indoor tanning bed d. An older client Source: Saunders 4th

ANS: C Rationale: Prolonged exposure to the sun (including indoor tanning), unusual cold, or other extreme conditions can damage the skin, posing the highest risk for skin disorders. An older client may be at a higher risk than a younger person. An adolescent may be prone to the development of acne, but this does not occur in all adolescents. An athlete would be at low risk of developing an integumentary problem. Strategy: Note the strategic words greatest risk in the question. Eliminate option 1 first as the client at the least risk. Eliminate options 2 and 4 next, because not all older people or adolescents are at risk for the development of integumentary disorders. Recalling that exposure to ultraviolet rays increases the risk for integumentary disorders will direct you to option 3. If you had difficulty with this question, review the risk factors associated with integumentary disorders. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 21). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., pp. 1208-1209). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

2262) A nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets that the client has: a. Hyperreflexia b. Ataxia c. Pronator drift d. Nystagmus Source: Saunders 4th

ANS: C Rationale: Pronator drift occurs when a client cannot maintain the hands in a supinated position with the arms extended and the eyes closed. This assessment may be done to detect small changes in muscle strength that might not otherwise be noted. Hyperreflexia is an excessive reflex action. Ataxia is a disturbance in gait. Nystagmus is characterized by fine, involuntary eye movements. Strategy: Looking at everyday meanings of words is a useful strategy that may help you with this question. The word drift means to move slightly or without effort. This will assist in directing you to option 3. Review the techniques for assessing muscle strength if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 936). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1911) A nurse is working with the client newly diagnosed with chronic renal failure (CRF) to set up a schedule for hemodialysis. The client states, "This is impossible! How can I even think about leading a normal life again if this is what I'm going to have to do?" The nurse assesses that the client is exhibiting: a. Withdrawal b. Depression c. Anger d. Projection Source: Saunders 4th

ANS: C Rationale: Psychosocial reactions to CRF and hemodialysis are varied and may include anger. Other reactions include personality changes, emotional lability, withdrawal, and depression. The individual client's response may vary depending on the client's personality and support systems. The client in this question is exhibiting anger. The client has not projected blame on the nurse, nor does the client statement reflect withdrawal or depression. Strategy: Use the process of elimination. Focus on the client's statement to direct you to option 3. Review the psychosocial reaction of the client with CRF if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 962-963). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1076) A client who has developed severe pulmonary edema would most likely exhibit which of the following? a. Mild anxiety b. Slight anxiety c. Extreme anxiety d. Moderate anxiety Source: Saunders 4th

ANS: C Rationale: Pulmonary edema causes the client to be extremely agitated and anxious. The client may complain of a sense of drowning, suffocation, or smothering. Strategy: Use the process of elimination. Noting the strategic word severe will direct you to option 3. Review the clinical manifestations associated with severe pulmonary edema if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 755, 760). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1103) A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. The nurse should immediately assess the client for signs and symptoms of which of the following? a. Pneumonia b. Pulmonary edema c. Pulmonary embolism d. Myocardial infarction Source: Saunders 4th

ANS: C Rationale: Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset, and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension. Strategy: Focus on the client's diagnosis to answer the question. Recalling the complications related to thrombophlebitis will direct you to option 3. Review these complications and the associated signs and symptoms if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 650-651, 813). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1034) A client has been admitted to a nursing unit with pulmonary sarcoidosis. A nurse assesses the client for which of the following signs that indicates a complication of the disorder? a. Weak pulse b. Weight loss c. Distended neck veins d. Bilateral lung crackles Source: Saunders 4th

ANS: C Rationale: Pulmonary sarcoidosis can lead to cor pulmonale (or failure of the right side of the heart), characterized by distended neck veins, elevated central venous pressure, full bounding pulse, weight gain, engorged liver, and peripheral edema. Bilateral lung crackles would indicate failure of the left side of the heart. Strategy: Recall that sarcoidosis is a restrictive lung disease. A complication of restrictive lung disease is cor pulmonale because the right side of the heart has to work hard continuously to overcome pulmonary resistance. Therefore, recalling the signs of failure of the right side of the heart will direct you to option 3. Review the complications of pulmonary sarcoidosis and the signs of failure of the right and left sides of the heart if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1871-1872). Philadelphia: W.B. Saunders. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., p. 777). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1040) A client has been taking pyrazinamide for 1 month. The client asks a nurse if the therapy is due to be terminated soon. The nurse evaluates that the medication probably will be continued based on a positive finding in which of the following reports? a. Blood culture b. Urine culture c. Sputum culture d. Wound culture Source: Saunders 4th

ANS: C Rationale: Pyrazinamide is an antitubercular medication given with other antitubercular medications. Pyrazinamide might not be discontinued if sputum cultures continue to be positive. Options 1, 2, and 4 are not related directly to the use of this medication. Strategy: Focus on the name of the medication. Recalling that this medication is an antitubercular medication will direct you to option 3. If this question was difficult, review this medication. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 735). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2642) A physician prescribes quinidine gluconate for a client. The nurse decides to withhold the medication and contact the physician if which of the following assessment findings is documented in the client's medical record? a. History of asthma b. Presence of infection c. Complete atrioventricular (AV) block d. Muscle weakness Source: Saunders 4th

ANS: C Rationale: Quinidine gluconate is an antidysrhythmic medication used to maintain normal sinus rhythm after conversion of atrial fibrillation or atrial flutter. It is contraindicated in complete AV block, intraventricular conduction defects, and abnormal impulses and rhythms due to escape mechanisms, and with myasthenia gravis. It is used with caution in clients with preexisting asthma, muscle weakness, infection with fever, and hepatic or renal insufficiency. Strategy: Note the strategic words withhold the medication and contact the physician. Recalling that the medication is an antidysrhythmic and has a direct cardiac effect will assist in directing you to the correct option. If you are unfamiliar with this medication and its contraindications, review this content. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 534). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2662) A physician has written an order for ranitidine (Zantac) 300 mg once daily. The client indicates understanding of use of this medication by stating that the prescribed dose is best taken: a. After lunch b. Before breakfast c. At bedtime d. With supper Source: Saunders 4th

ANS: C Rationale: Ranitidine should be taken at bedtime, when it is given as a single daily dose. This allows for prolonged effect and provides the greatest protection of the gastric mucosa both during sleep and around the clock. The other options are incorrect. Strategy: Use the process of elimination. Note that options 1, 2, and 4 are comparative or alike in that they suggest taking the medication close to mealtimes. Review the administration of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1008). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

912) The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician? a. Hypotension b. Bloody diarrhea c. Rebound tenderness d. A hemoglobin level of 12 mg/dL Source: Saunders 4th

ANS: C Rationale: Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the physician. Strategy: Use the process of elimination. Consider the expected manifestations that would occur in ulcerative colitis. This will assist in eliminating option 2. Recalling that bleeding would cause a lowered hemoglobin and hypotension will assist you in eliminating options 1 and 4. Review the normal assessment findings in ulcerative colitis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1347). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1998) A physician has prescribed Regular insulin 6 units and NPH insulin 20 units subcutaneously to be administered every morning. The nurse should prepare to administer the insulin by: a. Administering both Regular insulin and NPH insulin in separate syringes b. Shaking the NPH insulin vial to distribute the suspension c. Drawing up the Regular insulin first and then the NPH insulin in the same syringe d. Drawing up the NPH insulin first and then the Regular insulin in the same syringe Source: Saunders 4th

ANS: C Rationale: Regular insulin is always drawn up before the NPH insulin, and the NPH insulin can be drawn into the same syringe as for the Regular insulin. Insulins usually are administered 15 to 30 minutes before a meal. To mix the NPH insulin suspension, the vial should be gently rotated. Shaking introduces air bubbles into the solution. Strategy: Knowledge regarding the preparation and administration of insulin is required to answer this question. Use the process of elimination. Think of RN as a way to remember to draw up Regular before NPH. Review the principles related to the administration of insulin if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 621). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2081) A nurse is caring for a client who has been diagnosed as having a kidney mass and is scheduled for a renal biopsy. The client asks the nurse the reason for this procedure, when other tests such as an ultrasound exam are available. In formulating a response, the nurse incorporates the knowledge that renal biopsy: a. Helps differentiate between a solid mass and a fluid-filled cyst b. Provides an outline of the renal vascular system c. Provides a tissue specimen to examine for specific cytological information about the lesion d. Determines if the mass is growing rapidly or slowly Source: Saunders 4th

ANS: C Rationale: Renal biopsy with microscopic examination is a definitive test that gives specific information about whether the lesion is benign or malignant. An ultrasound study discriminates between a fluid-filled cyst and a solid mass. Renal arteriography outlines the renal vascular system. Strategy: Use the process of elimination. Recall that with a biopsy, the cells are examined under a microscope. This examination then yields specific information about the type of neoplastic cell present in the kidney mass. Review the purpose of a renal biopsy if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1672). Philadelphia: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 792). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

67) A nurse plans care for a client with chronic obstructive pulmonary disease, knowing that the client is most likely to experience what type of acid-base imbalance? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis Source: Saunders 4th

ANS: C Rationale: Respiratory acidosis is most often caused by hypoventilation. Chronic respiratory acidosis is most commonly caused by chronic obstructive pulmonary disease. In end-stage disease, pathological changes lead to airway collapse, air trapping, and disturbance of ventilation-perfusion relationships. Options 1, 2, and 4 are incorrect options. Strategy: Use the process of elimination. Note the strategic words most likely. Remembering that hypoventilation results in respiratory acidosis will direct you to option 3. Review the causes of respiratory acidosis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 283, 598-599). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1018) A client with no history of respiratory disease is admitted with respiratory failure. A nurse assesses the arterial blood gas report for which of the following results that are consistent with this disorder? a. Pa<sc>O</sc>₂ 58 mm Hg, Pa<sc>CO</sc>₂ 32 mm Hg b. Pa<sc>O</sc>₂ 60 mm Hg, Pa<sc>CO</sc>₂ 45 mm Hg c. Pa<sc>O</sc>₂ 49 mm Hg, Pa<sc>CO</sc>₂ 52 mm Hg d. Pa<sc>O</sc>₂ 73 mm Hg, Pa<sc>CO</sc>₂ 62 mm Hg Source: Saunders 4th

ANS: C Rationale: Respiratory failure is described as a Pa<sc>O</sc>₂ of 60 mm Hg or lower and a Pa<sc>CO</sc>₂ of 50 mm Hg or higher in a client with no history of respiratory disease. In a client with a history of a respiratory disorder with hypercapnia, increases of 5 mm Hg or more (Pa<sc>CO</sc>₂) from the client's baseline are considered diagnostic. Strategy: Use the process of elimination. Focusing on the client's diagnosis will direct you to option 3, the option with the lowest Pa<sc>O</sc>₂ level. Review the blood gas findings in a client with respiratory failure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 652-657). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1718) A nurse obtains the vital signs on an older client and notes that the client's heart rate is 60 beats/min and the respiratory rate is 24 breaths/min. The nurse should: a. Recheck the heart and respiratory rates in 30 minutes. b. Contact the physician to report the heart and respiratory rates. c. Document the findings. d. Check the client for signs of infection. Source: Saunders 4th

ANS: C Rationale: Respiratory rates are generally higher in older adults, with a normal rate of 16 to 25 breaths/min. The heart rate also decreases with age. Therefore, because the data in the question indicate normal findings, the nurse would document the heart rate and respiratory rate. Options 1, 2, and 4 are unnecessary based on the data in the question. Strategy: Focus on the data in the question. Recalling the normal respiratory rate in an older client and recalling that the heart rate decreases as a client ages will direct you to option 3. Review age-related changes in the cardiac and respiratory systems if you had difficulty with this question. Reference: Meiner, S., & Leuckenotte, A. (2006). Gerontologic nursing (3rd ed., pp. 504-505). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1424) The client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." The therapeutic response by the nurse is: a. "Have you shared your feelings with your family?" b. "I think we should talk more about your anger with your family." c. "You're feeling angry that your family continues to hope for you to be cured?" d. "Well, it sounds like you're being pretty pessimistic. After all, years ago, people died of pneumonia." Source: Saunders 4th

ANS: C Rationale: Restating is the therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. Option 3 uses the therapeutic technique of restating. In option 1, the nurse is attempting to assess the client's ability to discuss feelings openly with family members. In option 2, the nurse attempts to use focusing, but the attempt to discuss central issues is premature. In option 4, the nurse makes a judgment and is nontherapeutic in the one-to-one relationship. Strategy: Use therapeutic communication techniques to answer the question. Option 3 is the only option that identifies the use of a therapeutic technique and focuses on the client's feelings. Review these techniques if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 125). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-34). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 189). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1060) A client has been started on long-term therapy with rifampin (Rifadin). A nurse teaches the client that the medication: a. Should always be taken with food or antacids b. Should be double-dosed if one dose is forgotten c. Causes orange discoloration of sweat, tears, urine, and feces d. May be discontinued independently if symptoms are gone in 3 months Source: Saunders 4th

ANS: C Rationale: Rifampin should be taken exactly as directed. Doses should not be doubled or skipped. The client should not stop therapy until directed to do so by a physician. The medication should be administered on an empty stomach unless it causes gastrointestinal upset, and then it may be taken with food. Antacids, if prescribed, should be taken at least 1 hour before the medication. Rifampin causes orange-red discoloration of body secretions and will stain soft contact lenses permanently. Strategy: Use the process of elimination. Options 2 and 4 are inaccurate in general and are eliminated first. Eliminate option 1 next because of the close-ended word always. If you had difficulty with this question, review the side effects associated with this medication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1021). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1917) A nurse is reviewing the medical record of a client with a diagnosis of pyelonephritis. Which of the following disorders, if noted on the client's record, would the nurse identify as a risk factor for this disorder? a. Hypoglycemia b. Coronary artery disease c. Diabetes mellitus d. Orthostatic hypotension Source: Saunders 4th

ANS: C Rationale: Risk factors associated with pyelonephritis include diabetes mellitus, hypertension, chronic renal calculi, chronic cystitis, structural abnormalities of the urinary tract, presence of urinary stones, and presence of an indwelling urinary catheter or frequent catheterization. Strategy: Use the process of elimination. Recalling that diabetes mellitus can cause renal complications will direct you to option 3. Review the risk factors related with pyelonephritis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1713). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2300) A nurse assigned to the care of an unconscious client is making initial daily rounds. On entering the client's room, the nurse notes that the client is lying supine in bed, with the head of the bed elevated approximately 5 degrees. The nasogastric tube feeding is running at 70 mL/hr as ordered. The nurse auscultates adventitious breath sounds. Which nursing diagnosis would the nurse formulate for the client? a. Risk for imbalanced nutrition: less than body requirements b. Risk for injury c. Risk for aspiration d. Risk for deficient fluid volume Source: Saunders 4th

ANS: C Rationale: Risk for aspiration is defined by NANDA International as the state in which an individual is at risk for entry of gastrointestinal (GI) secretions, oropharyngeal secretions, or solids or fluids into tracheobronchial passages. Major defining characteristics specific for this client include reduced level of consciousness, depressed cough and gag reflexes, and feeding via a GI tube. Strategy: Use the ABCs—airway, breathing, and circulation—in answering the question. Given the description in the question, it is easy to eliminate options 1 and 4 first. Regarding the remaining options, recall that aspiration is one form of injury that the client could sustain. Review care of the unconscious client receiving tube feedings if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2058, 2060). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1860) A nurse in a long-term care facility is reviewing the physician's orders on an assigned client. The nurse notes that the physician orders ropinirole hydrochloride (Requip). The nurse determines that this medication has been prescribed to treat which of the following conditions in the client? a. Diabetes mellitus b. Coronary artery disease c. Parkinsonian syndrome d. Depression Source: Saunders 4th

ANS: C Rationale: Ropinirole hydrochloride is a medication that is used to treat idiopathic parkinsonian syndrome. It normally is administered three times a day to treat the client. This medication is not used to treat diabetes mellitus, coronary artery disease, or depression. Strategy: Knowledge regarding the action of ropinirole hydrochloride is required to answer this question. Remember that ropinirole is used to treat parkinsonian syndrome. If you had difficulty with this question or are unfamiliar with this medication, review its action and use. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1034). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1544) A rubella vaccine is prescribed to be administered to a 2-day postpartum client. The nurse preparing to administer the vaccine develops a list of the potential risks associated with this vaccine. The nurse reviews the list with the client and cautions the client to avoid: a. Sunlight for 3 days. b. Scratching the injection site. c. Pregnancy for 1 to 3 months after the vaccination. d. Sexual intercourse for 2 to 3 months after the vaccination. Source: Saunders 4th

ANS: C Rationale: Rubella vaccine is a live attenuated virus that evokes an antibody response that provides immunity for 15 years. Because rubella is a live vaccine, it will act as the virus and is potentially teratogenic in the organogenesis phase of fetal development. The client needs to be informed about the potential effects of this vaccine and the need to avoid becoming pregnant for 1 to 3 months after receiving the vaccine (depending on physician preference). Abstinence from sexual intercourse is not necessary, unless another form of effective contraception is not being used. The vaccine may cause local or systemic reactions but all are mild and short-lived. Sunlight has no effect on the person who is vaccinated. Strategy: Use the process of elimination. Recalling that rubella is a live vaccine will easily direct you to option 3. Review the risks associated with the administration of this vaccine if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 684). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

1307) The nurse is evaluating the respiratory outcomes for the client with Guillain-Barré syndrome. The nurse determines that which of the following is the least optimal outcome for the client? a. Spontaneous breathing b. Oxygen saturation of 98% c. Adventitious breath sounds d. Vital capacity within normal range Source: Saunders 4th

ANS: C Rationale: Satisfactory respiratory outcomes include clear breath sounds on auscultation, spontaneous breathing, normal vital capacity, and normal arterial blood gas levels and pulse oximetry. Strategy: Use the process of elimination, noting the strategic words least optimal. Only one option does not represent full respiratory function. This should help you eliminate each of the incorrect options. Review care of the client with Guillain-Barré syndrome if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1009, 1012). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2598) A nursing student is assisting a school nurse in performing scoliosis screening on the children in the school. The nurse assesses the student's preparation for conducting the screening. The nurse determines that the student demonstrates understanding of the disorder when the student states that scoliosis is characterized by: a. Excessive posterior curvature of the thoracic spine b. Abnormal anterior curvature of the lumbar spine c. Abnormal lateral curvature of the spine d. Abnormal curvature of the spine due to inflammation Source: Saunders 4th

ANS: C Rationale: Scoliosis is defined as an abnormal lateral curvature in any area of the spine. The region of the spine most commonly affected is the right thoracic area, where it results in rib prominence. Scoliosis does not occur as a sequela of inflammation. Option 1 describes kyphosis, which also is known as "humpback." Option 2 describes lordosis, which usually is exaggerated during pregnancy, in obesity, or in persons with large tumors. Strategy: Use the process of elimination. Correlate lateral with scoliosis to help you remember its description. Review the characteristics of scoliosis if you had difficulty with this question. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., p. 1782). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

2072) A nurse in the preoperative holding unit administers a dose of scopolamine to a client scheduled for surgery. The nurse tells the client to expect which side effect of the medication? a. Excessive urination b. Diaphoresis c. Dry mouth d. Pupillary constriction Source: Saunders 4th

ANS: C Rationale: Scopolamine is an anticholinergic medication that causes frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. The other options are incorrect. Strategy: Use the process of elimination. Recalling that this medication is an anticholinergic and knowledge of the side effects of this type of medication will direct you to option 3. Review the action and effects of this medication if you are unfamiliar with this content. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 129). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2283) A nurse is developing a discharge teaching plan for a postcraniotomy client that includes home care considerations. Which of the following items would be an inappropriate component of the teaching plan? a. Tub bath or shower is permitted, but the scalp is kept dry until the sutures are removed. b. Use a check-off system for administering anticonvulsant medications to avoid missing doses. c. Sounds will not be heard clearly unless they are loud. d. Obtain assistance with ambulation if client is light-headed. Source: Saunders 4th

ANS: C Rationale: Seizures are a potential complication that may occur for up to 1 year after surgery. For this reason, the client must diligently take anticonvulsant medications. The client and family are encouraged to keep track of the doses administered. The family should learn seizure precautions, and accompany the client while ambulating if dizziness or seizures tend to occur. The suture line is kept dry until sutures are removed to prevent infection. The postcraniotomy client typically is sensitive to loud noises and can find them excessively irritating. Control of environmental noise by others will be helpful for this client. Strategy: Use the process of elimination, noting the strategic word inappropriate. Eliminate option 1 first, because it is a general teaching point appropriate after many types of surgery. If you know that seizures are a potential postoperative risk for up to 1 year after surgery, this eliminates options 2 and 4 as well. Remember that many clients after craniotomy have increased sensitivity to or are irritated by loud noises. Review home care instructions after craniotomy if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1065-1066). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1517). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2670) A nurse is administering senna (Senokot) to an older client for the treatment of constipation. The client's spouse asks the nurse how the medication works. The nurse incorporates which of the following information in formulating a reply? a. It lines the wall of the bowel. b. It adds fiber and bulk to the stool. c. It increases peristalsis. d. It stimulates the vagus nerve to improve bowel tone. Source: Saunders 4th

ANS: C Rationale: Senna works by altering the transport of water and electrolytes in the large intestine, which causes accumulation of water in the mass of stool and increased peristalsis. The other options are incorrect actions for this medication. Strategy: To answer this question accurately, you must be familiar with this medication and its actions. Noting that the medication is used to treat constipation will assist you in answering correctly. Review the actions of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1050). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

963) The client who is advised to take senna (Senokot) to treat constipation asks the nurse how this medication works. The nurse would incorporate which statement when formulating a response? a. Senna adds fiber and bulk to the stool. b. Senna coats the bowel wall and makes it slippery. c. Senna accumulates water and increases peristalsis. d. Senna stimulates the vagus nerve to improve bowel tone. Source: Saunders 4th

ANS: C Rationale: Senna works by changing the transport of water and electrolytes in the large intestine, which causes accumulation of water in the mass of stool and increased peristalsis. The other options are incorrect. Strategy: Focus on the name of the medication and recall that it is a stimulant cathartic. Remember that senna increases peristalsis. If you are unfamiliar with this medication, review its action. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1049). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2440) A nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which of the following actions should the nurse take next? a. Medicate the client. b. Provide pin care. c. Call the physician. d. Remove 2 pounds of weight from the traction system. Source: Saunders 4th

ANS: C Rationale: Severe pain in a client in skeletal traction may indicate a need for realignment, or the traction weights applied to the limb may be too heavy. The nurse realigns the client; if this measure is ineffective, the nurse then calls the physician. Severe leg pain once traction has been established indicates a problem. Medicating the client should be done after trying to determine and treat the cause. The nurse should never remove the weights from the traction system without a specific order to do so. Providing pin care is unrelated to the problem as described. Strategy: Note the strategic word severe in the question. This should indicate to you that a problem exists. Recalling the causes of severe pain in a client in skeletal traction, and noting that the question addresses that the nurse has already ensured that the client is in proper alignment, should assist in directing you to option 3. If you had difficulty with this question, review the complications associated with skeletal traction. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1201). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

26) The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report but instead receives a sexually oriented photograph. The appropriate initial nursing action is to: a. Call the police. b. Cut up the photograph and throw it away. c. Call the nursing supervisor and report the incident. d. Call the laboratory and ask for the individual's name that sent the photograph. Source: Saunders 4th

ANS: C Rationale: Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a co-worker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harassment by another worker. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option 1 is unnecessary at this time. Options 2 and 4 are not appropriate initial actions. Strategy: Note the strategic word initial. This may indicate that one or more than one of the options is partially or totally correct. Use the skills of prioritizing to select the correct option. Remember that using the organizational channels of communication is best. This will assist in directing you to option 3. Review nursing responsibilities when sexual harassment occurs in the workplace if you had difficulty with this question. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., pp. 679, 681, 683, 685). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2343) A nurse has administered a dose of meperidine hydrochloride (Demerol), 100 mg, to a client with renal colic as treatment for pain. The nurse carefully monitors this client for which of the following as a side effect of this medication? a. Hypertension b. Increased respirations c. Urinary retention d. Bradycardia Source: Saunders 4th

ANS: C Rationale: Side effects of meperidine hydrochloride include respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urinary retention. Strategy: Use the process of elimination. In this question, associate the client's diagnosis with the correct option, because both are renal system related. If you had difficulty with this question, review the side effects of this medication. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 334). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 531). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2664) A nurse in the preoperative holding unit administers a dose of scopolamine to a client. The nurse interprets that which of the following signs and symptoms later displayed by the client is due to medication side effects? a. Excessive urination b. Diaphoresis c. Dry mouth d. Pupillary constriction Source: Saunders 4th

ANS: C Rationale: Side effects of scopolamine, an anticholinergic medication, are dry mouth, urinary retention, decreased sweating, and dilation of the pupils. Each of the incorrect options state the opposite of a side effect of this medication. Strategy: Use the process of elimination. Recalling that this medication is an anticholinergic will assist you in answering this question. Also, noting that the medication is being administered in the preoperative period will direct you to option 3. Review the side effects of this medication if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 131). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1993) A nurse is monitoring a postpartum client who is at risk for developing endometritis. Which of the following if noted during the first 24 hours after delivery would support a diagnosis of postpartum endometritis? a. Maternal oral temperature of 100.2° F b. Uterus two fingerbreadths below midline and firm c. Abdominal tenderness and chills d. Increased perspiration and appetite Source: Saunders 4th

ANS: C Rationale: Signs and symptoms in the postpartum period heralding endometritis include delayed uterine involution, foul-smelling lochia, tachycardia, abdominal tenderness, and temperature elevations up to 104° F. This intrauterine infection may lead to further maternal complications, such as infections of the fallopian tubes, ovaries, and blood (sepsis). Options 1, 2, and 4 represent normal maternal physiological responses in the immediate postpartum period. Strategy: Use the process of elimination and focus on the normal and abnormal expected findings in the immediate postpartum period. Options 1, 2, and 4 represent the normal adaptation of reproductive organs (involution) and maternal physiological responses due to decreased hormonal levels and fluid losses of labor. Option 3 clearly indicates abnormal findings that require further evaluation of the client for endometritis. Review the assessment findings in endometritis if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., pp. 747-748). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

1346) A nurse is assessing the casted extremity of a client. The nurse would assess for which of the following signs and symptoms indicative of infection? a. Dependent edema b. Diminished distal pulse c. Presence of a "hot spot" on the cast d. Coolness and pallor of the extremity Source: Saunders 4th

ANS: C Rationale: Signs and symptoms of infection under a casted area include odor or purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others. The physician should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished arterial pulse, and edema. Strategy: Use the process of elimination. Answer this question and think about what you would expect to note with infection—redness, swelling, heat, and purulent drainage. With this in mind, you can eliminate options 2 and 4 easily. From the remaining options, remember that "dependent edema" is not necessarily indicative of infection. Swelling would be continuous. The hot spot on the cast could signify infection underneath that area and is the correct answer to the question. Review signs of infection in an extremity with a cast if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1200). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1728) The nurse is caring for the client after pulmonary angiography with catheter insertion via the left groin. The nurse assesses for allergic reaction to the contrast medium by noting the presence of: a. Hematoma in the left groin. b. Discomfort in the left groin. c. Stridor. d. Hypothermia. Source: Saunders 4th

ANS: C Rationale: Signs of allergic reaction to the contrast dye include early signs such as localized itching and edema, which are then followed by more severe symptoms such as respiratory distress, stridor, and decreased blood pressure. Strategy: Focus on the subject, an allergic reaction. Hypothermia is an unrelated event and is eliminated first. Discomfort is expected, and is eliminated next. Hematoma formation is a complication of the procedure, but does not indicate allergic reaction, and is therefore eliminated. The remaining option is stridor, which is a sign of a severe allergic reaction and possible anaphylaxis. Review the signs of an allergic reaction to the contrast medium if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 101, 103). Philadelphia: W.B. Saunders. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 929). Philadelphia: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., pp. 772-773). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1865) A client diagnosed with severe preeclampsia is receiving magnesium sulfate by continuous intravenous infusion. Which of the following assessment findings would indicate that the medication should be discontinued? a. Respiratory rate of 16 breaths/min b. Decrease in blood pressure from 180/100 to 150/90 mm Hg c. Absence of deep tendon reflexes d. Urinary output of 45 mL during the past hour Source: Saunders 4th

ANS: C Rationale: Signs of magnesium toxicity include central nervous system depression. The client should maintain a respiratory rate over 13 breaths/min, deep tendon reflexes, and a urinary output greater than 30 mL/hr. A decrease in blood pressure is a positive finding, because preeclampsia is accompanied by hypertension. Strategy: Use the process of elimination and note the strategic words should be discontinued. Knowledge that the signs of magnesium toxicity include central nervous system depression will assist in directing you to option 3. Review the signs of magnesium toxicity if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., pp. 647-648). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Maternity—Intrapartum Alternate Question Types -> Multiple Choice

1309) The nurse is evaluating the status of the client who had a craniotomy 3 days ago. The nurse would suspect that the client is developing meningitis as a complication of surgery if the client exhibits: a. A negative Kernig's sign. b. Absence of nuchal rigidity. c. A positive Brudzinski's sign. d. A Glasgow Coma Scale score of 15. Source: Saunders 4th

ANS: C Rationale: Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed, right-angle position. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits. Strategy: Use the process of elimination, focusing on the client's diagnosis, meningitis. You can eliminate options 1, 2, and 4 because they are normal findings. Review the signs of meningitis if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2098-2099). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1612) The nurse is preparing a plan of care for the client in skin traction. The nurse includes in the plan that a priority intervention is to assess the client frequently for: a. The presence of bowel sounds b. Signs of infection around the pin sites c. Signs of skin breakdown d. Urinary incontinence Source: Saunders 4th

ANS: C Rationale: Skin traction is achieved by Ace wraps, boots, and slings that apply a direct force on the client's skin. Skin traction is usually removed and reapplied once a day. Traction is maintained with 5 to 8 lb of weight and this type of traction can cause skin breakdown. There are no pin sites with skin traction. Urinary incontinence is not related to the use of skin traction. Although constipation can occur as a result of immobility and monitoring bowel sounds may be a component of the assessment, this intervention is not the priority assessment. Strategy: Use the process of elimination. Note the strategic word priority in the question. Eliminate option 2 first because there are no pin sites with skin traction. Visualizing the traction setup and knowledge of the complications associated with this type of traction will direct you to option 3. Review the complications associated with skin traction and the priority nursing interventions if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 643). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1201). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

106) The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit which of the following foods? a. Apples b. Bananas c. Smoked sausage d. Steamed vegetables Source: Saunders 4th

ANS: C Rationale: Smoked foods are high in sodium. Options 1, 2, and 4 are fruits and vegetables that are low in sodium. Strategy: Note the strategic word limit and use the process of elimination, recalling the food items that are high in sodium. If you had difficulty with this question, review the foods high in sodium. Reference: Barker, H., & Aldrich, C. (2004). Nutrition and dietetics for health care (10th ed., p. 247). Edinburgh: Churchill Livingstone. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

976) The hospitalized client asks the nurse for sodium bicarbonate to relieve heartburn following a meal. The nurse reviews the client's medical record, knowing that the medication is contraindicated in which condition? a. Urinary calculi b. Chronic bronchitis c. Metabolic alkalosis d. Respiratory acidosis Source: Saunders 4th

ANS: C Rationale: Sodium bicarbonate is an electrolyte modifier and antacid, and it would aggravate metabolic alkalosis, which is a difficult acid-base imbalance to correct. The other options are incorrect. Strategy: Use the process of elimination. Focusing on the name of the medication, sodium bicarbonate, will direct you to option 3, metabolic alkalosis. Review the contraindications associated with the use of sodium bicarbonate if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1059). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1772) The nurse prepares to administer sodium polystyrene sulfonate (Kayexalate) to the client. Prior to administering the medication, the nurse reviews the action of the medication and understands that it releases: a. Bicarbonate in exchange for primarily sodium ions. b. Sodium ions in exchange for primarily bicarbonate ions. c. Sodium ions in exchange for primarily potassium ions. d. Potassium ions in exchange for primarily sodium ions. Source: Saunders 4th

ANS: C Rationale: Sodium polystyrene sulfonate (Kayexalate) is a cation exchange resin used for the treatment of hyperkalemia. The resin passes through the intestine or is retained in the colon. It releases sodium ions primarily in exchange for potassium ions. The therapeutic effect occurs 2 to 12 hours after oral administration and longer after rectal administration. Strategy: Use the process of elimination. Looking closely at the name of the medication (Kayexalate) may provide you with assistance regarding its action. If you had difficulty with this question, review the action of this very important medication. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 789). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2565) A nurse in the mental health unit is performing an assessment in a client who has a history of multiple somatic complaints involving several organ systems. Diagnostic studies revealed no organic pathology. The care plan developed for this client will reflect that the client is experiencing which of the following disorders? a. Schizophrenia b. Depression c. Somatization disorder d. Obsessive-compulsive disorder Source: Saunders 4th

ANS: C Rationale: Somatization disorder is characterized by a long history of multiple physical problems with no satisfactory organic explanation. The clinical findings associated with schizophrenia, depression, and obsessive-compulsive disorder are unrelated to somatic complaints. Strategy: Use the process of elimination. Note the relationship between somatic complaints in the question and somatization in the correct option. Review the characteristics of this disorder if you had difficulty with this question. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 260). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1626) Somatropin (Humatrope), a growth hormone, is prescribed for a client. The nurse reviews the assessment data in the client's health record, knowing that the medication is contraindicated in which of the following conditions? a. A child with growth hormone deficiency b. A child with pituitary dwarfism c. A 20-year-old with growth failure d. A child with growth failure Source: Saunders 4th

ANS: C Rationale: Somatotropin (Humatrope) should not be administered during or after epiphyseal closure. Efficacy of therapy declines as the client grows older and is usually lost entirely by age 20 to 24 years. Strategy: Use the process of elimination and note the strategic word contraindicated. Note the similarity between options 1, 2, and 4. These options all relate to growth failure. Note the difference in option 3, because it identifies a particular age of a client. Review the contraindications associated with the administration of somatotropin if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., pp. 790-791). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1655) Somatrem is prescribed for the client with pituitary dwarfism. The nurse explains to the client that the expected outcome of the medication is: a. Growth that begins in 4 to 5 years. b. An increase in height that will begin in late adulthood. c. An immediate increase in growth. d. Growth spurts that occur every 2 years. Source: Saunders 4th

ANS: C Rationale: Somatrem is a growth hormone used in the treatment of dwarfism. When treatment is started, height may be increased by as much as 6 inches. To monitor treatment, height and weight should be measured monthly. Options 1, 2, and 4 are incorrect. Strategy: Use the process of elimination. Options 1, 2, and 4 are comparative or alike in that each identifies lengthy and specific time frames related to the expected outcome of the medication. Review the expected outcome of somatrem if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 759). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2277) Members of the family of an unconscious client with increased intracranial pressure are talking at the client's bedside. They are discussing the client's condition and wondering if the client will ever recover. The nurse intervenes on the basis of the understanding that: a. The family needs immediate crisis intervention. b. The family could benefit from a conference with the physician. c. It is possible the client can hear the family. d. The client might have wanted a visit from the hospital chaplain. Source: Saunders 4th

ANS: C Rationale: Some clients who have awakened from an unconscious state have reported they remember hearing specific voices and conversations. Family and staff should assume that the client's sense of hearing is still intact and act accordingly. Studies also have demonstrated that positive outcomes are associated with coma stimulation—that is, speaking to and touching the client. Strategy: Use the process of elimination. The nurse would not infer that the client wants a visit from the chaplain from the family's speaking over the client at the bedside, so option 4 should be eliminated first. The family demonstrates no evidence of crisis and seems to be well informed. This eliminates options 1 and 2. Review psychosocial support measures for the client and family if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2064-2065). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1900) A client who is 8 weeks' pregnant calls the health care clinic and tells the nurse that she is experiencing nausea and vomiting every morning. The nurse suggests which of the following measures that will best promote relief of the symptoms? a. Eating a high-carbohydrate diet b. Eating a high-fat diet c. Eating dry crackers before arising d. Increasing fluids with meals Source: Saunders 4th

ANS: C Rationale: Some strategies for decreasing morning nausea are keeping crackers, melba toast, or dry cereal at the bedside to eat before getting up in the morning; eating smaller, more frequent meals; decreasing fats; and consuming adequate fluid between meals but not with meals. A high-carbohydrate diet could increase the episodes of nausea. Strategy: Note the strategic words best promote in the question. Use the process of elimination, noting the relationship between the words every morning in the question and before arising in the correct option. If you had difficulty with this question, review the measures that will relieve nausea and vomiting during pregnancy. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 137). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1244) The nurse is caring for a hearing-impaired client. Which of the following approaches will facilitate communication? a. Speak loudly. b. Speak frequently. c. Speak at a normal volume. d. Speak directly into the impaired ear. Source: Saunders 4th

ANS: C Rationale: Speaking in a normal tone to the client with impaired hearing and not shouting are important. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear. Strategy: Use the process of elimination and knowledge regarding effective communication techniques for the hearing impaired to answer this question. Remember, it is important to speak in a normal tone. If you had difficulty with this question, review these techniques. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1139). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

1138) A client with congestive heart failure is on a 1-g sodium diet. A nurse understands that which medication prescribed for the client promotes sodium excretion while conserving potassium? a. Furosemide (Lasix) b. Ethacrynic acid (Edecrin) c. Spironolactone (Aldactone) d. Hydrochlorothiazide (HydroDIURIL) Source: Saunders 4th

ANS: C Rationale: Spironolactone (Aldactone) is a potassium-sparing diuretic that promotes sodium excretion while conserving potassium. Options 1, 2, and 4 identify diuretics that do not conserve potassium. Strategy: Use the process of elimination. Recalling that spironolactone is a potassium-sparing diuretic will direct you to option 3. Review the potassium-sparing diuretics if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1074). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1124) In reviewing the medication records of the following group of clients, the nurse determines that which client would be at greatest risk for developing hyperkalemia? a. Client receiving furosemide (Lasix) b. Client receiving bumetanide (Bumex) c. Client receiving spironolactone (Aldactone) d. Client receiving hydrochlorothiazide (HCTZ) Source: Saunders 4th

ANS: C Rationale: Spironolactone is a potassium-sparing diuretic and competes with aldosterone at receptor sites in the distal tubule, resulting in excretion of sodium, chloride, and water and retention of potassium and phosphate. Use of the medications noted in options 1, 2, and 4 could result in hypokalemia. Strategy: Use the process of elimination. Eliminate options 1 and 2 because they are both loop diuretics, which lead to the side effect of hypokalemia. Next eliminate option 4 because it is a thiazide diuretic, which acts on the distal tubule and inhibits sodium, chloride, and potassium reabsorption. Review the effects of these medications if you had difficulty with this question. Reference: Lilley, L., Harrington, S., & Snyder, J. (2005). Pharmacology and the nursing process (4th ed., p. 431). St. Louis: Mosby. Reference: Skidmore-Roth, L. (2006). Mosby's 2006 nursing drug reference (20th ed., pp. 188, 467, 883-884). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2066) A nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan expecting that the physician will prescribe which of the following? a. Maintain the affected leg in a dependent position. b. Apply cool packs to the affected leg for 20 minutes every 4 hours. c. Maintain bedrest. d. Administer a opioid analgesic every 4 hours around the clock. Source: Saunders 4th

ANS: C Rationale: Standard management for the client with DVT includes bed rest for 5 to 7 days, limb elevation, relief of discomfort with warm moist heat, and analgesics as needed. Ambulation is contraindicated because such activity can cause the thrombus to dislodge and travel to the lungs. Opioid analgesics are not required to relieve pain, and pain normally is relieved with acetaminophen (Tylenol). Strategy: Use the process of elimination. Recalling that a concern in DVT is dislodgment will direct you to option 3. If you had difficulty with this question, review treatment measures for the client with this disorder. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1537). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 813). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2119) A client is admitted to the hospital with a diagnosis of myocardial infarction (MI). The client is started on streptokinase (Streptase) therapy. The nurse determines that teaching has been effective when the client's wife states that the purpose of the medication is to: a. Thin the blood b. Slow the clotting of the blood c. Dissolve any clots in the coronary arteries d. Prevent further clots from forming in the coronary arteries Source: Saunders 4th

ANS: C Rationale: Streptokinase converts plasminogen in the blood to plasmin. Plasmin is an enzyme that digests or dissolves fibrin clots wherever they exist. Options 1, 2, and 4 describe mechanisms of action of heparin sodium and warfarin sodium (Coumadin). Strategy: Use the process of elimination. Recalling that streptokinase dissolves clots will direct you to option 3. Review the action of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1079). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1083) A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiographic complexes on the screen. Which of the following should be the priority action of the nurse? a. Call a code blue. b. Call the physician. c. Check the client status and lead placement. d. Press the recorder button on the electrocardiogram console. Source: Saunders 4th

ANS: C Rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. Options 1, 2, and 4 are unnecessary. Strategy: Use the steps of the nursing process. Option 3 is the only option that addresses assessment. Review care of the client on a cardiac monitor if you had difficulty with this question. Remember to always assess the client directly before taking any action. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1583). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 711-712, 732). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

1670) The diabetic nurse specialist conducts a teaching session to a group of nursing students regarding sulfonylureas, oral hypoglycemic medications used for type 2 diabetes mellitus. The nurse specialist tells the students that the primary action of these medications is to: a. Decrease glucose production by the liver. b. Inhibit carbohydrate digestion. c. Promote insulin secretion by the pancreas. d. Decrease insulin resistance. Source: Saunders 4th

ANS: C Rationale: Sulfonylureas promote insulin secretion by the pancreas and may also increase tissue response to insulin. Biguanides decrease glucose production by the liver. α-Glucosidase inhibitors inhibit carbohydrate digestion. Thiazolidinediones decrease insulin resistance. Strategy: Knowledge regarding the specific action of the sulfonylureas is required to answer this question. Remember that sulfonylureas promote insulin secretion by the pancreas. Review this classification of medications if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 783-784). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2356) An emergency department nurse has administered 5 mL of syrup of ipecac to a 10-month-old child, followed by one-half glass of water. The nurse evaluates that the medication had the expected response if which of the following is noted? a. Increase in level of consciousness b. Elevation in blood pressure c. Vomiting d. Diarrhea Source: Saunders 4th

ANS: C Rationale: Syrup of ipecac is the medication used for induction of emesis after ingestion of many poisons, although its use is contraindicated after ingestion of strong acids or bases and in clients who are comatose, delirious, or experiencing convulsions. The dose for children younger than 1 year of age is 5 to 10 mL, followed by one-half to one glass of water. Diarrhea and sedation are expected side effects of the medication. Options 1 and 2 are incorrect. Strategy: Use the process of elimination. Eliminate option 1 because oral medications would not be given to a client with a decreased level of consciousness. Recalling the purpose and use of this medication will direct you to option 3. Review this content if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 633). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1394) The nurse is assigned to care for a client with systemic lupus erythematosus. The nurse plans care, knowing that this disorder is a(n): a. Local rash that occurs as a result of allergy b. Disease caused by overexposure to sunlight c. Inflammatory disease of collagen contained in connective tissue d. Disease caused by the continuous release of histamine in the body Source: Saunders 4th

ANS: C Rationale: Systemic lupus erythematosus is an inflammatory disease of collagen in connective tissue. Options 1, 2, and 4 are not associated with this disease. Strategy: Use the process of elimination. Eliminate option 1 because systemic lupus erythematosus is a systemic disorder, not a local one. Next, eliminate option 4 because it is comparative to option 1. From the remaining options, select option 3 because of its systemic characteristics. If you are unfamiliar with this disorder, review its characteristics. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 409-410). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1739). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

2546) A nurse is providing discharge instructions to a client who will be taking tacrolimus (Prograf) daily following allogeneic liver transplantation. The nurse instructs the client that which of the following is a frequent side effect related to this medication? a. A decrease in urine output b. Confusion c. Diarrhea d. Loss of memory Source: Saunders 4th

ANS: C Rationale: Tacrolimus is an immunosuppressant medication used in the prophylaxis of organ rejection in clients who receive allogeneic liver transplants. Frequent side effects include headache, tremors, insomnia, paresthesia, diarrhea, nausea, constipation, vomiting, abdominal pain, and hypertension. Adverse reactions and toxic effects include nephrotoxicity and pleural effusion, which can occur frequently. Nephrotoxicity is characterized by increasing serum creatinine and a decrease in urine output. Thrombocytopenia, leukocytosis, anemia, and atelectasis occur occasionally. Neurotoxicity including tremor, headache, and mental status changes also can occur. It is imperative for the nurse to assess laboratory results, particularly renal function tests, and to monitor intake and output closely. Strategy: Focus on the strategic words frequent side effect. Use the process of elimination. Eliminate options 2 and 4 first because they are comparative or alike. From the remaining options, recalling that a decrease in urinary output is an indication of nephrotoxicity (a toxic effect) will direct you to option 3. Review the frequent side effects of tacrolimus if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1093). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1392-1393). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1129) A home health care nurse is visiting an older client at home. Furosemide (Lasix) is prescribed for the client and the nurse teaches the client about the medication. Which of the following statements, if made by the client, indicates the need for further teaching? a. "I will sit up slowly before standing each morning." b. "I will take my medication every morning with breakfast." c. "I need to drink lots of coffee and tea to keep myself healthy." d. "I will call my doctor if my ankles swell or my rings get tight." Source: Saunders 4th

ANS: C Rationale: Tea and coffee are stimulants and mild diuretics. These are a poor choice for hydration. Taking the medication at the same time each day improves compliance. Because furosemide is a diuretic, the morning is the best time to take the medication so as not to interrupt sleep. Notification of the health care provider is appropriate if edema is noticed in the hands, feet, or face or if the client is short of breath. Sitting up slowly prevents postural hypotension. Strategy: Use the process of elimination, noting the strategic words need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Recalling that tea and coffee are stimulants and that diuretics potentially can worsen dehydration will direct you to option 3. In addition, coffee and tea are not healthy items to consume. Review client teaching points related to this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 525). Philadelphia: W.B. Saunders. Reference: Mosby. (2007). 2007 Mosby's nursing drug reference (20th ed., p. 492). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1871) A nurse in the prenatal clinic is conducting a session about nutrition to a group of adolescents who are pregnant. The appropriate measure to teach these adolescents is to: a. Avoid meals in fast food restaurants. b. Eliminate snacks during the day. c. Monitor for appropriate weight gain patterns. d. Eat only when hungry. Source: Saunders 4th

ANS: C Rationale: Telling an adolescent to avoid fast food restaurants and to eliminate snacks may cause the adolescent to rebel. Advising an adolescent to eat only when hungry could lead to a deficit in nutrients. The nurse should appropriately teach the adolescent about appropriate weight patterns and how to monitor these patterns. The adolescent is more likely to follow suggestions and adhere to the appropriate dietary patterns if the nurse explains why the weight gain is important for the fetus as well as the mother. Strategy: Focus on the client, who in this question is an adolescent. Recall the process of growth and development of this age group to assist in the process of elimination. This will direct you to option 3. If you had difficulty with this question, review the importance of nutrition in the pregnant adolescent. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 191). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1056) Terbutaline (Brethine) is prescribed for a client with bronchitis. A nurse understands that this medication should be used with caution if which of the following medical conditions is present in the client? a. Osteoarthritis b. Hypothyroidism c. Diabetes mellitus d. Polycystic disease Source: Saunders 4th

ANS: C Rationale: Terbutaline (Brethine) is a bronchodilator and is contraindicated in clients with hypersensitivity to sympathomimetics. It should be used with caution in clients with impaired cardiac function, diabetes mellitus, hypertension, or hyperthyroidism, and a history of seizures. The medication may increase blood glucose levels. Strategy: Knowledge regarding the contraindications and cautions associated with the use of this medication is needed to answer this question. Remember that terbutaline is used with caution in the client with diabetes mellitus. Review the contraindications and cautions associated with this medication if you are unfamiliar with them. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1111). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1571) The community health nurse is working with disaster relief in a local community following a hurricane that ruined many homes in the community. The nurse is working to find housing for the survivors and is organizing counseling services. The nurse's actions represent which type of level of prevention? a. Primary b. Secondary c. Tertiary d. Fourth Source: Saunders 4th

ANS: C Rationale: Tertiary prevention involves the reduction of the amount and degree of disability, injury, and damage following a crisis. Primary prevention means keeping the crisis from occurring and secondary prevention focuses on reducing the intensity and duration of the crisis during the crisis itself. There is no known fourth care prevention level. Strategy: Identify the scenario in the question and the role of the nurse in the question. Focus on these nursing roles and use knowledge regarding the various levels of prevention to answer the question. If you had difficulty with this question, review the levels of prevention. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 465). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1657) A community health nurse is working with disaster relief following a tornado. The nurse's goal for the community is to prevent as much injury and death as possible from the uncontrollable event. Finding safe housing for survivors, providing support to families, organizing counseling, and securing physical care when needed are all examples of which type of prevention? a. Primary level of prevention b. Secondary level of prevention c. Tertiary level of prevention d. Aggregate care prevention Source: Saunders 4th

ANS: C Rationale: Tertiary prevention involves the reduction of the amount and degree of disability, injury, and damage following a crisis. Primary prevention means keeping the crisis from occurring, and secondary prevention focuses on reducing the intensity and duration of a crisis during the crisis itself. There is no known aggregate care prevention level. Strategy: Identify the scenario in the question. Focus on this scenario and use knowledge regarding the various levels of prevention to answer the question. If you had difficulty with this question, review the levels of prevention. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 465). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Leadership and Management Alternate Question Types -> Multiple Choice

1668) The nurse encourages the pregnant human immunodeficiency virus (HIV)-positive client to report any early signs of vaginal discharge or perineal tenderness to the health care providers immediately. The client asks the nurse about the importance of this action and the nurse responds by telling the client that this is necessary to: a. Relieve anxiety for the pregnant client. b. Eliminate the need for further unnecessary screenings. c. Assist in identifying potential infections that may need to be treated. d. Minimize the financial cost of caring for an HIV-positive client. Source: Saunders 4th

ANS: C Rationale: The HIV-compromised client may be at high risk for superimposed infections during pregnancy. These include Candida infections, genital herpes, and anogenital condyloma. Early reporting of symptoms may alert the members of the health care team that further assessment and testing are needed to diagnose and manage additional maternal and fetal physiological risks. Options 1, 2, and 4 do represent possible outcomes of this nursing intervention, but are not the priority of care when promoting maternal-fetal well-being. Strategy: Focus on the subject of the question and use Maslow's Hierarchy of Needs theory. Option 3 is the only option that addresses physiological integrity. Review teaching points related to the pregnant HIV client if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 690). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

2298) A client is somewhat nervous about undergoing magnetic resonance imaging (MRI). Which statement by the nurse would provide the most reassurance to the client about the procedure? a. "It is necessary to remove any metal or metal-containing objects before having the MRI done, to avoid the metal being drawn into the magnetic field." b. "The MRI machine is a long, hollow narrow tube, and may make you feel somewhat claustrophobic." c. "Even though you are alone in the scanner, you will be in voice communication with the technologist at all times during the procedure." d. "You will be able to eat before the procedure unless you get nauseous easily. If so, you should eat lightly." Source: Saunders 4th

ANS: C Rationale: The MRI scanner is a hollow tube that gives some clients a feeling of claustrophobia. Metal objects must be removed before the procedure so they are not drawn into the magnetic field. The client may eat and take all prescribed medications before the procedure. If a contrast medium is used, the client may wish to eat lightly if he or she has a tendency to become nauseated easily. The client lies supine on a padded table, which moves into the imager. The client must lie still during the procedure. The imager makes tapping noises while scanning. The client is alone in the imager, but the nurse can reassure the client that the technologist is in voice communication with the client at all times during the procedure. Strategy: Use the process of elimination. Focus on the strategic words provide the most reassurance. All of the statements are factually true. The correct option is the only one that provides a measure of reassurance to the client. Review the content for MRI if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 759). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

39) The RN has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client will the RN plan to care for first? a. A client who is ambulatory b. A client scheduled for physical therapy at 1 <SC>PM </SC> c. A client with a fever who is diaphoretic and restless d. A postoperative client who has just received pain medication Source: Saunders 4th

ANS: C Rationale: The RN would plan to care for the client who has a fever and is diaphoretic and restless first because this client's needs are the priority. Waiting for pain medication to take effect before providing care to the postoperative client is best. The client who is ambulatory and the client scheduled for physical therapy later in the day do not have priority needs related to care. Strategy: Note the strategic words care for first and use principles related to prioritizing. Noting the words diaphoretic and restless will assist in directing you to this option. Review the principles related to prioritizing if you had difficulty with this question. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., p. 167). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 267-268). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

1233) The nurse is developing a teaching plan for the client with glaucoma. Which of the following instructions would the nurse include in the plan of care? a. Avoid overuse of the eyes. b. Decrease the amount of salt in the diet. c. Eye medications will need to be administered for the client's entire life. d. Decrease fluid intake to control the intraocular pressure. Source: Saunders 4th

ANS: C Rationale: The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life. Options 1, 2, and 4 are not accurate instructions. Strategy: Use the process of elimination. Recalling that medications are an integral component of the treatment plan will assist in directing you to the correct option. Review the treatment associated with the care of the client with glaucoma if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1947-1948). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 298). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

2620) A client with depression receiving phenelzine sulfate (Nardil) suddenly complains of a severe headache and neck stiffness and soreness and then begins to vomit. The nurse takes the client's blood pressure and notes that it is 210/102 mm Hg. On the basis of the findings, the nurse obtains which medication from the emergency drawer of the medication cart? a. Protamine sulfate b. Calcium gluconate c. Phentolamine d. Phenobarbital sodium (Luminal) Source: Saunders 4th

ANS: C Rationale: The antidote for hypertensive crisis is phentolamine, and a dosage of 5 to 10 mg is administered by intravenous injection. Hypertensive crisis may be manifested by hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia or bradycardia and constricting chest pain also may be present. Strategy: Use the process of elimination and focus on the subject, the antidote for phenelzine sulfate. Remember that the antidote for phenelzine sulfate is phentolamine. If you are unfamiliar with the antidotes associated with the use of certain medications and conditions, review this content. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., pp. 988-989). St. Louis: Mosby. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 352). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1498) The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be appropriate to make to this client? a. "You need to stop that behavior now." b. "You will need to be placed in seclusion." c. "You seem restless; tell me what is happening." d. "You will need to be restrained if you do not change your behavior." Source: Saunders 4th

ANS: C Rationale: The best statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and may assist the nurse in planning appropriate interventions for the client. Option 1 is demanding behavior that could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate. Strategy: Use the process of elimination. Eliminate option 1 because of the demand that it places on the client. Eliminate options 2 and 4 because they indicate threats to the client. Review appropriate nursing actions for the agitated client if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 509). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 502). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2686) A client is scheduled to receive a first dose of pentamidine (Pentam 300) intravenously. The nurse plans to carefully monitor which of the following during administration of the first dose? a. Respiratory rate b. Breath sounds c. Blood pressure d. Pulse rate Source: Saunders 4th

ANS: C Rationale: The blood pressure is monitored frequently during administration because pentamidine can cause severe and sudden hypotension, even with a single dose. The client should be supine while receiving the medication, and resuscitation equipment should be available. Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are comparative or alike and both relate to the respiratory system. Regarding the remaining options, it is necessary to know that this medication causes hypotension. Review the nursing interventions associated with use of this medication if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 969). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1622) The physician has written an order to start progressive ambulation as tolerated on a hospitalized client who experiences periods of confusion because of bed rest and prolonged confinement to the hospital room. Which nursing intervention would be appropriate when planning to implement the physician's order and to address the needs of the client? a. Ambulate the client in the room for short distances frequently. b. Ambulate the client to the bathroom in the client's room three times daily. c. Progressively ambulate the client in the hall three times daily. d. Assist with range-of-motion exercises three times daily to increase strength. Source: Saunders 4th

ANS: C Rationale: The cause of the confusion in this situation is bed rest and decreased sensory stimulation from prolonged confinement. Therefore, it is best to ambulate the client in the hall. This will increase sensory stimulation and may decrease confusion. Options 1 and 2 will not address the client's need for sensory stimulation. Option 4 is an action that should have been performed in preparation for ambulation while the client was on bed rest. Strategy: Use the process of elimination. Focus on the subject, confusion because of bed rest and prolonged confinement. Eliminate option 4 first, because this action should have been carried out in preparation for ambulation while the client was on bed rest. Next, eliminate options 1 and 2 because they are comparative or alike in that they both address ambulating the client in the hospital room. Review interventions related to promoting sensory stimulation if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1476-1478, 1571-1577). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2577) The home care nurse is visiting a child newly diagnosed with diabetes mellitus. The nurse is instructing the child and parents regarding actions to take if hypoglycemic reactions occur. The nurse tells the child to: a. Drink 8 ounces of diet cola at the first sign of weakness. b. Report to a hospital emergency department if the blood glucose is 60 mg/dL. c. Carry hard candies whenever leaving home in case a hypoglycemic reaction occurs. d. Administer glucagon immediately if shakiness is felt. Source: Saunders 4th

ANS: C Rationale: The child should be instructed to carry a source of glucose for ready use in the event of a hypoglycemic reaction. Hard candies such as LifeSavers will provide a source of glucose. A diet beverage is sugar-free and will not be helpful. If the blood glucose level is 60 mg/dL, a source of glucose may be needed, but it is not necessary to report to the emergency department. Glucagon is not administered if shakiness is felt but is used in an unconscious client or a client unable to swallow who is experiencing a hypoglycemic reaction. Strategy: Use the process of elimination and knowledge regarding the pathophysiologic changes associated with hypoglycemia to assist in directing you to option 3. Review the treatment for hypoglycemia if you had difficulty with this question. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., p. 1714). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

2417) A nurse is providing instructions to a client newly diagnosed with diabetes mellitus. The nurse gives the client a list of the signs of hyperglycemia. Which of the following specific signs of this complication is included on the list? a. Decreased urine output b. Profuse sweating c. Increased thirst d. Shakiness Source: Saunders 4th

ANS: C Rationale: The classic signs of hyperglycemia include polydipsia, polyuria, and polyphagia. Profuse sweating and shakiness would be noted in a hypoglycemic condition. Strategy: Use the process of elimination. Remembering the three <I>P</I>'s—polyuria, polydipsia, and polyphagia—will assist in directing you to the correct option. Review the signs of hyperglycemia if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1500). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

1843) A nurse is providing instructions to a client regarding measures to minimize the risk of dumping syndrome. The nurse tells the client to: a. Increase fluid intake, particularly at meal time. b. Maintain a high-carbohydrate diet. c. Maintain a low-Fowler's position while eating. d. Ambulate for at least 30 minutes following each meal. Source: Saunders 4th

ANS: C Rationale: The client at risk for dumping syndrome should be instructed to maintain a low-Fowler's position while eating and to lie down for at least 30 minutes after eating. The client also should be told that small frequent meals are best and to avoid liquids with meals. Avoiding high-carbohydrate food sources also will assist in minimizing dumping syndrome. Strategy: Note the strategic words minimize the risk. Knowledge of the physiology associated with dumping syndrome will assist you in directing you to the correct option. If you had difficulty with this question or are unsure about the measures to take to prevent this syndrome, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1300). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2242) A client with an exacerbation of chronic obstructive pulmonary disease (COPD) has been on oral glucocorticoids and is currently being weaned to triamcinolone (Azmacort) by inhalation. The nurse determines that the client understands the potential adverse effects to watch for during this medication change if the client states the need to report: a. Blurred vision, headache, and insomnia b. Chills, fever, and generalized rash c. Anorexia, nausea, weakness, and fatigue d. Vomiting, diarrhea, and increased thirst Source: Saunders 4th

ANS: C Rationale: The client being changed from oral to inhalation glucocorticoids could experience signs of adrenal insufficiency. The nurse teaches the client to report anorexia, nausea, weakness, and fatigue. Other signs that can be detected, which are objective in nature, include hypotension and hypoglycemia. Strategy: Use the process of elimination. To answer this question accurately, it is necessary to know that tapering of a glucocorticoid could result in adrenal insufficiency, and to know what those typical signs and symptoms are. Because option 4 seems most compatible with dehydration, eliminate that option first. Option 1 implies central nervous system involvement, so this may be eliminated next. From the remaining options, choose option 3, because option 2 seems to describe a hypersensitivity reaction. Review care of the client receiving glucocorticoids if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1173). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 168). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

954) The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography procedure. The nurse determines that the client needs further information if the client makes which statement? a. "I know I must sign the consent form." b. "I hope the throat spray keeps me from gagging." c. "I'm glad I don't have to lie still for this procedure." d. "I'm glad some IV medication will be given to relax me." Source: Saunders 4th

ANS: C Rationale: The client does have to lie still for endoscopic retrograde cholangiopancreatography (ERCP), which takes about 1 hour to perform. The client also has to sign a consent form. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed. Strategy: Note the strategic words needs further information. These words indicate a negative event query and ask you to select an option that is incorrect. Invasive procedures require consent, so option 1 can be eliminated. Noting the name of the procedure and considering the anatomical location will assist you in eliminating options 2 and 4. Review this procedure if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 501). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1244-1245). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1270) The client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client's history of: a. Hypertension b. Heart failure c. Prosthetic valve replacement d. Chronic obstructive pulmonary disorder Source: Saunders 4th

ANS: C Rationale: The client having a magnetic resonance imaging scan has all metallic objects removed because of the magnetic field generated by the device. A careful history is obtained to determine whether any metal objects are inside the client, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may heat up, become dislodged, or malfunction during this procedure. The client may be ineligible if significant risk exists. Strategy: Use the process of elimination, noting the strategic word ineligible. Note that each of the incorrect options is a medical disorder. The correct option is the name of a surgical procedure in which an artificial valve (sometimes metal) is implanted. An important concept regarding magnetic resonance imaging is the avoidance of any metal objects in the vicinity of the machine. Review the contraindications related to this procedure if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 101-102). Philadelphia: W.B. Saunders. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., pp. 757-758). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1509) The nurse is monitoring a client who is in seclusion. The nurse determines that the client is safe to come out of seclusion when the client: a. Needs to go to the bathroom b. Complains of feeling closed in c. Is no longer a threat to self or others d. Wants to be alone for a while in his or her own room Source: Saunders 4th

ANS: C Rationale: The client in seclusion must be assessed at regular intervals (usually every 15 to 30 minutes) for physical needs, safety, and comfort. Option 1 indicates a physical need that could be met with a urinal or bedpan, if necessary; it does not indicate that the client has calmed down enough to leave the seclusion room. Option 4 could be an attempt to manipulate the nurse. No indication is given that the client will exercise self-control when alone in the room. Option 2 indicates the need for supportive communication or possibly medication as needed; it does not necessitate discontinuing seclusion. Strategy: The subject of the question specifically relates to safety. Use the process of elimination and focus on the subject to direct you to option 3. Review seclusion procedures if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 646). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 498). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Evaluation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1467) The manic client announces to everyone in the dayroom that a stripper is coming to perform this evening. When the nurse firmly states that this will not happen, the manic client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, the nurse determines that the appropriate action would be to: a. Orient the client to time, person, and place. b. Tell the client that the behavior is not appropriate. c. Escort the manic client to her room, with assistance. d. Tell the client that smoking privileges are revoked for 24 hours. Source: Saunders 4th

ANS: C Rationale: The client is at risk for injury to self and others and therefore should be escorted out of the dayroom. Antipsychotic medications are useful to manage the manic client. Hyperactive and agitated behavior usually responds to haloperidol (Haldol). Option 4 may increase the agitation that already exists in this client. Orientation will not halt the behavior. Telling the client that the behavior is not appropriate already has been attempted by the nurse. Strategy: Use the process of elimination and Maslow's Hierarchy of Needs theory to answer the question. Look for the option that promotes safety of the client, other clients, and staff. If you had difficulty with this question, review the appropriate interventions when dealing with a manic client. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 210, 221). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 369). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2336) A nurse is providing instructions to the client scheduled for magnetic resonance imaging (MRI). Which instruction should the nurse provide to the client? a. The test will require that a dye be injected. b. Food and fluids are restricted for 12 hours before the test. c. Ear plugs can be worn if the noise from the machine is uncomfortable. d. The test may cause some pain, and pain medication will be prescribed to administer if pain occurs. Source: Saunders 4th

ANS: C Rationale: The client is informed that MRI is painless and that a contrast dye may or may not be used. Additionally, no dietary restrictions are necessary with MRI. The nurse informs the client that the MRI may damage credit cards and watches and that jewelry and hair clips cause artifacts. These objects should be removed before the test. The client is prepared for the beating noise of the MRI machine and is reassured that ear plugs may be applied if the noise is uncomfortable. Strategy: Use the process of elimination. Recalling that the machine is noisy will direct you to option 3. If you had difficulty with this question, review client preparation for MRI. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 759). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2310) A client is being prepared for electroconvulsive therapy (ECT). The nurse's plan of care for the night before ECT includes ensuring that the client: a. Is placed on nothing by mouth (NPO) status for 16 to 24 hours b. Receives no visitors and participates in limited unit activities c. Shampoos and dries the hair, cleaning it of all hair spray and creams d. Does not smoke at all Source: Saunders 4th

ANS: C Rationale: The client is instructed to shampoo and dry the hair the night before ECT treatment. In addition, the client is instructed not to use hair sprays or creams before ECT to reduce the risk of burns. Maintaining NPO status for 6 to 8 hours before treatment is adequate; NPO status for 16 to 24 hours is not necessary. Some hospitals place inpatient clients on NPO status at midnight before ECT in the morning. Some clients who are on cardiovascular medication may be instructed to take their medicine with sips of water several hours before ECT. Option 2 is incorrect, as is option 4. Strategy: Use the process of elimination and read each option carefully. Eliminate options 2 and 4 first because of the close-ended words no and at all. From the remaining options, eliminate option 1 because of the extended time frame. Review the pre-procedure preparation for ECT if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 606). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1846) A client arrives in the hospital emergency department complaining of severe thirst and polyuria. The client tells the nurse that she has a history of diabetes mellitus. A blood glucose level is drawn, and the result is 685 mg/dL. Which of the following should the nurse anticipate to be initially prescribed for the client? a. Glyburide (Diabeta) via the oral route b. Glucagon via the subcutaneous route c. Regular insulin via the intravenous (IV) route d. NPH insulin via the subcutaneous route Source: Saunders 4th

ANS: C Rationale: The client is most likely in diabetic ketoacidosis (DKA). Regular insulin via the IV route is the preferred treatment for DKA. Regular insulin is a short-acting insulin and is the only insulin that can be given intravenously; it is titrated to the client's high blood glucose levels. NPH insulin is an intermediate-acting insulin and is not appropriate for the emergency treatment of DKA. Glucagon is used to treat hypoglycemia, and glyburide is an oral hypoglycemia agent used to treat diabetes mellitus type 2. Strategy: The subject of the question is the accurate interpretation of the risk for DKA. Use the process of elimination and knowledge regarding the medications identified in the options to assist in directing you to option 3. If you had difficulty with this question, review the treatment measures for DKA. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1544). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

1054) A client has been prescribed a cough formula containing codeine sulfate. A nurse has given the client instructions for its use. The nurse concludes that the client understands the instructions if the client verbalizes to self-assess for: a. Excitability b. Rapid pulse c. Constipation d. Excessive urination Source: Saunders 4th

ANS: C Rationale: The client is taught about side effects that could occur with the use of codeine sulfate. The most common side effects include drowsiness, confusion, hypotension, nausea and vomiting, and constipation. Others include bradycardia, respiratory depression, and urinary retention. Strategy: Use the process of elimination. Remember that codeine sulfate causes constipation. Review the side effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 282). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1353) A client with right-sided weakness needs to learn how to use a cane while ambulating. The nurse plans to teach the client to position the cane by holding it with the: a. Left hand and placing the cane in front of the left foot b. Right hand and placing the cane in front of the right foot c. Left hand and moving it forward 12 inches, 6 inches lateral to the left foot d. Right hand and moving it forward 12 inches, 6 inches lateral to the right foot Source: Saunders 4th

ANS: C Rationale: The client is taught to hold the cane on the side opposite from the weakness. The reason is that with normal walking, the opposite arm and leg move together (called reciprocal motion). The cane is placed 4 to 6 inches lateral to the fifth toe. Strategy: Use the process of elimination. Knowing that the cane is held at the client's side, not in front, helps eliminate options 1 and 2 first. Knowing that the preferred method is to have the cane positioned on the stronger side helps in choosing option 3 over option 4. Review client teaching points related to the use of a cane if you had difficulty with this question. Reference: Harkreader, H., & Hogan, M. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed., p. 793). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1096) A client in ventricular fibrillation is about to be defibrillated. A nurse knows that to convert this rhythm effectively, the machine should be set at which of the following energy levels (in joules, J) for the first delivery? a. 50 J b. 100 J c. 200 J d. 360 J Source: Saunders 4th

ANS: C Rationale: The client may be defibrillated up to three times in succession. The energy levels used are 200, 300, and 360 J for the first, second, and third attempts, respectively. Strategy: Focus on the strategic words first delivery. As a general rule, though, remember that lower levels of energy are used for cardioversion. Higher levels are used in defibrillation. Review this procedure if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1685, 1687). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 742). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1183) The client with chronic renal failure returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 100.2° F. Which of the following is the appropriate nursing action? a. Encourage fluids. b. Notify the physician. c. Continue to monitor vital signs. d. Monitor the site of the shunt for infection. Source: Saunders 4th

ANS: C Rationale: The client may have an elevated temperature following dialysis because the dialysis machine warms the blood slightly. If the temperature is elevated excessively and remains elevated, sepsis would be suspected and a blood sample would be obtained as prescribed for culture and sensitivity determinations. Strategy: Use the process of elimination and focus on the data in the question. Recalling that an elevation in temperature is expected following dialysis will direct you to option 3. Review the normal expected findings following dialysis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1756). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1662) The nurse teaches skin care to the client receiving external radiation therapy. Which of the following statements, if made by the client, would indicate the need for further instruction? a. &quot;I will handle the area gently.&quot; b. &quot;I will avoid the use of deodorants." c. &quot;I will limit sun exposure to 1 hour daily.&quot; d. &quot;I will wear loose-fitting clothing.&quot; Source: Saunders 4th

ANS: C Rationale: The client needs to be instructed to avoid exposure to the sun. Options 1, 2, and 4 are accurate measures in the care of a client receiving external radiation therapy. Strategy: Use the process of elimination. Note the strategic words need for further instruction. These words indicate a negative event query and ask you to select an option that is incorrect. Eliminate option 1 because of the word gently and option 4 because of the word loose. From the remaining options, recalling that sun exposure is to be avoided will assist in answering the question. Review skin care measures for the client receiving external radiation if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 490-491). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

1746) The nurse provides instructions regarding the administration of oral cyclosporine (Sandimmune) solution to a client. Which of the following statements, if made by the client, would indicate the need for further instruction? a. "I need to mix the concentrate well and drink it immediately." b. "After taking the medication, I need to rinse the container with diluent and drink it to ensure that I have taken the complete dose." c. "I will purchase a dropper from the pharmacist to calibrate the amount of medication that I need." d. "I will mix the concentrate with orange juice to improve the taste." Source: Saunders 4th

ANS: C Rationale: The client needs to be instructed to dispense the oral liquid into a glass container using a specially calibrated pipette. The client should not use any other type of dropper to calibrate the amount of prescribed medication. Options 1, 2, and 4 are correct. Strategy: Use the process of elimination. Note the strategic words indicate the need for further instruction. These words indicate a negative event query and ask you to select an option that is incorrect. Knowledge regarding the administration of the oral concentrate will direct you to option 3. Review the client instructions regarding administering this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 293-294). Philadelphia: W.B. Saunders. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 598-599). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1160) The nurse has completed client teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. The nurse determines that the client best understands the information if the client states to record daily the: a. Amount of activity b. Pulse and respiratory rate c. Intake and output and weight d. Blood urea nitrogen and creatinine levels Source: Saunders 4th

ANS: C Rationale: The client on hemodialysis should monitor fluid status between hemodialysis treatments by recording intake and output and measuring weight daily. Ideally, the hemodialysis client should not gain more than 0.5 kg of weight/day. Strategy: Use the process of elimination. Recalling the pathophysiology of renal failure and the impact on the client's bodily functions will assist in answering the question. Also, note that option 3 relates to monitoring of fluid retention. Review teaching points for the client receiving hemodialysis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1755). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1134) A nurse is caring for a client receiving dopamine. Which of the following potential nursing diagnoses is appropriate for this client? a. Fluid volume excess b. Cardiac output increased c. Tissue perfusion ineffective d. Sensory perception disturbed Source: Saunders 4th

ANS: C Rationale: The client receiving dopamine therapy should be assessed for ineffective tissue perfusion related to peripheral vasoconstriction. Options 1, 2, and 4 are not related directly to this medication therapy. Strategy: Use the process of elimination. Recalling that dopamine causes peripheral vasoconstriction will direct you to option 3. Review the action of this medication if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 916-917). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2206) A nurse is planning care for a client who has just returned to the nursing unit after an oral cholecystogram. The nurse would expect to be able to delete which of the following orders on the client's care plan? a. Monitor hydration status. b. Assess for nausea and vomiting. c. Maintain a clear liquid diet for 72 hours. d. Monitor for abdominal discomfort. Source: Saunders 4th

ANS: C Rationale: The client should be able to resume the usual diet once the nurse is ensured that the client's gastrointestinal (GI) function is normal. It is not necessary to keep the client on clear liquids for 72 hours after the procedure. The nurse would monitor the client for complaints of GI discomfort and nausea and vomiting. The nurse would also assess hydration status as part of routine care for the client undergoing a GI diagnostic test. Strategy: Use the process of elimination. Note the strategic word delete. This tells you that the correct option is one that would have been needed before the procedure but is no longer necessary. Use knowledge related to dietary preparations for GI studies to answer the question. Review post-procedure care for this test if you had difficulty with this question. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., pp. 396-397). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Communication and Documentation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1370) A client with acute muscle spasms has been taking baclofen (Lioresal). The client calls the clinic nurse because of continuous feelings of weakness and fatigue and asks the nurse about discontinuing the medication. Which of the following responses to the client would be appropriate? a. "You should never stop the medication." b. "It is best that you taper the dose if you intend to stop the medication." c. "Weakness and fatigue commonly occur and will diminish with continued medication use." d. "It is all right to stop the medication if you think that you can tolerate the muscle spasms." Source: Saunders 4th

ANS: C Rationale: The client should be instructed that symptoms such as drowsiness, weakness, and fatigue are more intense in the early phase of therapy and diminish with continued medication use. The client should be instructed never to withdraw abruptly or stop the medication because abrupt withdrawal can cause visual hallucinations, paranoid ideation, and seizures. The nurse should inform the client that these symptoms will subside and encourage the client that continuing the use of the medication is the best option. Strategy: Use the process of elimination. Eliminate option 1 first because it is an extreme nursing response. Next, eliminate options 2 and 4 because these responses do not represent the scope of nursing practice. Review the effects of this medication if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 240). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1966) A home care nurse visits a client who has just returned home from the hospital after a mastectomy. The client has a Jackson-Pratt drain in place. The nurse instructs the client to avoid which of the following? a. Elevation of the arm when lying or sitting b. Emptying the drain to prevent infection c. Full range-of-motion exercises to the upper arm d. Applying lotion to the area after healing of the incision Source: Saunders 4th

ANS: C Rationale: The client should be instructed to limit upper arm range-of-motion exercises to the level of the shoulder only. Once the Jackson-Pratt drain has been removed, the client can begin full range-of-motion exercises to the upper arm as prescribed. The client should elevate the arm when sitting down or lying, and the client will be able to apply lotion to the incision once it has healed. The drain is emptied as needed. Strategy: Note the strategic word avoid. Use the process of elimination, focusing on the subject that a Jackson-Pratt drain is in place. Noting the word full in option 3 will direct you to this option. If you had difficulty with this question, review client teaching points related to mastectomy. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1109). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1805). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

2570) A nurse is providing instructions to the client with chronic atrial fibrillation who is being started on quinidine sulfate. The nurse plans to instruct the client to: a. Take the medication only on an empty stomach. b. Open the sustained-release capsules and mix with applesauce if the medication is difficult to swallow. c. Wear a medical identification bracelet. d. Stop taking the prescribed digoxin (Lanoxin) when this medication is started. Source: Saunders 4th

ANS: C Rationale: The client should be instructed to take quinidine sulfate exactly as prescribed. The client should not chew the sustained-release capsules or open the capsules and mix them with food. The client should be instructed to wear a medical identification bracelet or tag and to continue taking digoxin as prescribed. Quinidine sulfate is administered for atrial flutter or fibrillation only after the client has been digitalized. Strategy: Use the process of elimination. Eliminate option 1 first because of the close-ended word only. Eliminate option 2 next, knowing that sustained-released tablets or capsules should never be broken open or mixed with food. Focusing on the diagnosis of the client (atrial fibrillation) will assist in eliminating option 4. Review the client education points related to quinidine sulfate if you had difficulty with this question. Reference: Skidmore-Roth, L. (2007). Mosby's 2007 nursing drug reference (20th ed., p. 863). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2624) A client with insomnia has been started on zolpidem (Ambien). After instructing the client in how to obtain the maximal effect of zolpidem, the nurse determines that the client demonstrates understanding of correct administration of the medication by which of the following statements? a. "I wait till bedtime and take the medication with a snack." b. "I take the medication with milk or an antacid to avoid stomach upset." c. "I need to take the medication with a full glass of water." d. "I take the medication just after my evening meal." Source: Saunders 4th

ANS: C Rationale: The client should be instructed to take the medication at bedtime and to swallow the medication whole with a full glass of water. For faster onset of sleep, the client should be instructed not to take the medication with food or immediately after a meal. Antacids affect the absorption of the medication. Strategy: Use the process of elimination. Note the strategic words insomnia and maximal effect. Also, note the similarity in options 1, 2, and 4 in that they all indicate taking the medication with food. If you had difficulty with this question, review the principles related to the administration of zolpidem. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 918). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2223) A nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which observation by the nursing instructor would indicate an inappropriate action? a. Hyperventilating the client with 100% oxygen before suctioning b. Applying suction intermittently during withdrawal of the catheter c. Suctioning the client every hour d. Applying suction only during withdrawal of the catheter Source: Saunders 4th

ANS: C Rationale: The client should be suctioned as needed. Unnecessary suctioning needs to be avoided because it can increase secretions and cause mechanical trauma to the tissues. The client should be hyperoxygenated with 100% oxygen before suctioning. Suction is not applied during insertion of the catheter, and intermittent suction and a twirling motion of the catheter are used during withdrawal. Strategy: Note the strategic word inappropriate and visualize the procedure. Noting the words every hour in option 3 and thinking about the effects of suctioning will direct you to this option. The client should be suctioned as needed, not on a preset scheduled time unless specifically required and indicated by the physician. Review the procedure for suctioning if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1783). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2163) A nurse has administered diazepam (Valium) 5 mg by the intravenous (IV) route to a client. The nurse should plan to maintain the client on bedrest for at least: a. 30 minutes b. 1 hour c. 3 hours d. 12 hours Source: Saunders 4th

ANS: C Rationale: The client should remain in bed for at least 3 hours after a parenteral dose of diazepam. The medication is a centrally acting skeletal muscle relaxant and also has antianxiety, sedative-hypnotic, and anticonvulsant properties. Cardiopulmonary side effects of the medication include apnea, hypotension, bradycardia, and cardiac arrest. For this reason, resuscitative equipment also is kept nearby. Strategy: Use the process of elimination. Recalling the effects of diazepam administered by the IV route would help you eliminate the 30- and 60-minute time frames as too brief. Twelve hours, on the other hand, is excessive, which leaves the 3-hour time frame as the correct option. Review nursing considerations related to administering this medication by the IV route if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 395). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1708) The nurse is preparing to discontinue a client's nasogastric (NG) tube. The client is positioned properly and the tube has been flushed with 15 mL of air to clear secretions. Prior to removing the tube, the nurse makes which statement to the client? a. "Take a deep breath when I tell you and breathe normally while I remove the tube." b. "Take a deep breath when I tell you and bear down while I remove the tube." c. "Take a deep breath when I tell you and slowly exhale while I remove the tube." d. "Take a deep breath when I tell you and hold it while I remove the tube." Source: Saunders 4th

ANS: C Rationale: The client should take a deep breath because the client's airway will be temporarily obstructed during tube removal. The client is then told to exhale slowly and the tube is withdrawn during exhalation. Bearing down could inhibit the removal of the tube. Breathing normally could result in aspiration of gastric secretions during inhalation. Holding the breath does not facilitate tube removal. Strategy: Use the process of elimination. Attempt to visualize the process of tube removal to direct you to option 3. Remember, exhaling slowly will facilitate the process of removal. Review the procedure for removal of a nasogastric tube if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1407). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1555) The nurse is teaching the client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which of the following positions that will aggravate breathing? a. Sitting up with the elbows resting on knees b. Standing and leaning against a wall c. Lying on the back in a low-Fowler's position d. Sitting up and leaning on a table Source: Saunders 4th

ANS: C Rationale: The client should use the positions outlined in options 1, 2, and 4. These allow for maximal chest expansion. The client should not lie on the back because it reduces movement of a large area of the client's chest wall. Sitting is better than standing, whenever possible. If no chair is available, then leaning against a wall while standing allows accessory muscles to be used for breathing and not posture control. Strategy: Use the process of elimination, noting the strategic words dyspneic episodes and avoid. Also, note that options 1, 2, and 4 are comparative or alike in that they all address upright positions. If you had difficulty with this question, review client teaching points related to emphysema. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 597, 603). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2143) A client has been taught to use a walker to aid in mobility after internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if the client: a. Holds the walker using the hand grips b. Leans forward slightly when advancing the walker c. Advances the walker with reciprocal motion d. Supports body weight on the hands while advancing the weaker leg Source: Saunders 4th

ANS: C Rationale: The client should use the walker by placing the hands on the hand grips for stability. The client lifts the walker to advance it, and leans forward slightly while moving it. The client walks into the walker, supporting the body weight on the hands while moving the weaker leg. A disadvantage of the walker is that it does not allow for reciprocal walking motion. If the client were to try to use reciprocal motion with a walker, the walker would advance forward one side at a time as the client walks; thus, the client would not be supporting the weaker leg with the walker during ambulation. Strategy: Use the process of elimination. Note the strategic word incorrectly. This indicates a negative event query and asks you to select an incorrect action. Visualize each of the descriptions in the options. Recalling that reciprocal motion is moving one leg and the opposite arm at the same time will direct you to option 3. Review client teaching points related to the use of a walker if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 125). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 948-949). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1524) The client with schizophrenia has been started on medication therapy with clozapine (Clozaril). The nurse assesses the results of which laboratory study to monitor for adverse effects from this medication? a. Platelet count b. Blood glucose level c. White blood cell count d. Liver function studies Source: Saunders 4th

ANS: C Rationale: The client taking clozapine (Clozaril) may experience agranulocytosis, which is monitored by reviewing the results of the white blood cell count. Treatment is interrupted if the white blood cell count drops below 3000/mm³. Agranulocytosis could be fatal if undetected and untreated. The other options are not related specifically to the use of this medication. Strategy: Use the process of elimination. Recalling that this medication causes agranulocytosis will direct you to option 3. Review the adverse effects of this medication if you had difficulty with this question Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 464). St. Louis: Mosby. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 278). Philadelphia: W.B. Saunders. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., pp. 131-132). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1777) The client is admitted 24 hours following an aspirin overdose. The nurse assesses this client for which signs and symptoms indicating the acid-base disturbance that could occur in the client? a. Bradycardia and hyperactivity b. Restlessness, confusion, and a positive Trousseau's sign c. Headache, nausea, vomiting, and diarrhea d. Bradypnea, dizziness, and paresthesias Source: Saunders 4th

ANS: C Rationale: The client who ingests a large amount of aspirin (acetylsalicylic acid) is at risk for developing metabolic acidosis 24 hours after the poisoning. If metabolic acidosis occurs, the client may exhibit hyperpnea with Kussmaul's respirations, headache, nausea, vomiting, diarrhea, fruity smelling breath because of improper fat metabolism, central nervous system depression, twitching, convulsions, and hyperkalemia. Shortly after aspirin overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism. By 24 hours postoverdose, however, the compensatory mechanism fails and the client reverts to metabolic acidosis. Strategy: Knowledge about the clinical manifestations of metabolic acidosis will easily direct you to option 3. Use the process of elimination, recalling the significant gastrointestinal symptoms that can occur in this disorder. Review the clinical manifestations of metabolic acidosis if this question was difficult. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 93). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2254) Aluminum hydroxide (Amphogel) is prescribed for a client with chronic renal failure (CRF). The nurse should instruct the client to take this medication: a. On an empty stomach b. At bedtime c. With meals d. In the morning on arising Source: Saunders 4th

ANS: C Rationale: The client who is receiving aluminum hydroxide should take the medication with meals. The phosphate-binding effect is most effective when it is taken with food. If tablets are used, they should be chewed well before swallowing. Strategy: Use the process of elimination. Note that options 1, 2, and 4 are comparative or alike in that they all suggest administering the medication without a food item. Review the administration of this medication for the client with CRF if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 45). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2098) A client is in extreme pain from scrotal swelling that is caused by epididymitis. The nurse administers an intramuscular opioid analgesic in the left arm to relieve the pain. The nurse should plan to do which of the following actions next? a. Tell the client to perform range-of-motion (ROM) exercises to the left arm to promote absorption of the medication into the bloodstream. b. Check the name bracelet of the client. c. Put up the side rails on the bed. d. Dim the lights in the room. Source: Saunders 4th

ANS: C Rationale: The client who receives an opioid analgesic should immediately have the side rails raised on the bed to prevent injury once the medication has taken effect. Dimming the light in the room is the next most helpful action. The name bracelet should have been checked before administering the medication. It is unnecessary to do ROM exercises to the affected arm. Strategy: Use the process of elimination. Eliminate option 2, because this should have been done before administration of the medication. Option 1 is not necessary and may be eliminated next. Regarding the remaining options, note that the question asks you for the action to be taken next. Although option 4 is a correct action, it would be done on leaving the room. As part of protecting the client's safety after administration of an opioid analgesic, the side rails would be put up first. Review the safety measures to be implemented after administration of an opioid analgesic if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 304, 490). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1880). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1908) A client diagnosed with chronic renal failure (CRF) is scheduled to begin hemodialysis. The nurse assesses that which of the following neurological and psychosocial manifestations if exhibited by this client would be unrelated to the CRF? a. Labile emotions b. Withdrawal c. Euphoria d. Depression Source: Saunders 4th

ANS: C Rationale: The client with CRF often experiences a variety of psychosocial changes. These are related to uremia, as well as the stress associated with living with a chronic disease that is life-threatening. Clients with CRF may have labile emotions or personality changes and may exhibit withdrawal, depression, or agitation. Delusions and psychosis also can occur. Euphoria is not part of the clinical picture for the client in renal failure. Strategy: Use the process of elimination. Note the strategic word unrelated. Eliminate options 2 and 4 first because they are comparative or alike. Regarding the remaining options, it is necessary to know that labile emotions are also characteristic of the disease and may be related to psychosocial factors as well as uremia. Review psychosocial considerations for the client with CRF if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 954-956). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1301) The client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness? a. Giving client full control over care decisions and restricting visitors b. Providing positive feedback and encouraging active range of motion c. Providing information, giving positive feedback, and encouraging relaxation d. Providing intravenously administered sedatives, reducing distractions, and limiting visitors Source: Saunders 4th

ANS: C Rationale: The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well. Strategy: Use the process of elimination. Option 1 should be eliminated first because it is not practical to think that the client would be given full control over all care decisions. The client who is paralyzed cannot participate in active range of motion, which eliminates option 2. From the remaining options, option 3 is more beneficial in helping the client cope than option 4. Review care of the client with Guillain-Barré syndrome if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2181). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1009, 1012). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1296) The nurse has given instructions to the client with Parkinson's disease about maintaining mobility. The nurse determines that the client understands the directions if the client states that he or she will: a. Sit in soft, deep chairs. b. Exercise in the evening to combat fatigue. c. Rock back and forth to start movement with bradykinesia. d. Buy clothes with many buttons to maintain finger dexterity. Source: Saunders 4th

ANS: C Rationale: The client with Parkinson's disease should exercise in the morning when energy levels are highest. The client should avoid sitting in soft deep chairs because they are difficult to get up from. The client can rock back and forth to initiate movement. The client should buy clothes with Velcro fasteners and slide-locking buckles to support the ability to dress self. Strategy: Use the process of elimination. Option 2 is not useful to clients with fatigue from any disorder, so eliminate this option first. Knowing that the client with Parkinson's has difficulty with movement and dexterity helps eliminate options 1 and 4 next. Review client teaching points with Parkinson's disease if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2174). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 962). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2212) A client is diagnosed with a mild case of ulcerative colitis. The nurse doing dietary teaching gives the client examples of foods to eat that represent which of the following therapeutic diets? a. High fat with milk b. High protein without milk c. Low roughage without milk d. Low roughage with milk Source: Saunders 4th

ANS: C Rationale: The client with a mild to moderate case of ulcerative colitis often is prescribed a diet that is low in roughage and does not include milk. This will help to reduce the frequency of diarrhea for this client. Options 1, 2, and 4 are incorrect. Strategy: To answer this question correctly, it is necessary to know that the disorder is characterized by diarrhea. It is then necessary to know which types of diet reduce this symptom. Recalling that milk products aggravate diarrhea, eliminate options 1 and 4 first. Choose between the remaining options by deciding which is less irritating to the inflamed tissue of the colon. Review dietary measures for the client with ulcerative colitis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1348). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1313) The nurse is caring for the client who has suffered a spinal cord injury. The nurse further assesses the client for other signs of autonomic dysreflexia if the client experiences: a. Sudden tachycardia b. Pallor of the face and neck c. Severe, throbbing headache d. Severe and sudden hypotension Source: Saunders 4th

ANS: C Rationale: The client with a spinal cord injury is at risk for autonomic dysreflexia with an injury above the level of T7. Autonomic dysreflexia is characterized by severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. Autonomic dysreflexia is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury. Strategy: Use the process of elimination. Recalling that a massive sympathetic nervous system response occurs, causing the severe hypertension, the throbbing headache, and flushing of the face and neck will direct you to the correct option. Review the signs of autonomic dysreflexia if you had dificulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2229). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 987-988). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

981) The client is taking lansoprazole (Prevacid) for the chronic management of peptic ulcer disease. The nurse advises the client to take which product if needed for a headache? a. Naproxen (Aleve) b. Ibuprofen (Motrin) c. Acetaminophen (Tylenol) d. Acetylsalicylic acid (aspirin) Source: Saunders 4th

ANS: C Rationale: The client with peptic ulcer disease should avoid taking medications that are irritating to the stomach lining. Irritants would include aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). The client should be advised to take acetaminophen for a headache. Strategy: Use the process of elimination. Remember that options that are comparative or alike are not likely to be correct. With this in mind, eliminate options 1 and 2 first because both medications are NSAIDs. From the remaining options, choose acetaminophen over aspirin because it is least irritating to the stomach. Review this condition and this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 669). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1290, 1305). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2322) A clinic nurse is providing instructions to a client with a diagnosis of pharyngitis. The nurse instructs the client to: a. Drink warm tea throughout the day. b. Drink warm hot chocolate in place of coffee. c. Avoid foods that are highly seasoned. d. Restrict fluid intake to 1000 mL daily. Source: Saunders 4th

ANS: C Rationale: The client with pharyngitis should be instructed to consume cool clear fluids, ice chips, or ice pops to soothe the painful throat. Citrus products should be avoided because they irritate the throat. Milk and milk products are avoided because they tend to increase mucus production. Foods that are highly seasoned are irritating to the throat and should be avoided, and the client should be instructed to eat bland foods and drink 2000 to 3000 mL of fluid daily unless contraindicated. Strategy: Use the process of elimination. Recalling that pharyngitis is an inflammation of the throat will direct you to option 3. Review teaching points for the client with pharyngitis if you had difficult with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1800). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2232) A nurse is caring for a postoperative pneumonectomy client. Which of the following findings on nursing assessment of the client would be an adverse sign/symptom indicating pulmonary edema? a. Respiratory rate of 20 breaths/min b. Pain with deep breathing c. Lung crackles d. Increased chest tube drainage Source: Saunders 4th

ANS: C Rationale: The client with pulmonary edema that developed after pneumonectomy demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis. A respiratory rate of 20 breaths/min is within normal limits. Pain with deep breathing is expected and is managed with analgesics. The client with pneumonectomy most likely will not have a chest tube. Strategy: Use the process of elimination. Increased chest drainage indicates hemorrhage, not pulmonary edema, and is eliminated first. Additionally, the client with pneumonectomy most likely will not have a chest tube. A respiratory rate of 20 breaths/min is normal, and pain with deep breathing is expected in the immediate postoperative period, so these may be eliminated next. Crackles in lung fields indicate pulmonary edema and is the correct option. Review the signs of pulmonary edema if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 214). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 625). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1038) A client tells a nurse that a physician has stated a diagnosis of uncomplicated or simple silicosis and asks the nurse exactly what this means. In formulating a response, the nurse incorporates the knowledge that: a. There is evidence of silica in the bloodstream but no clinical symptoms. b. The client has normal pulmonary function studies but has shortness of breath. c. The client has mild ventilation restriction and has fibrosis on chest x-ray. d. Massive pulmonary fibrosis is visible on chest x-ray, but no extrapulmonary symptoms are apparent. Source: Saunders 4th

ANS: C Rationale: The client with simple silicosis may be asymptomatic or have mild ventilatory restriction and has evidence of fibrosis on chest x-ray. Pulmonary function studies reveal some decreases in vital capacity and total lung volume. Massive fibrosis is not evident at this stage. This disease is restricted to the respiratory system only. Strategy: Use the process of elimination. Option 4 has the least amount of fit with a disorder that is described as simple or uncomplicated and therefore is eliminated first. Because silicosis is a pulmonary disease, option 1 is eliminated. Option 2 is incongruent; it would be difficult for a person to have shortness of breath and have normal pulmonary function tests. Review the pathophysiology associated with simple silicosis if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 612). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2239) A client diagnosed with tuberculosis is distressed over the loss of physical stamina and fatigue. The nurse plans to teach the client that: a. This is a short-lived problem, which should be gone within 1 week of drug therapy. b. This is an unexpected finding with tuberculosis, but it should resolve within 1 month or so. c. This is expected, and the client should gradually increase activity as tolerated. d. This is expected and will last for at least 1 year. Source: Saunders 4th

ANS: C Rationale: The client with tuberculosis has significant fatigue and loss of physical stamina. This can be very frightening for the client. The nurse teaches the client that this will resolve as the therapy progresses and that the client should gradually increase activity as energy levels permit. Options 1, 2, and 4 are incorrect. Strategy: A helpful concept to remember in answering this question is that fatigue due to respiratory problems may not resolve easily and is an expected occurrence, due to tissue hypoxia. Knowing this, you can eliminate options 1 and 2 first. From the remaining options, select option 3 because it provides accurate information and is reassuring. Review client education points related to tuberculosis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 644). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 607). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1091) A client has developed atrial fibrillation, with a ventricular rate of 150 beats/min. The nurse should assess the client for which associated signs or symptoms? a. Flat neck veins b. Nausea and vomiting c. Hypotension and dizziness d. Hypertension and headache Source: Saunders 4th

ANS: C Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats/min is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. Strategy: Use the process of elimination. Flat neck veins are normal or indicate hypovolemia, so eliminate option 1. Nausea and vomiting (option 2) are associated with vagus nerve activity and do not correlate with a tachycardic state. From the remaining options, think of the consequences of falling cardiac output to direct you to option 3. Review the effects of atrial fibrillation if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 727-728). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

117) A client receiving parenteral nutrition (PN) complains of a headache. A nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse interprets that the client is experiencing which complication of PN therapy? a. Sepsis b. Air embolism c. Hypervolemia d. Hyperglycemia Source: Saunders 4th

ANS: C Rationale: The client's signs and symptoms are consistent with hypervolemia. The increased intravascular volume increases the blood pressure, whereas the pulse rate increases as the heart tries to pump the extra fluid volume. The volume also causes neck vein distention and shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms presented in the question do not indicate hyperglycemia, air embolism, or sepsis. Strategy: Use the process of elimination, focusing on the signs and symptoms presented in the question. Recalling the signs of hypervolemia will direct you to option 3. If you had difficulty with this question, review the signs of hypervolemia. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 990). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

951) The hospitalized client with gastroesophageal reflux disease is complaining of chest discomfort that feels like heartburn following a meal. After administering an ordered antacid, the nurse encourages the client to lie in which position? a. Supine, with the head of bed flat b. On the stomach, with the head flat c. On the left side, with the head of bed elevated 30 degrees d. On the right side, with the head of bed elevated 30 degrees Source: Saunders 4th

ANS: C Rationale: The discomfort of reflux is aggravated by positions that compress the abdomen and the stomach. These include lying flat on the back or on the stomach after a meal or lying on the right side. The left side-lying position with the head of the bed elevated is most likely to give relief to the client. Strategy: To answer this question correctly, evaluate each of the positions described in terms of their ability to put pressure on the stomach and cause reflux. Using knowledge of anatomy and these basic nursing positions, you should be able to eliminate each of the incorrect options. Review care of the client with gastroesophageal reflux disease if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1263). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 1013, 1015). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1449) A depressed client is ready for discharge. The nurse feels comfortable that the client has a good understanding of the disease process when the client states: a. "I'll never let this happen to me again. I won't let my boss or my job or my family get to me." b. "I've learned I am a good person and that I am worthy of giving and receiving love. I don't need anyone; I have myself to rely on." c. "It's important for me to eat well, exercise, and to take my medication. If I begin to lose my appetite or not sleep well, I've got to get in to see my doctor." d. "I don't know what happened to me. I've always been able to make decisions for myself and for my business. I don't ever want to feel so weak or vulnerable again." Source: Saunders 4th

ANS: C Rationale: The exact cause of depression is not known but is believed to be related to a biochemical disruption of neurotransmitters in the brain. Diet, exercise, and medication are recognized treatment for the disease process. Options 1, 2, and 4 offer no insight into the disease process. In addition, options 1 and 4 reflect possible blaming or personal failure; option 2 reflects an unwillingness to reach out to others. Strategy: Use the process of elimination, looking for the umbrella option. Option 3 is the only option that incorporates a holistic treatment approach, good nutrition, exercise, and medication, as well as the client's knowledge of the signs of possible relapse. Review concepts related to depression if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 232-233). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 348). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 338-339). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2318) A 6-year-old child with diabetes mellitus and the child's mother come to the health care clinic for a routine examination. The nurse evaluates the data collected during this visit to determine if the child has been euglycemic since the last visit. Which information is the most significant indicator of euglycemia? a. Daily glucose monitor log b. Fasting blood glucose performed on the day of the clinic visit c. Glycosylated hemoglobin d. Dietary history for the previous week Source: Saunders 4th

ANS: C Rationale: The glycosylated hemoglobin assay measures the glucose molecules that attach to the hemoglobin A molecules and remain there for the life of the red blood cell, approximately 120 days. This is not reversible and cannot be altered by human intervention. Daily glucose logs for the period are useful if they are kept regularly and accurately. However, they reflect only the blood glucose at the time the test was done. A fasting blood glucose test performed on the day of the clinic visit is time-limited in its scope, as is the dietary history. Strategy: Use the process of elimination and note the strategic words since the last visit. Look for the option that would evaluate long-term euglycemia. This will assist in eliminating options 1, 2, and 4 because these options reflect short-term monitoring. If you had difficulty with this question, review the purpose and significance of the glycosylated hemoglobin assay. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., pp. 1711-1712). St. Louis: Mosby. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1468). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Child Health Alternate Question Types -> Multiple Choice

1562) The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific physician orders, the nurse would avoid placing the client in which of the following positions? a. Neck in neutral position b. Head of bed elevated 30 to 45 degrees c. Flat, with head turned to the side d. Head midline Source: Saunders 4th

ANS: C Rationale: The head of the client at risk for or with increased intracranial pressure (ICP) should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the neck, or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down. Strategy: Use the process of elimination, noting the strategic words at risk for increased intracranial pressure and avoid. Visualize each of the positions identified in the options and identify the position that is detrimental to the client with increased ICP. This would be the position that interferes with arterial circulation to the brain or venous drainage from the brain. The only position that meets one of those criteria is option 3. Review care of the client at risk for or with increased ICP if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2201). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1044-1045). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2266) A nurse is conducting a neurological assessment including a health history on a client with a neurological disorder. The nurse notes that the client is having difficulty in answering the questions and should: a. Defer the health history and proceed with the neurological examination. b. Defer both the health history and the neurological examination. c. Ask a family member to stay during the interview. d. Ask a second nurse to be present during the interview. Source: Saunders 4th

ANS: C Rationale: The health history and physical assessment for a client with a neurological problem are very similar to those for any other client, with perhaps a more intense neurological examination. If the client is confused or agitated, or has difficulty hearing or speaking, the nurse should ask a significant other or family member to stay with the client during the history-taking to ensure accurate data. Options 1 and 2 will not obtain the assessment data. Option 4 is of no benefit. Strategy: Use the process of elimination and focus on the subject, conducting a neurological assessment. The only option that will assist in obtaining assessment data is option 3. Review neurological assessment if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 932-933, 1031-1035). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

29) The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds a client lying on the floor. The nurse performs a thorough assessment, assists the client back to bed, notifies the physician of the incident, and completes an incident report. Which of the following should the nurse document on the incident report? a. The client fell out of bed. b. The client climbed over the side rails. c. The client was found lying on the floor. d. The client became restless and tried to get out of bed. Source: Saunders 4th

ANS: C Rationale: The incident report should contain the client's name, age, and diagnosis. The report should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. Option 3 is the only option that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse. Strategy: Use the process of elimination and read the information contained in the question to select the correct option. Remember to focus on factual information when documenting, and avoid including interpretations. This will direct you to option 3. Review documentation principles related to incident reports if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 481-482). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Communication and Documentation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2009) A client enters the hospital emergency department with a nosebleed. On assessment, the client tells the nurse that the nosebleed just suddenly began. The nurse notes no obvious facial injury. Which of the following should be the initial nursing action? a. Prepare a nasal balloon for insertion. b. Insert nasal packing. c. Sit the client down, ask the client to lean forward, and apply pressure to the nose for 5 to 10 minutes. d. Place the client in a semi-Fowler's position and apply ice packs to the nose. Source: Saunders 4th

ANS: C Rationale: The initial nursing action for a client with a nosebleed would be to sit the client down, ask the client to lean forward, and apply pressure to the nose for 5 to 10 minutes. Placing the client in semi-Fowler's position would encourage the client to swallow blood. Preparing a nasal balloon and inserting nasal packing are not appropriate initial interventions. A nasal balloon and nasal packing are used when conservative measures fail. Strategy: Use the process of elimination. Focus on the strategic word initial. Eliminate options 1 and 2 first, knowing that initial treatment is always directed at a conservative measure. Attempt to visualize each of the remaining options. Note that the correct option addresses the application of pressure. If you had difficulty with this question, review the initial interventions for a client with nosebleed. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 564-565). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2324) A client arrives in the hospital emergency department with a bloody nose. The initial nursing action is to: a. Place the client in supine position. b. Apply an ice collar around client's neck. c. Assist the client to a sitting position with the head tilted forward. d. Instruct the client to swallow the blood until the bleeding can be controlled. Source: Saunders 4th

ANS: C Rationale: The initial nursing action to treat the client with a bloody nose is to loosen clothing around the neck to prevent pressure on the carotid artery. The client should be assisted to a sitting position with the head tilted slightly forward, and pressure should be applied to the nares by pitching the nose toward the septum for 10 minutes. Ice packs can be applied to the nose and forehead. If these actions are not successful in controlling the bleeding, an ice collar may be applied, along with a topical vasoconstrictive medication. The physician also may prescribe packing of the nostrils. The client should be provided with an emesis basin and should be instructed not to swallow blood, to reduce the risk of nausea and vomiting. Strategy: Note the strategic word initial in the question. Attempt to visualize the interventions that would be taken in this situation. This will direct you to option 3. If you had difficulty with this question, review initial interventions for the client experiencing epistaxis. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 565). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1764) A client arrives in the emergency room in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on self. The initial nursing assessment would focus on the: a. Object of the crisis b. Presence of support systems c. Physical condition of the client d. Client's coping mechanisms Source: Saunders 4th

ANS: C Rationale: The initial nursing assessment of a client in a crisis state is to evaluate the physical condition of the client, the potential for self-harm, and the potential for harm to others. Once this has been determined and appropriate interventions have been initiated, the nurse would then proceed with the mental health interview. Strategy: Use Maslow's Hierarchy of Needs theory to answer the question. Physiological needs take priority over other needs. Option 3 is the only option that addresses a physiological need. Review care of the client in crisis if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 562). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 229, 357, 375-376). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1999) A nurse is assisting a female client to collect a midstream urine specimen. The nurse uses the principles of aseptic technique by: a. Cleansing the meatus with antiseptic pads using upward strokes b. Letting go of the labia once this tissue is cleansed, to allow the client to urinate c. Making sure that the fingers avoid touching the inside of the collection container d. Instructing the client to urinate in the container after the labia have been cleansed Source: Saunders 4th

ANS: C Rationale: The inside of the container is sterile, and sterility must be maintained. Fingers touching the inside of the container would cause the container to become unsterile. The meatus should be cleansed from front to back (toward the anus). Upward strokes would bring bacteria from the anal region toward the urinary meatus. The labia should remain open during the procedure. If they are allowed to close, this tissue will have to be cleansed again with the antiseptic pads. The client should void a small amount into the toilet before urinating into the specimen container, to allow some of the organisms near the meatus to leave the area. Strategy: Focus on the strategic word aseptic. Use the process of elimination and attempt to visualize the procedure as you read through the options. Knowledge of the principles of aseptic technique and collection of a sterile specimen will assist in directing you to option 3. If you are unfamiliar with this procedure, review this content. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 800, 1336-1339). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2273) A nurse has implemented a bowel maintenance program for an unconscious client. The nurse would evaluate the plan as best meeting the needs of the client if which of the following methods was successful in stimulating a bowel movement? a. Fleet enema b. Soap solution enema (SSE) c. Glycerin suppository d. Fecal disimpaction Source: Saunders 4th

ANS: C Rationale: The least amount of invasiveness needed to produce a bowel movement is best. Fecal disimpaction is done only when the client's rectum has become impacted from constipation as a result of inattention or failure of other measures. Enemas may be needed on an every-other-day basis, but they are used cautiously (even if not contraindicated) because the Valsalva maneuver can increase intracranial pressure. Glycerin suppositories are the least invasive and usually stimulate bowel evacuation within a half-hour. Stool softeners may be prescribed on a regular schedule to avoid hard, dry stools. Strategy: Use the process of elimination, noting the strategic words best meeting the needs. Considering most invasive to least invasive, you would eliminate the disimpaction first, followed by the SSE and Fleet enema, leaving the glycerin suppository as the correct option. Review the procedure for implementing an effective bowel maintenance program if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2064). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1619) The maternity nurse is providing an in-service educational session to nursing students regarding the process of conception. The nurse instructs the nursing students that fertilization of a mature ovum occurs in which of the following areas? a. Uterus b. Ovary c. Distal third of the fallopian tube d. Wall of the myometrium Source: Saunders 4th

ANS: C Rationale: The mature ovum is transported through the fallopian tube by the muscular action of the tube and the movement of the cilia within the tube. Fertilization normally occurs in the distal third of the fallopian tube near the ovaries. The ovum, fertilized or not, enters the uterus about 3 days after its release from the ovum. Options 1, 2, and 4 are incorrect. Strategy: Use the process of elimination. Knowledge regarding the process of fertilization is required to answer this question. Remember that fertilization occurs in the fallopian tube. Review the process of fertilization if you are unfamiliar with it. Reference: Wong, D., Perry, S., Hockenberry, M., et al. (2006). Maternal child nursing care (3rd ed., p. 194). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

2415) A nurse is performing an assessment on a client being admitted to the nursing unit who has sustained an extensive burn injury involving greater than 25% of total body surface area (TBSA). In performing the assessment, the nurse knows that the maximum amount of edema that occurs from a burn normally is seen: a. Immediately after the injury b. Within 12 hours after the injury c. Between 18 and 24 hours after the injury d. Between 42 and 72 hours after the injury Source: Saunders 4th

ANS: C Rationale: The maximum amount of edema in a client with a burn injury is seen between 18 and 24 hours after the injury. With adequate fluid resuscitation, the transmembrane potential is restored to normal within 24 to 36 hours after the burn. Options 1, 2, and 4 are incorrect. Strategy: Knowledge of the pathophysiology associated with a burn injury is required to answer this question. If you had difficulty with this question or are unfamiliar with the expected assessment findings in the client with a burn injury, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1439). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

988) Theophylline tablets are prescribed for a client with chronic airflow limitation, and the nurse instructs the client about the medication. Which statement by the client indicates a need for further teaching? a. "I will take the medication with food." b. "Periodic blood levels will need to be obtained." c. "I will take the medication on an empty stomach." d. "I will continue to take the medication even if I am feeling better." Source: Saunders 4th

ANS: C Rationale: The medication should be administered with food such as milk and crackers to prevent gastrointestinal irritation. Options 1, 2, and 4 are appropriate statements regarding the use of this medication. Strategy: Use the process of elimination, noting the strategic words need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Noting that options 1 and 3 are opposite in terms of administering the medication should alert you that one of these options is the correct answer. Recalling that the client with chronic airflow limitation experiences gastrointestinal upset will direct you easily to option 3. If you are unfamiliar with this medication, review this content. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 596). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1962) A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central line. Which nursing intervention would specifically provide assessment data related to the most common complication related to TPN? a. Weighing the client daily b. Monitoring intake and output (I&O) c. Monitoring the temperature d. Monitoring the blood urea nitrogen (BUN) level Source: Saunders 4th

ANS: C Rationale: The most common complication associated with TPN is infection. Monitoring the temperature would provide the assessment data that would indicate infection in the client. Weighing the client daily and monitoring I&O would provide information related to fluid volume overload. Monitoring the BUN level would not provide information related to infection and is most closely related to assessing renal function. Strategy: Use the process of elimination. Focus on the subject of the question, the most common complication of TPN. Eliminate options 1 and 2 first because they are comparative or alike. Regarding the remaining options, knowing that infection is the most common complication of TPN will direct you to option 3. Review the complications associated with TPN if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 708-709). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1028) A client has experienced pulmonary embolism. A nurse assesses for which symptom, which is most commonly reported? a. Hot, flushed feeling b. Sudden chills and fever c. Chest pain that occurs suddenly d. Dyspnea when deep breaths are taken Source: Saunders 4th

ANS: C Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include tachycardia, fever, diaphoresis, cough, anxiety, and possibly syncope. Strategy: Use the process of elimination. Because pulmonary embolism does not result from an infectious process or an allergic reaction, eliminate options 1 and 2 first. To select between options 3 and 4, look at them closely. Option 4 states dyspnea when deep breaths are taken. Although dyspnea commonly occurs with pulmonary embolism, dyspnea is not associated only with deep breathing. Therefore, eliminate option 4. Review the signs of pulmonary embolism if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 650). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1624) The nurse is caring for a post-term, small-for-gestational age (SGA) newborn infant immediately after admission to the nursery. The priority nursing action would be to monitor: a. Urinary output. b. Total bilirubin levels. c. Blood glucose levels. d. Hemoglobin and hematocrit levels. Source: Saunders 4th

ANS: C Rationale: The most common metabolic complication in the small-for-gestational age (SGA) newborn infant is hypoglycemia, which can produce central nervous system abnormalities and mental retardation if not corrected immediately. Urinary output, although important, is not the highest priority action because the post-term SGA infant is typically dehydrated because of placental dysfunction. Hemoglobin and hematocrit levels are monitored because the post-term SGA infant exhibits polycythemia, although this also does not require immediate attention. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery. Strategy: Use the process of elimination and knowledge regarding the SGA newborn infant. Recalling that the most common metabolic complication in the SGA newborn infant is hypoglycemia will direct you to option 3. Review the SGA newborn content if you had difficulty with this question. Reference: Wong, D., Perry, S., Hockenberry, M., et al. (2006). Maternal child nursing care (3rd ed., pp. 820-821). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

2601) A client with muscle spasms in the lumbar area of the spine has been started on cyclobenzaprine (Flexeril). The client indicates an understanding of this medication's most frequent side effect by stating the need for special caution related to: a. Confusion b. Excitability c. Drowsiness d. Weakness Source: Saunders 4th

ANS: C Rationale: The most common side effects of cyclobenzaprine are drowsiness, dizziness, and dry mouth. This medication is a centrally acting skeletal muscle relaxant used in the management of muscle spasm due to a variety of conditions. Fatigue, nervousness, and confusion are less frequent central nervous system effects of cyclobenzaprine. Strategy: Note the strategic words most frequent. Recalling that the medication is used to treat muscle spasms will assist in directing you to option 3. Review the most common side effects of this medication if this question was difficult. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 298). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1881) A nurse is assessing a client with a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse understands that which of the following is unassociated with this condition? a. Elevated levels of human chorionic gonadotropin (hCG) b. Vaginal bleeding c. Excessive fetal activity d. Larger-than-normal uterus for gestational age Source: Saunders 4th

ANS: C Rationale: The most common signs and symptoms of gestational trophoblastic disease (hydatidiform mole) include elevated levels of hCG, vaginal bleeding, larger-than-normal uterus for gestational age, failure to detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting, and early development of gestational hypertension. Fetal activity would not be noted. Strategy: Use the process of elimination and focus on the diagnosis of the client. Note the strategic word unassociated. Recalling that fetal activity would not be noted will assist you in answering the question. Review the clinical manifestations associated with gestational trophoblastic disease if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., pp. 629-630). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

2482) A clinic nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the blood urea nitrogen (BUN) level is normal if which of the following values is noted on the laboratory report? a. 35 mg/dL b. 29 mg/dL c. 15 mg/dL d. 7 mg/dL Source: Saunders 4th

ANS: C Rationale: The normal BUN level ranges from 8 to 25 mg/dL. Options 1 and 2 reflect elevated values. Option 4 reflects a lower-than-normal value. Strategy: To answer this question, it is necessary to know the normal BUN level. Review this laboratory test if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 256). Philadelphia: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 952). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2480) A clinic nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the white blood cell (WBC) count is normal if which of the following values is noted on the laboratory report? a. 2,000/μL b. 3,800/μL c. 8,400/μL d. 12,500/μL Source: Saunders 4th

ANS: C Rationale: The normal WBC count ranges from 4500 to 11,000/μL. Options 1 and 2 indicate a low value. Option 4 indicates an elevated value. Strategy: Knowledge of the normal WBC count is required to answer this question. Review this laboratory test if you had difficulty with this question. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 994). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2426) A client has been receiving a series of medications as part of intravenous (IV) antineoplastic therapy. The nurse implements neutropenic precautions after noting which of the following laboratory results for this client? a. Clotting time of 10 minutes b. Ammonia level of 20 mcg/dL c. White blood cell (WBC) count of 2,000/mm³ d. Platelet count of 100,000/mm³ Source: Saunders 4th

ANS: C Rationale: The normal WBC is 5,000 to 10,000/mm³. When the WBC count drops, neutropenic precautions should be implemented to protect the client from infection. Bleeding precautions should be initiated when the platelet count drops and will include avoiding trauma such as from rectal temperatures or injections. The normal platelet count is 150,000 to 450,000 cells/mm³. The normal clotting time is 8 to 15 minutes. The normal ammonia value is 15 to 45 mcg/dL. Strategy: Use knowledge of normal and abnormal laboratory values as they relate to antineoplastic medications to answer the question. Eliminate options 1 and 2 first because they are normal values. Regarding the remaining options, correlate a low WBC count with the need for neutropenic precautions and a low platelet count with the need for bleeding precautions. If you had difficulty with this question, review care of the client receiving chemotherapy. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 535-537). Philadelphia: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 994). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

93) An adult female client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this result is most likely caused by which of the following conditions noted in the client's history? a. Dehydration b. Heart failure c. Iron deficiency anemia d. Chronic obstructive pulmonary disease Source: Saunders 4th

ANS: C Rationale: The normal hemoglobin level for an adult female client is 12 to 15 g/dL. Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body's need for more oxygen-carrying capacity. Strategy: Use the process of elimination. Evaluate each of the options in terms of whether each is likely to raise or lower the hemoglobin level. Also, note the relationship between hemoglobin level in the question and option 3. Review the normal hemoglobin level if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 639). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 894). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

62) A nurse caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.0 mg/dL. Which electrocardiographic change would the nurse expect to note based on the magnesium level? a. Prominent U waves b. Prolonged PR interval c. Depressed ST segment d. Widened QRS complexes Source: Saunders 4th

ANS: C Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL indicates hypomagnesemia. In hypomagnesemia, the nurse would note tall T waves and a depressed ST segment. Options 2 and 4 would be noted in a client experiencing hypermagnesemia. Prominent U waves occur with hypokalemia. Strategy: First, you must determine that the client is experiencing hypomagnesemia. Next, identify the electrocardiographic changes that occur in this condition. If you had difficulty with this question, review the normal magnesium level and the electrocardiographic changes that occur in hypomagnesemia and hypermagnesemia. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 243). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1563) The nurse reviews the arterial blood gas (ABG) results of an assigned client and notes that the laboratory report indicates a pH of 7.30, P<sc>CO</sc>₂of 58 mm Hg, P<sc>O</sc>₂ of 80 mm Hg, and H<sc>CO</sc>₃^-of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis Source: Saunders 4th

ANS: C Rationale: The normal pH is 7.35 to 7.45. The normal P<sc>co</sc>₂ is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and the Pco₂ is elevated. Options 1, 2, and 4 are incorrect interpretations of the values identified in the question. Strategy: Remember that in a respiratory imbalance you will find an opposite response between the pH and P<sc>co</sc>₂. Also, remember that the pH is low in an acidotic condition. Recalling this information will allow you to eliminate each of the incorrect options. Review interpretation of blood gas results if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 283). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1021) A nurse is taking pulmonary artery catheter measurements of a client with acute respiratory distress syndrome. The pulmonary capillary wedge pressure reading is 12 mm Hg. The nurse interprets that this reading is: a. High and expected b. Low and unexpected c. Normal and expected d. Uncertain and unexpected Source: Saunders 4th

ANS: C Rationale: The normal pulmonary capillary wedge pressure (PCWP) is 8 to 13 mm Hg, and the client is considered to have high readings if they exceed 18 to 20 mm Hg. The client with acute respiratory distress syndrome has a normal PCWP, which is an expected finding because the edema is in the interstitium of the lung and is noncardiac. Strategy: To answer this question correctly, you must know that the PCWP is normal. This makes sense if you know that in acute respiratory distress syndrome, fluid accumulates in the interstitium of the lung and not in the vascular bed. Learn the normal PCWP reading if you are unfamiliar with it. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 208, 1557). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2474) A nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the serum protein level is normal if which of the following values is noted on the laboratory report? a. 0.4 g/dL b. 3.7 g/dL c. 6.4 g/dL d. 9.8 g/dL Source: Saunders 4th

ANS: C Rationale: The normal range for the serum protein level in the adult client is 6.0 to 8.0 g/dL. Options 1 and 2 identify low protein levels. Option 4 identifies an elevated protein level. Strategy: Knowledge of the normal protein level is needed to answer this question. Review this laboratory test if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 913). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

91) An adult client with cirrhosis has been following a diet with optimal amounts of protein because neither an excess nor a deficiency of protein has been helpful. The nurse evaluates the client's status as being most satisfactory if the total protein level is which of the following values? a. 0.4 g/dL b. 3.7 g/dL c. 6.4 g/dL d. 9.8 g/dL Source: Saunders 4th

ANS: C Rationale: The normal range for total serum protein level in the adult client is 6.0 to 8.0 g/dL. The client with cirrhosis often has low total protein levels as a result of inadequate nutrition. Excess protein is not helpful, though, because a function of the liver is to metabolize protein. A diseased liver may not metabolize protein well. Options 1 and 2 identify low values, and option 4 identifies a high protein value. Strategy: Use the process of elimination. Note the strategic words most satisfactory. Recalling the normal total protein level will direct you to option 3. Review this laboratory range if you had difficulty with this question. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 758). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2479) A clinic nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the urine specific gravity is normal if which of the following values is noted on the laboratory results? a. 1.002 b. 1.010 c. 1.020 d. 1.030 Source: Saunders 4th

ANS: C Rationale: The normal range for urine specific gravity is between 1.016 and 1.022. Options 1 and 2 represents a low value. Option 4 reflects an elevated value. Strategy: Knowledge of the normal value for urine specific gravity will direct you to option 3. Review this laboratory test if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 1013). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2463) A nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the serum ammonia level is normal if which of the following values is noted? a. 5 mcg/dL b. 10 mcg/dL c. 40 mcg/dL d. 80 mcg/dL Source: Saunders 4th

ANS: C Rationale: The normal serum ammonia level ranges from 19 to 60 mcg/dL, depending on the laboratory running the test. Options 1, 2, and 4 identify abnormal serum ammonia levels. Strategy: Knowledge of the normal serum ammonia level is needed to answer this question. Remember that the normal level ranges from 19 to 60 mcg/dL. Review this normal level if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 163). Philadelphia: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 52). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

77) The nurse is assigned to a 40-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of: a. 45 units/L b. 100 units/L c. 300 units/L d. 500 units/L Source: Saunders 4th

ANS: C Rationale: The normal serum amylase level is 25 to 151 units/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Options 1 and 2 are within normal limits. Option 4 is an extremely elevated level seen in acute pancreatitis. Strategy: Use the process of elimination and note the strategic word chronic in the question. Recalling the normal amylase level and focusing on the strategic word will direct you to option 3. Review this level and the findings in chronic pancreatitis if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 172). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1406). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1771) The nurse is caring for a client with a diagnosis of hyperthyroidism. Laboratory studies are performed and the serum calcium level is 12.0 mg/dL. Which medication would the nurse anticipate to be prescribed for the client? a. Calcium gluconate b. Calcium chloride c. Calcitonin d. Large doses of vitamin D Source: Saunders 4th

ANS: C Rationale: The normal serum calcium level is 8.6 to 10.0 mg/dL. This client is experiencing hypercalcemia. Calcium gluconate and calcium chloride are medications used for the treatment of tetany that occurs from acute hypocalcemia. In hypercalcemia, large doses of vitamin D need to be avoided. Calcitonin, a thyroid hormone, decreases the plasma calcium level by increasing the incorporation of calcium into the bones, thus keeping it out of the serum. Strategy: First, you need to determine that the client is experiencing hypercalcemia. With this knowledge, you can easily eliminate options 1 and 2 because you would not administer medication that would add calcium to the body. Remembering that excessive vitamin D is a causative factor of hypercalcemia will assist in eliminating option 4. If you had difficulty with this question, review the treatment for hypercalcemia. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 767). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

82) An adult client has had laboratory work done as part of a routine physical examination. The nurse interprets that the client may have a mild degree of renal insufficiency if which of the following serum creatinine levels is noted? a. 0.2 mg/dL b. 0.5 mg/dL c. 1.9 mg/dL d. 3.5 mg/dL Source: Saunders 4th

ANS: C Rationale: The normal serum creatinine level for adults is 0.6 to 1.3 mg/dL. The client with a mild degree of renal insufficiency would have a slightly elevated level. A creatinine level of 0.2 mg/dL is low, and a level of 0.5 mg/dL is just below normal. A creatinine level of 3.5 mg/dL may be associated with acute or chronic renal failure. Strategy: Note the strategic word mild. This tells you that the correct option will be an abnormal value but perhaps not the most abnormal of all the options. Recall the normal value for this common laboratory test to direct you to option 3. Review the normal value for this laboratory test if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 428). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1740). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

92) An adult client was diagnosed with acute pancreatitis 9 days ago. The nurse interprets that the client is recovering from this episode if the serum lipase level decreases to which of the following values, which is just below the upper limit of normal? a. 20 units/L b. 80 units/L c. 135 units/L d. 350 units/L Source: Saunders 4th

ANS: C Rationale: The normal serum lipase level is 10 to 140 units/L. The client who is recovering from acute pancreatitis usually has elevated lipase levels for about 10 days after the onset of symptoms. This makes lipase a valuable test in monitoring the client's pancreatic function because serum amylase levels usually return to normal 3 days after the onset of symptoms. Option 3 is the only option that contains a value just below the upper limit of normal. Strategy: Use the process of elimination and knowledge of the serum lipase level to answer this question. Noting the strategic words just below the upper limit of normal will assist in directing you to option 3. Review the range for this laboratory value if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 724). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2469) A nurse checks the laboratory results of a serum drug level assay for a client taking digoxin (Lanoxin) 0.125 mg daily. Which of the following values would indicate a therapeutic level? a. 0.1 ng/mL b. 0.3 ng/mL c. 1.8 ng/mL d. 2.4 ng/mL Source: Saunders 4th

ANS: C Rationale: The normal therapeutic range for digoxin is 0.5 to 2.0 ng/mL. A value of 2.4 exceeds the therapeutic range and could be toxic to the client. Options 1 and 2 identify values lower than the therapeutic range. Strategy: Focus on the subject, a therapeutic level. Recalling that this level for digoxin is 0.5 to 2.0 ng/mL will direct you to option 3. Review this level if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 477). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1052) A nurse is preparing to administer a dose of naloxone hydrochloride (Narcan) intravenously to a client with an intravenous opioid overdose. The nurse plans to have which of the following available as supportive equipment in case it is needed? a. Nasogastric tube b. Paracentesis tray c. Resuscitation equipment d. Central line insertion tray Source: Saunders 4th

ANS: C Rationale: The nurse administering naloxone for suspected opioid overdose should have resuscitation equipment readily available to support naloxone therapy if it is needed. Other adjuncts that may be needed include oxygen, mechanical ventilator, and vasopressors. Strategy: Use the process of elimination. Note the strategic words intravenous opioid overdose. Recalling the effects of these medications will direct you to option 3. Option 3 is also the umbrella response. Review this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 600). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2268) A nurse has formulated a nursing diagnosis of ineffective breathing pattern for a client with a neurological disorder. Which of the following activities would be an inappropriate component of the care plan for this client? a. Keep the head and neck in good alignment. b. Elevate the head of the bed 30 degrees. c. Keep the client lying in a supine position. d. Keep suction equipment at the bedside. Source: Saunders 4th

ANS: C Rationale: The nurse maintains a patent airway for the client by keeping the head and neck in good alignment and elevating the head of bed 30 degrees unless contraindicated. Suction equipment is kept at the bedside if secretions need to be cleared. The client should be kept in a side-lying position whenever possible to minimize the risk of aspiration. Strategy: Use the process of elimination and note the strategic word inappropriate. Options 1 and 4 can be eliminated first because these are safe nursing actions. Additionally, option 4 addresses suctioning, which refers to maintaining a patent airway. From the remaining options, select option 3 because it puts the client at greater risk of aspiration. Review care of the client with a neurological disorder if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2060, 2063). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1051). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2227) A nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which of the following observations is made? a. Secretions are becoming bloody. b. Heart rate decreases from 78 to 54 beats/min. c. Coughing occurs with suctioning. d. Skin color becomes cyanotic. Source: Saunders 4th

ANS: C Rationale: The nurse monitors for adverse effects of suctioning, which include cyanosis, excessively rapid or slow heart rate, and sudden development of bloody secretions. If any of these signs is observed, the nurse immediately stops suctioning and reports the adverse effect to the physician. Coughing is a normal response to suctioning for the client with an intact cough reflex and does not indicate that the client cannot tolerate the procedure. Strategy: Use the process of elimination, noting the strategic words tolerating the procedure. Cyanosis and bradycardia are abnormal findings and are eliminated first. Because the cough reflex normally is present and suctioning triggers coughing, this is the preferable option from the two remaining. Review the complications associated with suctioning if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1884, 1888). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1101). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

37) The RN is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? a. A client requiring colostomy irrigation b. A client receiving continuous tube feedings c. A client who requires urine specimen collections d. A client with difficulty swallowing food and fluids Source: Saunders 4th

ANS: C Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a nursing assistant would be to care for the client who requires urine specimen collections. The nursing assistant is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by unlicensed personnel. The client with difficulty swallowing food and fluids is at risk for aspiration. Strategy: Note the strategic words, most appropriate, and note the subject, an assignment to a nursing assistant. Eliminate option 4 first because of the words difficulty swallowing. Next, eliminate options 1 and 2 because they are comparative or alike and are both invasive procedures. Review the principles of delegation if you had difficulty with this question. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., p. 546). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 42, 350, 378). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

127) A nurse is preparing to hang the first bag of total parenteral nutrition (TPN) solution via the central line of an assigned client. The nurse obtains which most essential piece of equipment before hanging the solution? a. Urine test strips b. Blood glucose meter c. Electronic infusion pump d. Noninvasive blood pressure monitor Source: Saunders 4th

ANS: C Rationale: The nurse obtains an electronic infusion pump before hanging a TPN solution. Because of the high glucose content, use of an infusion pump is necessary to ensure that the solution does not infuse too rapidly or fall behind. Because the client's blood glucose level is monitored every 4 to 6 hours during administration of TPN, a blood glucose meter also will be needed, but this is not the most essential item needed before hanging the solution. Urine test strips (to measure glucose) rarely are used because of the advent of blood glucose monitoring. A noninvasive blood pressure monitor is unnecessary for this procedure. Strategy: Note the strategic words most essential. They tell you that the correct option identifies the item needed to start the infusion. Use the process of elimination and knowledge of the procedure for initiating TPN to direct you to option 3. Review these procedures if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 989). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1160-1161). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1736) The client with retinal detachment is admitted to the nursing unit in preparation for a scleral buckling procedure. Which of the following would the nurse anticipate to be prescribed? a. Bathroom privileges only b. Elevating the head of the bed to 45 degrees c. Placing an eye patch over the client's affected eye d. Wearing dark glasses to read or watch television Source: Saunders 4th

ANS: C Rationale: The nurse places an eye patch over the client's affected eye to reduce eye movement. Some clients may need bilateral patching. Depending on the location and size of the retinal break, activity restrictions may be needed immediately. These restrictions are necessary to prevent further tearing or detachment and to promote drainage of any subretinal fluid. The nurse positions the client as prescribed by the physician. Strategy: Use the process of elimination. Remember that the eye needs to be protected and rested. This should direct you to option 3. If you had difficulty with this question, review care of the client with retinal detachment. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1103). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1891) A nurse in the postpartum unit is observing the mother-infant bonding process in a client. Which of the following observations if made by the nurse would indicate the potential for a maladaptive interaction? a. The mother is observed talking to the newborn. b. The mother performs cord care for the newborn. c. The mother requests that the nurse feed the newborn because she is feeling fatigued. d. The mother verbalized discomfort with the new role of motherhood. Source: Saunders 4th

ANS: C Rationale: The nurse should be alert to maladaptive interaction between the maternal-infant bonding process. If the nurse notes that the mother is avoiding interaction with the newborn, or is avoiding caring for the newborn, the nurse should suspect the potential for a maladaptive interaction. Expressing discomfort with the new role of motherhood is a normal expected process, and it is important for the mother to verbalize concerns. Talking to the newborn or willingness to perform cord care does not indicate a maladaptive response. Strategy: Focus on the subject of the question. Note the strategic words maladaptive interaction. The only option that indicates this potential is option 3. Review the maternal-infant bonding process if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 783). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

1081) A nurse is preparing to ambulate a client on the third day after cardiac surgery. The nurse would plan to do which of the following to enable the client to best tolerate the ambulation? a. Remove telemetry equipment. b. Provide the client with a walker. c. Premedicate the client with an analgesic. d. Encourage the client to cough and deep breathe. Source: Saunders 4th

ANS: C Rationale: The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery because analgesia will promote rest, decrease myocardial oxygen consumption resulting from pain, and allow better participation in activities such as coughing, deep breathing, and ambulation. Options 2 and 4 will not help in tolerating ambulation. Removal of telemetry equipment is contraindicated unless prescribed. Strategy: Use the process of elimination. Focus on the subject, how best to tolerate the ambulation. Coughing and deep breathing will not actively help endurance, so eliminate option 4. Removal of telemetry equipment is contraindicated unless ordered. From the remaining options, focusing on the subject will direct you to option 3. Review comfort measures for the client following cardiac surgery if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1645). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 767, 860). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

122) A nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is 1 hour behind. Which of the following actions by the nurse is appropriate? a. Adjust the infusion rate to catch up over the next hour. b. Increase the infusion rate to catch up over the next 2 hours. c. Ensure that the fat emulsion infusion rate is infusing at the prescribed rate. d. Adjust the infusion rate to run wide open until the solution is back on time. Source: Saunders 4th

ANS: C Rationale: The nurse should not increase the rate of a fat emulsion to make up the difference if the infusion timing falls behind. Doing so could place the client at risk for fat overload. The same principle applies to PN; increasing the rate suddenly in this case could cause hyperglycemia and fluid overload. Therefore, options 1, 2, and 4 are incorrect. Strategy: Note the strategic word appropriate. Remember also that options that are comparative or alike are not likely to be correct. This guides you to eliminate options 1 and 2 first. Choose option 3 over option 4, recalling that the nurse never increases the infusion rate or adjusts an infusion rate to run wide open if an infusion is behind. Review these safety principles if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 989). St. Louis: Mosby. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., pp. 1062-1063). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2679) A nurse is planning the client assignments for the day for the nursing team, which includes a licensed practical nurse (LPN) and a nursing assistant. Of the following clients, which would the nurse most appropriately assign to the LPN? a. A client with stable congestive heart failure who has early-stage Alzheimer's disease b. A client who was treated for dehydration and is weak and needs assistance with bathing c. A client with emphysema who is receiving oxygen at 2 L/min by nasal cannula and becomes dyspneic on exertion d. A client who is scheduled for an electrocardiogram and a chest x-ray examination Source: Saunders 4th

ANS: C Rationale: The nurse would most appropriately assign the client with emphysema to the LPN. This client has an airway problem and has the highest-priority needs among the clients presented in the options. The clients described in options 1, 2, and 4 can appropriately be cared for by the nursing assistant. Strategy: Use the process of elimination. Eliminate option 1 first because of the word stable in this option. Next, eliminate option 4 because no data are provided to indicate that this client has priority needs. Regarding the remaining options, use the ABCs—airway, breathing, and circulation—to direct you to option 3. Review the principles related to nursing assignments if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 42, 378-379). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

172) A nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. The next nursing action would be to: a. Call for help. b. Extinguish the fire. c. Activate the fire alarm. d. Confine the fire by closing the room door. Source: Saunders 4th

ANS: C Rationale: The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire then is confined by closing all doors and, finally, the fire is extinguished. Strategy: Remember the mnemonic <I>RACE</I> to prioritize in the event of a fire. <I>R</I> is rescue clients in immediate danger, <I>A</I> is alarm (sound the alarm), <I>C</I> is confine the fire by closing all doors, and <I>E</I> is extinguish or evacuate. If you had difficulty with this question, review the principles related to fire safety. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 991). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2204) Which of the following persons as described is at the highest risk for committing suicide? a. A 24-year-old client who just had an argument with her roommate b. A 71-year-old client with a cardiac disorder c. A 75-year-old client with metastatic cancer d. A 30-year-old newly divorced client who states she has custody of the children Source: Saunders 4th

ANS: C Rationale: The person at highest risk for suicide is the client with terminal illness. Other high-risk groups include adolescents, drug abusers, and persons, who have experienced recent losses, have few or no social supports, and with a history of suicide attempts and a suicide plan. Strategy: Use the process of elimination, focusing on the strategic words highest risk. This will direct you to option 3, the client with terminal illness. Review the risk factors associated with suicide if you had difficulty with this question. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 475-476). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1199) The nurse is documenting the assessment and care of a hospitalized client following an uncomplicated cystoscopy. Which one of the following would be an unlikely notation postprocedure for this client? a. Voiding pink-tinged urine b. Assisted to tub room for sitz bath c. Traction applied to Foley catheter d. Increasing fluid intake without nausea Source: Saunders 4th

ANS: C Rationale: The purpose of applying traction to the Foley catheter is to control bleeding. The client with an uncomplicated cystoscopy should not require a Foley catheter and should not be experiencing bleeding. Bleeding is a complication following cystoscopy. Strategy: Use the process of elimination. Notice the strategic words uncomplicated and unlikely. Eliminate option 1, because pink-tinged urine may be a normal finding for the first few days following a cystoscopy. The nurse should document the urine color. Eliminate option 2, because care of the client following cystoscopy includes ambulating with assistance caused by the potential for orthostatic hypotension and sitz baths are used to relieve bladder spasms. The nurse should document this activity. Eliminate option 4, because the client should be encouraged to increase fluid intake following cystoscopy. The nurse should document the client's ability to ingest fluids following the procedure. Review management of the client undergoing cystoscopy if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., and Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 1166, 1169-1170). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Communication and Documentation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2164) A nurse has an order to administer diazepam (Valium) 5 mg by the intravenous (IV) route to a client. The nurse administers the medication over a period of at least: a. 15 seconds b. 30 seconds c. 1 minute d. 5 minutes Source: Saunders 4th

ANS: C Rationale: The recommended rate of infusion of diazepam is to give each 5 mg of the medication over at least 1 minute. This will prevent adverse side effects including apnea, bradycardia, hypotension, and possibly cardiac arrest. Strategy: Use the process of elimination. A majority of medications administered by the IV route to a client must be given over at least 1 minute. Because of this requirement, you could eliminate options 1 and 2 first as excessively brief. Regarding the remaining options, it is much more likely that it is given over 1 minute than 5 minutes. Review the procedure for administering diazepam by the IV route if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 394). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2292) A client is experiencing chronic insomnia. The nurse interprets that which of the following areas of the brain is involved? a. Hippocampus and frontal lobe b. Temporal lobe and frontal lobe c. Reticular activating system and cerebral hemispheres d. Limbic system and cerebral hemispheres Source: Saunders 4th

ANS: C Rationale: The reticular activating system in conjunction with the cerebral hemispheres is responsible for arousal. The temporal lobe, hippocampus, and frontal lobe are responsible for memory. The limbic system is responsible for feelings and affect. Strategy: Use the process of elimination. Note the word activating in option 3. This may help you to recall that this area of the brain is responsible for wake and sleep patterns. Review the basic functions of the different areas of the brain if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 510). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1024). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2575) The ambulatory care nurse is providing instructions regarding skin care to a client after removal of a leg cast. The nurse instructs the client to: a. Soak the skin for 1 hour six times daily to assist in removing any dry scales. b. Scrub the skin vigorously with soap and water to remove the dead skin. c. Apply an emollient lotion to the skin to enhance softening. d. Avoid the use of sunscreen on the skin for at least 2 years. Source: Saunders 4th

ANS: C Rationale: The skin under a casted area may be discolored and crusted with dead skin layers. The client should gently soak and wash the skin for the first few days; however, soaking for 1 hour six times daily is excessive and could potentially lead to skin breakdown. The skin should not be scrubbed vigorously because this action also could lead to skin breakdown. The skin should be patted dry, and a lubricating lotion should be applied. The client should avoid overexposing the skin to the sunlight. Strategy: Use the process of elimination. Note that options 1, 2, and 4 are comparative or alike in that they can lead to skin damage and breakdown. Review home care measures following removal of a cast if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1205). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

1965) A nurse is providing instructions regarding high-sodium food items to avoid to a client with a diagnosis of hypertension. The nurse instructs the client to avoid: a. Cantaloupe b. Broccoli c. Mineral water d. Bananas Source: Saunders 4th

ANS: C Rationale: The sodium level can increase by the use of several types of products including toothpaste and mouthwash; over-the-counter medications such as analgesics, antacids, laxatives, and sedatives; and softened water, as well as some mineral water. Clients are instructed to read labels for sodium content. Water that is bottled, distilled, deionized, and demineralized may be used for drinking and cooking. Fresh fruits and vegetables are low in sodium. The client would avoid consuming mineral water. Strategy: Note the strategic word avoid in the question. Use the process of elimination, noting that options 1, 2, and 4 are comparative or alike in that they all identify fresh fruits and vegetables. Note that the correct option states mineral. This means that the item contains minerals. If you had difficulty with this question, review items low in sodium. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1503). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 786). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1830) A registered nurse (RN) is observing a licensed practical nurse (LPN) who is caring for a client with a uterine tumor who had a vaginal hysterectomy. The RN should intervene if the RN noted the LPN doing which of the following? a. Performing range-of-motion exercises to the client's legs b. Elevating the knee gatch on the client's bed c. Removing the antiembolism stockings during morning care d. Assisting the client to ambulate Source: Saunders 4th

ANS: B Rationale: After a vaginal hysterectomy, the client is at risk for deep vein thrombosis or thrombophlebitis. The nurse should implement measures that prevent this complication. Range of motion exercises, antiembolism stockings, and ambulation are important measures to prevent this complication. Antiembolism stockings are removed to provide hygiene care and are then replaced. If the RN notes that the LPN used the knee gatch on the bed, the RN should intervene. This action would inhibit venous return, increasing the risk for deep vein thrombosis or thrombophlebitis. Strategy: Note the strategic word intervene in the question. This tells you that the correct option is an incorrect nursing action. Recalling that this client is at risk for thrombophlebitis will assist in directing you to option 2. If you had difficulty with this question, review care of the client after vaginal hysterectomy. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1086). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1840). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

1715) The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Prior to administering an intermittent tube feeding, the nurse understands that the 40 mL of gastric aspirate should be: a. Discarded properly and recorded as output on the client's I&O record. b. Poured into the nasogastric tube through a syringe with the plunger removed. c. Mixed with the formula and poured into the nasogastric tube through a syringe with the plunger removed. d. Diluted with water and injected into the nasogastric tube by putting pressure on the plunger. Source: Saunders 4th

ANS: B Rationale: After checking residual feeding contents, the gastric contents are reinstilled into the stomach by removing the syringe bulb or plunger and pouring the gastric contents into the syringe and through the nasogastric tube. Gastric contents should be reinstilled to maintain the client's electrolyte balance. The gastric contents should be poured into the nasogastric tube through a syringe without a plunger and not injected by pushing on the plunger. Gastric contents do not need to be mixed with water, nor should it be discarded. Strategy: Use the process of elimination. Eliminate option 4 because of the words putting pressure. Recalling that gastric contents need to be reinstilled to maintain electrolyte balance will assist in eliminating options 1 and 3. Review care of the client with a nasogastric tube and nasogastric tube feedings if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1305-1306). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2625) A nurse has an order to give heparin sodium 5000 units subcutaneously. The nurse should plan to do which of the following to administer this medication? a. Inject via an infusion device. b. Change the needle after withdrawing the medication from the vial. c. Inject ½ inch from the umbilicus. d. Massage the injection site after administration. Source: Saunders 4th

ANS: B Rationale: After heparin sodium is drawn up from the vial, the needle is changed before injection to prevent contact of the medication with tissue along the needle tract. Heparin sodium administered subcutaneously does not require an infusion device and is injected at least 2 inches from the umbilicus or any scar tissue. The needle is withdrawn rapidly, and the site is not massaged (although pressure is applied). Strategy: Use the process of elimination. Focus on the medication to be administered to eliminate options 3 and 4. Because the medication is to be administered subcutaneously, option 1 is eliminated. Review the procedure for administering heparin sodium by the subcutaneous route if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 571). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2332) A student nurse develops a plan of care for a client after a lumbar puncture. The nursing instructor corrects the student if the student documents which intervention in the plan? a. Maintain the client in a flat position. b. Restrict fluid intake for a period of 2 hours. c. Inspect the puncture site for swelling, redness, and drainage. d. Assess the client's ability to void and move the extremities. Source: Saunders 4th

ANS: B Rationale: After the lumbar puncture, the client remains flat in bed for 6 to 24 hours, depending on the physician's orders. A liberal fluid intake is encouraged to replace the cerebrospinal fluid removed during the procedure, unless contraindicated by the client's condition. The nurse checks the puncture site for redness and drainage and assesses the client's ability to void and move the extremities. Strategy: Use the process of elimination. Note the strategic words corrects the student in the question. Recalling the importance of fluid intake after the procedure will direct you to option 2. If you had difficulty with this question, review post-procedure care for lumbar puncture. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 740). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2323) An ambulatory care nurse is preparing a list of instructions for the adult client who is being discharged after tonsillectomy. The nurse avoids placing which of the following on the list? a. Avoid hot fluids. b. Consume carbonated beverages and milk products. c. Avoid raw vegetables. d. Rest in bed or on a couch for 24 hours. Source: Saunders 4th

ANS: B Rationale: After tonsillectomy, the client is instructed to advance the diet from cool clear liquids to full liquids. Hot fluids and carbonated beverages should be avoided because they may be irritating to the throat. Milk and milk products are avoided because they may cause the client to cough, which could cause pain at the surgical site. Foods and snacks that are rough in texture, such as raw fruits or vegetables, should be avoided for 10 days to protect the operative site and to prevent bleeding. The client should be instructed to rest in bed or on a couch for 24 hours after the surgical procedure and gradually resume full activity. Strategy: Note the strategic word avoids. Use the process of elimination, focusing on the anatomical location of the operative procedure to assist in directing you to option 2. If you had difficulty with this question, review client teaching points after tonsillectomy. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1799-1800). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2080) A nurse is caring for a client just after ureterolithotomy and is monitoring the drainage from the ureteral catheter hourly. The catheter stops draining suddenly. The nurse assesses the clientand eliminates which of the following as the cause of the problem? a. Blood clots b. Ureteral edema c. Catheter displacement d. Chemical sediment Source: Saunders 4th

ANS: B Rationale: After ureterolithotomy, a ureteral catheter is put in place. Urine flows freely through it for the first 2 to 3 days. As ureteral edema diminishes, urine leaks around the ureteral catheter and drains directly into the bladder. At this point, drainage through the ureteral catheter diminishes. Immediately after surgery, absence of drainage usually is caused by displacement, blockage from blood clots, mucus shreds, or chemical sediment. Strategy: Use the process of elimination. Note the strategic word eliminates. Eliminate options 1 and 4 first, because either of these items could easily cause blockage of the tube. Regarding the remaining options, knowing that displacement causes failure of drainage will direct you to option 2. Review care of the client after this surgical procedure if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 889). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

945) The client is admitted to the hospital with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? a. Select foods high in fat. b. Increase intake of fluids, including juices. c. Eat a good supper when anorexia is not as severe. d. Eat less often, preferably only three large meals daily. Source: Saunders 4th

ANS: B Rationale: Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet because fat may be tolerated poorly because of decreased bile production. Small frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important. Strategy: Use the process of elimination. Knowledge regarding the nutritional problems associated with hepatitis and focusing on the client's complaints will assist in directing you to the correct option. Review measures to provide adequate nutrition in the client with hepatitis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1386). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1113). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1914) A client with chronic renal failure has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now presents with mental cloudiness, dementia, and complaints of bone pain. The nurse interprets that these assessment data are compatible with: a. Phosphate overdose b. Aluminum intoxication c. Advancing uremia d. Folic acid deficiency Source: Saunders 4th

ANS: B Rationale: Aluminum intoxication can occur when there is accumulation of aluminum, an ingredient in many phosphate-binding antacids. It results in mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. It may be treated with aluminum-chelating agents, which make aluminum available to be dialyzed from the body. It can be prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum. Strategy: Use the process of elimination. Note the relationship between the name of the medication in the question and the correct option. Review the clinical manifestations of aluminum intoxication if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 961). Philadelphia: W.B. Saunders. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 46). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., pp. 900-901). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2700) A nurse has an order to give amiodarone (Cordarone) intravenously to a client. During administration of this medication, the nurse includes monitoring which of the following as the priority nursing action? a. Skin color and dryness b. Cardiac rhythm c. Oxygen saturation level d. Blood pressure Source: Saunders 4th

ANS: B Rationale: Amiodarone is an antiarrhythmic used to treat life-threatening ventricular arrhythmias that do not respond to first-line agents. The client requires continuous cardiac monitoring, with infusion of the medication by an intravenous pump. Although the other assessments are not incorrect, monitoring of cardiac rhythm is the priority nursing action. Strategy: Use the process of elimination. Note the strategic word priority. Recalling that amiodarone is an antiarrhythmic will direct you to option 2. If this question was difficult, review the classification of this medication and its administration. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 89). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2407) A home care nurse is visiting a client with a skin infection who is receiving amoxicillin (Amoxil) 500 mg every 8 hours. Which of the following would indicate to the nurse that the client is experiencing a frequent side effect related to the medication? a. Severe abdominal cramps b. Vaginal drainage c. Fever d. Severe watery diarrhea Source: Saunders 4th

ANS: B Rationale: Amoxicillin is a type of penicillin. Frequent side effects include gastrointestinal disturbances, headache, and oral or vaginal candidiasis (perineal itching). Less common but more harmful adverse reactions that can occur include superinfection, such as potentially fatal antibiotic-associated colitis, which results from altered bacterial balance. Symptoms and signs would include abdominal cramps, severe watery diarrhea, and fever. Strategy: Focus on the strategic words frequent side effect. This will assist in eliminating options 1 and 4. Regarding the remaining options, recall that antibiotics can alter the normal vaginal flora, to assist in directing you to option 2. If you had difficulty with this question, review the frequent side effects associated with the use of this medication. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 431). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 52). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

1188) The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of: a. Infection b. Hyperglycemia c. Hypophosphatemia d. Disequilibrium syndrome Source: Saunders 4th

ANS: B Rationale: An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis. Strategy: Use the process of elimination. Noting the client's diagnosis and recalling that the dialysate solution contains glucose will direct you to option 2. Review the complications associated with peritoneal dialysis if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 957-958). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1585) A client with diabetes mellitus is self-administering NPH insulin from a vial that is kept at room temperature. The client asks the nurse about the length of time an unrefrigerated vial of insulin will maintain its potency. The appropriate response to the client is which of the following? a. 2 weeks b. 1 month c. 2 months d. 6 months Source: Saunders 4th

ANS: B Rationale: An insulin vial in current use can be kept at room temperature for up to 1 month without significant loss of activity. Direct sunlight and heat must be avoided. Strategy: Use the process of elimination. Note the strategic word unrefrigerated in the question. This word will assist in directing you to the correct option. If you are unfamiliar with the concepts related to insulin stability, review this information. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 778). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2203) Which statement made by a nursing assistant indicates to the registered nurse that the assistant understands the concepts related to suicide? a. "When a person talks about making suicide threats, the only thing the person wants is attention from family and friends." b. "Discussing suicide with a client is not harmful." c. "Depressed clients are the only persons who commit suicide." d. "Those clients who talk about suicide never do it." Source: Saunders 4th

ANS: B Rationale: An open discussion of suicide will not encourage a client to make a decision to do so and in fact often will help to prevent it. Such a discussion offers the health care professional the opportunity to assess the reality of suicide for the client and take necessary precautions to keep the client safe. Options 1, 3, and 4 are inaccurate statements regarding suicide. Strategy: Use the process of elimination. Note the words only in options 1 and 3 and never in option 4. If you had difficulty with this question, review the concepts related to suicide. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 477). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1781) The nurse is formulating a plan of care for a client receiving enteral feedings. Which nursing diagnosis is of highest priority for this client? a. Imbalanced nutrition, less than body requirements b. Risk for aspiration c. Risk for deficient fluid volume d. Diarrhea Source: Saunders 4th

ANS: B Rationale: Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places the client at risk for aspiration. Options 1 and 4 may be appropriate nursing diagnoses, but are not of highest priority. Option 3 is not likely to occur in this client. Strategy: Note the strategic words highest priority. Use the ABCs—airway, breathing, and circulation. Option 2 addresses airway management. Options 1, 3, and 4 are possible problems, but are not as high a priority as airway maintenance. Review care of the client receiving enteral feedings if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 985). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

11) Which of the following clients has the lowest risk of obesity and diabetes mellitus? a. A 45-year-old Native-American male b. A 23-year-old Asian-American female c. A 35-year-old Hispanic-American male d. A 40-year-old African-American female Source: Saunders 4th

ANS: B Rationale: Asian Americans have the lowest risk of obesity and diabetes mellitus from the options provided. Native Americans, African Americans, and Hispanic Americans have a high risk of obesity and diabetes mellitus. Strategy: Note the strategic words lowest risk, obesity, and diabetes mellitus. Think about the health practices of each cultural group to direct you to option 2. If you had difficulty with this question, review the characteristics of this culture. Reference: Giger, J.N., & Davidhizar, R.E. (2004). Transcultural nursing: Assessment and intervention (4th ed., pp. 201-202, 241-242, 267-268). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1581) The nurse is caring for a client receiving bolus feedings via a Levin-type nasogastric tube. As the nurse is finishing the feeding, the client asks for the bed to be positioned flat to sleep. The nurse understands that the appropriate position for this client at this time is which of the following? a. Head of bed flat, with the client in the supine position for at least 30 minutes b. Head of bed elevated 30 to 45 degrees, with the client in the right lateral position for 60 minutes c. Head of bed elevated 45 to 60 degrees, with the client in the supine position for 30 minutes d. Head of bed in a semi-Fowler's position, with the client in the left lateral position for 60 minutes Source: Saunders 4th

ANS: B Rationale: Aspiration is a possible complication associated with nasogastric tube feeding. The head of the bed is elevated 30 to 45 degrees for at least 30 minutes following bolus tube feeding to prevent vomiting and aspiration. The right lateral position uses gravity to facilitate gastric retention to prevent vomiting. The flat supine position is to be avoided for the first 30 minutes after a tube feeding. Strategy: Use the process of elimination. Note that there are three components to each answer—the level of elevation of the head, the client's position, and the duration. Option 1 can be eliminated immediately because this position could result in aspiration. Options 2 and 4 are the same elevation, but the right lateral position is the correct position. Option 3 is eliminated because of the supine position. Review care of the client receiving a bolus tube feeding if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1431). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1886) A pediatric nurse is caring for a 3-year-old boy with a diagnosis of acute lymphocytic leukemia (ALL). The child is crying and complaining that his knees hurt. Which of the following nursing interventions would be appropriate? a. Ask the child if he would like a "baby aspirin." b. Administer acetaminophen (Tylenol) to the child. c. Apply heat to the child's knees and elevate the knees on a pillow. d. Involve the child in a diversional activity. Source: Saunders 4th

ANS: B Rationale: Aspirin is not administered to the child with ALL because of its anticoagulant properties and because administering aspirin could lead to bleeding in the joints. Heat also would increase the pain by increasing circulation to the area. Diversional activities would not relieve the pain. Strategy: Use the process of elimination. Knowing that aspirin would increase bleeding that may be occurring in a child with ALL will help to eliminate this option. Eliminate option 4 because it is unrelated to a physiological need. Regarding the remaining options, use the principles related to heat effects to eliminate option 3. If you had difficulty with this question, review the care of a child with ALL. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1341). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Caring Content Area -> Child Health Alternate Question Types -> Multiple Choice

2263) A nurse is testing a client for astereognosis. The nurse should ask the client to close the eyes and to: a. Identify three numbers or letters traced in the client's palm. b. Identify three objects placed in the hand, one at a time. c. State whether one or two pinpricks are felt when the skin is pricked bilaterally in the same place. d. Ask the client to identify the smallest distance between two detectable pinpricks, made with two pins held at various distances. Source: Saunders 4th

ANS: B Rationale: Astereognosis is the inability to discern the form or configuration of common objects using the sense of touch. Option 1 describes testing for agraphesthesia, the inability to recognize the form of written symbols. Options 3 and 4 test for extinction phenomenon and two-point stimulation, respectively. Strategy: This question may be difficult for you because it requires knowledge of the common difficulties with proprioception to correctly identify the method used to test each. Review the assessment techniques related to proprioception if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2032). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2540) A nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy? a. Tiredness b. The presence of asterixis c. Decreased serum ammonia levels d. Complaints of fatigue Source: Saunders 4th

ANS: B Rationale: Asterixis is a flapping tremor of the hand that is an early sign of hepatic encephalopathy. The exact cause of this disorder is not known, but abnormal ammonia metabolism may be implicated. Increased serum ammonia levels are thought to interfere with normal cerebral metabolism. Tremors and drowsiness would also be noted. Strategy: Focus on the subject, hepatic encephalopathy, and note the strategic word early. Eliminate options 1 and 4 first because these signs are vague. Regarding the remaining options, recalling that the ammonia level will be elevated in this disorder will direct you to option 2. Review the signs of hepatic encephalopathy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1346-1347). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2378) A client with gastrointestinal hypermotility has an order to receive atropine sulfate. The nurse should withhold the medication and question the order if the client has a history of which of the following? a. Biliary colic b. Narrow-angle glaucoma c. Peptic ulcer disease d. Sinus bradycardia Source: Saunders 4th

ANS: B Rationale: Atropine sulfate can cause a blockade of muscarinic receptors on the iris sphincter, producing mydriasis (dilation of the pupils). It also produces cycloplegia (relaxation of the ciliary muscles). It is contraindicated in clients with narrow-angle glaucoma. The other options are therapeutic reasons for using the medication. Strategy: Recall that atropine sulfate is an anticholinergic medication. Next, think about the effects of an anticholinergic, and about the therapeutic reasons for using atropine sulfate, to direct you to option 2. Review the contraindications to use of atropine sulfate if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 288). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2697) A nurse working in a long-term care facility notes that several clients are taking pilocarpine hydrochloride (Isopto Carpine) eye drops. The nurse ensures that which medication is available on the nursing unit for use if a client should develop systemic toxicity from pilocarpine hydrochloride? a. Disulfiram (Antabuse) b. Atropine sulfate c. Naloxone hydrochloride (Narcan) d. Cyclopentolate (Cyclogyl) Source: Saunders 4th

ANS: B Rationale: Atropine sulfate must be available in the event of systemic toxicity from pilocarpine hydrochloride. Pilocarpine toxicity is manifested by vertigo, bradycardia, tremors, hypotension, syncope, cardiac dysrhythmias, and seizures. Disulfiram is an alcohol deterrent used in the management of alcoholism in selected clients. Naloxone hydrochloride is an opioid antagonist used to reverse narcotic-induced respiratory depression. Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication used preoperatively for surgical procedures on the eye. Strategy: Recalling that pilocarpine is a cholinergic agent will assist in directing you to the correct option. Refresh your knowledge of antidotes for various medications and review the adverse effects of this medication if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 286). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 1196). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1128) A nurse is monitoring a client who is taking propranolol (Inderal). Which assessment data would indicate a potential serious complication associated with propranolol? a. The development of complaints of insomnia b. The development of audible expiratory wheezes c. A baseline blood pressure of 150/80 mm Hg followed by a blood pressure of 138/72 mm Hg after two doses of the medication d. A baseline resting heart rate of 88 beats/min followed by a resting heart rate of 72 beats/min after two doses of the medication Source: Saunders 4th

ANS: B Rationale: Audible expiratory wheezes may indicate a serious adverse reaction, bronchospasm. β-blockers may induce this reaction, particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and should be monitored. Strategy: Use the process of elimination, eliminating options 3 and 4 because these are expected effects from the medication. Note the strategic words potential serious complication. These strategic words will direct you to option 2. Review the adverse effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 982). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 730). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1367) Baclofen (Lioresal) is prescribed for a client with multiple sclerosis. The nurse monitors the client, knowing that the primary therapeutic effect of this medication is which of the following? a. Increased muscle tone b. Decreased muscle spasms c. Increased range of motion d. Decreased local pain and tenderness Source: Saunders 4th

ANS: B Rationale: Baclofen is a skeletal muscle relaxant and acts at the spinal cord level to decrease the frequency and amplitude of muscle spasms in clients with spinal cord injuries or debilitating diseases such as multiple sclerosis. Options 1, 3, and 4 are not associated effects of this medication. Strategy: Use the process of elimination. Recalling that this medication is a skeletal muscle relaxant will direct you easily to option 2. Review this medication if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 240). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1369) A nurse is providing discharge instructions to a client receiving baclofen (Lioresal). Which of the following would be included in the teaching plan? a. Restrict fluid intake. b. Avoid the use of alcohol. c. Notify the physician if fatigue occurs. d. Stop the medication if diarrhea occurs. Source: Saunders 4th

ANS: B Rationale: Baclofen is a skeletal muscle relaxant. The client should be cautioned against the use of alcohol and other central nervous system (CNS) depressants because baclofen potentiates the depressant activity of these agents. Constipation rather than diarrhea is an adverse effect. Restriction of fluids is not necessary, but the client should be warned that urinary retention can occur. Fatigue is related to a CNS effect that is most intense during the early phase of therapy and diminishes with continued medication use. The client does not need to notify the physician about fatigue. Strategy: Use the process of elimination. Recalling that baclofen is a skeletal muscle relaxant will direct you easily to option 2. If you were unsure of the correct option, use general principles related to medication administration. Alcohol should be avoided with the use of medications. Review client teaching points related to this medication if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 240). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2355) A nurse is providing medication instructions to a client with multiple sclerosis receiving baclofen (Lioresal). Which information should the nurse include in the instructions? a. Stop taking the medication if diarrhea occurs. b. Watch for urinary retention as a side effect. c. Restrict fluid intake while taking this medication. d. Notify the physician if fatigue occurs. Source: Saunders 4th

ANS: B Rationale: Baclofen, a skeletal muscle relaxant, also is a central nervous system (CNS) depressant, which can cause urinary retention. The client should not restrict fluid intake. Constipation, rather than diarrhea, is an adverse effect of baclofen. Fatigue is a CNS effect that is most intense during the early phase of therapy and diminishes with continued medication use. It is not necessary to notify the physician if fatigue occurs. Strategy: Recalling that baclofen has CNS depressant properties will direct you to the correct option. Also, using general principles of medication administration and side effects will assist you in selecting the correct option. Review the client teaching points related to this medication if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 238). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2517) The client with a documented exposure to tuberculosis is being started on medication therapy with isoniazid (INH). The nurse plans to set up appointments for the client to have which of the following laboratory studies done periodically during the course of therapy? a. Serum creatinine determination b. Liver function testing by monitoring liver enzymes c. Platelet count d. Blood urea nitrogen determination Source: Saunders 4th

ANS: B Rationale: Because INH therapy can cause elevated hepatic enzymes and hepatitis, liver enzymes are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is older than 50 years of age or who abuses alcohol. The other options are incorrect. Strategy: Use the process of elimination. Eliminate options 1 and 4 first because they both relate to renal function. From the remaining options, it is necessary to recall that the medication is hepatotoxic. Review the adverse effects of antituberculosis medications if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 643). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1665) The emergency room nurse is caring for a client admitted with diabetic ketoacidosis. The physician prescribes IV insulin. The nurse plans to prepare which type of insulin for the client? a. NPH b. Regular c. Lente d. Ultralente Source: Saunders 4th

ANS: B Rationale: Because Regular insulin forms a true solution and is safe for IV use. It is the only type of insulin that can be administered by the IV route. Strategy: Remember that Regular insulin is the only type of insulin that can be administered by the IV route. If you had difficulty with this question, review the different types of insulin and their methods of administration. Reference: Gahart, B., & Nazareno, A. (2006). 2006 intravenous medications (22nd ed., p. 694). St. Louis: Mosby. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 620-621). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2609) A client has been receiving foscavir (Foscarnet) as part of therapy for the treatment of cytomegalovirus retinitis and acquired immunodeficiency syndrome (AIDS). The home health nurse periodically reviews results of which laboratory blood test to assess for adverse responses to this medication? a. Albumin concentration b. Creatinine concentration c. CD4⁺ cell count d. Lymphocyte count Source: Saunders 4th

ANS: B Rationale: Because foscavir is toxic to the kidneys, serum creatinine is monitored before therapy, two or three times per week during induction therapy, and at least weekly during maintenance therapy. It also may cause decreased levels of calcium, magnesium, phosphorus, and potassium, so these are monitored with the same frequency. The blood tests in options 1, 3, and 4 are not associated with adverse responses to the medication. Strategy: Use the process of elimination. Recalling that foscavir is toxic to the kidneys will direct you to option 2. Review the adverse effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 515). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

2348) A nurse is providing discharge instructions to the mother of a child who has been prescribed tetracycline hydrochloride. The nurse stresses to the mother the importance of which of the following measures in giving this medication to the child? a. Dilute the medication with water in a Styrofoam glass. b. Use a straw when giving the medication. c. Give the medication with chocolate milk. d. Give the medication with milk. Source: Saunders 4th

ANS: B Rationale: Because tetracycline can cause permanent staining of the teeth, a straw should be used and the mouth should be rinsed after administration. The medication should be administered 1 hour before or 2 hours after consumption of milk. Diluting the medication with water is unnecessary. Strategy: Use the process of elimination. Recalling that tetracycline can cause staining of the teeth will direct you to option 2. If you had difficulty with this question, review the client teaching points related to the administration of this medication. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 446). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., pp. 982-983, 991). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2637) A nurse has given instructions to the client taking lithium carbonate (Eskalith). The nurse determines that the client needs further information if the client states: a. "I will take the lithium with meals." b. "I will decrease fluid intake while taking the lithium." c. "Lithium blood levels must be monitored very closely." d. "I will call my doctor if excessive diarrhea, vomiting, or sweating occurs." Source: Saunders 4th

ANS: B Rationale: Because therapeutic and toxic dosage ranges are narrow, lithium blood levels must be monitored closely. They are measured more frequently when the client begins the medication and then once every several months after the levels stabilize. The client should be instructed to stop taking the medication and call the physician if excessive diarrhea, vomiting, or diaphoresis occurs. Lithium is irritating to the gastric mucosa and should be taken with meals. A normal diet and normal salt and fluid intake (1500 to 3000 mL per day) should be maintained because lithium decreases sodium reabsorption by the renal tubules, leading to sodium depletion. A low sodium intake causes a relative increase in lithium retention and could lead to toxicity. Strategy: Use the process of elimination. Note the strategic words needs further information in the question. Such phrasing indicates a negative event query and the need to select an incorrect statement. Remember that generally, it is important that clients be taught to maintain an adequate fluid intake. Review the client teaching points related to the administration of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 699). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1806) A client is scheduled for a fiberoptic gastrointestinal (GI) procedure. The nurse instructs the client to remain on clear liquids for 3 days before the test because a clear liquid diet: a. Stimulates peristalsis b. Has little or no residue c. Promotes a laxative action d. Contains no calories and lacks nutrients Source: Saunders 4th

ANS: B Rationale: Before a GI procedure, the physician generally desires that the GI tract be cleansed of substances. Cleansing of the colon and intestine may take 3 days. As clear liquid diets have little or no residue, the GI tract will have an opportunity to empty of solid contents. This will enable the physician to view the GI tract clearly. Clearing the GI tract via diet is safer than having enemas until clear. Options 1, 3, and 4 are inaccurate regarding a clear liquid diet. Strategy: Focus on the subject of the question. Eliminate options 1 and 3 first because they are comparative or alike. Next, eliminate option 4 because of the close-ended words no and lack. Review the purpose of a clear liquid diet in preparation for a GI procedure if you had difficulty with this question. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed.). St. Louis: Mosby, p. 416. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1298). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2389) A client with cancer is receiving a continuous intravenous infusion of morphine sulfate. The nurse monitoring the client for adverse effects would become most concerned about which of the following vital signs? a. Temperature of 99.1° F b. Respirations of 10 breaths/min c. Blood pressure of 110/70 mm Hg d. Apical heart rate of 90 beats/min Source: Saunders 4th

ANS: B Rationale: Before an opioid is administered, respiratory rate, blood pressure, and pulse rate should be assessed. Morphine sulfate should be withheld and the physician notified if the respiratory rate is at or below 12 breaths/min, if the blood pressure is significantly below the pretreatment value, or if the pulse rate is significantly above or below pretreatment value. A temperature of 99.1° F is not associated with the use of morphine sulfate. Strategy: Use the process of elimination. Knowing that morphine sulfate primarily affects the respiratory rate will direct you to option 2. If you are unfamiliar with adverse effects related to the administration of this medication, review this content. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 859). St. Louis: Mosby. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 797). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2658) A client must learn how to mix Regular and NPH insulin in the same syringe. The nurse should include which of the following teaching points in these instructions? a. Keep both bottles in the refrigerator at all times. b. Rotate the NPH insulin bottle in the hands before mixing. c. Take all of the air out of the bottle before mixing. d. Draw up the NPH insulin into the syringe first. Source: Saunders 4th

ANS: B Rationale: Before mixing different types of insulin, the NPH bottle should be rotated for at least 1 minute between both hands to resuspend the insulin and warm the medication. Insulin can be stored at room temperature. Additional bottles of insulin for future use should be stored in the refrigerator. Regular insulin is drawn up before NPH insulin. Air does not have to be removed from the insulin bottle. Strategy: Use the process of elimination. Eliminate options 1 and 3 first because of the close-ended word all. Regarding the remaining options, think of RN as a memory aid: draw up Regular insulin before NPH. This concept will direct you to option 2. Review this procedure if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 621). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1533) A client begins to experience extrapyramidal side effects from an antipsychotic medication. The nurse anticipates that the physician will prescribe which of the following to treat this condition? a. Haloperidol (Haldol) b. Benztropine (Cogentin) c. Prochlorperazine (Compazine) d. Chlorpromazine (Thorazine) Source: Saunders 4th

ANS: B Rationale: Benztropine (Cogentin) is an anticholinergic medication used to treat drug-induced extrapyramidal reactions, except tardive dyskinesia. Options 1, 3, and 4 are antipsychotic medications. Antipsychotic medications can cause extrapyramidal reactions. Strategy: Focus on the medications in the options. Recalling the classifications of each will direct you to option 2. Remember that benztropine (Cogentin) is an anticholinergic medication. Review the side effects and extrapyramidal reactions of antipsychotic medications if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 128). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1209) Bethanechol chloride (Urecholine) is prescribed for a client with urinary retention. Which disorder would be a contraindication to the administration of this medication? a. Gastric atony b. Urinary strictures c. Neurogenic atony d. Gastroesophageal reflux Source: Saunders 4th

ANS: B Rationale: Bethanechol chloride (Urecholine) can be hazardous to clients with urinary tract obstruction or weakness of the bladder wall. The medication has the ability to contract the bladder and thereby increase pressure within the urinary tract. Elevation of pressure within the urinary tract could rupture the bladder in clients with these conditions. Strategy: Use the process of elimination. Noting that the medication is used for urinary retention may assist in directing you to option 2. Review the contraindications associated with this medication if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 285). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2017) A home care nurse has instructed a client how to perform the three-point gait with the use of crutches. The nurse observes the client using this gait to ensure correct performance of the maneuvers for this gait. Which of the following observations if made by the nurse would indicate that the client understands how to perform this type of gait? a. The client moves the right crutch forward, along with the left foot, and then brings the right foot and the left crutch forward. b. The client moves the left crutch forward, along with the right foot, and then brings the left foot and the right crutch forward. c. The client moves both crutches forward and then swings both feet forward to the crutches. d. The client moves both crutches forward, along with the affected leg and then moves the unaffected leg forward. Source: Saunders 4th

ANS: D Rationale: In a three-point gait, the client is instructed to simultaneously move both crutches and the affected leg forward and then to move the unaffected leg forward. Options 1 and 2 identify a four-point gait. Option 3 identifies a swing-through gait. Strategy: Note the strategic words three-point gait in the question. Visualize each of the descriptions in the options to assist you in answering the question. Eliminate options 1, 2, and 3 because none of these options represents a three-point gait. Review client instructions regarding a three-point gait if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2501). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1204). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

198) A nurse understands that which of the following is a correct guideline for adult cardiopulmonary resuscitation (CPR) for a health care provider? a. One breath should be given for every five compressions. b. Two breaths should be given for every 15 compressions. c. Initially, two quick breaths should be given as rapidly as possible. d. Each rescue breath should be given over 1 second and should produce visible chest rise. Source: Saunders 4th

ANS: D Rationale: In adult CPR, each rescue breath should be given over 1 second and should produce a visible chest rise. Excessive ventilation (too many breaths per minute or breaths that are too large or forceful) may be harmful and should not be performed. Health care providers should employ a 30:2 compression-to-ventilation ratio for the adult victim. Options 1, 2, and 3 are incorrect. Strategy: Read each option carefully. Noting the words visible chest rise in option 4 will direct you to this option. Review CPR guidelines for the adult if you had difficulty with this question. Reference: American Heart Association. (2005-2006). Highlights of the 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Currents in Emergency Cardiovascular Care, 16(4), 13. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1888) A nurse is caring for a child with a diagnosis of hemophilia, and hemarthrosis is suspected because the child is complaining of pain in the joints. Which of the following should the nurse expect to be prescribed for the child? a. Nonsteroidal anti-inflammatory drugs (NSAIDs) for the pain b. The application of a heating pad to the affected joint c. Range-of-motion exercises to the affected joint d. Application of a bivalved cast for joint immobilization Source: Saunders 4th

ANS: D Rationale: In an acute period, immobilization of the joint would be prescribed. NSAIDs can prolong bleeding time and would not be prescribed for the child. Heat will increase blood flow to the area so it would promote increased bleeding to the area. Range of motion during the acute period can increase the bleeding and would be avoided at this time. Strategy: Use the process of elimination and focus on the subject of the question. Knowing the principles related to the effects of heat will assist you in eliminating option 2. Recalling that NSAIDs can prolong bleeding time will assist in eliminating option 1. From the remaining options, select option 4 because range-of-motion exercises also will increase the bleeding. Review care of the child with hemarthrosis if you had difficulty with this question. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., p. 1538). St. Louis: Mosby. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 954). St. Louis: Mosby. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1316). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Child Health Alternate Question Types -> Multiple Choice

34) A nurse employed in an emergency department is assigned to triage clients arriving to the emergency room for treatment on the evening shift. The nurse should assign highest priority to which of the following clients? a. A client complaining of muscle aches, a headache, and malaise b. A client who twisted her ankle when she fell while rollerblading c. A client with a minor laceration on the index finger sustained while cutting an eggplant d. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce Source: Saunders 4th

ANS: D Rationale: In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, acute neurological deficits, and those who have sustained chemical splashes to the eyes are classified as emergent and are the number 1 priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as number 2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are the number 3 priority. Strategy: Note the strategic words highest priority. Use the ABCs—airway, breathing, and circulation—to direct you to option 4. A client experiencing chest pain is always classified as priority number 1 until a myocardial infarction has been ruled out. Review the triage classification system commonly used in a hospital emergency department if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 161-162). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1846). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

1189) The nurse is monitoring an 88-year-old woman at risk for developing a urinary tract infection. Which of the following, if noted, would alert the nurse to the possibility of the presence of a urinary tract infection for this client? a. Fever b. Urgency c. Frequency d. Confusion Source: Saunders 4th

ANS: D Rationale: In an older client, the only symptom of a urinary tract infection may be something as vague as increasing mental confusion. Frequency and urgency may commonly occur in an older client. Therefore, these symptoms are not specific to urinary tract infection in the older client. Fever can be associated with a variety of conditions. Strategy: Use the process of elimination. Note the client's age in the question. Eliminate options 2 and 3 because these symptoms may commonly occur in an older client. Eliminate option 1 next because fever can be associated with a variety of conditions. Review the clinical manifestations of urinary tract infection that occur in the older client if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 863). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1784) The clinic nurse is monitoring a client with anorexia nervosa. Which statement, if made by a client, would indicate to the nurse that treatment has been effective? a. "I no longer have a weight problem." b. "I don't want to starve myself anymore." c. "I'll eat until I don't feel hungry." d. "My friends and I went out to lunch today." Source: Saunders 4th

ANS: D Rationale: In anorexia nervosa, the client tries to establish identity and control by self-imposed starvation. Options 1, 2, and 3 are verbalizations of the client's intentions. Option 4 is a measurable action that can be verified. Strategy: Note the strategic words that treatment has been effective. With this in mind, use the process of elimination and select the option that is measurable. Option 4 is the only measurable action. Review anorexia nervosa if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 390). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2195) A psychiatric home care nurse visits a client with a phobia who experiences panic attacks and teaches the client to use paradoxical intention. The nurse employs which method to teach the client this form of therapy? a. Having the client confront the anxiety-provoking stimulus and providing support during the episode b. Using progressive relaxation toward the client's individual anxiety hierarchy, increasing the level of difficulty, and pairing relaxation with the gradual exposure to reduce the client's anxiety c. Presenting the anxiety-provoking stimulus without any preparation of the client and having the client remain exposed until the anxiety subsides d. Instructing the client to do what he fears and if possible to exaggerate the outcome of this exposure to the point of humor Source: Saunders 4th

ANS: D Rationale: In cognitive-behavioral therapy, the client with a phobia who experiences panic attacks will be treated with a combination of cognitive restructuring, exposure therapy, and paradoxical intention. In paradoxical intention, the client is instructed to do what he fears and if possible to exaggerate it to the point of humor. When this occurs, the client is taught to prevent the anxiety by variety of coping mechanisms. This assists the client to regain an internal locus of control or feeling of empowerment and to master response to the anxiety-provoking issue, situation, or person. Option 1 describes in vivo therapy, which is a type of exposure therapy. Option 2 describes systematic desensitization, another type of exposure therapy. Option 3 describes flooding, which probably is the most intensive therapy. Strategy: Use the process of elimination. Note the relationship between intention in the question and to do what he fears in the correct option. If you had difficulty with this question, review the cognitive-behavioral therapies that are used with clients in the community who suffer from panic attacks. Reference: Mosby. (2006). Mosby's medical, nursing, & health dictionary (7th ed., p. 1392). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

42) The nurse manager of a critical care unit must speak to a staff nurse about an employment issue, tardiness. Nearly every day during the past week, the staff nurse has been from 5 to 20 minutes late, missing portions of the daily client status conferences. The manager had verbally counseled the staff nurse 3 months prior to the latest incidence of tardiness about the same issue. When they meet, the nurse manager's best approach to the staff nurse is to: a. Send the staff nurse to the Human Resources Department for counseling. b. Ask the staff nurse to tell the manager about the facts surrounding the tardiness. c. Inform the staff nurse that, based on unreliability caused by tardiness issues, the nurse is terminated. d. Provide the staff nurse with a detailed notice of intent to terminate if any further incident of tardiness occurs. Source: Saunders 4th

ANS: D Rationale: In general, the process for corrective action begins with an oral reprimand and then a written reprimand. In addition to the written reprimand, the manager should be prepared to work with the staff nurse to develop a plan of action. The manager must notify the staff nurse, in writing, of the potential for termination based on tardiness. If this were the first instance, the manager would ask the staff nurse to describe the facts surrounding the tardiness in order for the manager to assist the staff nurse with problem-solving strategies or to examine the need for moving the staff nurse to a different shift, if indicated. Managers are expected to deal with personnel issues, and tardiness is a frequent problem that managers face. Human resources serves as a support to the actions of the manager, but does not assume the role of dealing with the employee. Managers must give notice prior to termination as a risk management strategy. Strategy: Note that the series of tardinesses are the second offense. Remember that the process for corrective action begins with an oral reprimand and then a written reprimand. Review the principles and processes of disciplinary action if you had difficulty with this question. Reference: Marriner-Tomey, A. (2004). Guide to nursing management and leadership (7th ed., pp. 418-425) St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Leadership and Management Alternate Question Types -> Multiple Choice

1455) A hospitalized client is being considered for electroconvulsive therapy. The client appears calm, but the family is anxious. The client's mother begins to cry and states, "My son's brain will be destroyed. How can the doctor do this to him?" The appropriate nursing response is: a. "It sounds as though you need to speak to the psychiatrist." b. "Your son has decided to have this treatment. You should be supportive to him." c. "Perhaps you'd like to see the electroconvulsive therapy room and speak to the staff." d. "It sounds as though you have some concerns about the electroconvulsive therapy procedure. Why don't we sit down together and discuss any concerns that you may have?" Source: Saunders 4th

ANS: D Rationale: In option 4, the nurse encourages the client and the family to verbalize fears and concerns. Options 1, 2, and 3 avoid dealing with concerns and are blocks to communication. Strategy: Use the process of elimination and therapeutic communication techniques. Option 4 is the only therapeutic option. Options 1, 2, and 3 are blocks to communication. Review these therapeutic techniques if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 228, 450-452). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-34, 605). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1872) A nurse in a health care clinic is preparing to conduct a nutritional session with a group of culturally diverse pregnant women. At the first session, the nurse will be meeting with each client individually. The nurse prepares a list of items to be included in the session and lists which item as the first priority? a. Review the MyPyramid food guide. b. Weigh each client and ask the client to document the weight on a progress chart. c. Discuss the costs of food items. d. Identify the food preferences and methods of food preparation for each client. Source: Saunders 4th

ANS: D Rationale: In order to determine each client's nutritional status and needs, the first priority of the nurse is to identify each client's food preferences. Cultural background and knowledge about nutrition are important factors influencing food choices and nutritional status. Although options 1, 2, and 3 may be a component of the sessions, option 4 is the first priority. Strategy: Focus on the strategic words culturally diverse and first priority. Use the process of elimination and recall that it is necessary to include cultural factors in providing instructions to the client. If you had difficulty with this question, review cultural considerations related to nutrition. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., pp. 185-186). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

2494) A nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. A priority intervention in the plan of care is to: a. Keep the legs aligned with the heart. b. Position the client onto the side every shift. c. Clean the skin with alcohol every hour. d. Elevate the legs higher than the heart. Source: Saunders 4th

ANS: D Rationale: In the client with a venous disorder, the legs are elevated above the level of the heart to assist with the return of venous blood to the heart. Option 2 specifies infrequent care intervals, so it is not the priority intervention. Alcohol is very irritating and drying to tissues and should not be used in areas of skin breakdown. Strategy: Use the process of elimination, noting the strategic word priority. Recalling that the legs need to be elevated in a venous disorder will direct you to option 4. Review care of clients with a venous disorder if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 817). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1202) The client who has a cold is seen in the emergency room with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which of the following medications? a. Diuretics b. Antibiotics c. Antitussives d. Decongestants Source: Saunders 4th

ANS: D Rationale: In the client with benign prostatic hyperplasia, episodes of urinary retention can be triggered by certain medications, such as decongestants, anticholinergics, and antidepressants. The client should be questioned about the use of these medications if the client has urinary retention. Retention also can be precipitated by other factors, such as alcoholic beverages, infection, bed rest, and becoming chilled. Strategy: Use the process of elimination. The question is asking about medications that could exacerbate or contribute to urinary retention in the client with benign prostatic hyperplasia. Diuretics should help voiding; therefore, readily eliminate option 1. Antibiotics should have no effect at all, and thus eliminate option 2. From the remaining options, recalling that medications that contain anticholinergics may cause urinary retention will direct you to option 4. Review the factors that can precipitate urinary retention in the client with benign prostatic hyperplasia if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1018-1019). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1719) An infant returns to the nursing unit following surgery for a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving IV fluids and a gastrostomy tube is in place. Following assessment, the nurse positions the infant and: a. Connects the gastrostomy to the feeding pump. b. Attaches the gastrostomy tube to low suction. c. Tapes the gastrostomy tube to the bed linens. d. Elevates the gastrostomy tube. Source: Saunders 4th

ANS: D Rationale: In the immediate postoperative period, the gastrostomy tube is elevated, allowing gastric contents to pass into the small intestine and air to escape. This promotes comfort and decreases the risk of leakage at the anastomosis. Options 1, 2, and 3 are incorrect. Strategy: Option 3 can be easily eliminated because this action could cause accidental removal of the tube. Option 2 can be eliminated next, because suction on a surgical site could disrupt the repair. Recalling that feedings are not initiated in the immediate postoperative period will assist in directing you to the correct option. Review postoperative nursing care if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1114). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Child Health Alternate Question Types -> Multiple Choice

2525) A nursing student is performing an otoscopic examination in an adult client. The nursing instructor observes the student perform this procedure. Which observation by the instructor indicates that the student is using correct technique for the procedure? a. Pulling the pinna down and back before inserting the speculum b. Pulling the earlobe down and back before inserting the speculum c. Using the smallest speculum available d. Tilting the client's head slightly away and holding the otoscope upside down before inserting the speculum Source: Saunders 4th

ANS: D Rationale: In the otoscopic examination, the nurse tilts the client's head slightly away and holds the otoscope upside down as if it were a large pen. The pinna is pulled up and back and the nurse visualizes the external canal while slowly inserting the speculum. A small speculum is used in pediatric clients. The nurse may not be able to adequately visualize the ear canal if a small speculum is used in the adult client. Strategy: Use the process of elimination. Note that the question specifies an adult client. Eliminate options 1 and 2 first because they are comparative or alike. Use basic knowledge regarding the administration of ear medications and visualize the techniques of otoscopic examination to assist you in selecting the correct option from those remaining. Review this examination if you had difficulty with this question. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., p. 350). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

1430) During the termination phase of the nurse-client relationship, the clinic nurse observes that the client has made several sarcastic remarks and has an angry affect. The most appropriate interpretation of the behavior is that the client: a. Needs to be admitted to the hospital. b. Needs to be referred to the psychiatrist as soon as possible. c. Requires further treatment and is not ready to be discharged. d. Is displaying typical behaviors that can occur during termination. Source: Saunders 4th

ANS: D Rationale: In the termination phase of a relationship, it is normal for a client to demonstrate a number of regressive behaviors that can be disturbing to the nurse. Typical behaviors include return of symptoms, anger, withdrawal, and minimizing the relationship. The anger that the client is experiencing is a normal behavior during the termination phase and does not necessarily indicate the need for hospitalization or treatment. Strategy: Note the strategic words termination phase. This alone may assist in directing you to option 4. Additionally, note that options 1, 2, and 3 are comparable. These options address the need for further supervised treatment. If you are unfamiliar with the client behaviors associated with the termination phase, review this content. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 431-437). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 23, 47). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1418) Unresolved feelings related to loss most likely may be recognized during which phase of the therapeutic nurse-client relationship? a. Working b. Trusting c. Orientation d. Termination Source: Saunders 4th

ANS: D Rationale: In the termination phase, the relationship comes to a close. Ending treatment sometimes may be traumatic for clients who have come to value the relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resurface during this phase. Options 1, 2, and 3 are incorrect. Strategy: Note the strategic words unresolved, loss, and recognized in the question. Considering the phases of the therapeutic nurse-client relationship will direct you to option 4. Review these phases and the nursing implications if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 437). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 23-24). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Mental Health Alternate Question Types -> Multiple Choice

94) A client with diabetes mellitus has a glycosylated hemoglobin A_1c level of 9%. Based on this test result, the nurse plans to teach the client about the need to: a. Avoid infection. b. Take in adequate fluids. c. Prevent and recognize hypoglycemia. d. Prevent and recognize hyperglycemia. Source: Saunders 4th

ANS: D Rationale: In the test result for glycosylated hemoglobin A_1c, 7% or less indicates good control, 7% to 8% indicates fair control, and 8% or higher indicates poor control. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus, the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes. Strategy: Use the process of elimination and knowledge regarding the values for this test and their significance to answer the question. Focusing on the level identified in the question will assist in directing you to option 4. If you had difficulty with this question or are unfamiliar with this test, review this content. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 615). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 882, 1507). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

6) A Chinese-American client experiencing anemia, which is believed to be a yin disorder, is likely to treat it with: a. Magnetic therapy. b. Intercessory prayer. c. Foods considered to be yin. d. Foods considered to be yang. Source: Saunders 4th

ANS: D Rationale: In the yin and yang theory, health is believed to exist when all aspects of the person are in perfect balance. Yin foods are cold and yang foods are hot. Cold foods are eaten when one has a hot illness and hot foods are eaten when one has a cold illness. Options 1 and 2 are not associated with the yin and yang theory. Strategy: Use the process of elimination and knowledge regarding the theory of yin and yang. Remember that cold foods are eaten when one has a hot illness and hot foods are eaten when one has a cold illness. If you are unfamiliar with this theory, review its elements. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1286). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1397) The home care nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors associated with the allergy, the nurse questions the client about an allergy to which food item? a. Eggs b. Milk c. Yogurt d. Bananas Source: Saunders 4th

ANS: D Rationale: Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts are at risk for developing a latex allergy. This is thought to be to the result of a possible cross-reaction between the food and the latex allergen. Options 1, 2, and 3 are unrelated to latex allergy. Strategy: Use the process of elimination and knowledge regarding the food items related to a latex allergy. Eliminate options 1, 2, and 3 because they are comparative or alike and relate to dairy products. Review the food items associated with a risk for latex allergy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2325). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 512). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1758) The nurse is developing a plan of care for the client experiencing anxiety following the loss of a job. The client is verbalizing concerns regarding the ability to meet their role expectations and financial obligations. The appropriate nursing diagnosis for this client is: a. Dysfunctional family process b. Disturbed thought process c. Risk for anxiety d. Ineffective coping Source: Saunders 4th

ANS: D Rationale: Ineffective coping may be evidenced by inability to meet basic needs, inability to meet role expectations, alteration in social participation, use of inappropriate defense mechanisms, or impairment of usual patterns of communication. Disturbed thought processes are evidenced by altered attention span, distractibility, and disorientation to time, place, person, and events. A dysfunctional family process may exist when the family has difficulty adapting or responding to the changes or traumatic experience of the member in crisis. Strategy: Use the data presented in the question to direct you to the correct option. Option 3 can be easily eliminated because the client is presently experiencing anxiety. Eliminate option 1 because there are no data in the question that address the family. Similarly, there are no data to suggest disturbed thought processes, so this option can be eliminated, leaving option 4 as the correct option. Review nursing diagnoses for the client experiencing anxiety if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 192-193). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2384) A client with status epilepticus has been prescribed phenytoin (Dilantin) to be given by the IV route. The nurse administering the medication is careful not to exceed the recommended infusion rate of: a. 750 mg/min b. 100 mg/min c. 60 mg/min d. 50 mg/min Source: Saunders 4th

ANS: D Rationale: Intravenous administration of phenytoin is performed slowly (no faster than 50 mg/min) because rapid administration can cause cardiovascular collapse. It should not be added to any existing IV infusion because this is likely to produce a precipitate in the solution. Solutions are highly alkaline and can cause local venous irritation. Strategy: Use the process of elimination. Noting that the medication is to be administered by the IV route, select the option that indicates the slowest route of administration. If you are unfamiliar with the procedure for administering this medication by the IV route, review this content. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 993). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

27) The nursing instructor provides a lecture to nursing students regarding the issue of client&#39;s rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which of the following, if identified by the student, indicates an understanding of a violation of this client right? a. Performing a procedure without consent b. Threatening to give a client a medication c. Telling the client that he or she cannot leave the hospital d. Observing care provided to the client without the client's permission Source: Saunders 4th

ANS: D Rationale: Invasion of privacy takes place with unreasonable intrusion into an individual's private affairs. Performing a procedure without consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment. Strategy: The strategic words in the question are invasion of client privacy. Focus on these strategic words to direct you to option 4. If you had difficulty with this question, review those situations that include invasion of privacy. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 413-414). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Safe and Effective Care Environment Integrated Process -> Caring Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1540) A client who has been taking iodine solution (Lugol's solution, potassium iodide solution) is admitted to the emergency room and an iodine overdose is suspected. Gastric lavage is initiated to remove the iodine from the stomach. In addition to treatment with gastric lavage, the nurse anticipates that which of the following will be administered? a. Calcium gluconate b. Vitamin K c. Acetylcysteine (Mucomyst) d. Sodium thiosulfate Source: Saunders 4th

ANS: D Rationale: Iodine solution can cause iodine toxicity. Iodine is corrosive and an overdose will injure the gastrointestinal tract. Symptoms include abdominal pain, vomiting, and diarrhea. Swelling of the glottis may result in asphyxiation. Treatment consists of gastric lavage to remove iodine from the stomach and administration of sodium thiosulfate to reduce iodine to iodide. Calcium gluconate is used for acute hypocalcemia. Mucomyst is the antidote for acetaminophen (Tylenol) overdose. Vitamin K is the antidote for warfarin (Coumadin). Strategy: Use the process of elimination. Knowledge of the specific antidotes for medication overdose is required to answer this question. You should be able to eliminate options 1, 2, and 3 easily because these medications should be familiar to you. If they are not familiar and you are unsure of these antidotes, review this content. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 764-766). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2003) A male client arrives at the hospital emergency department and tells the nurse that there is something in his eye. The nurse looks into the client's eye and notes that the foreign body is visible and is not embedded. The appropriate nursing action is which of the following? a. Irrigate the eye with normal saline. b. Tell the client that the surgeon will need to be called. c. Tell the client that the object will work its way out. d. Touch the object gently with a cotton swab and lift it out. Source: Saunders 4th

ANS: D Rationale: Irrigating the eye with a solution may cause the foreign body to move, with the potential to cause trauma in another area of the eye. Because the foreign body is not embedded and is easily seen by the nurse, a surgeon is not needed. Allowing the object to remain in the eye may cause additional trauma if the object moves. Lifting the foreign body from the eye by touching the object gently with a cotton swab and lifting it out will involve the least amount of trauma. Strategy: Focus on the information provided in the question. Use the process of elimination and eliminate options 2 and 3 first. Regarding the remaining options, recall that attempting to irrigate the eye may cause the foreign body to move, possibly causing additional trauma. Lifting the foreign body from the eye would cause the least amount of trauma. Review emergency treatment to eye injuries if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 445). St. Louis: Mosby. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1105-1106). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

2122) A physician prescribed digoxin (Lanoxin) 0.25 mg for a client with atrial fibrillation. The medication is available as 0.125-mg tablets. The nurse calculates that the client will receive two tablets of digoxin. When the nurse hands the medication to the client, the client looks at the medication and states, "Every time I get chest pain, I will take one of these heart pills." After double-checking the dosage calculation, the nurse decides to: a. Not administer the medication as prescribed and calculated b. Administer one-half tablet of the medication instead of the dosage calculated c. Administer the medication as prescribed and calculated, and monitor for untoward effects, such as seizures d. Administer the medication as prescribed and calculated, and proceed with further client teaching Source: Saunders 4th

ANS: D Rationale: It is appropriate to treat atrial fibrillation with the prescribed and calculated dose of digoxin as indicated in the question. The subject of the question is that the client verbalizes inaccurate and unsafe knowledge regarding this medication and the treatment for chest pain. This client needs further education regarding the safe administration of medications for episodes of chest pain. Strategy: Use the process of elimination. Perform the calculation first and determine that the dose determined by the nurse is correct. From this point, eliminate options 1 and 2. Note the subject of the question, the need for client teaching. This should direct you to option 4. Review the normal dosage of digoxin if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 357). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2013) A nursing student is developing a plan of care for a client with a chest tube that is attached to a Pleur-Evac drainage system. The nurse intervenes if the student writes which incorrect intervention in the plan? a. Position the client in semi-Fowler's position. b. Add water to the suction chamber as it evaporates. c. Tape the connection sites between the chest tube and the drainage system. d. Instruct the client to avoid coughing and deep breathing. Source: Saunders 4th

ANS: D Rationale: It is important to encourage the client to cough and deep breathe when a chest tube drainage system is in place. This will assist in facilitating appropriate lung re-expansion. Water is added to the suction chamber as it evaporates to maintain the full suction level prescribed. Connections between the chest tube and the drainage system are taped to prevent accidental disconnection. The client is positioned in semi-Fowler's to facilitate ease in breathing. Strategy: Note the strategic word incorrect in the question. This indicates a negative event query and directs you to select an incorrect intervention. Use principles associated with the use of the closed chest drainage system to assist you in answering the question. Recalling that coughing and deep breathing are necessary to promote re-expansion of the lung will assist in directing you to option 4. If you had difficulty with this question, review the care of a client with a closed chest tube drainage system. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1865). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Leadership and Management Alternate Question Types -> Multiple Choice

1982) A pregnant client seen in the health care clinic tells the nurse that the iron supplement started 1 week ago is causing nausea, constipation, and heartburn and that she would like to stop taking the medication. The nurse appropriately responds by telling the client that: a. "The fetus needs the iron." b. "You need to see the physician immediately." c. "You need to stop the medication immediately." d. "These reactions are most prominent during initial therapy and lessen with continued use." Source: Saunders 4th

ANS: D Rationale: It is most important that pregnant clients receive iron supplements because of the extra demands placed on maternal circulation by the fetus. Although option 1 may be true, it is not the appropriate response considering the options presented. Option 3 is an inappropriate and incorrect response because the iron does not have to be discontinued. Option 2 is unnecessary at this time. Strategy: Use the process of elimination. Eliminate options 2 and 3 first because they are comparative or alike and both use the word immediately. From the remaining options, select option 4 because it addresses the subject and provides the client with information regarding the complaints experienced from the medication. Review the action and effects of this medication if you had difficulty with this question. Reference: Kee, J., & Hayes, E., McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 798-799). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 634). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1787) An older postoperative client has been tolerating a full liquid diet and the nurse plans to advance the diet to solid food as prescribed. Which assessment is most important for the nurse to make prior to advancing the diet to solids? a. Food preferences b. Cultural preferences c. Presence of bowel sounds d. Ability to chew Source: Saunders 4th

ANS: D Rationale: It may be necessary to modify a client's diet of solid food to a soft or chopped (puréed) diet if the client has difficulty chewing. Food and cultural preferences should be ascertained on admission. Bowel sounds should have previously been assessed and present before introducing any diet. Strategy: Note the strategic word older and tolerating a full liquid diet. Eliminate options 1 and 2 first because they are comparative or alike. Eliminate option 3 next because the client has been tolerating a full liquid diet, so bowel sounds have been present. The subject relates to consistency of food. Option 4 is the only option that addresses a factor affecting food consistency. Review nursing assessment of a client on a progressive diet if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 697-698). Philadelphia: W.B. Saunders. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed., p. 416). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1945) A nurse is explaining an upper gastrointestinal series to a client and provides the client with the pre-procedure and post-procedure instructions. The nurse informs the client that after this procedure, the stools can be expected to remain white for: a. 1 week b. 6 hours c. 8 hours d. 1 to 2 days Source: Saunders 4th

ANS: D Rationale: It takes at least 12 to 24 hours for a substance to pass through the colon. One week is too long a period of time and 6 to 8 hours is too short a period due to residual barium and decreased peristalsis. Strategy: Use the process of elimination and knowledge regarding the passage of substances through the colon to assist in answering the question. Recalling that it takes at least 12 to 24 hours for a substance to pass through the colon will assist in directing you to option 4. Review client instructions related to this test if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 1109). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1382) Which of the following individuals is least likely at risk for the development of Kaposi's sarcoma? a. A kidney transplant client b. A male with a history of same-gender partners c. A client receiving antineoplastic medications d. An individual working in an environment in which he or she is exposed to asbestos Source: Saunders 4th

ANS: D Rationale: Kaposi's sarcoma is a vascular malignancy that presents as a skin disorder and is a common acquired immunodeficiency syndrome indicator. Malignancy is seen most frequently in men with a history of same-gender partners. Although the cause of Kaposi's sarcoma is not known, it is considered to be caused by an alteration or failure in the immune system. The renal transplantation client and the client receiving antineoplastic medications are at risk for immunosuppression. Exposure to asbestos is not related to the development of Kaposi's sarcoma. Strategy: Use the process of elimination. Note the strategic words least likely at risk. Option 2 can be eliminated easily. Note that options 1 and 3 are comparative or alike. These clients are at risk for immunosuppression. With this in mind, these options can be eliminated. If you had difficulty with this question, review the risk factors associated with Kaposi's sarcoma. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2393). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

74) A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on this documentation, which of the following did the nurse observe? a. Respirations that cease for several seconds b. Respirations that are regular but abnormally slow c. Respirations that are labored and increased in depth and rate d. Respirations that are abnormally deep, regular, and increased in rate Source: Saunders 4th

ANS: D Rationale: Kussmaul's respirations are abnormally deep, regular, and increased in rate. Apnea is described as respirations that cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate. Strategy: Use the process of elimination and knowledge of the description of Kussmaul's respirations. Recalling that this type of respiration occurs in diabetic ketoacidosis will direct you to option 4. Review the characteristics of this type of respiration if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1327). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 650, 1088). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2307) A nurse is preparing to administer prescribed medications to the client with hepatic encephalopathy. The nurse anticipates that the physician's orders will include: a. Magnesium hydroxide (Milk of Magnesia) b. Phenolphthalein (Ex-Lax) c. Psyllium hydrophilic mucilloid (Metamucil) d. Lactulose (Chronulac) Source: Saunders 4th

ANS: D Rationale: Lactulose is a hyperosmotic laxative agent that has the adjunct benefit of lowering serum ammonia levels. This occurs because the medication lowers bowel pH and aids in the conversion of ammonia in the gut to the ammonium ion, which is poorly absorbed. Magnesium hydroxide is a saline laxative. Phenolphthalein is a stimulant laxative. Psyllium hydrophilic mucilloid is a bulk laxative. Strategy: Focus on the client's diagnosis, hepatic encephalopathy. Recalling that the ammonia level is elevated in this diagnosis and the medication used to lower this level will direct you to option 4. Review care of the client with hepatic encephalopathy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1357). Philadelphia: W.B. Saunders. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 663). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2371) A nurse is performing an admission assessment on a client who has a history of glaucoma and uses latanoprost (Xalatan) eye drops. Which assessment finding would indicate a side effect of these eye drops? a. Elevated blood pressure b. Irregular pulse c. Periorbital edema d. Brown pigmentation of the iris Source: Saunders 4th

ANS: D Rationale: Latanoprost is a topical medication used to lower intraocular pressure in clients with open-angle glaucoma and ocular hypertension. The most significant side effect is heightened brown pigmentation of the iris. Other side effects include blurred vision, burning, stinging, conjunctival hyperemia, and punctate keratopathy. The heightened pigmentation does not progress further once the medication is discontinued but does not regress. Remember that this medication can cause brown pigmentation of the iris. The other options are not noted with this medication. Strategy: Knowledge of this antiglaucoma medication is needed to answer this question. Remember this medication can cause brown pigmentation of the iris. If you are unfamiliar with this medication and its side effects, review this content. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 731). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1276) The client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: a. Is clear and tests negative for glucose b. Is grossly bloody in appearance and has a pH of 6 c. Clumps together on the dressing and has a pH of 7 d. Separates into concentric rings and tests positive for glucose Source: Saunders 4th

ANS: D Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose. Strategy: Use the process of elimination and knowledge regarding the characteristics of CSF. Recall that CSF contains glucose, whereas other secretions, such as mucus, do not. Knowing that CSF separates into rings also will help you answer this question. Review testing for CSF fluid if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1050). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1252) The clinic nurse notes that following several eye examinations, the physician has documented a diagnosis of legal blindness in the client's chart. The nurse reviews the results of the Snellen chart test expecting to note which finding? a. 20/20 vision b. 20/40 vision c. 20/60 vision d. 20/200 vision Source: Saunders 4th

ANS: D Rationale: Legal blindness is defined as 20/200 or less with corrected vision (glasses or contact lenses) or visual acuity of less than 20 degrees of the visual field in the better eye. Strategy: Knowledge of the definition of legal blindness is required to answer this question. Remember that legal blindness is defined as 20/200 or less with corrected vision. Review this definition if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1107-1108). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1854) A hospitalized client is diagnosed with scabies. The physician recommended that the client and the client's roommate be treated with lindane. Which of the following if noted on this client's chart would alert the nurse to notify the physician before the treatment with lindane? a. Client history of coronary artery disease b. Client history of diabetes c. Client history of hypertension d. Client history of seizure disorders Source: Saunders 4th

ANS: D Rationale: Lindane can penetrate intact skin and can cause convulsions if absorbed in sufficient quantities. A client with a preexisting seizure disorder is at high risk for convulsions. Other clients at high risk for convulsions include premature infants and children. Lindane should not be used on pediatric clients unless safer medications have failed to control the infection. Options 1, 2, and 3 do not identify contraindications related to the use of this medication. Strategy: Specific knowledge regarding the contraindications of lindane is required to answer this question. Remember that lindane is contraindicated in clients with a history of seizure disorder. If you are unfamiliar with these contraindications, review this medication. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 1141). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2641) Lisinopril (Prinivil) has been prescribed for a client. The nurse instructs the client to: a. Discontinue the medication if nausea occurs. b. Expect to note a full therapeutic effect immediately. c. Take the medication with food only. d. Rise slowly from a reclining to a sitting position. Source: Saunders 4th

ANS: D Rationale: Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor used in the treatment of hypertension. The client should be instructed to rise slowly from a reclining to a sitting position, and to dangle the legs from the bed for a few moments before standing to reduce the hypotensive effect. It is not necessary to take the medication with food. If nausea occurs, the client should drink a non-cola carbonated beverage and eat salted crackers or dry toast. A full therapeutic effect may be achieved in 1 to 2 weeks. Strategy: Recall that this medication is an antihypertensive. Next, apply the principles of care that are relevant with this class of medication. Remember that antihypertensives can cause orthostatic hypotension. If you had difficulty with this question, review the teaching points related to this medication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 697). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

24) A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. The appropriate response to the client is which of the following? a. "I will sign as a witness to your signature." b. "You will need to find a witness on your own." c. "Whoever is available at the time will sign as a witness for you." d. "I will call the nursing supervisor to seek assistance regarding your request." Source: Saunders 4th

ANS: D Rationale: Living wills are required to be in writing and signed by the client. The client's signature must be witnessed by specified individuals or notarized. Many states prohibit any employee, including a nurse of a facility where the client is receiving care, from being a witness. Option 2 is nontherapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor. Strategy: Note the strategic word appropriate. Options 1 and 3 are comparative or alike and should be eliminated first. Option 2 is eliminated because it is a nontherapeutic response. Review legal implications associated with wills if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 106). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 409-410). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2671) A nurse has just given a client a dose of a PRN medication called loperamide (Imodium). The nurse documents in the client's record that the client received this medication for complaints of: a. Tarry stools b. Abdominal pain c. Constipation d. Diarrhea Source: Saunders 4th

ANS: D Rationale: Loperamide is an antidiarrheal agent commonly administered after the client experiences loose stools. It is used to treat both acute diarrhea and chronic diarrhea from disorders such as inflammatory bowel disease. It also can be used to reduce the volume of drainage from an ileostomy. Strategy: Recalling that this medication is an antidiarrheal will direct you to option 4. Review the action and use of loperamide if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 703). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Communication and Documentation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1600) The nurse in the labor room is performing an initial assessment on a newborn infant. On assessment of the newborn infant's head, the nurse notes that the ears are low-set. Which of the following nursing actions would be appropriate? a. Cover the ears with gauze pads. b. Document the findings. c. Arrange for hearing testing. d. Notify the physician. Source: Saunders 4th

ANS: D Rationale: Low or oddly placed ears are associated with a variety of congenital defects and should be reported immediately. Although the findings would be documented, the most appropriate action would be to notify the physician. Options 1, 2, and 3 are inaccurate and inappropriate nursing actions. Strategy: Use the process of elimination. Knowledge regarding the normal assessment findings in a newborn infant is required to answer this question. Recall that low-set ears is an abnormal finding will easily direct you to option 4. Review normal assessment findings in a newborn if you had difficulty with this question. Reference: Wong, D., Perry, S., Hockenberry, M., et al. (2006). Maternal child nursing care (3rd ed., p. 714). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

2460) A community health nurse is providing an educational session to community members regarding Lyme disease. The nurse informs the community members that this disease: a. Can be contagious by skin contact with an infected person b. Can be caused by the inhalation of spores from bird droppings c. Is caused by contamination from cat feces d. Is caused by a tick bite Source: Saunders 4th

ANS: D Rationale: Lyme disease is a multisystem infection that results from a bite by a tick that is usually carried by several species of deer. Persons bitten by the Ixodes ticks are infected with the spirochete Borrelia burgdorferi. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. Toxoplasmosis is caused from the ingestion of cysts from contaminated cat feces. Lyme disease cannot be transmitted from one person to another. Strategy: Use the process of elimination. Recalling that this disease is caused by a bite will assist in eliminating the incorrect options. If you had difficulty with this question, review the cause of Lyme disease. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 418). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

1868) A senior nursing student is assigned to care for a client with severe preeclampsia who is receiving an intravenous infusion of magnesium sulfate. The coassigned nurse asks the student to describe the actions and effects of this medication. Which of the following statements if made by the student indicates the need for further research? a. "It produces flushing and sweating due to decreased peripheral blood pressure." b. "It decreases the central nervous system activity acting as an anticonvulsant." c. "It decreases the frequency and duration of uterine contractions." d. "It increases acetylcholine, blocking neuromuscular transmission." Source: Saunders 4th

ANS: D Rationale: Magnesium sulfate produces flushing and sweating due to decreased peripheral blood pressure. It decreases the central nervous system activity, acting as an anticonvulsant, and decreases the frequency and duration of uterine contractions. Magnesium sulfate decreases (not increases) acetylcholine, blocking neuromuscular transmission. Strategy: Note the strategic words need for further research. Knowledge regarding the action of magnesium sulfate and reading each option carefully will assist in directing you to option 4. If you are unfamiliar with the actions and effects of this medication, review this content. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., pp. 645-646). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Maternity—Intrapartum Alternate Question Types -> Multiple Choice

1472) A client with a diagnosis of major depression, recurrent, with psychotic features, is admitted to the mental health unit. To create a safe environment for the client, the nurse most importantly devises a plan of care that deals specifically with the client's: a. Self-care deficit. b. Imbalanced nutrition. c. Deficient knowledge. d. Disturbed thought processes. Source: Saunders 4th

ANS: D Rationale: Major depression, recurrent, with psychotic features, alerts the nurse that in addition to the criteria that designates the diagnosis of major depression, one also must deal with the client's psychosis. Psychosis is defined as a state in which a person's mental capacity to recognize reality and to communicate and relate to others is impaired, thus interfering with the person's ability to deal with the demands of life. Disturbed thought processes generally indicate a state of increased anxiety in which hallucinations and delusions prevail. Although all the nursing diagnoses may be appropriate because the client is experiencing psychosis, option 4 is the correct option. Strategy: Use the process of elimination. All the nursing diagnoses listed may be appropriate for a client diagnosed with major depression. The strategic words leading to the correct option are psychotic features, in which the client often suffers with disturbed thought processes, such as hallucinations and delusions. Review appropriate nursing diagnoses for major depression and psychotic features if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 220, 458). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 335). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 385). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1465) A nurse is conducting a group therapy session. During the session, a client with mania consistently talks and dominates the group session, and her behavior is disrupting group interactions. The nurse would initially: a. Ask the client to leave the group session. b. Ask another nurse to escort the client out of the group session. c. Tell the client that she will not be able to attend any future group sessions. d. Tell the client that she needs to allow other clients in the group time to talk. Source: Saunders 4th

ANS: D Rationale: Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the client's behavior. Initially, asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and further escalate the client's behavior. Option 2 is also an inappropriate initial action because it violates the client's right to receive treatment and is a threatening action. Strategy: Use the process of elimination and note the strategic word initially. Eliminate options 1 and 2 first because they are comparative or alike. Next, eliminate option 3 because it violates the client's right to receive treatment and is a threatening action. Remember that setting firm limits with the client initially is best. Review care of a client with mania if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 445). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 364). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1326) Mannitol (Osmitrol) is prescribed for the client with increased intracranial pressure following a head injury. The nurse prepares to administer this medication knowing that the therapeutic action is to: a. Prevent the filtration of sodium and water through the kidneys. b. Prevent the filtration of sodium and potassium through the kidneys. c. Induce diuresis by promoting the reabsorption of sodium and water in the loop of Henle. d. Induce diuresis by raising the osmotic pressure of glomerular filtrate, thereby inhibiting tubular reabsorption of water and solutes. Source: Saunders 4th

ANS: D Rationale: Mannitol is an osmotic diuretic that induces diuresis by raising the osmotic pressure of glomerular filtrate, thereby inhibiting tubular reabsorption of water and solutes. Mannitol is used to reduce intracranial pressure in the client with head trauma. Strategy: Use the process of elimination. Read the question carefully, noting that it identifies a client with increased intracranial pressure. The only option that suggests an action that will produce diuresis and thus reduce intracranial pressure is option 4. If you had difficulty with this question, review the action of mannitol. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 520). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2123) A client has a closed head injury with increased intracranial pressure (ICP). The increased ICP is being effectively managed by mannitol (Osmitrol) 25 g by the intravenous (IV) route every 2 hours. The nurse is planning to administer this medication via IV pump and plans to administer this medication: a. By giving it rapidly over 5 minutes by IV bolus b. Mixed in solution with the IV antibiotics c. Piggybacked into the packed red blood cells d. By giving it slowly over 30 to 90 minutes Source: Saunders 4th

ANS: D Rationale: Mannitol is an osmotic diuretic. When used to treat increased ICP, it is given slowly over 30 to 90 minutes, not rapidly and not via IV bolus. Mannitol should not be mixed in solution with antibiotics, and nothing should be piggybacked with packed red blood cells. Strategy: Use the process of elimination. Options containing the word rapidly or slowly should be assessed carefully. Generally, it is incorrect to choose rapidly for IV administration of most medications. Review the procedure for administering this medication by the IV route if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 782). St. Louis: Mosby. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 721). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2029) A nurse has admitted a client with a diagnosis of an acute attack of Ménière's disease to the hospital. The nurse reviews the physician's orders for the client. Which order should the nurse question? a. Diphenhydramine (Benadryl) b. Diazepam (Valium) c. Atropine sulfate d. Ambulation 4 times daily Source: Saunders 4th

ANS: D Rationale: Medical interventions during the acute phase of Ménière's disease include using atropine sulfate or diazepam to decrease the autonomic nervous system function. Diphenhydramine may be prescribed for its antihistamine effects, and a vasodilator also will be prescribed. The client will remain on bedrest during the acute attack. When allowed out of bed, the client will need assistance with walking, sitting, or standing. Strategy: Use the process of elimination. Noting the strategic words acute attack will assist in directing you to option 4. It also is the option that is different because it is not a medication. If you had difficulty with this question, review the treatment for a client with an acute attack of Ménière's disease. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 467). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

966) Psyllium hydrophilic mucilloid (Metamucil) has been prescribed for a client. The nurse should teach the client to take this medication with which of the following? a. A dose of an antacid b. Gelatin, applesauce, or pudding c. A multivitamin and mineral supplement d. A full glass of liquid, followed by another Source: Saunders 4th

ANS: D Rationale: Metamucil is a bulk-forming laxative and should be taken with a full glass of water or juice, followed by another glass of liquid. This will help prevent impaction of the medication in the stomach or small intestine. The other options are incorrect. Strategy: Use the process of elimination. Option 1 should be eliminated first because most medications are not taken with antacids. Eliminate options 2 and 3 next because they have no physiological benefit for medication effect. Review client teaching points related to this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 987). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1070) A client admitted to the hospital with chest pain and history of type II diabetes mellitus is scheduled for cardiac catheterization. Which of the following medications would need to be held for 48 hours before and after the procedure? a. Regular insulin b. Glipizide (Glucotrol) c. Repaglinide (Prandin) d. Metformin (Glucophage) Source: Saunders 4th

ANS: D Rationale: Metformin (Glucophage) needs to be withheld 48 hours before and after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system, the client would be at increased risk for lactic acidosis. The medications in options 1, 2, and 3 do not need to be withheld 48 hours before and after cardiac catheterization. Strategy: Use the process of elimination. Eliminate options 2 and 3 first. Although these medications may be held on the morning of the procedure because of the client's NPO status, there is no indication for withholding the medication the day prior to and the day postprocedure. Regular insulin may be administered if elevated blood glucose levels from infused intravenous solutions occur on the day of the procedure. Review preprocedure and postprocedure interventions if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed., p. 1509). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2617) The mother of a child with attention-deficit hyperactivity disorder (ADHD) has been given instructions about how to administer methylphenidate (Ritalin) to the child. The nurse determines that the mother understands the information if she states that it is best to administer the medication: a. With an evening snack b. At the evening meal c. At bedtime d. Just before the noontime meal Source: Saunders 4th

ANS: D Rationale: Methylphenidate is best taken shortly before meals and no later than 1:00 <sc>PM</sc> for children or after 6:00 <sc>PM</sc> for adults because the stimulating effect of the medication may keep the client awake. The other options are incorrect. Strategy: Use the process of elimination. Eliminate options 1, 2, and 3 because they are all comparative or alike. If you had difficulty with this question, review the client teaching points related this medication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007. (p. 757). Philadelphia: W.B. Saunders. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 302). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2290) A nurse is caring for a client with an exacerbation of multiple sclerosis. Which of the following scheduled medications will the nurse administer to hasten recovery from the exacerbation? a. Lioresal (Baclofen) by mouth and diazepam (Valium) intravenously b. Carbamazepine (Tegretol) and phenytoin (Dilantin) by mouth c. Phenytoin (Dilantin) intravenously, then tapered to oral route d. Methylprednisolone (Solu-Medrol) intravenously Source: Saunders 4th

ANS: D Rationale: Methylprednisolone or adrenocorticotropic hormone may be prescribed to be administered intravenously to accelerate recovery from an exacerbation of multiple sclerosis. Carbamazepine may be prescribed for trigeminal neuralgia, and phenytoin may be prescribed to control seizures. Lioresal and diazepam are used to treat muscle spasticity. Strategy: Use the process of elimination and note the subject, an exacerbation. Recalling that methylprednisolone is a corticosteroid will direct you to option 4. Review the uses and actions of these medications if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 820). St. Louis: Mosby. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 758). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., pp. 835-836). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 550). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

956) The client has a new order for metoclopramide (Reglan). On review of the chart, the nurse identifies that this medication can be safely administered with which condition? a. Intestinal obstruction b. Peptic ulcer with melena c. Diverticulitis with perforation d. Vomiting following cancer chemotherapy Source: Saunders 4th

ANS: D Rationale: Metoclopramide is a gastrointestinal stimulant and antiemetic. Because it is a gastrointestinal stimulant, it is contraindicated with gastrointestinal obstruction, hemorrhage, or perforation. It is used in the treatment of emesis after surgery, chemotherapy, and radiation. Strategy: Use the process of elimination. Recalling the classification and action of this medication and that it is an antiemetic will direct you to option 4. Review the action of this medication if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 690-691). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1537) The nurse is planning to instruct the Mexican American client about nutrition and dietary restrictions. When developing the plan, the nurse is aware that this ethnic group: a. Enjoys food that lack color, flavor, and texture. b. Primarily eat raw fish. c. Enjoys eating red meat. d. Views food as a primary form of socialization. Source: Saunders 4th

ANS: D Rationale: Mexican foods are rich in color, flavor, texture, and spiciness. In the Mexican-American culture, any occasion is seen as a time to celebrate with food and enjoy the companionship of family and friends. Because food is a primary form of socialization in the Mexican culture, Mexican Americans may have difficulty adhering to a prescribed diet. Asian Americans eat raw fish, rice, and soy sauce. European Americans prefer carbohydrates and red meat. Strategy: Use the process of elimination and knowledge regarding the food practices and preferences and the meaning of food in the Mexican-American culture. If you had difficulty with this question, review the food preferences associated with this culture. Reference: Giger, J., & Davidhizar, R. (2004). Transcultural nursing (5th ed., pp. 158-159). St. Louis: Mosby. Reference: Nix, S. (2005.). Williams' basic nutrition and diet therapy (12th ed., p. 251). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1329) The nurse is caring for a client receiving morphine sulfate 10 mg subcutaneously every 4 hours for pain. Because this medication has been prescribed for this client, which nursing action would be included in the plan of care? a. Encourage fluids. b. Monitor the client's temperature. c. Maintain the client in a supine position. d. Encourage the client to cough and deep-breathe. Source: Saunders 4th

ANS: D Rationale: Morphine sulfate suppresses the cough reflex. Clients need to be encouraged to cough and deep-breathe to prevent pneumonia. Options 1, 2, and 3 are not associated specifically with the use of this medication. Strategy: Use the process of elimination. The question is asking specifically about a nursing action related to this medication. Recalling that morphine sulfate suppresses the cough reflex and the respiratory reflex will direct you to the correct option. Additionally, use the ABCs—airway, breathing, and circulation—when selecting the correct option. Review the nursing considerations when administering this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 797). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1435) A home health nurse is talking to the spouse of a client taking an antidepressant. The spouse says, "Now that my husband is responding to the antidepressant, the suicidal risk is over and you can stop making these home visits." After analyzing this statement, which of the following is the appropriate nursing response? a. "I need to continue with my visits. Your comment reflects a lack of knowledge that this disease runs in families." b. "I agree with you. Clients who want to kill themselves are only suicidal for a limited time. No one can feel self-destructive forever." c. "I agree with you. The suicidal threats were really attention seeking. Continuing to visit would reinforce your husband's use of manipulation." d. "I need to continue with my visits. Most suicides occur within 3 months after improvement begins because the client now has the energy to carry out the suicidal intentions." Source: Saunders 4th

ANS: D Rationale: Most suicides occur within 3 months after the beginning of the improvement, when the client has the energy to carry out the suicidal intentions. Options 1, 2, and 3 are incorrect because they fail to address safety and involve giving false information. Strategy: Use the process of elimination and knowledge regarding the facts about suicide to answer the question. Recalling that a critical time for a suicidal client is when the client has energy will direct you to option 4. Review the concepts related to suicide and therapeutic communication techniques if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 560-561, 566). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-34). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1145) A client is being discharged with a prescription for propranolol (Inderal). In developing a medication teaching plan, a nurse would include which of the following instructions? a. Exercise will prevent orthostatic hypotension. b. Hot baths and showers are advised to increase vasodilation. c. Medication should be taken on an empty stomach to enhance absorption. d. Medication should be withheld if the pulse rate drops below 60 beats/min. Source: Saunders 4th

ANS: D Rationale: Most β blockers may be administered with food or on an empty stomach, but propranolol is absorbed best if taken with meals or directly after eating. Exercise will not prevent orthostatic hypotension. Hot showers and baths are not advised. The client needs to be instructed in how to take the pulse rate and to notify the physician if the heart rate falls below 60 beats/min. Strategy: Use the process of elimination. Recalling that bradycardia can occur with propranolol will direct you to option 4. If you had difficulty with this question, review the client teaching points related to this medication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 444-445). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2409) A nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when: a. Suctioning is required frequently. b. Excessive secretions are suctioned from the tube and stoma. c. The client's skin and mucous membranes are light pink in color. d. Aspiration of gastric contents occurs during suctioning. Source: Saunders 4th

ANS: D Rationale: Necrosis of the tracheal wall can lead to formation of an abnormal opening between the posterior trachea and the esophagus. The opening, called a tracheoesophageal fistula, allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents. Options 1, 2, and 3 are not signs of this complication. Strategy: Use knowledge of anatomy and medical terminology to assist you in answering this question. A fistula is an abnormal opening, and the term tracheoesophageal means "trachea-to-esophagus." This will direct you to option 4. Review the signs of tracheoesophageal fistula if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 577). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1824) A nurse in the labor room measures the Apgar score in a newborn infant and notes that it is 4. Which of the following actions by the nurse has highest priority? a. Place the newborn infant in the radiant warmer incubator. b. Initiate an IV line on the newborn infant. c. Place the newborn infant on a cardiorespiratory monitor. d. Administer oxygen via resuscitation bag to the newborn infant. Source: Saunders 4th

ANS: D Rationale: Newborn infants with an Apgar score of 5 to 7 often require resuscitative interventions. Scores of less that 5 indicate that the newborn infant is having difficulty adjusting to extrauterine life and requires more vigorous resuscitation. The immediate nursing action should be to administer oxygen via resuscitation bag. Although the newborn infant may require a cardiorespiratory monitor, an IV line, and may need to be placed in a radiant warmer incubator, the initial action of the nurse should be to provide resuscitative measures. Strategy: Note the strategic word priority in the question. Use the ABCs—airway, breathing, and circulation—to assist you in answering the question. Also, knowledge regarding the Apgar scoring system will assist in directing you to option 4. Review care of the newborn infant with a low Apgar score if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 298). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

1136) A home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL. The client is taking cholestyramine (Questran). Which of the following statements, if made by the client, indicates the need for further education? a. "Constipation and bloating might be a problem." b. "I'll continue to watch my diet and reduce my fats." c. "Walking a mile each day will help the whole process." d. "I'll continue my nicotinic acid from the health food store." Source: Saunders 4th

ANS: D Rationale: Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver abnormalities. All lipid-lowering medications also can cause liver abnormalities, so a combination of nicotinic acid and cholestyramine resin is to be avoided. Constipation and bloating are the two most common side effects. Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels. Strategy: Use the process of elimination and note the strategic words need for further education. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Remembering that over-the-counter medications should be avoided when a client is taking a prescription medication will direct you to option 4. Review client teaching points related to this medication if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 678). Philadelphia: W.B. Saunders. Reference: Lilley, L., Harrington, S., & Snyder, J. (2005). Pharmacology and the nursing process (4th ed., pp. 483, 489). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2115) A nurse has taught a client with subarachnoid hemorrhage about the effects of nimodipine (Nimotop), which has been prescribed for 3 weeks. The nurse evaluates that the client understands the purpose of this medication if the client states that it is a: a. β-Adrenergic blocker that will decrease blood pressure b. Vasodilator that has an affinity for cerebral blood vessels c. Calcium channel blocker that will reduce the blood pressure d. Calcium channel blocker that will decrease spasm in cerebral blood vessels Source: Saunders 4th

ANS: D Rationale: Nimodipine is a calcium channel-blocking agent that has an affinity for cerebral blood vessels. It is used to prevent or control vasospasm in cerebral blood vessels, thereby reducing the chance for rebleeding. It is typically ordered for 3 weeks' duration. Strategy: Use the process of elimination. Recalling that nimodipine is a calcium channel-blocking agent will assist in eliminating options 1 and 2. Knowing that calcium channel blockers primarily decrease vasospasm will direct you to option 4 from the remaining options. Review the purpose of nimodipine if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 838). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 480). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2627) A client with angina pectoris has been given a new prescription for nitroglycerin transdermal patches. The client indicates an understanding of how to use this medication administration system by making which of the following statements? a. "I need to place the patch in the area of a skin fold to promote better adherence." b. "I need to wait until the next day to apply a new patch if it falls off." c. "I need to alternate daily dosage times to prevent tolerance to the medication." d. "I need to apply the patch in the morning and leave it in place for 12 to 14 hours as directed." Source: Saunders 4th

ANS: D Rationale: Nitroglycerin is a coronary vasodilator used for coronary artery disease. The client should apply a new patch each morning and leave it in place for 12 to 14 hours in accordance with physician directions. This prevents the client from developing tolerance (as happens with 24-hour use). The client should avoid placing the patch in skin folds or excoriated areas. The client does not need to wait to apply a new patch if it falls off because the medication is released continuously in small amounts through the skin. Strategy: Use the process of elimination, noting the strategic words indicates an understanding. Recalling that preventing tolerance is a concern will direct you to option 4. Review the concepts related to transdermal patches if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 842). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 583). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2573) The ambulatory care nurse is providing instructions to a client who has had a bone scan. The nurse should instruct the client to: a. Avoid eating or drinking for 24 hours. b. Ambulate vigorously several times for the next 2 days. c. Take a liquid laxative daily for the next 3 days. d. Increase fluid intake for the next 24 to 48 hours. Source: Saunders 4th

ANS: D Rationale: No special restrictions are necessary after a bone scan. The client should be encouraged to drink large amounts of water for 24 to 48 hours to facilitate urinary excretion of the radioisotope. Options 1, 2, and 3 are incorrect. Strategy: Use the process of elimination, reading each option carefully. Recalling that a radioisotope is used in this procedure will assist in directing you to option 4. Review postprocedure care of the client after a bone scan if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 282). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1995) A nursing student is caring for an older client with a diagnosis of benign prostatic hyperplasia (BPH). The nursing instructor asks the student to identify the clinical manifestations associated with this condition. The student needs to further research the condition if the student stated that which of the following was an early symptom of BPH? a. Nocturia b. Decreased force of urine stream c. Difficulty initiating urine stream d. Hematuria Source: Saunders 4th

ANS: D Rationale: Nocturia, decreased force of urinary stream, and difficulty initiating urinary stream are all early signs of benign prostatic hypertrophy. Hematuria is not an early sign of BPH. Strategy: Focus on the strategic words needs to further research and early. Use the process of elimination, noting that options 2 and 3 are comparative or alike in indicating an obstruction in urinary flow. Regarding the remaining options, focusing on these strategic words will direct you to option 4. If you had difficulty with this question or are unfamiliar with the early manifestations of this condition, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1016). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2104) A nurse is caring for a client with an intracranial pressure (ICP) monitoring device. The nurse would become most concerned if the ICP readings drifted to and stayed in the vicinity of: a. 5 mm Hg b. 8 mm Hg c. 14 mm Hg d. 22 mm Hg Source: Saunders 4th

ANS: D Rationale: Normal ICP readings range from 5 to 15 mm Hg pressure. Pressures greater than 20 mm Hg are considered to represent increased ICP, which seriously impairs cerebral perfusion. Strategy: Use the process of elimination. Because elevated ICP is a clinical concern (no one ever speaks of low ICP), then you should be able to eliminate at least the two lowest numbers. Regarding the remaining options, remembering that 15 mm Hg is the high end of normal will direct you to option 4. Review the normal ICP range if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2189). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

20) A nursing graduate is employed as a staff nurse in a local hospital. During orientation, the new graduate asks the nurse educator about the need to obtain professional liability insurance. The appropriate response by the nurse educator is: a. "It is very expensive and not necessary." b. "The hospital's liability insurance will cover your actions." c. "The majority of suits are filed against physicians and the hospital." d. "Nurses are encouraged to have their own professional liability insurance." Source: Saunders 4th

ANS: D Rationale: Nurses need their own professional liability insurance for protection against malpractice law suits. Nurses erroneously assume that they are protected by an agency's professional liability policies. Usually, when a nurse is sued, the employer also is sued for the nurse's actions or inactions. Even though this is the norm, nurses are encouraged to have their own professional liability insurance. Strategy: Note that the subject of the question relates to "obtaining professional liability insurance." This subject should direct you to option 4. Review liability related to malpractice insurance if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 418). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1050) The nurse is preparing to administer the first dose of omalizumab (Xolair) to a client. The nurse should have which of the following items available for possible use during the administration of this medication? a. Emesis basin b. Nasogastric tube c. Suction equipment d. Medications for severe anaphylactic reactions Source: Saunders 4th

ANS: D Rationale: Omalizumab is an anti-inflammatory used for long-term control of asthma. Anaphylactic reactions can occur with the administration of omalizumab. The nurse administering the medication should have medications for the treatment of severe hypersensitivity available. Options 1, 2, and 3 are unnecessary. Strategy: Use the process of elimination. Recall that anaphylactic reactions can occur with the administration of omalizumab and that omalizumab is not associated with gastric side effects or increased mucus production. Review this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2006). Mosby's 2006 nursing drug reference (p. 715). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

969) The client has a PRN order for ondansetron (Zofran). For which condition should the nurse administer this medication to the postoperative client? a. Paralytic ileus b. Incisional pain c. Urinary retention d. Nausea and vomiting Source: Saunders 4th

ANS: D Rationale: Ondansetron is an antiemetic used to treat postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy. The other options are incorrect. Strategy: Use the process of elimination. Recalling that this medication is an antiemetic will direct you to option 4. Review this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 869). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

990) A community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is: a. Dyspnea b. Chest pain c. A bloody, productive cough d. A cough with the expectoration of mucoid sputum Source: Saunders 4th

ANS: D Rationale: One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. Options 1, 2, and 3 are late symptoms and signify cavitation and extensive lung involvement. Strategy: Use the process of elimination and note the strategic word first in the question. This should direct you easily to option 4. If you are unfamiliar with the signs associated with tuberculosis, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 641). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

123) A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse next assesses the client to detect the presence of which of the following? a. Thirst b. Polyuria c. Decreased blood pressure d. Crackles on auscultation of the lungs Source: Saunders 4th

ANS: D Rationale: Optimal weight gain on PN is 1 to 2 lb/week. The client who has a weight gain of 5 lb/week while receiving PN is likely to have fluid retention that can result in hypervolemia. Signs of hypervolemia include increased blood pressure, crackles on lung auscultation, a bounding pulse, jugular vein distention, headache, and weight gain more than desired. Options 1 and 2 are associated with hyperglycemia. Option 3 is likely to be noted in deficient fluid volume. Strategy: Focus on the subject of the question, a weight gain of 5 lb in 1 week. This should direct your thinking to the potential for hypervolemia. With this in mind, use the process of elimination, selecting the option that identifies the signs of hypervolemia. If you had difficulty with this question, review the signs and symptoms of complications associated with the administration of PN. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., p. 1060). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1716) The client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? a. "An advantage of this technique is that change is likely to last." b. "This form of therapy can be applied to new situations." c. "Talking to oneself is a basic component of this form of therapy." d. "It provides a negative reinforcement when the stimulus is produced." Source: Saunders 4th

ANS: D Rationale: Option 4 describes aversion therapy. Options 1, 2, and 3 are characteristics of self-control therapy. Strategy: Use the process of elimination. Note the strategic words need for further teaching in the question. These words indicate a negative event query and ask you to select an option that is incorrect. Think about the subject, self-control. This subject should easily direct you to option 4. If you are unfamiliar with self-control therapy, review this content. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 29-30). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Teaching and Learning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1416) Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of the client's blood, the client begins to shout "You're all vampires. Let me out of here!" The appropriate nursing response is which of the following? a. "What makes you think that I am a vampire?" b. "I'll leave and come back later for your blood." c. "I am not going to hurt you; I am going to help you." d. "It must be frightening to think that others want to hurt you." Source: Saunders 4th

ANS: D Rationale: Option 4 helps the client focus on the emotion underlying the delusion but does not argue with it. Option 1 places the client in a position that requires a response. Option 2 avoids the client. Option 3 is an attempt to convince the client to believe another thought. This response may cause the client to hold the delusion more strongly. Strategy: Use the process of elimination and therapeutic communication techniques to answer the question. Option 4 is the only option that recognizes the client's needs and focuses on the client's feelings. Review therapeutic communication techniques if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 237). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-34). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 1018). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1433) The nurse is performing an admission assessment on a client and is attempting to obtain subjective data regarding the client's sexual and reproductive status. The client states, "I don't want to discuss this; it's private and personal." Which statement, if made by the nurse, indicates that the nurse is therapeutic? a. "I hate being asked these sorts of questions too." b. "I am a professional nurse, and as such I'll have you know that all information is kept confidential." c. "This is difficult for you to speak about, but I am trying to perform a complete assessment and I need this information." d. "I know that some of these questions are difficult for you, but as a professional nurse, I need to have complete information so I can provide the best care." Source: Saunders 4th

ANS: D Rationale: Option 4 is the only option that identifies a therapeutic response and keeps the focus on the client. In option 1, the nurse's feelings are the focus. This response clearly ignores the fact that the subject is about the client and the client's discomfort, not about the nurse. In option 2, the nurse becomes pompous and condescending, which is not therapeutic. In option 3, the nurse begins correctly with an empathic stance but then becomes demanding. Strategy: Use of the process of elimination and therapeutic communication techniques. This will direct you to option 4. Review therapeutic communication techniques if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 433). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-34, 553-554). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1494) A client comes to the clinic after losing all personal belongings in a hurricane. The nurse develops a nursing diagnosis of Coping, ineffective. Which of the following is the least realistic goal for this client? a. The client will develop adaptive coping patterns. b. The client will identify a realistic perception of stressors. c. The client will express and share feelings regarding the present crisis. d. The client will stop blaming himself or herself for the lack of insurance. Source: Saunders 4th

ANS: D Rationale: Options 1, 2, and 3 identify a positive movement toward increased self-esteem and problem solving. Option 4 places undue pressure on the client by implying that the client was negligent and contributed to the loss. Strategy: Use the process of elimination and note the strategic words least realistic. The words realistic, adaptive, and express and share feelings in options 1, 2, and 3, respectively, identify positive goals. This should assist in directing you to option 4. There is no data in the question that indicates that the client lacked insurance, as option 4 reflects. Review expected outcomes for the client who experienced a crisis if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 228). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 465). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2374) A client who has been diagnosed with pneumonia has been given a prescription for erythromycin. Client teaching about this medication should include which of the following? a. Take the medication with juice. b. Take the medication at bedtime with a snack. c. Take the medication with a meal. d. Take the medication on an empty stomach. Source: Saunders 4th

ANS: D Rationale: Oral erythromycin should be administered on an empty stomach with a full glass of water. Some preparations may be administered with food if gastrointestinal upset occurs, but it is best to administer on an empty stomach. Strategy: Use the process of elimination. Eliminate options 1, 2, and 3 because they are comparative or alike in that they all identify administering the medication with a food or fluid that must be digested. If you are unfamiliar with the administration of erythromycin, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 436). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1225) The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which of the following would the nurse expect to observe? a. A pink-colored tympanic membrane b. A pearly colored tympanic membrane c. A transparent and clear tympanic membrane d. A red, dull, thick and immobile tympanic membrane Source: Saunders 4th

ANS: D Rationale: Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane, with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head. Strategy: Knowledge regarding the pathophysiology associated with mastoiditis is required to answer this question. Remember that mastoiditis reveals a red, dull, thick, and immobile tympanic membrane. If you had difficulty with this question, review the assessment findings associated with this disorder. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1130-1131). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

942) The client with Crohn's disease has a nursing diagnosis of pain, acute. The nurse should teach the client to avoid which action in managing this problem? a. Massaging the abdomen b. Using relaxation techniques c. Using antispasmodic medication d. Lying supine with the legs straight Source: Saunders 4th

ANS: D Rationale: Pain associated with Crohn's disease is alleviated by the use of analgesics and antispasmodics and also by having the client practice relaxation techniques, applying local cold or heat to the abdomen, massaging the abdomen, and lying with the legs flexed. Lying with the legs extended is not useful because it increases the muscle tension in the abdomen, which could aggravate inflamed intestinal tissues as the abdominal muscles are stretched. Strategy: Note the strategic word avoid. This word indicates a negative event query and asks you to select an option that is an incorrect action. Use the process of elimination and use general knowledge of pain management strategies, application of cold or heat, and client positioning to answer this question. If this question was difficult, review pain management techniques for the client with Crohn's disease. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 870). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 818). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1187) A client newly diagnosed with renal failure has just been started on peritoneal dialysis. During the infusion of the dialysate, the client complains of abdominal pain. Which action by the nurse is appropriate? a. Stop the dialysis. b. Slow the infusion. c. Decrease the amount to be infused. d. Explain that the pain will subside after the first few exchanges. Source: Saunders 4th

ANS: D Rationale: Pain during the inflow of dialysate is common during the first few exchanges because of peritoneal irritation; however, the pain usually disappears after 1 to 2 weeks of treatment. The infusion amount should not be decreased, and the infusion should not be slowed or stopped. Strategy: Use the process of elimination. Eliminate options 1, 2, and 3 because they are comparative or alike actions. Review the complications associated with peritoneal dialysis and the appropriate nursing actions if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1758-1759). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2363) A client with acquired immunodeficiency syndrome (AIDS) experiences nausea, vomiting, and abdominal pain after taking didanosine (Videx). The ambulatory care nurse provides which of the following as telephone advice to this client? a. "Take crackers and milk with each dose of the medication." b. "Decrease the dose of the medication until the next clinic visit." c. "This is an uncomfortable but expected side effect of the medication." d. "Report to the health care clinic to be seen by the physician." Source: Saunders 4th

ANS: D Rationale: Pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the administration of didanosine. Clients should be monitored for indications of developing pancreatitis, which include increased serum amylase in association with increased serum triglycerides, decreased serum calcium, and nausea, vomiting, or abdominal pain. If evolving pancreatitis is diagnosed, the medication should be discontinued. The client should be seen by the health care physician. Strategy: Use the process of elimination, focusing on the client's complaints. Recalling that nausea, vomiting, and abdominal pain are signs of pancreatitis and that pancreatitis is associated with the use of this medication will direct you to the correct option. If you had difficulty with this question, review the adverse reactions related to this medication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 354). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2121) A client is admitted to the hospital emergency department with an acute anterior wall myocardial infarction. The nurse discusses streptokinase (Streptase) therapy with the client and spouse. The spouse is concerned about the dangers of this treatment. Which of the following statements by the nurse is appropriate? a. "Your loved one is very ill. The physician has made the best decision for you." b. "There is no reason to worry. We use this medication all the time." c. "I'm certain you made the correct decision to use this medication." d. "You have concerns about whether this treatment is the best option." Source: Saunders 4th

ANS: D Rationale: Paraphrasing is restating the client's or family member's own words. Option 1 represents a communication block that denies the person's right to an opinion. Option 2 is offering a false reassurance. In option 3, the nurse is expressing approval, which can be harmful to the client-nurse or family-nurse relationship. Strategy: Use therapeutic communication techniques. Option 4 is the only option that is therapeutic and addresses the client's feelings. Review therapeutic communication techniques if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 877). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 437). St. Louis: Mosby. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 797). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

903) The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? a. Bradycardia b. Numbness in the legs c. Nausea and vomiting d. A rigid, board-like abdomen Source: Saunders 4th

ANS: D Rationale: Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which becomes rigid and board-like. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding. Strategy: Use the process of elimination and note the strategic words most likely. Option 2 can be eliminated easily because it is not related to perforation. Eliminate option 1 next because tachycardia rather than bradycardia would develop if perforation occurs. From the remaining options, focusing on the strategic words will help direct you to option 4. Review the signs of a perforated ulcer if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 754). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2364) A client with acquired immunodeficiency syndrome (AIDS) is taking zalcitabine (Hivid). The ambulatory care nurse interprets that the client is experiencing an adverse effect of this medication if which of the following is reported by the client? a. Ringing in the ears b. Burning with urination c. Diarrhea d. Numbness or burning sensations in the arms or legs Source: Saunders 4th

ANS: D Rationale: Peripheral neuropathy is an adverse effect associated with the use of zalcitabine, which manifests initially as numbness and burning sensations in the extremities. It may progress to sharp shooting pains or severe continuous burning if the medication is not withdrawn. Pain of severe neuropathy requires opioid analgesics for control. Clients should be informed about the early symptoms of neuropathy and instructed to report them immediately. Neuropathic changes will reverse slowly if the medication is withdrawn early but may become irreversible if the medication is continued. The other options are not associated with use of this medication. Strategy: Use the process of elimination. Recalling that peripheral neuropathy is an adverse effect will direct you to the correct option. If you had difficulty with this question, review the adverse effects associated with this medication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1226). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2205) A nursing instructor teaches a group of nursing students about violence in the family. Which statement by a student indicates a need for further teaching? a. "Abusers usually have poor self-esteem." b. "Abusers use fear and intimidation." c. "Abusers often are jealous or self-centered." d. "Abuse occurs more often in low-income families." Source: Saunders 4th

ANS: D Rationale: Personal characteristics of abusers include low self-esteem, immaturity, dependence, insecurity, and jealousy. Abusers often will use fear and intimidation to the point at which their victims will do anything just to avoid further abuse. The statement that abuse occurs more often in lower socioeconomic groups is incorrect. Strategy: Use the process of elimination. Note the strategic words need for further teaching in the question. This phrasing indicates a negative event query and asks you to select an incorrect statement. Options 1, 2, and 3 are all true statements. If you had difficulty with this question, review the characteristics of abusers and family violence. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 509). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Teaching and Learning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1525) A client is scheduled for discharge and will be taking phenobarbital (Luminal) for an extended period of time. The nurse would place highest priority on teaching the client which of the following points that directly relates to client safety? a. Take the medication only with meals. b. Take medication at the same time each day. c. Use a dose container to help prevent missed doses. d. Avoid drinking alcohol while taking this medication. Source: Saunders 4th

ANS: D Rationale: Phenobarbital (Luminal) is an anticonvulsant and hypnotic agent. The client should avoid taking any other central nervous system depressants such as alcohol while taking this medication. The medication may be given without regard to meals. Taking the medication at the same time each day enhances compliance and maintains more stable blood levels of the medication. Using a dose container or "pillbox" may be helpful for some clients. Strategy: Use the process of elimination. Focus on the subject, client safety and note the strategic words highest priority. This tells you that more than one or all the options may be partially or totally correct and that you must prioritize your answer. Remember, alcohol should not be consumed when a hypnotic is taken. Review client teaching points related to this medication if you had difficulty with this question. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., pp. 309-310). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2521) A nursing student is assigned to care for a client with glaucoma for whom pilocarpine hydrochloride (Isopto Carpine) eye drops have been prescribed. The nursing instructor asks the student to describe the action of the eye medication. Which statement by the student indicates an understanding of the purpose of this medication? a. "The medication blocks responses that are sent to the brain that directs the actions of the muscles in the eye." b. "The medication dilates the eye to prevent increased pressure from occurring." c. "The medication prevents blurred vision by relaxing the muscles of the eyes." d. "The medication increases the blood flow to the retina and also will lower the pressure in the eye." Source: Saunders 4th

ANS: D Rationale: Pilocarpine hydrochloride is a miotic that is used to lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork. Options 1, 2, and 3 are incorrect. Strategy: Read the question carefully and note that it states that the client has glaucoma. This should provide you with the clue that will direct you to the correct option. Prevention of increased intraocular pressure is the goal in clients with glaucoma. Options 1, 2 and 3 all describe actions related to mydriatic medications, which primarily dilate the pupils and relax the ciliary muscles. Review the action of pilocarpine hydrochloride if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 1195). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

158) A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which of the following? a. Increased hematocrit level b. Increased hemoglobin level c. Decline of elevated temperature to normal d. Decreased oozing of blood from puncture sites and gums Source: Saunders 4th

ANS: D Rationale: Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of red blood cells. An elevated temperature would decline to normal after infusion of granulocytes if those cells were instrumental in fighting infection in the body. Strategy: Use the process of elimination and knowledge regarding the potential uses and benefits of the various types of blood product transfusions. Eliminate options 1 and 2 first because they are comparative or alike. From the remaining options, recalling that platelets are necessary for proper blood clotting will direct you to option 4. If this question was difficult, review the types of blood products available for transfusion. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 915). Philadelphia: W.B. Saunders. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., p. 971). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

989) A nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which of the following positions will the nurse instruct the client to assume? a. Sitting up in bed b. Side-lying in bed c. Sitting in a recliner chair d. Sitting on the side of the bed and leaning on an overbed table Source: Saunders 4th

ANS: D Rationale: Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall. Strategy: Use the process of elimination. Eliminate options 1 and 3 first because they are comparative or alike. Next, eliminate option 2 because this position will not enhance breathing. If you had difficulty with this question, review the positions that will decrease the work of breathing in a client with emphysema. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 597). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 675). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

51) A nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium? a. Obtaining a controlled IV infusion pump b. Monitoring urine output during administration c. Diluting in appropriate amount of normal saline d. Preparing the medication for bolus administration Source: Saunders 4th

ANS: D Rationale: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via a pump or controller. The usual concentration of IV potassium chloride is 20 to 40 mEq/L. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is recommended, but dextrose solution is avoided because this type of solution increases intracellular potassium shifting. The IV bag containing the potassium chloride is always gently agitated before hanging. The IV site is monitored closely because potassium chloride is irritating to the veins and the risk of phlebitis exists. The nurse monitors urinary output during administration and contacts the physician if the urinary output is less than 30 mL/hr. Strategy: Use the process of elimination and knowledge regarding the administration of potassium chloride intravenously. Noting the strategic word unprepared in the question and bolus in option 4 will direct you to the correct option. Review the administration of potassium chloride if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 intravenous medications (22nd ed., p. 1022). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2381) A client who began medication therapy with prazosin hydrochloride (Minipress) 1 week earlier arrives at the health care clinic for follow-up evaluation and care. The nurse interprets that the client is experiencing the expected benefit of therapy if which of the following is noted? a. Increased pulse b. Increased platelet count c. Decreased blood glucose level d. Decreased blood pressure Source: Saunders 4th

ANS: D Rationale: Prazosin hydrochloride is antihypertensive medication used to treat high blood pressure. A decrease in blood pressure indicates a therapeutic effect from the medication. The items listed in options 1, 2, and 3 are unrelated to the use of this medication. Strategy: Note the name of this medication, Minipress. This should guide you to option 4, the action of lowering blood pressure. If you had difficulty with this question, review the action and use of this medication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 437). Philadelphia: W.B. Saunders, p. 954. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1366) Alendronate (Fosamax) is prescribed for a client with osteoporosis. The nurse instructs the client to: a. Take the medication at bedtime. b. Take the medication in the morning with breakfast. c. Lie down for 30 minutes after taking the medication. d. Take the medication with a full glass of water after rising in the morning. Source: Saunders 4th

ANS: D Rationale: Precautions need to be taken with the administration of alendronate to prevent gastrointestinal side effects (especially esophageal irritation) and to increase absorption of the medication. The medication needs to be taken with a full glass of water after rising in the morning. The client should not eat or drink anything for 30 minutes following administration and should not lie down after taking the medication. Strategy: Knowledge regarding the administration of alendronate is needed to answer this question. Recalling that this medication can cause esophageal irritation will direct you to option 4. Review this medication if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1167). St. Louis: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1711). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2168) A nurse has an order to administer phenytoin (Dilantin) 100 mg by the intravenous (IV) route to a client. The nurse administers the medication after preparing it in: a. 5% dextrose in 0.45% normal saline b. Lactated Ringer's solution c. 5% dextrose in water with an in-line filter d. 0.9% (normal) saline with an in-line filter Source: Saunders 4th

ANS: D Rationale: Precipitation will occur if phenytoin is mixed with any solution other than 0.9% (normal) saline. This is especially true with solutions containing dextrose. An in-line filter reduces the chance of precipitants entering the bloodstream. Phenytoin is very irritating to the vein wall or other tissues. Strategy: A very important concept related to IV phenytoin (Dilantin) administration is that the medication can be mixed only in 0.9% saline. Remembering this principle will direct you to option 4. Review the procedure for administering phenytoin by the IV route if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 993). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1090) A client is having frequent premature ventricular contractions. A nurse would place priority on assessment of which of the following? a. Sensation of palpitations b. Causative factors, such as caffeine c. Precipitating factors, such as infection d. Blood pressure and oxygen saturation Source: Saunders 4th

ANS: D Rationale: Premature ventricular contractions can cause hemodynamic compromise. The shortened ventricular filling time with the ectopic beat leads to decreased stroke volume and, if frequent enough, to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders, states of hypoxemia or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by intake of caffeine, nicotine, or alcohol. Strategy: Note the strategic words priority on assessment. Use the ABCs—airway, breathing, and circulation—to direct you to option 4. Review the effects of premature ventricular contractions if you had difficulty with this question. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., p. 681). St. Louis: Mosby. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 729). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

1246) The nurse notes that the physician has documented a diagnosis of presbycusis on the client's chart. The nurse plans care knowing that the condition is: a. Tinnitus that occurs with aging b. Nystagmus that occurs with aging c. A conductive hearing loss that occurs with aging d. A sensorineural hearing loss that occurs with aging Source: Saunders 4th

ANS: D Rationale: Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. Options 1, 2, and 3 are incorrect. Strategy: Knowledge regarding the description of presbycusis is required to answer this question. Remember that presbycusis is a gradual sensorineural loss. If you are unfamiliar with this condition, review this age-related disorder. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1134). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

1774) The nurse is preparing to care for a client following a gastroscopy procedure. The nurse includes which appropriate component in the nursing care plan? a. Place the client in a supine position to provide comfort. b. Monitor the client's vital signs every hour for 4 hours. c. Provide saline gargles immediately upon return to the unit to aid in comfort. d. Check the gag reflex by using tongue depressor to stroke the back of client's throat. Source: Saunders 4th

ANS: D Rationale: Prior to the gastroscopy procedure, medication is given to prevent a gag reflex. On return from the procedure, the nurse must test the client's gag reflex to ensure that it is present to prevent aspiration of contents. The client must be placed in a side-lying or semi-Fowler's position to avoid aspiration. Vital signs should be taken every 30 minutes for 2 hours to detect abnormalities. Saline gargles must only be administered when the gag reflex has been confirmed. Strategy: Use of the ABCs—airway, breathing, and circulation—will assist in answering the question. Option 4 is the only option that addresses the airway. If you had difficulty with this question, review the care of the client following a gastroscopy procedure. Reference: Chernecky, C., & Berger, B. (2001). Laboratory tests and diagnostic procedures (3rd ed., p. 590). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2677) A nurse has administered prochlorperazine (Compazine) to a client for relief of nausea and vomiting. The nurse then assesses this client for which frequent side effect of this medication? a. Diarrhea b. Drooling c. Excessive tearing d. Blurred vision Source: Saunders 4th

ANS: D Rationale: Prochlorperazine is a phenothiazine-type antiemetic and antipsychotic agent. A frequent side effect is blurred vision. Other frequent side effects of this medication are dry eyes, dry mouth, and constipation. Strategy: Recalling that this medication is a phenothiazine-type antiemetic and recalling its side effects will direct you to option 4. If you are unfamiliar with the side effects of this medication, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 969). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

959) The client is receiving propantheline bromide (Pro-Banthine) as adjunctive treatment for peptic ulcer disease. How should the nurse administer this medication? a. With meals b. With antacids c. Just after meals d. 30 minutes before meals Source: Saunders 4th

ANS: D Rationale: Propantheline bromide is an antimuscarinic anticholinergic medication that decreases gastrointestinal secretions. Propantheline should be administered 30 minutes before meals. The other options are incorrect. Strategy: Use the process of elimination. Option 2 could be eliminated first because most medications cannot be administered with antacids as a result of interactive effects. Next, eliminate options 1 and 3 because they are comparative or alike. Review this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2007). Mosby's 2007 nursing drug reference (20th ed., p. 844). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2666) A client with peptic ulcer disease who has been given a prescription for propantheline (Pro-Banthine) asks the nurse how to take the medication. The nurse explains that this medication should be taken: a. With meals b. Just after meals c. With antacids d. 30 minutes before meals Source: Saunders 4th

ANS: D Rationale: Propantheline decreases gastrointestinal (GI) secretions because it is an antimuscarinic anticholinergic medication. It should be administered 30 minutes before meals. The other options are incorrect. Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are comparative or alike. Eliminate option 3 next because most medications cannot be administered with antacids because of the potential for interactive effects. If the medication is unfamiliar to you, review the client teaching points regarding administration. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 726). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2076) An older client with cystitis has an indwelling urinary catheter. A nurse observing a nursing assistant care for the client would intervene if the nursing assistant: a. Used soap and water to cleanse the perineal area b. Kept the drainage bag below the level of the bladder c. Used the drainage tubing port to obtain urine samples d. Allowed the drainage tubing to rest under the leg Source: Saunders 4th

ANS: D Rationale: Proper care of an indwelling urinary catheter is especially important to prevent prolonged infection or reinfection in the client with cystitis. The nurse and all caregivers must use strict aseptic technique when emptying the drainage bag or obtaining urine specimens. The perineal area is cleansed thoroughly using mild soap and water at least twice a day and following a bowel movement. The drainage bag is kept below the level of the bladder to prevent urine from being trapped in the bladder, and for the same reason, the drainage tubing is not placed under the client's leg. The tubing must drain freely at all times. Strategy: Use the process of elimination. Note the strategic words would intervene. This phrasing indicates a negative event query and directs you to select an incorrect action. Eliminate option 1 first, because this constitutes a basic standard of care for the client with an indwelling catheter. Option 3 also is consistent with principles of asepsis and is eliminated next. Regarding the remaining options, note that option 2 promotes drainage, whereas option 4 could impede drainage. Review care of the client with an indwelling urinary catheter if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1358). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2210) A client with peptic ulcer disease states that stress frequently causes exacerbation of the disease. The nurse determines that which of the following items mentioned by the client is most likely to be responsible for the exacerbations? a. Sleeping 8 to 10 hours a night b. Eating five or six small meals per day c. Ability to work at home periodically d. Frequent need to work overtime on short notice Source: Saunders 4th

ANS: D Rationale: Psychological or emotional stressors that exacerbate peptic ulcer disease may be found either at home or in the workplace. The frequent need to work overtime on short notice is the item that is potentially most stressful, because it is the item over which the client has the least control. An ability to work at home periodically is not necessarily stressful because it allows increased client control over timing and location of work. Adequate rest and proper dietary pattern (options 1 and 2) should alleviate symptoms, not worsen them. Strategy: Use the process of elimination. Begin to answer this question by eliminating options 1 and 2 because they are healthy living habits. Recall that psychological stress may be worsened in situations characterized by little client control. This would help you to choose option 4 as the correct answer. Review care of the client with peptic ulcer disease if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 755). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1305). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

996) A nurse instructs a client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: a. Promote oxygen intake. b. Strengthen the diaphragm. c. Strengthen the intercostal muscles. d. Promote carbon dioxide elimination. Source: Saunders 4th

ANS: D Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing. Strategy: Visualize the use of this procedure to assist you in answering correctly. Knowledge regarding the respiratory conditions in which this type of breathing is helpful also will assist in directing you to option 4. Review the purpose of this breathing technique, if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 557, 672). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1130). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2181) A client with myasthenia gravis has difficulty chewing and has received a prescription for pyridostigmine (Mestinon). The nurse plans to check to see that the client takes the medication: a. Just after meals b. Between meals c. With meals d. 30 minutes before meals Source: Saunders 4th

ANS: D Rationale: Pyridostigmine is a cholinergic medication used to increase muscle strength in the client with myasthenia gravis. For the client who has difficulty chewing, the medication should be administered 30 minutes before meals to enhance the client's ability to eat. Strategy: Focus on the subject, the client's difficulty with chewing. Knowing that the medication increases muscle strength will direct you to option 4. Review the administration of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 990). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2126) A client is experiencing impotence after taking guanfacine (Tenex). The client states, "I would sooner have a stroke than keep living with the side effects of this medication." The appropriate response by the nurse is: a. "I can understand completely." b. "That doctor should change your prescription." c. "You wouldn't really want to have a stroke." d. "You are concerned about the side effects of your medication." Source: Saunders 4th

ANS: D Rationale: Reflection of the client's own comment lets the client know that the nurse hears the concern without judging. The nurse cannot understand what the client is experiencing. Option 3 is confrontational and unsupportive. Strategy: Use therapeutic communication techniques when responding to the client. Select nonjudgmental responses that reflect the fact that the nurse is listening to the client's concerns. Review therapeutic communication techniques if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 646). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 178). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 437). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1280) The nurse is evaluating the neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? a. Hyperreflexia b. Positive reflexes c. Reflex emptying of the bladder d. Inability to elicit a Babinski's reflex Source: Saunders 4th

ANS: D Rationale: Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a positive Babinski's reflex. Strategy: Recall that spinal shock is characterized by the loss of movement of skeletal muscles, bowel or bladder wall, and depressed reflex action. Return of any of these indicates that spinal shock is beginning to resolve. Note that options 1, 2, and 3 are comparative or alike, indicating the presence of reflexes. Review signs of spinal shock if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2215, 2218). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1419) A client with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The therapeutic response to the client is: a. "I don't see you as a failure." b. "You have everything to live for." c. "Feeling like this is all part of being ill." d. "You've been feeling like a failure for a while?" Source: Saunders 4th

ANS: D Rationale: Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. Options 1, 2, and 3 block communication because they minimize the client's experience and do not facilitate exploration of the client's expressed feelings. Strategy: Use the process of elimination and therapeutic communication techniques to direct you to the option that directly addresses the client's feelings and concerns. Also, option 4 is the only option stated in the form of a question and is open-ended; thus, it will encourage the verbalization of feelings. Review therapeutic communication techniques if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 125-126, 566). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-34). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1892) The postpartum nurse is caring for a woman who just delivered a healthy newborn. The nurse should be most concerned with the presence of subinvolution if which of the following occurs? a. Increased estrogen and progesterone levels as noted on laboratory analysis b. An oral temperature of 99.0° F following delivery c. The presence of afterpains d. Retained placental fragments from delivery Source: Saunders 4th

ANS: D Rationale: Retained placental fragments and infections are the primary causes of subinvolution. When either of these processes is present, the uterus will have difficulty contracting. An oral temperature of 99.0° F after delivery and the presence of afterpains are expected findings following delivery. Option 1 is not a cause of subinvolution and is unrelated to the subject of the question. Strategy: Note the strategic words most concerned in the question. Eliminate options 2 and 3 first because these are expected findings after delivery. Regarding the remaining options, focus on the anatomical location of the disorder. This will assist in directing you to option 4. If you had difficulty with this question, review the causes of subinvolution. Reference: Wong, D., Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2006). Maternal child nursing care (3rd ed., p. 590). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

1015) A nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which of the following? a. Slow deep respirations b. Rapid deep respirations c. Paradoxical respirations d. Pain, especially with inspiration Source: Saunders 4th

ANS: D Rationale: Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site and exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest. Strategy: Use the process of elimination. Focusing on the anatomical location of the injury will direct you to option 4. Review the assessment findings in rib fractures if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1901). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1969) A clinic nurse has conducted a health screening clinic to identify female clients at risk for developing cervical cancer. The nurse is reviewing the assessment findings in the records of the clients who attended the clinic. Which client is at the lowest risk for developing this type of cancer? a. A client who had early, frequent intercourse with multiple sexual partners b. A multiparity client c. A client with a history of chronic cervicitis d. A single White client Source: Saunders 4th

ANS: D Rationale: Risk factors associated with cervical cancer include early, frequent intercourse with multiple sexual partners, multiparity, chronic cervicitis, and a history of genital herpes or human papilloma. Cervical cancer also occurs with higher frequency in the black race. Regarding the options provided, the single white client is at lowest risk for the development of cervical cancer. Strategy: Use the process of elimination and knowledge regarding the risk factors associated with cervical cancer to answer this question. Focus on the strategic words lowest risk. This will direct you to option 4. If you had difficulty with this question, review the risks associated with cervical cancer. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1072). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

1334) A nurse is conducting health screening for osteoporosis. Which of the following clients is at greatest risk of developing this disorder? a. A 25-year-old woman who jogs b. A 36-year-old man who has asthma c. A 70-year-old man who consumes excess alcohol d. A sedentary 65-year-old woman who smokes cigarettes Source: Saunders 4th

ANS: D Rationale: Risk factors for osteoporosis include female gender, postmenopausal, advanced age, low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids, anticonvulsants, and/or furosemide (Lasix) also increases risk. Strategy: Use the process of elimination. Eliminate option 1 first. The 25-year-old woman who jogs (exercises using the long bones) has negligible risk. The 36-year-old man with asthma is eliminated next because his only risk factor might be long-term corticosteroid use. Of the two remaining options, the 65-year-old woman has higher risk (age, gender, postmenopausal, sedentary, smoking) than the 70-year-old man (age, alcohol consumption). Review the risk factors associated with osteoporosis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1158). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1529) The nurse is administering risperidone (Risperdal) to a client who is scheduled to be discharged. Prior to discharge, which of the following should the nurse teach the client? a. Get adequate sunlight. b. Avoid foods rich in potassium. c. Continue driving as usual. d. Get up slowly when changing positions. Source: Saunders 4th

ANS: D Rationale: Risperidone (Risperdal) can cause orthostatic hypotension. Sunlight should be avoided by the client taking this medication. Food interaction is not a concern. With any psychotropic medication, caution needs to be taken until the individual can determine whether his or her level of alertness is affected. Strategy: Knowledge regarding the nursing considerations related to the administration of risperidone is required to answer this question. Remember that risperidone can cause orthostatic hypotension. Review this medication if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 465). St. Louis: Mosby. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., p. 132). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1572) A pregnant woman in her second trimester calls the prenatal clinic nurse to report a recent exposure to a child with rubella. Which of the following responses by the nurse would be appropriate and supportive to the woman? a. "There is no need to be concerned if you don't have a fever or rash within the next 2 days." b. "Be sure to tell the doctor on your next prenatal visit, but there is little risk in the second trimester." c. "You should avoid all school-age children during pregnancy." d. "You were wise to call. I will check your rubella titer screening results and we can immediately identify if future interventions are needed." Source: Saunders 4th

ANS: D Rationale: Rubella virus is spread by aerosol droplet transmission through the upper respiratory tract and has an incubation period of 14 to 21 days. The risks of maternal and subsequent fetal infection during the second trimester include hearing loss and congenital anomalies. Rubella titer determination is a standard antenatal test for childbearing women during their initial screening and entry into the health care delivery system. Option 4 helps clarify maternal concerns with accurate information based on the acquisition of rubella infection and potential fetal side effects. Strategy: Use the process of elimination and knowledge regarding the transmission of rubella virus to the fetus. Also, use of therapeutic communication techniques will direct you to option 4. Option 4 addresses the client's concerns. Review concepts related to exposure to rubella during pregnancy if you had difficulty with this question. Reference: Lowdermilk, D., & Perry, A. (2004). Maternity and woman's health care (8th ed., pp. 210, 212). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

2142) A nurse is caring for an older client who had a hip pinned after being fractured. Which of the following should the nurse avoid to minimize the chance for further injury? a. Side rails in the up position b. Use of a nightlight in the hospital room and bathroom c. Call bell placed within reach d. Delays in responding to the call light Source: Saunders 4th

ANS: D Rationale: Safe nursing actions intended to prevent injury to the client include keeping side rails up, bed in low position, and providing a call bell that is within the client's reach. Responding promptly to the client's use of the call light minimizes the chance that the client will try to get up alone, which could result in a fall. Strategy: Use the process of elimination. Note the strategic word avoid. This indicates a negative event query and asks you to select the unsafe action. Because options 1 and 3 (side rails up and call bell in reach) are standard nursing actions, they are eliminated. Use of a nightlight would help prevent falls, so this option can be eliminated. Review basic nursing actions to prevent injury if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 642-643). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1215). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1960) A nurse is providing instructions to the client with psoriasis who will be receiving ultraviolet light (UVL) therapy. Which the following statements would be appropriate for the nurse to include in the instructions for this client? a. "Each treatment will last at least 30 minutes." b. "Your entire body will be exposed to the light treatment." c. "You will need to wear cotton clothes during the treatment." d. "You will need to wear eye goggles during the treatment." Source: Saunders 4th

ANS: D Rationale: Safety precautions are required during UVL therapy. Most UVL therapies require the person to stand in a light treatment chamber for up to a maximum of 15 minutes. The client will not wear clothing on the body parts to be exposed and will expose only those areas requiring treatment to the UVL. Protective goggles are required to prevent exposure of the eyes to the UVL. The face also is shielded with a loosely applied cloth if it is unaffected by the psoriasis. Direct contact with the light bulbs for the treatment should be avoided, to prevent burning of the skin. Strategy: Use the process of elimination. Think about the safety measures involved with exposure to UVL and the purpose of the treatment. This will direct you to option 4. If you had difficulty with this question, review client teaching for UVL treatment. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1605). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

2067) A client with a diagnosis of varicose veins is scheduled for treatment by sclerotherapy and asks the nurse to describe the procedure. The appropriate nursing response is which of the following? a. "It involves tying off the veins to prevent sluggishness of blood from occurring." b. "It involves tying off the veins so that circulation is redirected in another area." c. "It involves surgically removing the varicosity, so anesthesia will be required." d. "It involves injecting an agent into the vein to damage the vein wall and close it off." Source: Saunders 4th

ANS: D Rationale: Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damages the vessel and causes aseptic thrombosis that results in vein closure. With no blood flow through the vessel, distention will not occur. The surgical procedure for varicose veins is vein ligation and stripping. This procedure involves tying off the varicose vein and large tributaries and then removal of the vein with the use of a hook and wires applied through multiple small incisions in the leg. Strategy: Use the process of elimination, focusing on the name of the treatment. Recalling that a vessel that is sclerosed is blocked will assist in directing you to option 4. If you had difficulty with this question, review this procedure. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 818). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1104) A client seeks treatment in a physician's office for unsightly varicose veins, and sclerotherapy is recommended. Before leaving the examining room, the client says to the nurse, "Can you tell me again how this sclerotherapy is done?" Which of the following statements would reflect accurate teaching by the nurse? a. "The varicosity is surgically removed." b. "The vein is tied off at the upper end to prevent stasis from occurring." c. "The vein is tied off at the lower end to prevent stasis from occurring." d. "An agent is injected into the vein to damage the vein wall and close the vein off." Source: Saunders 4th

ANS: D Rationale: Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damages the vessel and causes aseptic thrombosis, which results in vein closure. With no blood flow through the vessel, there is no distention. The surgical procedure for varicose veins is vein ligation and stripping. This procedure involves tying off the varicose vein and large tributaries and then removing the vein with hook and wires via multiple small incisions in the leg. Strategy: Use the process of elimination and note the name of the procedure, sclerotherapy. A vessel that is sclerosed is blocked. This will direct you to option 4. Review this procedure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 818). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1782) A client who has a gastrostomy tube for feeding refuses to participate in the plan of care, will not make eye contact, and does not speak to the family or visitors. The nurse assesses that this client is using which type of coping mechanism? a. Self-control b. Problem-solving c. Accepting responsibility d. Distancing Source: Saunders 4th

ANS: D Rationale: Self-control is demonstrated by stoicism and hiding feelings. Problem solving involves making plans and verbalizing what will be done. Accepting responsibility places the responsibility for a situation on one's self. Distancing is an unwillingness or inability to discuss events. Strategy: Note the strategic words refuses, will not, and does not. These words indicate ineffective coping. Option 4, distancing, is the one option that is indicative of ineffective coping. If you had difficulty with this question, review coping mechanisms. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 73, 526). Philadelphia: W.B. Saunders. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 292-293). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 437). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1492) The nurse has been working with a victim of rape in a clinic setting for the past 4 weeks. Which of the following is unrealistic as a short-term initial goal? a. Physical wounds will heal. b. The client will participate in the treatment plan. c. The client will verbalize feelings about the event. d. The client will resolve feelings of fear and anxiety related to the rape trauma. Source: Saunders 4th

ANS: D Rationale: Short-term goals include the beginning stages of dealing with the rape trauma. Clients will be expected initially to keep appointments, participate in care, begin to explore feelings, and begin to heal any physical wounds that were inflicted at the time of the rape. Strategy: Use the process of elimination and note the strategic words unrealistic and short-term initial goal. Use the process of elimination, considering each option and the reality of the option statement being achieved short term. Note the word resolve in option 4. This word should provide you with the clue that this option is a long-term goal. Review expected outcomes in the plan of care for the client who has been raped if you had difficulty with this question. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 533-534). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1330) Meperidine hydrochloride (Demerol) is prescribed for the client with pain. For which of the following would the nurse monitor as a side effect of this medication? a. Diarrhea b. Bradycardia c. Hypertension d. Urinary retention Source: Saunders 4th

ANS: D Rationale: Side effects of meperidine (Demerol) include respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urinary retention. Strategy: Use the process of elimination. Remember that a side effect of meperidine is urinary retention. Review the side effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 735). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 531). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2178) A client with Parkinson's disease has begun therapy with levodopa (Dopar). The nurse determines that the client understands the action of the medication if the client verbalizes that results may not be apparent for: a. 24 hours b. 2 to 3 days c. 1 week d. 2 to 3 weeks Source: Saunders 4th

ANS: D Rationale: Signs and symptoms of Parkinson's disease usually begin to resolve within 2 to 3 weeks of starting therapy, although in some clients marked improvement may not be seen for up to 6 months. The client needs to understand this concept to aid in compliance with medication therapy. Strategy: To answer this question accurately, you need to know when this medication begins to produce the expected effects. Remember that this effect takes approximately 2 to 3 weeks. Review the actions and effects of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 491). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1127) A client is being treated with procainamide (Procanbid) for a cardiac dysrhythmia. Following intravenous administration of the medication, the client complains of dizziness. What intervention should the nurse take first? a. Administer ordered nitroglycerin tablets. b. Measure the heart rate on the rhythm strip. c. Obtain a 12-lead electrocardiogram immediately. d. Auscultate the client's apical pulse and obtain a blood pressure. Source: Saunders 4th

ANS: D Rationale: Signs of toxicity from procainamide include confusion, dizziness, drowsiness, decreased urination, nausea, vomiting, and tachydysrhythmias. If the client complains of dizziness, the nurse should assess the vital signs first. Although options 2 and 3 may be interventions, these would be done after the vital signs are taken. Nitroglycerin is a vasodilator and will lower the blood pressure. Strategy: Use the steps of the nursing process to eliminate options 1 and 3. From the remaining options, remember always to assess the client first, not the monitoring devices. Therefore, option 4 is correct. Review the signs of toxicity and the nursing interventions if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 intravenous medications (22nd ed., p. 1030). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2683) A client rings the call bell and asks for medication to relieve postoperative gas pains. The nurse selects which of the following medications to be given as ordered on the medication sheet? a. Magnesium hydroxide (MOM) b. Droperidol (Inapsine) c. Acetaminophen (Tylenol) d. Simethicone (Mylicon) Source: Saunders 4th

ANS: D Rationale: Simethicone is an antiflatulent used in the relief of pain due to excessive gas in the gastrointestinal (GI) tract. Magnesium hydroxide is an antacid and laxative, and droperidol relieves postoperative nausea and vomiting. Acetaminophen is a non-opioid analgesic. Strategy: Use the process of elimination, noting the strategic words postoperative gas pains. Recall the actions for each of the listed medications to direct you to option 4. If this question was difficult for you, review the actions and uses of the medications listed in the options. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 783). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1384) A client is suspected of having systemic lupus erythematous. The nurse monitors the client, knowing that which of the following is one of the initial characteristic signs of systemic lupus erythematous? a. Weight gain b. Subnormal temperature c. Elevated red blood cell count d. Rash on the face across the bridge of the nose and on the cheeks Source: Saunders 4th

ANS: D Rationale: Skin lesions or rash on the face across the bridge of the nose and on the cheeks is an initial characteristic sign of systemic lupus erythematosus (SLE). Fever and weight loss may also occur. Anemia is most likely to occur later in SLE. Strategy: Use the process of elimination and note the strategic words characteristic signs. Recalling the characteristic butterfly rash associated with SLE will direct you to option 4. If you are unfamiliar with this disorder, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2354). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 410). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

2393) A client admitted with hypertensive crisis has an intravenous (IV) infusion of 1000 mL of normal saline with 20 mEq of potassium chloride added. An order is written to administer sodium nitroprusside by continuous IV infusion. The nurse should plan to do which of the following to administer this medication? a. Check the solution for a faint brown coloration and discard it if this is noticed. b. Monitor the blood pressure every 15 minutes during administration. c. Piggyback the sodium nitroprusside into the IV line containing the potassium chloride. d. Protect the sodium nitroprusside from light with an opaque material. Source: Saunders 4th

ANS: D Rationale: Sodium nitroprusside can be degraded by light and should be protected with an opaque material. It is dispensed in powdered form and must be dissolved and diluted for the IV solution. A fresh solution may have a faint brown coloration, but solutions that are deeply colored, such as blue green or dark red, should be discarded. No other medication should be mixed with the infusion solution. During the infusion, the blood pressure should be monitored continuously either through an arterial line or with an electronic monitoring device. Strategy: Use the process of elimination. Remember that this medication needs to be protected from light. If you had difficulty with this question, review the preparation and administration of this medication. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 902). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2059) A male client arrives in the hospital emergency department and tells the nurse that he twisted his ankle while jogging. The client is seen by the physician and is diagnosed with a sprained ankle. The nurse provides instructions to the client regarding home care for the injury. Which statement if made by the client would indicate an understanding of appropriate care measures for the next 24 hours? a. "I should place hot packs on my ankle." b. "I should wrap my ankle with blankets." c. "I should try to ambulate at least 10 minutes out of every hour." d. "I should elevate my foot above the level of the heart." Source: Saunders 4th

ANS: D Rationale: Soft tissue injuries such as sprains are treated with RICE (rest, ice, compression, and elevation) for the first 24 to 48 hours after the injury, depending on physician prescription. Ice is applied intermittently for 20 to 30 minutes at a time. The client should rest and not walk around, and the foot should be elevated and not placed in a dependent position. Heat is not used for the first 24 hours because this could cause venous congestion, thereby increasing edema and pain. Blankets would produce heat to the affected area. Strategy: Use the process of elimination. Recalling that ice is applied to an injury for the first 24 hours will assist in eliminating options 1 and 2. Additionally, these options are comparative or alike. Regarding the remaining options, recalling the general rule that "when an injury occurs, edema follows" will assist in directing you to option 4. Review the measures related to a sprained ankle if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1226). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1476) The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal. Which of the following would alert the nurse to the potential for withdrawal delirium? a. Hypotension, ataxia, hunger b. Stupor, agitation, muscular rigidity c. Hypotension, coarse hand tremors, agitation d. Hypertension, changes in level of consciousness, hallucinations Source: Saunders 4th

ANS: D Rationale: Some of the symptoms associated with withdrawal delirium typically are anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions. Strategy: Use the process of elimination. Review each option carefully to ensure that all the symptoms in the option are correct. Eliminate options 1 and 3 first, knowing that hypertension rather than hypotension occurs. From the remaining options, recalling that the client who is stuporous is not likely to exhibit withdrawal delirium will direct you to option 4. Review these symptoms if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 317-318). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1894) A nurse in the prenatal clinic is providing nutritional counseling to a pregnant client. The nurse instructs the client to increase the intake of folic acid and tells the client that which of the following food items is highest in folic acid? a. Chicken b. Pork c. Cheese d. Green leafy vegetables Source: Saunders 4th

ANS: D Rationale: Sources of folic acid include green leafy vegetables, whole grains, fruits, liver, dried peas, and beans. Chicken, rice, and cheese are not high in folic acid. Cheese is a dairy product and is high in calcium. Chicken is a good source of protein. Pork is a good source of thiamine. Strategy: Use the process of elimination. Recalling that green leafy vegetables are high in folic acid will assist in directing you to option 4. If you had difficulty with this question and are unfamiliar with the food items highest in folic acid, review this content. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 180). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

2391) A client with hypertension has begun taking spironolactone (Aldactone). The ambulatory care nurse teaches the client to limit intake of which of the following foods? a. Rice b. Salad c. Oatmeal d. Citrus fruits Source: Saunders 4th

ANS: D Rationale: Spironolactone is a potassium-sparing diuretic that causes hyperkalemia as the principal adverse effect. Clients are instructed to restrict their intake of potassium-rich foods, such as citrus fruits and bananas. The other foods listed are appropriate to include in the diet. Strategy: Note the strategic word limit in the question. Recalling that spironolactone is potassium-sparing diuretic and knowing which foods are high in potassium will direct you to option 4. If you are unfamiliar with the adverse effects of this medication and the foods with high and low potassium content, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1076). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2446) A nurse is monitoring a client with a Sengstaken-Blakemore tube. The client complains of severe pain of abrupt onset. Which of the following nursing actions is appropriate? a. Administer the prescribed analgesics. b. Reposition the client. c. Assess the lumens of the tubes. d. Cut the tube. Source: Saunders 4th

ANS: D Rationale: Spontaneous rupture of the gastric balloon, upward migration of the tube, and occlusion of the airway are possible complications associated with a Sengstaken-Blakemore tube. Esophageal rupture also may occur and is characterized by the abrupt onset of severe pain. In the event of either of these life-threatening emergencies, the tube is cut and removed. Strategy: Use the process of elimination, noting the strategic words abrupt onset and severe pain. Recalling the complications associated with a Sengstaken-Blakemore tube will direct you to option 4. If you had difficulty with this question, review nursing interventions and the complications that can occur with this type of tube. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1345). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1378-1379). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2296) A client with a neurological problem has a nursing diagnosis of hyperthermia. Which of the following measures would be least appropriate for the nurse to use in trying to lower the client's body temperature? a. Giving tepid sponge baths b. Administering acetaminophen (Tylenol) per protocol c. Applying a hypothermia blanket d. Placing ice packs in the axilla and groin areas Source: Saunders 4th

ANS: D Rationale: Standard measures to lower body temperature include removing bed covers, providing cool sponge baths, using an electric fan in the room, administering acetaminophen, and placing a hypothermia blanket under the client. Ice packs are not used because they could cause shivering, which increases cellular oxygen demands, with the potential for increase in intracranial pressure. If shivering occurs, it is managed with chlorpromazine (Thorazine). Strategy: Use the process of elimination, noting the strategic words least appropriate. This phrasing indicates a negative event query and asks you to select an incorrect action. It may be helpful to look at this question from the standpoint of relative body surface area that would be benefited by each of the measures identified in the options. Tepid sponge baths and a hypothermia blanket would affect a good portion of the client's skin to reduce heat. Acetaminophen (Tylenol) is a medication that has an antipyretic effect. The ice packs are the incorrect option, because they would affect the skin only in the area of the axilla and groin, giving less generalized cooling, with increased risk of shivering. Review nursing care related to the client with hyperthermia if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2208). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1614) The mother arrives at a well-baby clinic with her 1-month-old infant. She expresses concern because one of the infant's eyes appears to be crossed. The appropriate and supportive response by the nurse is which of the following? a. "The infant will probably need surgery." b. "This condition is probably permanent." c. "It bears watching because the other eye may do the same thing." d. "This is normal in the young infant but should not be present after about age 4 months." Source: Saunders 4th

ANS: D Rationale: Strabismus, also called lazy eye, is a condition in which the eyes are not aligned because of lack of coordination of the extraocular muscles. It is normal in the young infant but should not be present after about age 4 months. Options 1, 2, and 3 are not appropriate responses to the mother of a 1-month-old infant. Strategy: Use the process of elimination and note the strategic words 1-month-old infant. Also, use therapeutic communication techniques. Options 1, 2, and 3 may cause fear and concern in the mother. If you had difficulty with this question, review this disorder. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., pp. 150, 186). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Child Health Alternate Question Types -> Multiple Choice

978) The client with a gastric ulcer has an order for sucralfate (Carafate), 1 g by mouth four times daily. The nurse schedules the medication for which times? a. With meals and at bedtime b. Every 6 hours around the clock c. One hour after meals and at bedtime d. One hour before meals and at bedtime Source: Saunders 4th

ANS: D Rationale: Sucralfate is a gastric protectant. The medication should be scheduled for administration 1 hour before meals and at bedtime. The medication is timed to allow it to form a protective coating over the ulcer before food intake stimulates gastric acid production and mechanical irritation. The other options are incorrect. Strategy: Use the process of elimination. Focusing on the client's diagnosis will assist in directing you to option 4. Review the administration of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1082). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2272) A nurse is suctioning an unconscious client who has a tracheostomy. The nurse needs to avoid which of the following actions in this procedure? a. Keeping a supply of suction catheters at the bedside b. Auscultating breath sounds to determine the need for suctioning c. Hyperoxygenating the client before, during, and after suctioning d. Making sure not to suction for longer than 30 seconds Source: Saunders 4th

ANS: D Rationale: Suction equipment should be kept at the bedside of an unconscious client, regardless of whether an artificial airway is used. The nurse auscultates breath sounds every 2 to 4 hours, or more frequently as needed. The client should be hyperoxygenated before, during, and after suctioning to minimize cerebral hypoxia. Suctioning should not be performed for longer than 10 seconds at one time, to prevent cerebral hypoxia and a rise in intracranial pressure (ICP). Strategy: Use the process of elimination, noting the strategic word avoid. This indicates a negative event query and asks you to select an incorrect action. Visualize this procedure, remembering that airway is the priority. If you had difficulty with this question, review suctioning procedures. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2060). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1440) The nurse is caring for a client with a phobia who is being treated for the condition. The client is introduced to short periods of exposure to the phobic object while in a relaxed state. The nurse understands that this form of behavior modification can best be described as: a. Milieu therapy b. Aversion therapy c. Self-control therapy d. Systematic desensitization Source: Saunders 4th

ANS: D Rationale: Systematic desensitization is a form of therapy used when the client is introduced to short periods of exposure to the phobic object while in a relaxed state. Gradually exposure is increased until the anxiety about or fear of the object or situation has ceased. Options 1, 2, and 3 are incorrect. Strategy: Use the process of elimination. Focus on the strategic words introduced to short periods of exposure. This will direct you to the correct option. If you had difficulty with this question, review systematic desensitization. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 326-327). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 29-30). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2522) Pilocarpine hydrochloride (Isopto Carpine) is prescribed for the client with glaucoma. The nurse checks the medication supply room to ensure that atropine sulfate is available for administration in the event that systemic toxicity occurs from the use of pilocarpine hydrochloride. The nurse also documents to monitor for which of the following signs of systemic toxicity? a. Tachycardia b. Hypertension c. Anorexia d. Bradycardia Source: Saunders 4th

ANS: D Rationale: Systemic absorption of pilocarpine hydrochloride can produce toxicity, manifested as vertigo, bradycardia, tremors, hypotension, syncope, cardiac dysrhythmias, and seizures. Atropine sulfate is the antidote for systemic reactions that occur with pilocarpine. Strategy: Use the process of elimination. Note that options 1 and 4 identify opposite effects. This feature in examination questions may indicate that one of these options is correct. Recalling the signs of toxicity or the effects of atropine sulfate will direct you to option 4. Review the signs of toxicity if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 1195). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Communication and Documentation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1827) A community health nurse who is conducting a teaching session about the risks of testicular cancer has reviewed a list of instructions regarding testicular self-examination (TSE) with the clients attending the session. Which statement by a client indicates a need for further instruction? a. "TSE is performed once a month." b. "TSE should be performed on the same day of each month." c. "The scrotum is held in one hand and the testicle is rolled between the thumb and forefinger of the other hand." d. "It is best to do TSE first thing in the morning before a bath or shower." Source: Saunders 4th

ANS: D Rationale: TSE is performed once a month and should be done on the same day of each month, as an aid to help the client remember to perform the exam. The scrotum is held in one hand and the testicle is rolled between the thumb and forefinger of the other hand. It is best to perform the exam during or after a warm shower or bath when the scrotum is most relaxed. Strategy: Note the strategic words need for further instruction and use the process of elimination. This phrasing indicates a negative event query and directs you to select an incorrect statement. Visualizing this procedure will direct you to option 4. Review this procedure if you are unfamiliar with it. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 731-732). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

1862) Tamsulosin hydrochloride (Flomax) has been prescribed for a client with benign prostatic hypertrophy (BPH). The nurse should instruct the client to take the medication: a. With breakfast b. With the lunch time meal c. With a glass of milk d. 30 minutes after a meal Source: Saunders 4th

ANS: D Rationale: Tamsulosin hydrochloride is a medication that will relieve mild to moderate manifestations of BPH and improve urinary flow rates. The medication should be administered 30 minutes after meals because food decreases the peak plasma concentration and lengthens the time to achieve peak plasma medication concentrations. Options 1, 2, and 3 are incorrect. Strategy: Use the process of elimination to assist in answering, noting that options 1, 2, and 3 are comparative or alike because they all indicate administration of the medication with food. If you had difficulty with this question or are unfamiliar with this medication, review its method of administration. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1097). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

137) The nurse is inserting an intravenous line into a client's vein. After the initial stick, the nurse continues to advance the catheter if the nurse notes that a. The catheter advances easily. b. The vein is distended under the needle. c. The client does not complain of discomfort. d. Blood return shows in the backflash chamber of the catheter. Source: Saunders 4th

ANS: D Rationale: The IV catheter has entered the lumen of the vein successfully when blood backflash shows in the IV catheter. The vein should have been distended by the tourniquet before the vein was cannulated. Client discomfort varies with the client, the site, and the nurse's insertion technique and is not a reliable measure of catheter placement. The nurse should not advance the catheter until placement in the vein is verified by blood return. Strategy: Use the process of elimination, focusing on the subject of the question: correct placement of an IV catheter. Noting the strategic words blood return in option 4 will direct you to this option. Review the steps for inserting an IV catheter if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., p. 912). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1167-1168). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2303) A clinic nurse administers a Mantoux skin test to a client. The nurse tells the client to return to the clinic for reading the results in: a. 24 to 36 hours b. 24 to 48 hours c. 36 to 48 hours d. 48 to 72 hours Source: Saunders 4th

ANS: D Rationale: The Mantoux skin test is the most accurate and reliable tuberculin skin test currently available. Interpretation of the Mantoux test result should be done 48 to 72 hours after the injection. Strategy: Knowledge of the correct reading times after a Mantoux skin test is required to answer this question. Remember that the reading time is 48 to 72 hours after injection. Review this content if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 766). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2452) A nurse is preparing to wean a client from a ventilator by the use of a T-piece. Which of the following would not be a component of the plan of care with this type of weaning process? a. The client is removed from the mechanical ventilator for a short period of time. b. The T-piece is connected to the client's artificial airway. c. Supplemental oxygen is provided through the T-piece at an F<SC>IO</SC> ₂(fraction of inspired oxygen) that is 10% higher than a ventilator setting. d. The respiratory rate on the ventilator is gradually decreased until the client can do all of the work of breathing on his or her own. Source: Saunders 4th

ANS: D Rationale: The T-piece (or Briggs device) requires that the client be removed from the mechanical ventilation for short periods of time, usually beginning with a 5-minute period. The ventilator is disconnected and the T-piece is connected to the client's artificial airway. Supplemental oxygen is provided through the device, often at an F<SC>IO</SC> ₂ that is 10% higher than the ventilator setting. Strategy: Use the process of elimination. Note the strategic word not in the question. Focus on the subject, T-piece, to assist in directing you to option 4. If you had difficulty with this question, review the process of weaning a client from a mechanical ventilator using a T-piece. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 669). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1757) Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with pain and the nurse instructs the client about the purpose of the TENS unit. Which statement by the client indicates the need for further instructions? a. "Electrodes are attached to the skin." b. "The unit relieves pain." c. "The unit will reduce the needs for analgesics." d. "Hospitalization is required because the unit is not portable." Source: Saunders 4th

ANS: D Rationale: The TENS unit is portable and the client controls the system for relieving pain and reducing the need for analgesics. It is attached to the skin of the body by electrodes. Hospitalization is not required. Strategy: Use the process of elimination. Note the words need for further instructions in the question. These words indicate a negative event query and ask you to select an option that is incorrect. You should be directed to option 4, because it would not be a cost-effective pain management technique if the client required hospitalization. Review the principles related to the TENS unit if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 84, 385). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1904) A client who has had a prostatectomy has been instructed in perineal exercises to gain control of the urinary sphincter. The nurse determines that the client demonstrates a need for further instruction by stating that he will perform which of the following as part of these exercises? a. Tightening the muscles as if trying to prevent urination b. Contracting the abdominal, gluteal, and perineal muscles c. Tightening the rectal sphincter while relaxing abdominal muscles d. Performing the Valsalva maneuver Source: Saunders 4th

ANS: D Rationale: The Valsalva maneuver is avoided after prostatectomy, because it increases the risk of bleeding in the postoperative period. An acceptable exercise is tightening the abdominal, gluteal, and perineal muscles as if trying to prevent urination. Another acceptable exercise is tightening the rectal sphincter while relaxing the abdominal muscles; this prevents the Valsalva maneuver from occurring. Strategy: Use the process of elimination. Note the strategic words need for further instruction. This phrasing indicates a negative event query and directs you to select an incorrect statement. The types of movement in the exercises described in options 1, 2, and 3 are comparative or alike and are all muscle tightening types of movements. On the other hand, the Valsalva maneuver involves bearing down or pushing types of movement. Review client teaching related to perineal exercises after prostatectomy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1025-1026). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1694). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1522) The client has been started on medication therapy with alprazolam (Xanax). When the nurse teaches the client that the medication should not be discontinued abruptly, the client asks why. The nurse incorporates which of the following in formulating a reply? a. The client is likely to become resistant to medication effects. b. The client is likely to suffer irreversible damage to the kidneys. c. Abruptly stopping the medication will make the medication much less effective if it must be restarted. d. Rebound central nervous system excitation could occur, causing feelings of restlessness and irritability. Source: Saunders 4th

ANS: D Rationale: The abrupt withdrawal of alprazolam (Xanax) could result in seizure activity from rebound central nervous system excitation. All clients receiving this medication should be warned of this danger. The other options are incorrect. Strategy: Use the process of elimination. Remember that options that are comparative or alike are not likely to be correct. With this in mind, eliminate options 1 and 3 first. From the remaining options, recalling the adverse effects will direct you to option 4. If this question was difficult, review the adverse effects associated with this medication. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., p. 240). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

66) A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Pco₂ is 90 mm Hg, and HCO₃^- is 22 mEq/L. The nurse interprets the results as indicating which condition? a. Metabolic acidosis with compensation b. Respiratory acidosis with compensation c. Metabolic acidosis without compensation d. Respiratory acidosis without compensation Source: Saunders 4th

ANS: D Rationale: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Pco₂ is 35 to 45 mm Hg. In respiratory acidosis the pH is decreased and the Pco₂ is elevated. The normal bicarbonate (HCO₃^-) level is 22 to 27 mEq/L. Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. Therefore, the condition is without compensation. Options 1, 2, and 3 are incorrect. Strategy: Use the process of elimination. Remember that in a respiratory imbalance you will find an opposite response between the pH and the Pco₂. Also, remember that the pH is decreased in an acidotic condition and that compensation is reflected by a normal pH. Review the interpretation of arterial blood gas values if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 351-352). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1322) The nurse is caring for a client in the emergency room diagnosed with Bell's palsy. The client has been taking acetaminophen (Tylenol), and acetaminophen overdose is suspected. The nurse anticipates that the antidote to be prescribed is: a. Pentostatin (Nipent) b. Auranofin (Ridaura) c. Fludarabine (Fludara) d. Acetylcysteine (Mucomyst) Source: Saunders 4th

ANS: D Rationale: The antidote for acetaminophen is acetylcysteine (Mucomyst). The normal therapeutic serum level of acetaminophen is 10 to 20 mcg/mL. A toxic level is higher than 50 mcg/mL, and levels higher than 200 mcg/mL could indicate hepatotoxicity. Auranofin (Ridaura) is a gold preparation used to treat rheumatoid arthritis. Fludarabine (Fludara) and pentostatin (Nipent) are antineoplastic agents. Strategy: Use the process of elimination. Eliminate options 1 and 3 first because they are comparative or alike (antineoplastic agents). Recalling that auranofin is used to treat rheumatoid arthritis will direct you to option 4. Review the antidote for acetaminophen if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 13). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1152) A nurse has an order to begin administering warfarin sodium (Coumadin) to a client. While implementing this order, the nurse ensures that which of the following medications is available on the nursing unit as the antidote for warfarin sodium? a. Protamine sulfate b. Potassium chloride c. Aminocaproic acid (Amicar) d. Vitamin K (AquaMEPHYTON) Source: Saunders 4th

ANS: D Rationale: The antidote to warfarin sodium (Coumadin) is vitamin K and should be readily available for use if excessive bleeding or hemorrhage occurs. Aminocaproic acid is the antidote for thrombolytic agents. Protamine sulfate is the antidote for heparin. Potassium chloride is administered to treat potassium deficit. Strategy: Knowledge regarding the various antidotes is needed to answer this question. Remember that the antidote for warfarin sodium (Coumadin) is vitamin K. Review these antidotes if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1121). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

121) At the beginning of a shift, a nurse assesses a client receiving parenteral nutrition (PN) with fat emulsion (lipids) piggybacked to the line. The nurse notes that the fat emulsion tubing has a 0.22-μm filter. Which of the following actions by the nurse is appropriate? a. Leave the system alone. b. Check the line for patency. c. Inspect the filter for clogging. d. Replace with a tubing without a filter. Source: Saunders 4th

ANS: D Rationale: The appropriate action by the nurse is to replace the tubing. A 0.22-µm filter is appropriate for the administration of PN, but fat emulsion should be administered without a filter. If fat emulsion is mixed into the PN solution, then a 1.2-µm or larger filter should be used to allow the fat emulsion to pass through. Therefore, options 1, 2, and 3 are incorrect. Strategy: Use the process of elimination, recalling that fat emulsion should be administered without a filter. This will direct you to option 4. If you had difficulty with this question, review the procedure for the administration of fat emulsion. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 989). St. Louis: Mosby. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., p. 1062). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1866) A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and would suspect a diagnosis of placenta previa if which of the following is noted? a. Painful vaginal bleeding b. Abdominal pain c. Back pain d. Painless vaginal bleeding Source: Saunders 4th

ANS: D Rationale: The classic sign of placenta previa is the sudden onset of painless uterine bleeding. Options 1, 2, and 3 identify signs and symptoms of abruptio placentae. Strategy: Use the process of elimination. Note that options 1 and 4 oppose each other, which can be an indication that one of them may be correct. Recall that in placenta previa, the client experiences painless vaginal bleeding. If you are unfamiliar with these signs and symptoms, review this content. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 624). St. Louis: Mosby. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 632). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Maternity—Intrapartum Alternate Question Types -> Multiple Choice

1740) The nurse is admitting a client to the nursing unit who is suspected of having tuberculosis (TB). The nurse plans to admit the client to a room that has: a. Ultraviolet light and three air exchanges per hour. b. Ten air exchanges per hour and venting to the outside. c. Venting to the outside and ultraviolet light. d. Venting to the outside, six air exchanges per hour, and ultraviolet light. Source: Saunders 4th

ANS: D Rationale: The client is admitted to a private room that has at least six air exchanges per hour, and that has negative pressure in relation to surrounding areas. The room should be vented to the outside, and should have ultraviolet lights installed. Strategy: Use the process of elimination. Knowing that the air must vent to the outside helps eliminate option 1. Knowing that ultraviolet light is useful in killing these organisms helps you eliminate option 2. From the remaining options, recall that there must be an airflow system that allows for at least six air exchanges per hour. If you had difficulty with this question, review care of the hospitalized client with TB. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1849). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2330) A nurse is assisting the physician in performing a lumbar puncture on a client. The nurse prepares the client for the procedure by placing the client in which position? a. Supine b. Prone c. Lateral d. Fetal position Source: Saunders 4th

ANS: D Rationale: The client is assisted into a fetal position at the edge of the bed with the knees drawn up to the chest. This position allows full flexion of the spine and wider spaces between the vertebrae. The nurse also would place a pillow between the client's legs to prevent the upper leg from rolling forward and a small pillow under the client's head to support the spine in a horizontal position. Strategy: Use the process of elimination. Visualizing the procedure will direct you to option 4. If you had difficulty with this question, review the procedure for lumbar puncture. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 739). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1026) A nurse has conducted discharge teaching with a client diagnosed with tuberculosis. The client has been taking medication for 1½ weeks. The nurse evaluates that the client has understood the information if the client makes which of the following statements? a. "I need to continue drug therapy for 2 months." b. "I can't shop at the mall for the next 6 months." c. "I can return to work if a sputum culture comes back negative." d. "I should not be contagious after 2 to 3 weeks of medication therapy." Source: Saunders 4th

ANS: D Rationale: The client is continued on medication therapy for 6 to 12 months, depending on the situation. The client generally is considered not to be contagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of three sputum cultures are negative. Strategy: Use the process of elimination. Knowing that the medication therapy lasts for at least 6 months helps you eliminate option 1 first. Knowing that three sputum cultures must be negative helps you to eliminate option 3 next. From the remaining options, recalling that the client is not contagious after 2 to 3 weeks of therapy will direct you to option 4. If you had difficulty with this question, review the infectious period of tuberculosis. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1847-1848). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 644). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

926) The client who has undergone creation of a colostomy has a nursing diagnosis of Disturbed body image. What action by the client indicates the most significant progress toward identified goals? a. Looking at the ostomy site b. Reading the ostomy product literature c. Watching the nurse empty the ostomy bag d. Practicing proper cutting of the ostomy appliance Source: Saunders 4th

ANS: D Rationale: The client is expected to have a body image disturbance after colostomy. The client progresses through normal grieving stages to adjust to this change. The client demonstrates the greatest deal of acceptance when the client participates in the actual colostomy care. Each incorrect option represents an interest in colostomy care but is a passive activity. The correct option shows the client participating in self-care. Strategy: Note the strategic words colostomy and most significant progress. Eliminate options 1, 2, and 3 because they are similar or alike and indicate passive activities. Review psychosocial adjustment in a client with a colostomy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 837). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1325-1326). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1231) The client is being discharged from the ambulatory care unit following cataract removal. The nurse provides instructions regarding home care. Which of the following, if stated by the client, indicates an understanding of the instructions? a. "I will take aspirin if I have any discomfort." b. "I will sleep on the side that I was operated on." c. "I will not lift anything if it weighs more than 10 pounds." d. "I will wear my eye shield at night and my glasses during the day." Source: Saunders 4th

ANS: D Rationale: The client is instructed to wear a metal or plastic shield to protect the eye from accidental injury and is instructed not to rub the eye. Glasses may be worn during the day. Aspirin or medications containing aspirin are not to be administered or taken by the client and the client is instructed to take acetaminophen (Tylenol) as needed for pain. The client is instructed not to sleep on the side of the body on which the operation occurred. The client is not to lift more than 5 lb. Strategy: Use the process of elimination, noting the strategic words understanding of the instructions. Recalling that the operative site needs to be protected will direct you to option 4. If you had difficulty with this question, review the discharge instructions for the client following cataract extraction. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1951). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1413) The nurse is working with a client who has sought counseling after trying to rescue a neighbor involved in a house fire. In spite of the client's efforts, the neighbor died. Which action does the nurse engage in with the client during the working phase of the nurse-client relationship? a. Exploring the client's ability to function b. Exploring the client's potential for self-harm c. Inquiring about the client's perception or appraisal of the neighbor's death d. Inquiring about and examining the client's feelings that may block adaptive coping Source: Saunders 4th

ANS: D Rationale: The client must first deal with feelings and negative responses before the client can work through the meaning of the crisis. Option 4 pertains directly to the client's feelings. Options 1 and 2 do not directly address the client's feelings. Option 3 is more of an assessment question. Strategy: Focus on the subject of the question, the working phase of the nurse-client relationship. Think about the interventions that occur in this phase. Using the process of elimination, focus on this subject and on the option that focuses on the feelings of the client. This will direct you to option 4. Review the phases of the nurse-client relationship if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 511). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 19, 22-23). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1374) A client is to receive a prescription for methocarbamol (Robaxin). The nurse provides instructions to the client about the medication. Which of the following client statements would indicate a need for further education? a. "My urine may turn brown or green." b. "I might get some nasal congestion from this medication." c. "This medication is prescribed to help relieve my muscle spasms." d. "If my vision becomes blurred, I don't need to be concerned about it." Source: Saunders 4th

ANS: D Rationale: The client needs to be told that the urine may turn brown, black, or green. Other adverse effects include blurred vision, nasal congestion, urticaria, and rash. The client needs to be instructed that if these adverse effects occur to notify the physician. Strategy: Use the process of elimination. Note the strategic words need for further education. These words indicate a negative event query and ask you to select an option that is incorrect. This will assist in directing you to option 4. If you had difficulty with this question, review this medication. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 237). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

115) A nurse is preparing to change the total parenteral nutrition (TPN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which most essential action during the tubing change? a. Breathe normally. b. Turn the head to the right. c. Exhale slowly and evenly. d. Take a deep breath, hold it, and bear down. Source: Saunders 4th

ANS: D Rationale: The client should be asked to perform the Valsalva maneuver during tubing changes. This helps avoid air embolism during tubing changes. The nurse asks the client to take a deep breath, hold it, and bear down. If the IV line is on the right, the client turns his or her head to the left. This position will increase intrathoracic pressure. Options 1 and 3 are inappropriate and could cause the potential for an air embolism during the tubing change. Strategy: Note the strategic words most essential. Use the process of elimination, recalling that air embolism is a complication that can occur during tubing changes. This will direct you to option 4. Review the procedure for PN bag and tubing change if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 257). Philadelphia: W.B. Saunders. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., p. 1053). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1956) A nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which of the following statements would be appropriate for the nurse to include? a. "The ear mold for the hearing aid should be washed with mild soap and water once a month." b. "The hearing aid should be removed from the ear at the end of the day and then turned off after removal." c. "The hearing aid contains a lifelong battery so you will not need to be concerned about changing batteries." d. "The hearing aid should not be worn if an ear infection is present." Source: Saunders 4th

ANS: D Rationale: The client should be instructed that the hearing aid should not be worn if an ear infection is present. The client should be instructed to turn the hearing aid off before removing it from the ear to prevent any squealing feedback. The hearing aid should be turned off when not in use and the client should keep extra batteries on hand at all times. The client should wash the ear mold frequently with mild soap and water, with the use of a pipe cleaner to clean the cannula of the hearing aid. Strategy: Use the process of elimination. Eliminate option 1 because of the words once a month. Eliminate option 2 because of the words then turned off after removal. Eliminate option 3 because of the words lifelong battery. If you had difficulty with this question, review instructions for the client with a hearing aid. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1976). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1137). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

2614) A client is starting to take imipramine (Tofranil) once each day. The nurse determines that additional client teaching is needed on the basis of which of the following statements by the client? a. "I won't notice any medication effects for at least 2 weeks." b. "I need to avoid alcohol while taking this medication." c. "I'll be sure to take a missed medication dose as soon as possible unless it is almost time for the next dose." d. "I'll take the medication in the morning before breakfast." Source: Saunders 4th

ANS: D Rationale: The client should be instructed to take a single daily dose of the medication at bedtime, not in the morning, because of the side effects. The client should take the medication exactly as directed and, if a dose is missed, should take it as soon as possible unless it is almost time for another dose. The medication effects may not be noticed for at least 2 weeks, and the client should avoid alcohol or other central nervous system depressants during therapy. Strategy: Note the strategic words additional client teaching is needed. Use the process of elimination, knowledge regarding the administration of this medication, and general principles related to medication administration to direct you to option 4. If you are unfamiliar with the administration of this medication, review this content. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 398). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed.). Philadelphia: W.B. Saunders, p. 350. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 440). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2427) A nursing instructor has just completed a lecture to nursing students regarding care of the client with a burn injury, and a major aspect of the lecture was care of the client at the scene of a fire. Which statement if made by a nursing student indicates a need for further instruction? a. Flames may be extinguished by rolling the client on the ground. b. Flames may be smothered by the use of a blanket or another cover. c. Flames should be doused with water. d. The client should be maintained in a standing position because the flames may spread to the other parts of the body. Source: Saunders 4th

ANS: D Rationale: The client should be placed or maintained in a supine position; otherwise; flames may spread to other parts of the body, causing more extensive injury. Flame burns may be extinguished by rolling the client on the ground, smothering the flames with a blanket or other cover, or dousing the flames with water. Strategy: Use the process of elimination, noting the strategic words need for further instruction in the question. These words indicate a negative event query and the need to select an incorrect statement. Recalling that the client should be kept in a supine position will assist in directing you to option 4. If you had difficulty with this question, review care of the burn-injured client at the scene of injury. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1627). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

131) The nurse is planning to provide a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse would avoid writing which of the following incorrect items on the instruction sheet? a. Wear a Medic-Alert tag or bracelet. b. Have a repair kit available in the home for use if needed. c. Keep the insertion site protected when in the shower or bath. d. Keep activity level to a minimum while this catheter is in place. Source: Saunders 4th

ANS: D Rationale: The client should be taught that only minor activity restrictions apply with this type of catheter. The client should protect the site during bathing and should carry or wear a Medic-Alert identification. The client should have a repair kit in the home for use as needed because the catheter is for long-term use. Strategy: Use the process of elimination and note the strategic words avoid and incorrect. Recalling that the PICC is for long-term use will assist in directing you to option 4. To keep activity to a minimum with such a catheter is unreasonable. Review home care instructions for a client with a PICC if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., pp. 926, 929). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

965) The nurse has given instructions to the client who just received a prescription for diphenoxylate hydrochloride with atropine sulfate (Lomotil). Which statement by the client indicates understanding of the medication and its properties? a. Take the medication with a bulk-forming laxative. b. Anticipate side effects of nervous system excitability. c. Expect increased salivation while taking the medication. d. Stay within the prescribed dose because it can be habit-forming. Source: Saunders 4th

ANS: D Rationale: The client should not exceed the recommended dose because it may be habit-forming. The medication is an antidiarrheal and therefore should not be taken with a laxative. Side effects of the medication include dry mouth and drowsiness. Strategy: Use the process of elimination. Noting the strategic word atropine will assist in eliminating options 2 and 3. Recalling that the medication is an antidiarrheal will assist in eliminating option 1. Review the properties of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2007). Mosby's 2007 nursing drug reference (20th ed., p. 371). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2162) A client has been prescribed cyclobenzaprine (Flexeril) for the treatment of painful muscle spasms accompanying a herniated intervertebral disk. The nurse should withhold the medication and question the order if the client has concurrent orders to take: a. Furosemide (Lasix) b. Valproic acid (Depakene) c. Ibuprofen (Motrin) d. Tranylcypromine (Parnate) Source: Saunders 4th

ANS: D Rationale: The client should not receive cyclobenzaprine if the client has taken monoamine oxidase inhibitors (MAOIs) such as tranylcypromine or phenelzine within the last 14 days. Otherwise, the client could experience hyperpyretic crisis, convulsions, or death. Strategy: Knowledge regarding the contraindications associated with the use of cyclobenzaprine will assist in answering the question. Recalling the classifications of the medications in each option will assist in directing you to option 4. Review the contraindications associated with the use of cyclobenzaprine if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 297). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2045) A nurse is providing instructions to a client with a seizure disorder who will be taking phenytoin (Dilantin). Which statement if made by the client would indicate an understanding of the information about this medication? a. "I should take my medication before coming to the laboratory to have a blood level drawn." b. "I should monitor for side effects and adjust my medication dose depending on how severe the side effects are." c. "I should try to avoid alcohol, but if I'm not able to, I can drink alcohol in moderation." d. "I need to perform good oral hygiene, including flossing and brushing my teeth." Source: Saunders 4th

ANS: D Rationale: The client should perform good oral hygiene, including flossing and brushing the teeth. The client also should see a dentist at regularly scheduled times, because gingival hyperplasia is a side effect of this medication. The client should be instructed that follow-up serum blood levels are important and that, on the day of the scheduled laboratory test, the client should avoid taking the medication before the specimen is drawn. The client should not adjust dosages, and the client should avoid alcohol while taking this medication. Strategy: Use the process of elimination. Note the strategic words understanding of the information. Knowledge that gingival hyperplasia is a side effect of this medication will assist in directing you to the correct option. If you had difficulty with this question, review client teaching points for the administration of phenytoin. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 930). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2145) A nurse has taught a client with a below-the-knee amputation about prosthesis and stump care. The nurse determines that the client has understood the instructions if the client states to: a. Wear a clean nylon stump sock daily. b. Toughen the skin of the stump by rubbing it with alcohol. c. Prevent cracking of the skin of the stump by applying lotion daily. d. Using a mirror to inspect all areas of the stump each day. Source: Saunders 4th

ANS: D Rationale: The client should wear a clean woolen stump sock each day. The stump is cleansed daily with a gentle soap and water and is dried carefully. Alcohol is avoided because it could cause drying or cracking of the skin. Oils, creams, and lotions also are avoided because they are too softening to the skin for safe prosthesis use. The client should inspect all surfaces of the stump daily for irritation, blisters, or breakdown. Nylon is a synthetic material that does not allow the best air circulation and holds in moisture. Strategy: Use the process of elimination. Read each option carefully. Note that option 4 addresses the first step of the nursing process, assessment. Review client teaching points related to prosthesis and stump care if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1527). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1271) The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure? a. Side-lying, with a pillow under the hip b. Prone, with a pillow under the abdomen c. Prone, in slight-Trendelenburg's position d. Side-lying, with the legs pulled up and head bent down onto chest Source: Saunders 4th

ANS: D Rationale: The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae. Strategy: Use the process of elimination. Recall that a lumbar puncture is the introduction of a needle into the subarachnoid space. The correct option is the only position that flexes the vertebrae for easier needle insertion. Review positioning procedures for a lumbar puncture if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2042-2045). Philadelphia: W.B. Saunders. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 739). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1851) A clinic nurse has provided instructions regarding home care measures to a female client diagnosed with pelvic inflammatory disease (PID). Which of the following statements if made by the client indicates an understanding of these measures? a. "I need to douche once in the morning and once in the evening." b. "I need to wear tampons instead of sanitary pads when I have my menstrual period." c. "I need to see the physician to get an intrauterine device for birth control." d. "I need to avoid tight-fitting clothing." Source: Saunders 4th

ANS: D Rationale: The client who has been diagnosed with PID should avoid frequent douching because this decreases the natural flora that controls the growth of infectious organisms. The client should wear cotton undergarments that breathe and clothes should not fit tightly. Tampons, if worn, should be changed frequently after recovery but should not be used during an acute infection. In fact, many health care providers recommend avoiding the use of tampons indefinitely. Intrauterine devices increase the client's susceptibility to PID. Strategy: Use the process of elimination noting the strategic words indicates an understanding. Evaluate each option for its risk of triggering inflammation or infection. This will assist in directing you to option 4. Review these home care measures if you are unfamiliar with them. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1065). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

163) The nurse listening to morning report learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which of the following daily serum laboratory studies to assess the effectiveness of the transfusion? a. Hematocrit level b. Erythrocyte count c. Hemoglobin level d. White blood cell count Source: Saunders 4th

ANS: D Rationale: The client who has neutropenia may receive a transfusion of granulocytes, or white blood cells. These clients often have severe infections and are unresponsive to antibiotic therapy. The nurse notes the results of follow-up white blood cell counts to evaluate the effectiveness of the therapy. The nurse also continues to monitor the client for signs and symptoms of infection. Erythrocyte count and hemoglobin and hematocrit levels are determined after transfusion of packed red blood cells. Strategy: Use the process of elimination. Recalling that granulocytes are a component of white blood cells will assist in directing you to option 4. In addition, note that options 1, 2, and 3 are comparative or alike in that these options all refer to erythrocytes. Review the key points related to types of blood products if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 915-916). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2571) A nurse is providing instructions to a client with a diagnosis of Addison's disease regarding the administration of prescribed glucocorticoids. The nurse should instruct the client: a. To avoid taking the medication if nausea occurs b. To stop the medication if side effects occur c. That minimal side effects will occur with use of this medication d. That an increased dose of medication may be needed during times of stress Source: Saunders 4th

ANS: D Rationale: The client with Addison's disease will require lifelong replacement of adrenal hormones. The medications must be taken daily, and an alternate route of administration must be used if the client cannot take oral medications for any reason, such as nausea and vomiting. Additional doses of glucocorticoids will be needed during times of stress. The nurse must emphasize that the client must call the physician to obtain a prescription for a dosage increase when experiencing stressful situations. Abrupt withdrawal of this medication can result in addisonian crisis. Although side effects are mild at lower doses, more severe side effects occur with long-term glucocorticoid administration. It is very unsafe to stop taking the medication without first consulting the physician. Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are comparative or alike. Recalling that side effects are associated with the use of glucocorticoids will assist in eliminating option 3. Review client teaching points related to glucocorticoids if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1219-1220). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 696). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

1906) A client newly diagnosed with chronic renal failure (CRF) has many learning needs regarding the disease. The nurse prepares a teaching plan to help the client adapt to the disease. The nurse recognizes that which of the following client characteristics or factors is least likely to interfere with the client's ability to learn? a. Anxiety b. Memory deficits c. Short attention span d. Presence of family Source: Saunders 4th

ANS: D Rationale: The client with CRF may have several barriers to learning. Anxiety about the disease and its ramifications frequently may interfere with learning. Physiological effects of the disease process also impair the client's mental functioning. Specifically, the client may exhibit a short attention span and have memory deficits. Mental functioning usually improves once hemodialysis has begun. The presence of family members is helpful because they need to understand the disease and treatment and may help reinforce information with the client after the formal teaching session is over. Strategy: Use the process of elimination. Note the strategic words least likely. Eliminate option 1, knowing that anxiety commonly interferes with learning. Options 2 and 3 are comparative or alike, in that they reflect neurological impairment and are eliminated next. Recall that the presence of family members does not necessarily interfere with learning; in fact, they may be quite helpful. Review Teaching and Learning principles if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1744-1745). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 348-349). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1672) The client with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which statement by the nurse is appropriate? a. "This is permanent, but looks are deceiving and are not that important." b. "Don't be concerned; this problem can be covered with clothing." c. "Try not to worry about it; there are other things to be concerned about." d. "Usually these physical changes slowly improve following treatment." Source: Saunders 4th

ANS: D Rationale: The client with Cushing's syndrome should be reassured that most physical changes resolve with treatment. Options 1, 2, and 3 are not therapeutic responses. Strategy: Use the process of elimination. If you are unfamiliar with this disorder, you can easily eliminate options 1, 2, and 3 because these statements are not therapeutic responses to a client. Review the effects of treatment in a client with Cushing's syndrome if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 1328-1329). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

1306) The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse brings which of the following items into the client's room? a. Nebulizer and pulse oximeter b. Blood pressure cuff and flashlight c. Flashlight and incentive spirometer d. Electrocardiographic monitoring electrodes and intubation tray Source: Saunders 4th

ANS: D Rationale: The client with Guillain-Barré syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of electrocardiographic monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely. Strategy: Use the process of elimination. With an ascending paralysis, the client is at risk for involvement of respiratory muscles and subsequent respiratory failure. Option 4 is the only option that includes an intubation tray, which would be needed if the client's status deteriorated to needing intubation and mechanical ventilation. This option most directly addresses airway. Review care of the client with Guillain-Barré syndrome if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1007, 1010). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1295) The client with Parkinson's disease is embarrassed about the symptoms of the disorder, and is bored and lonely. The nurse would plan which of the following approaches as most therapeutic in helping the client cope with the disease? a. Plan only a few activities for the client during the day. b. Assist the client with activities of daily living as much as possible. c. Cluster activities at the end of the day when the client is most bored. d. Encourage and praise perseverance in exercising and performing activities of daily living. Source: Saunders 4th

ANS: D Rationale: The client with Parkinson's disease tends to become withdrawn and depressed and should become an active participant in personal care to prevent this. Activities should be planned throughout the day to inhibit daytime sleeping and boredom. The nurse gives the client encouragement and praises the client for perseverance. Exercise helps prevent progression of the disease, and self-care improves self-esteem. Strategy: Use the process of elimination, focusing on the subject. Options 1 and 3 are the least helpful of all the options and are eliminated first. Option 2 is well intentioned but is not therapeutic in helping the client cope with the disease. Option 4 is the best choice. Review care of the client with Parkinson's disease if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2174). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 961, 963). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1836) A nurse provides dietary instructions to a client with a diagnosis of cholecystitis. Which of the following food items identified by the client indicates an understanding of foods to avoid? a. Fresh fruit b. Fresh vegetables c. Poultry without skin d. Brown gravy Source: Saunders 4th

ANS: D Rationale: The client with cholecystitis should decrease overall intake of dietary fat. Foods that should be avoided include sausage, gravies, fatty meats, fried foods, products made with cream, and desserts. Appropriate food choices include fruits and vegetables, fish, and poultry without skin. Strategy: Use the process of elimination and focus on the client's diagnosis. Recalling that the client should decrease fat intake will direct you to option 4. If you had difficulty with this question, review the food items that are high and low in fat. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1315). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2079) A nurse is teaching a client with nephrotic syndrome about managing the disorder. The nurse instructs the client to adjust which of the following upward or downward according to the amount of edema present? a. Water intake b. Salt intake c. Use of diuretics d. Activity level Source: Saunders 4th

ANS: D Rationale: The client with nephrotic syndrome usually has a standard limit set on sodium intake. Fluids are not restricted unless the client also is hyponatremic. Diuretics are ordered on a specific schedule, and doses are not titrated according to the level of edema. The client is taught to adjust the activity level according to the amount of edema. As edema decreases, activity can increase. Correspondingly, as edema increases, the client should increase rest periods and limit activity. Bed rest is recommended during periods of severe edema. Strategy: Use the process of elimination. Knowing that sodium intake is not modified upward or downward if sodium restriction is ordered allows you to eliminate option 2 first. Likewise, knowing that medications are not adjusted unless such changes are prescribed allows you to eliminate option 3 next. Regarding the remaining options, it is necessary to know that fluids may or may not be restricted (depending on serum sodium level), whereas activity level is adjusted downward as edema increases. Review care of the client with pyelonephritis if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 926, 930). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1715). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1197) The nurse has taught the client with polycystic kidney disease about management of the disorder and prevention and recognition of complications. The nurse determines that the client understands the instructions if the client states that there is no reason to be concerned about: a. Burning on urination b. A temperature of 100.6° F c. New-onset shortness of breath d. A blood pressure of 105/68 mm Hg Source: Saunders 4th

ANS: D Rationale: The client with polycystic kidney disease should report any signs and symptoms of urinary tract infection so that treatment may begin promptly. Lowered blood pressure is not a complication of polycystic kidney disease, and it is an expected effect of antihypertensive therapy. The client would be concerned about increases in blood pressure because control of hypertension is essential. The client may experience heart failure as a result of hypertension, and thus any symptoms of heart failure, such as shortness of breath, are also a concern. Strategy: Use the process of elimination and note the strategic words understands and no reason to be concerned. Recalling that the client with polycystic kidney disease is likely to be hypertensive will direct you to option 4. Also, note that options 1, 2, and 3 identify signs of complications. Review teaching points for the client with polycystic kidney disease if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1711). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1174) The client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse would look at the results of the prostate examination, which should reveal that the prostate gland is: a. Soft and swollen b. Reddened, swollen, and boggy c. Tender and edematous with ecchymosis d. Tender, indurated, and warm to the touch Source: Saunders 4th

ANS: D Rationale: The client with prostatitis has a swollen and tender prostate gland that is also warm to the touch, firm, and indurated. Systemic symptoms include fever with chills, perineal and low back pain, and signs of urinary tract infection, which often accompany the disorder. Strategy: Use the process of elimination. Begin to answer this question by reasoning that inflammation of the prostate gland would cause the area to be tender. This would allow you to eliminate options 1 and 2. Recalling that inflammation is accompanied by local warmth will direct you to option 4. Review the signs of prostatitis if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1035). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1879-1880). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1909) A client with chronic renal failure (CRF) is on a fluid restriction. The client is fatigued and therefore has a limited tolerance for activity. The client takes aluminum hydroxide gel (Alternagel) as a phosphate binder. On the basis of this information, the nurse determines that the client is most at risk for which of the following nursing diagnoses? a. Impaired physical mobility b. Activity intolerance c. Deficient fluid volume d. Constipation Source: Saunders 4th

ANS: D Rationale: The client with renal failure is almost certain to have a problem with constipation as a result of factors such as fluid restriction, fatigue that limits exercise, and dietary restrictions. In addition, phosphate-binding antacids such as aluminum hydroxide gel cause constipation as a side effect. Strategy: Use the process of elimination. Focus on the information in the question and recall that aluminum hydroxide gel causes constipation. Review the side effects of this type of phosphate binder if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 958, 965). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1277) The family of a client with a spinal cord injury rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and complains of a severe headache. The pulse rate is 40 beats/min and the blood pressure is 230/100 mm Hg. The nurse acts quickly, suspecting that the client is experiencing: a. Spinal shock b. Pulmonary embolism c. Malignant hyperthermia d. Autonomic dysreflexia Source: Saunders 4th

ANS: D Rationale: The client with spinal cord injury is at risk for autonomic dysreflexia with an injury above the level of T7. Autonomic dysreflexia is characterized by severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. Autonomic dysreflexia is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury. Strategy: Use the process of elimination. Begin by eliminating options 1 and 2. The client in spinal shock would be hypotensive (not hypertensive), and the client&#39;s clinical picture does not correlate with pulmonary embolism. (Knowing also that autonomic dysreflexia does not occur until spinal shock resolves may be useful.) Recalling that malignant hyperthermia occurs with anesthesia will assist you in eliminating option 3. Review the signs of autonomic dysreflexia if you have difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2229). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 987-988). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2240) A nurse is assessing a client with the typical clinical manifestations of tuberculosis. The nurse would expect the client to report having fatigue and cough that have been present for: a. 1 or 2 days b. Almost 1 week c. 1 to 2 weeks d. Several weeks to months Source: Saunders 4th

ANS: D Rationale: The client with tuberculosis may report signs and symptoms that have been present for weeks or even months. These may include fatigue, lethargy, chest pain, anorexia and weight loss, night sweats, low-grade fever, and cough with mucoid or blood-streaked sputum. It may be the production of blood-tinged sputum that finally forces some clients to seek care. Strategy: Use the process of elimination. Eliminate options 2 and 3 because they are comparative or alike. From the remaining options, eliminate option 1 because of the short time period. Review the clinical manifestations of tuberculosis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 641). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2556) A nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a ventricular rate of 150 beats/min. The nurse should next assess the client for which of the following? a. Flat neck veins b. Complaints of nausea c. Complaints of headache d. Hypotension Source: Saunders 4th

ANS: D Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate higher than 100 beats/min is at risk for low cardiac output due to loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. Strategy: Use the process of elimination. Focus on the dual subject, atrial fibrillation and a rapid ventricular rate. Eliminate option 1 first because flat neck veins are normal or indicate hypovolemia. Eliminate option 2 next because both nausea and vomiting would be associated with vagus nerve activity, which does not correlate with a tachycardic state. Regarding the remaining options, recall that a falling cardiac output will result in hypotension. Review the effects of atrial fibrillation if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 728, 758). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1659) A nurse is providing instructions to a new mother regarding cord care for a newborn infant. Which statement, if made by the mother, indicates a need for further instructions? a. "The cord will fall off in 1 to 2 weeks." b. "Alcohol may be used to clean the cord." c. "I should cleanse the cord two or three times a day." d. "I need to fold the diaper above the cord to prevent infection." Source: Saunders 4th

ANS: D Rationale: The cord should be kept clean and dry to decrease bacterial growth. The diaper should be folded below the cord to keep urine away from the cord. The cord should be cleansed two or three times a day with soap and water or other prescribed agents. Cord care is required until the cord dries up and falls off, between 7 and 14 days after birth. Strategy: Use the process of elimination. Read each option carefully and attempt to visualize the descriptions in each option. Also, note the strategic words need for further instructions. These words indicate a negative event query and ask you to select an option that is incorrect. Knowing that option 4 suggests folding the diaper above the cord should assist in directing you to this option because the cord could become saturated and contaminated with urine with this method of diapering. Review concepts related to cord care if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 521). Philadelphia: W.B. Saunders. Reference: Wong, D., Perry, S., Hockenberry, M., et al. (2006). Maternal child nursing care (3rd ed., pp. 762-763). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

2030) A nurse in the health care clinic is preparing to perform an otoscopic examination on an adult client. In performing the examination, the nurse should: a. Position the client lying flat on the side of the ear to be examined. b. Pull the ear lobe down and back before inserting the speculum. c. Tilt the client's head forward before inserting the speculum. d. Pull the pinna up and back before inserting the speculum. Source: Saunders 4th

ANS: D Rationale: The correct procedure for performing an otoscopic examination on an adult is to pull the pinna up and back to allow visualization of the external canal while slowly inserting the speculum. The nurse would tilt the client's head slightly away and hold the otoscope upside down as if it were a large pen. The examination would be performed with the client in a sitting position. If the client were lying on the side to be examined, examination of the affected ear would not be possible. Strategy: Use the process of elimination, noting the strategic word adult in the question. Use knowledge regarding the administration of ear medications to assist in directing you to the correct option because these procedures are comparative or alike. If you had difficulty with this question, review this assessment technique. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1116-1117). Philadelphia: W.B. Saunders. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., p. 350). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

1809) A client is being seen in the clinic for symptoms of hyperinsulinism. The nurse provides information to the client regarding dietary measures for the condition. Which of the following diets would be appropriate to suggest to the client? a. Low-fiber, high-fat diet b. Limiting food intake to two meals per day c. Large amounts of carbohydrates between low protein meals d. Small frequent meals with protein, fat, and carbohydrates at each meal Source: Saunders 4th

ANS: D Rationale: The definition of hyperinsulinism is an excessive insulin secretion in response to consuming carbohydrate-rich foods. This leads to hypoglycemia. It is often treated with a diet that provides for limited stimulation of the pancreas. Carbohydrates can produce a rapid rise in blood glucose levels. However, carbohydrates are necessary in the diet. Proteins do not stimulate insulin secretion. Fats are needed in the diet to provide calories. The best diet for hyperinsulinism will contain proteins and fats whenever carbohydrates are consumed. Diets high in soluble fiber may be beneficial. Strategy: Knowledge regarding the causes of hyperinsulinism and knowledge regarding basic dietary needs will assist in answering this question. Eliminate option 1 because this option suggests a high-fat diet, which would promote obesity and other health problems. Eliminate option 2 because this option would provide for long periods of fasting, which could lead to hypoglycemic episodes. Option 3 would increase insulin secretion and worsen the problem of hyperinsulinism. Review dietary measures for the client with hyperinsulinism if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., pp. 937-938). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 781-783). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1020) A nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome? a. Bilateral wheezing b. Inspiratory crackles c. Intercostal retractions d. Increased respiratory rate Source: Saunders 4th

ANS: D Rationale: The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles. Strategy: Use the process of elimination, noting the strategic word earliest. Eliminate option 3 first because intercostal retraction is a later sign of respiratory distress. Of the remaining options, recall that adventitious breath sounds (options 1 and 2) would occur later than an increased respiratory rate. Review the early signs of acute respiratory distress syndrome if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 1839-1840). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1669) The pregnant client who is anemic tells the nurse that she is concerned about her baby's condition following delivery. Which nursing response would best support the client? a. "You will not have any problems if you follow all the advice the doctor has given you." b. "Your baby will need to spend a few days in the neonatal intensive care unit following delivery." c. "Don't worry about your baby; complications are rare." d. "The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential." Source: Saunders 4th

ANS: D Rationale: The effects of maternal iron deficiency anemia on the developing fetus and neonate are unclear. In general, it is believed that the fetus will receive adequate maternal stores of iron, even if a deficiency is present. Neonates of severely anemic mothers have been reported to experience reduced red cell volume, hemoglobin level, and iron stores. Options 1 and 3 provide false reassurance to the client. Option 2 will cause further concern in the client. Option 4 provides the most realistic support for the client and allows the nurse an opportunity to review the client's plan of care to clarify information and reassure the mother. Strategy: Use the process of elimination and therapeutic communication techniques to answer the question. Eliminate options 1 and 3 because these options provide false reassurance to the client. Eliminate option 2 next, because this response will cause further concern in the client. If you had difficulty with this question, review therapeutic communication technique and the effects of maternal anemia on the fetus. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., pp. 379, 920). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1118) A home care nurse is making a routine visit to a client receiving digoxin (Lanoxin) in the treatment of heart failure. The nurse would particularly assess the client for which of the following? a. Diarrhea and hypotension b. Fatigue and muscle twitching c. Thrombocytopenia and weight gain d. Anorexia, nausea, and visual disturbances Source: Saunders 4th

ANS: D Rationale: The first signs and symptoms of digoxin toxicity in adults include abdominal pain, nausea, vomiting, visual disturbances (blurred, yellow, or green vision, halos around lights), bradycardia, and other dysrhythmias. Options 1, 2, and 3 are unrelated to digoxin therapy. Strategy: Use the process of elimination, noting that the client is receiving digoxin. Recalling the signs of digoxin toxicity will direct you to option 4. Review these signs if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 762). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

10) A nurse educator asks a student to list the five categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine (NCCAM), to a group of nursing students. Which of the following, if stated by the nursing student, would indicate an understanding of the five categories of CAM? a. Herbology, hydrotherapy, acupuncture, nutrition, and chiropractic care b. Mind-body medicine, traditional Chinese medicine, homeopathy, naturopathy, and healing touch c. Biologically based practices, body-based practices, magnetic therapy, massage therapy, and Trager body work d. Whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine Source: Saunders 4th

ANS: D Rationale: The five categories of complementary and alternative medicine (CAM) include whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine. The other options contain therapies within each category of CAM. Strategy: Use knowledge of the five categories of CAM to assist in answering this question. Noting that the question asks about categories, not therapies, will assist in answering correctly. Review CAM if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 95-97). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 913-915). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1637) Which of the following fluids would be appropriate for a client who may be experiencing excess fluid volume secondary to congestive heart failure? a. 0.9% normal saline b. 0.45% normal saline c. Lactated Ringer's solution d. 5% dextrose in 0.9% normal saline Source: Saunders 4th

ANS: D Rationale: The fluid of choice for a client with excess fluid volume is a hypertonic solution of 5% dextrose in 0.9% normal saline. This solution would pull fluid into the intravascular space; the kidneys could then excrete the excess fluid. The 0.45% normal saline solution is hypotonic. The lactated Ringer's and 0.9% normal saline solutions are both isotonic solutions. Strategy: Use the process of elimination and focus on the subject of the question, excess fluid volume. Recall that a hypertonic solution (5% dextrose in 0.9% normal saline) would pull fluid into the intravascular space for excretion from the body. Review the different solutions and their classification of tonicity if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 356). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2600) A nurse is performing an assessment on a client admitted to the nursing unit with a diagnosis of brain attack (stroke). On assessment, the nurse notes that the client is unable to understand spoken language. The nursing care plan will reflect that the client probably experienced impairment of: a. The frontal lobe and optic nerve tracts b. Concept formation and abstraction c. The occipital lobe d. The auditory association areas Source: Saunders 4th

ANS: D Rationale: The frontal lobe controls voluntary muscle activity including speech, and an impairment can result in expressive aphasia. The parietal lobe contains association areas for concept formation, abstraction, spatial orientation, body and object size and shape, and tactile sensation. The occipital lobe contains areas related to vision. Auditory association and storage areas are located in the temporal lobe and relate to understanding the spoken language. Strategy: Use the process of elimination. Focusing on the strategic words unable to understand spoken language will direct you to option 4. Review assessment of the client with a stroke if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1042). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

130) A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which of the following intravenous solutions will most likely be prescribed to increase intravascular volume, replace immediate blood loss, and increase blood pressure? a. 0.45% sodium chloride b. 0.33% sodium chloride c. 0.225% sodium chloride d. Lactated Ringer's solution Source: Saunders 4th

ANS: D Rationale: The goal of therapy with this client is to expand intravascular volume as quickly as possible. Lactated Ringer's (hypertonic solution) would increase intravascular volume and immediately replace lost fluid volume until a transfusion could be administered, resulting in an increase in the client's blood pressure. The solutions in options 1, 2, and 3 would not be given to this client because they are hypotonic solutions and, instead of increasing intravascular space, the solutions would move into the cells via osmosis. Strategy: Focus on the data in the question, noting that the client requires increased intravascular volume. Recalling IV fluid types and how hypotonic and hypertonic solutions function within the intravascular space will direct you to the correct option. Review these types of IV fluids if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 715). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

110) A client is receiving nutrition by means of parenteral nutrition (PN). A nurse monitors the client for complications of the therapy and assesses the client for which of the following signs of hyperglycemia? a. Fever, weak pulse, and thirst b. Nausea, vomiting, and oliguria c. Sweating, chills, and abdominal pain d. Weakness, thirst, and increased urine output Source: Saunders 4th

ANS: D Rationale: The high glucose concentration in PN places the client at risk for hyperglycemia. Signs of hyperglycemia include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul's respirations, diuresis, and coma, when hyperglycemia is severe. If the client has these symptoms, the blood glucose level should be checked immediately. Options 1, 2, and 3 do not identify signs specific to hyperglycemia. Strategy: Use the process of elimination. Remember that for an option to be correct, all of the parts of that option must be correct. Begin to answer this question by eliminating options 1 and 3 because chills and fever are indicative of infection. Choose option 4 over option 2 because the client with hyperglycemia has increased urine output rather than decreased urine output. Review the signs of hyperglycemia if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., p. 1050). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2250) Bethanechol chloride (Urecholine) by injection is prescribed for the client with urinary retention. The nurse anticipates that this medication will be prescribed by which of the following routes? a. Intravenously b. Intramuscularly c. Intradermally d. Subcutaneously Source: Saunders 4th

ANS: D Rationale: The injectable form of bethanechol chloride is intended for subcutaneous administration only. Bethanechol must never be injected intramuscularly or intravenously because the resulting high drug level can cause severe toxicity, resulting in bloody diarrhea, bradycardia, profound hypotension, and cardiovascular collapse. Strategy: Knowledge regarding the route of administration of this medication is required to answer this question. Remember that this medication is administered subcutaneously. Review this content if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 135). Philadelphia: W.B. Saunders. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 283). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 99). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1180) The client is scheduled for an intravenous pyelogram. Before the test, the priority nursing action would be to: a. Restrict fluids. b. Administer a sedative. c. Administer an oral preparation of radiopaque dye. d. Determine a history of iodine or seafood allergies. Source: Saunders 4th

ANS: D Rationale: The iodine-based dye used during intravenous pyelography can cause allergic reactions such as itching, hives, rash, a tight feeling in the throat, shortness of breath, and bronchospasm. Assessing for allergies is the priority. Strategy: Use the process of elimination and note the strategic word priority in the question. Use the steps of the nursing process as a guide. Options 1, 2, and 3 address implementation. Option 4 is the only option that addresses assessment. Review preprocedure care for the client undergoing intravenous pyelography if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 696). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

2410) A nurse is assessing the renal function of a client at risk for renal failure. After noting the amount of urine output and urine characteristics, the nurse then proceeds to assess which of the following as the best indirect indicator of renal status? a. Jugular vein distention b. Level of consciousness c. Apical heart rate d. Blood pressure Source: Saunders 4th

ANS: D Rationale: The kidneys normally receive 20% to 25% of the cardiac output, even under conditions of rest. For kidney function to be optimal, adequate renal perfusion is necessary. Perfusion can best be estimated by the blood pressure, which is an indirect reflection of the adequacy of cardiac output. The heart rate affects the cardiac output but can be altered by factors unrelated to kidney function. Jugular vein distention and level of consciousness are unrelated items. Strategy: Use the process of elimination. Focusing on the subject of the question, best indirect indicator of renal status, will assist in directing you to option 4. Review assessment of renal function if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1661). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2449) The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which of the following? a. Excessive secretions b. The presence of a mucous plug c. Kinks in the ventilator tubing d. Displacement of the endotracheal tube Source: Saunders 4th

ANS: D Rationale: The low-exhaled volume alarm will sound if the client does not receive the preset tidal volume. Possible causes of inadequate tidal volume include disconnection of the ventilator tubing from the artificial airway, a leak in the endotracheal or tracheostomy cuff, displacement of the endotracheal tube or tracheostomy tube, and disconnection at any location of the ventilator parts. Options 1, 2, and 3 would cause the high-pressure alarm to sound. Strategy: Note the strategic words low-exhaled volume alarm in the question. Use the process of elimination, thinking about the causes of low exhaled volume to direct you to option 4. If you are unfamiliar with the causes of ventilator alarms, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 667). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2360) A clinic nurse is caring for a client with a diagnosis of scabies who has just been prescribed crotamiton (Eurax). The nurse instructs the client to do which of the following when applying this medication? a. Apply the medication to the entire body, avoiding the skin folds and creases, and wash it off in 12 hours. b. Apply the medication to the entire body, washing it off after 2 hours. c. Apply the application to the entire body, leave it on for 24 hours, and then take a cleansing bath. d. Massage the medication into the skin from the chin downward; apply a second application in 24 hours, followed by a cleansing bath 48 hours after the second application. Source: Saunders 4th

ANS: D Rationale: The medication is massaged into the skin of the entire body, starting with the chin and working downward. The head and face are treated only if needed. Special attention should be given to skin folds and creases. Contact with eyes, mucous membranes, and any region of inflammation should be avoided. A second application is made 24 hours after the first. A cleansing bath should be taken 48 hours after the second application; if needed, treatment can be repeated in 7 days. Strategy: Read each option carefully and use the process of elimination. Eliminate options 1, 2, and 3 because of the words entire body. Also, option 1 is eliminated because skin folds and creases would not be avoided. Review client teaching points related to this medication if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 1141). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1227) The nurse is developing a plan of care for the client scheduled for cataract surgery. The nurse documents which most appropriate nursing diagnosis in the plan of care? a. Anxiety b. Self-care deficit c. Nutrition, imbalanced d. Sensory perception, disturbed Source: Saunders 4th

ANS: D Rationale: The most appropriate nursing diagnosis for the client scheduled for cataract surgery is Sensory perception, disturbed (visual) related to lens extraction and replacement. Although options 1, 2, and 3 identify nursing diagnoses that may be appropriate, they are not related specifically to cataract surgery. Strategy: Use the process of elimination. When asked questions regarding a nursing diagnosis, use the information presented in the question to select an option. Remember that disorders of the eye or ear relate to sensory perceptual alterations. Review care of the client scheduled for cataract surgery if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1094). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

2554) A client has been diagnosed with polycystic kidney disease. On assessment of the client, the nurse will look for which of the following as the most common manifestation of this disorder? a. Headache b. Complaints of low pelvic pain c. Hypotension d. Flank pain and hematuria Source: Saunders 4th

ANS: D Rationale: The most common findings with polycystic kidney disease are hematuria and flank or lumbar pain that is either colicky in nature or dull and aching. Other common findings include proteinuria, calculi, uremia, and palpable kidney masses. Hypertension is another common finding and may be associated with cardiomegaly and heart failure. The client may complain of a headache, but this is not a specific assessment finding in polycystic kidney disease. Strategy: Focus on the strategic words most common. Note the relationship between the word kidney in the name of the disorder and the word flank in the correct option. Review the manifestations of polycystic kidney disease if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1708). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2404) The parents bring their child to the emergency department and tell the nurse that the child has been complaining of colicky abdominal pain located in the lower right quadrant of the abdomen. The nurse suspects that the child has which of the following disorders? a. Peritonitis b. Hirschsprung's disease c. Intussusception d. Appendicitis Source: Saunders 4th

ANS: D Rationale: The most common symptom of appendicitis is a colicky, periumbilical, or lower abdominal pain located in the right quadrant. The classic signs and symptoms of intussusception are acute, colicky abdominal pain with currant jelly-like stools. Clinical manifestations of Hirschsprung's disease include constipation, abdominal distention, and ribbon-like, foul-smelling stools. Peritonitis is a complication that can follow perforation or intestinal obstruction. Strategy: Focus on the strategic words lower right quadrant. Use concepts of anatomy and recall that the appendix is located in the lower right quadrant. Review the clinical manifestations associated with appendicitis if you had difficulty with this question. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., p. 1404). St. Louis: Mosby. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 858). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Child Health Alternate Question Types -> Multiple Choice

1278) The client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? a. Strict adherence to a bowel retraining program b. Keeping the linen wrinkle-free under the client c. Preventing unnecessary pressure on the lower limbs d. Limiting bladder catheterization to once every 12 hours Source: Saunders 4th

ANS: D Rationale: The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and Foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas. Strategy: Use the process of elimination. Remember that autonomic dysreflexia is caused by noxious stimuli to the bowel, bladder, or skin. With this in mind, you can eliminate easily each of the incorrect options. Review the measures to minimize the risk of autonomic dysreflexia if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 987-988). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1012) A female client is scheduled to have a chest radiograph. Which of the following questions is of most importance to the nurse assessing this client? a. "Can you hold your breath easily?" b. "Are you wearing any metal chains or jewelry?" c. "Are you able to hold your arms above your head?" d. "Is there any possibility that you could be pregnant?" Source: Saunders 4th

ANS: D Rationale: The most important item to ask about is the client's pregnancy status because pregnant women should not be exposed to radiation. Clients also are asked to remove any chains or metal objects that could interfere with obtaining an adequate film. A chest radiograph most often is obtained at full inspiration, which gives optimal lung expansion. If a lateral view of the chest is ordered, the client is asked to raise the arms above the head. Most films are done in a posterior-anterior view. Strategy: Note the strategic words most important. Eliminate options 1 and 3 first, because they can be determined by the radiological technologist. Option 4 is a higher priority than option 2 because of potential negative teratogenic consequences to the fetus. Review client preparation for a chest radiograph if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 360). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

2093) A nurse is preparing to teach a client who has just had a urinary diversion about ostomy care. The client has a nursing diagnosis of disturbed body image. The nurse determines that the client is making the best initial positive adaptation if the client: a. Asks to defer ostomy care to the spouse b. Asks to wait 1 more day before beginning to learn ostomy care c. States that ostomy care is the nurse's job while the client is in the hospital d. Agrees to look at the ostomy Source: Saunders 4th

ANS: D Rationale: The most positive initial step in learning to care for an ostomy and to accept it as a part of the self is to be able to look at the ostomy. Once the client is able to look at the ostomy and touch it, learning about ostomy care can then proceed more successfully. Each of the other options indicates a deferral or refusal on the part of the client, which makes them less than optimal choices. Strategy: Use the process of elimination. Note the strategic words best initial positive. Options 2 and 3 do not illustrate adaptation in any way and are eliminated first. Option 4 is an action on the part of the client, whereas option 1 is still a refusal to participate in any way in ostomy care. Review the client behaviors that indicate adaptation to a disturbed body image if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 837). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1853) A nurse is providing discharge instructions to the mother of a child who had a cleft palate repair. Which of the following statements should the nurse make to the mother? a. "You should use a plastic spoon to feed the child." b. "You need to monitor the child's temperature for signs of infection using an oral thermometer." c. "You can allow the child to use a pacifier but only for 30 minutes at a time." d. "You need to use a short nipple on the child's bottle." Source: Saunders 4th

ANS: D Rationale: The mother should be instructed that straws, pacifiers, spoons, or fingers must be kept away from the child's mouth for 7 to 10 days after surgery. Additionally, the mother should be advised to avoid taking oral temperatures. A short nipple should be placed on the child's bottle and the mother should be instructed to give the child baby food or baby food mixed with water. A pacifier should not be used for at least 2 weeks following the surgical repair. Strategy: Use the process of elimination. Consider the anatomical location of the surgical procedure to assist in directing you to option 4. If you had difficulty with this question, review the client teaching points following a cleft palate repair surgery. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., pp. 459, 462-464). St. Louis: Mosby. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 876). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

1547) The child with croup is being discharged from the hospital. The nurse provides instructions to the mother and advises the mother to bring the child to the emergency room if the child: a. Appears tired. b. Takes fluids poorly. c. Is irritable. d. Develops stridor. Source: Saunders 4th

ANS: D Rationale: The mother should be instructed to bring the child to the emergency room if the child develops stridor at rest, cyanosis, severe agitation or fatigue, or moderate to severe retractions, or is unable to take oral fluids. Strategy: Use the ABCs, airway, breathing and circulation, to direct you to option 4. If you had difficulty with this question, review home care instructions for the child with croup. Reference: Wong, D., Perry, S., Hockenberry, M., et al. (2006). Maternal child nursing care (3rd ed., p. 802). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

2561) A nurse is performing an assessment on a client who was admitted to the hospital with a diagnosis of carbon monoxide poisoning. Which of the following assessments performed by the nurse would primarily elicit data related to a deterioration of the client's condition? a. Skin color b. Apical rate c. Respiratory rate d. Level of consciousness Source: Saunders 4th

ANS: D Rationale: The neurological system is primarily affected by carbon monoxide poisoning. With high levels of carbon monoxide, the neurological status progressively deteriorates. Although options 1, 2, and 3 would be a component of the assessment of the client with carbon monoxide poisoning, assessment of the neurological status of the client would elicit data specific to a deterioration in the client's condition. Strategy: Note the strategic word primarily in the question, and use the process of elimination. Recalling that carbon monoxide depresses the nervous system will direct you to option 4. Review the effects of carbon monoxide poisoning if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1628-1629). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

76) A client is brought to the emergency room stating that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to do which of the following next? a. Prepares to administer an antidote b. Draws a sample for type and crossmatch and transfuse the client c. Draws a sample for an activated partial thromboplastin time (aPTT) level d. Draws a sample for prothrombin (PT) and international normalized ratio (INR) level Source: Saunders 4th

ANS: D Rationale: The next action is to draw a sample for PT and INR level to determine the client's anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client if an antidote (vitamin K) or blood transfusion is needed. The aPTT monitors the effects of heparin therapy. Strategy: Use a process of elimination. Eliminate option 3 because it is unrelated to warfarin therapy and relates to heparin therapy. Next, eliminate options 1 and 2 because these therapies would not be implemented unless the PT and INR levels are known. Review care to the client receiving warfarin therapy and the purpose of the PT and INR if you had difficulty with this question. Reference: Lehne, R.A. (2004). Pharmacology for nursing care (5th ed., p. 552). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2412) A nurse caring for a client with a head injury is monitoring the client for signs of increased intracranial pressure. The nurse reviews the record and notes that the cerebrospinal fluid (CSF) pressure is averaging 8 mm Hg. The nurse analyzes these results as: a. Increased b. Borderline c. Compensating d. Normal Source: Saunders 4th

ANS: D Rationale: The normal CSF pressure is 5 to 10 mm Hg. A pressure of 8 mm Hg is within normal range. Strategy: Recalling that the normal CSF pressure is 5 to 10 mm Hg will direct you to option 4. Review assessment of CSF pressure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 943). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

87) A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin (aPTT) time is 65 seconds. The client's baseline before the initiation of therapy was 30 seconds. The nurse anticipates that which action is needed? a. Discontinuing the heparin infusion b. Increasing the rate of the heparin infusion c. Decreasing the rate of the heparin infusion d. Leaving the rate of the heparin infusion as is Source: Saunders 4th

ANS: D Rationale: The normal activated partial thromboplastin time (aPTT) varies between 20 and 36 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal. Thus, the client's aPTT is within the therapeutic range, and the dose should remain unchanged. Strategy: To answer this question accurately, you must be familiar with the normal aPTT level and the therapeutic level needed following institution of heparin therapy. Remember that the normal range is 20 to 36 seconds and that the aPTT should be between 1.5 and 2.5 times normal when the client is receiving heparin therapy. If this question was difficult, review this laboratory test and the expected level if the client is receiving heparin. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., pp. 138-140). Philadelphia: W.B. Saunders. Reference: Gahart, B., & Nazareno, A. (2006). 2006 intravenous medications (22nd ed., p. 633). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1770) The nurse is caring for a client whose magnesium level is 3.5 mg/dL. Which assessment sign or symptom would the nurse most likely expect to note in the client based on this magnesium level? a. Tetany b. Twitches c. Positive Trousseau's sign d. Loss of deep tendon reflexes Source: Saunders 4th

ANS: D Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A client with a magnesium level of 3.5 mg/dL is experiencing hypermagnesemia. Assessment signs and symptoms include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau's sign are seen in a client with hypomagnesemia. Strategy: First, it is necessary to determine that the client is experiencing hypermagnesemia. Next, use the process of elimination, noting that options 1, 2, and 3 are comparative or alike in that they reflect neurological excitability. If you had difficulty with this question, review the assessment signs and symptoms of magnesium imbalance. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 630). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1918) A client is undergoing diagnostic tests to rule out a diagnosis of renal disease.<br/>The laboratory results indicate a ratio of blood urea nitrogen (BUN) to creatinine of 15:1. <br/>The nurse determines that this result indicates: a. A fluid volume deficit b. Liver failure c. A fluid volume excess d. A normal ratio Source: Saunders 4th

ANS: D Rationale: The normal ratio of BUN to creatinine is approximately 10:1 to 15:1. A value lower than 10:1 would indicate diminished urea concentration. A value greater than 15:1 would indicate inadequate renal function. Strategy: It is necessary to know the normal ratio of BUN to creatinine to answer the question. Recall that the normal ratio is 10:1 to 15:1. Review the normal values and the importance of this test in relation to kidney function if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 256). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

58) A nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the physician and the physician prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid? a. Peas b. Cauliflower c. Low-fat yogurt d. Processed oat cereals Source: Saunders 4th

ANS: D Rationale: The normal serum sodium level is 135 to 145 mEq/L. A serum sodium level of 150 mEq/L indicates hypernatremia. Based on this finding, the nurse would instruct the client to avoid foods high in sodium. Low-fat yogurt, cauliflower, and peas are good food sources of phosphorus. Processed foods are high in sodium content. Strategy: First, you must determine that the client has hypernatremia. Next, note the strategic word avoid in the question. Eliminate options 1 and 2 first because these are vegetables. From the remaining options, note the word processed in option 4. Processed foods tend to be higher in sodium content. Review foods high in sodium content if you had difficulty with this question. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed., p. 609). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2137) A client being mechanically ventilated after experiencing a fat embolism is visibly anxious. The nurse should: a. Encourage the client to sleep until arterial blood gas results improve. b. Ask a family member to stay with the client at all times. c. Ask the physician for an order for succinylcholine. d. Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed. Source: Saunders 4th

ANS: D Rationale: The nurse always speaks to the client calmly and provides reassurance to the anxious client. Morphine sulfate often is prescribed for pain and anxiety in the client receiving mechanical ventilation. In option 1, the nurse does nothing to reassure or help the client. Family members also are stressed, not just because of the complication but because of the original injury. It is not beneficial to ask the family to take on the burden of remaining with the client at all times. Succinylcholine (option 3) is a neuromuscular blocker but has no antianxiety properties. Strategy: Use the process of elimination and knowledge of the therapeutic interventions that will reassure the client. Focusing on this subject and noting the relationship between the words anxious in the question and reassurance in option 4 will direct you to the correct answer. Review therapeutic interventions for the client on a mechanical ventilator if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1891). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 60, 663). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2405) A nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which of the following to obtain the assessment data? a. Turn the flashlight on directly in front of the eye and watch for a response. b. Check pupil size; then ask the client to alternate looking at the flashlight and the examiner's finger. c. Instruct the client to look straight ahead; then shine the flashlight from the temporal area to the eye. d. Ask the client to follow the flashlight through the six cardinal positions of gaze. Source: Saunders 4th

ANS: D Rationale: The nurse asks the client to follow the flashlight through the six cardinal positions of gaze to assess for eye movement related to cranial nerves III, IV, and VI. Option 2 assesses accommodation of the eye. Options 1 and 3 relate to pupillary response to light. Also, shining the light directly into the client's eye without asking the client to focus on a distant object is not an appropriate technique. Strategy: Focus on the subject of the question, assessing eye movement. Note the relationship between this topic and the words six cardinal positions of gaze in the correct option. Review the techniques for assessing cranial nerves III, IV, and VI if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 931-939). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1648) The 32-year-old female client has a history of fibrocystic disorder of the breasts. The nurse interviewing the client asks whether the breast lumps are more noticeable: a. In the spring months b. In the autumn c. After menses d. Before menses Source: Saunders 4th

ANS: D Rationale: The nurse assesses the client with fibrocystic breast disorder for worsening of symptoms (breast lumps, painful breasts, and possible nipple discharge) before the onset of menses. This is associated with cyclical hormone changes. Strategy: Use the process of elimination. Note the strategic words more noticeable. This implies that there is a predictable variation in symptoms. Use knowledge of the effects of various hormones in the body to select the correct option. Review the characteristics of fibrocystic breast disease if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1792). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

2439) A nurse is preparing a plan of care for a client in skeletal leg traction with an overbed frame. Which of the following nursing interventions should be included in the plan of care to best assist the client with self-positioning in bed? a. Encourage the client to push with the unaffected leg on the bed mattress to help with repositioning. b. Use the assistance of four nurses to reposition the client. c. Place a draw sheet on the mattress for pulling the client up in bed. d. Place a trapeze on the bed frame to provide a means for the client to lift the hips off the bed. Source: Saunders 4th

ANS: D Rationale: The nurse can best assist the client in skeletal traction with repositioning by providing a trapeze on the bed frame for the client's use. Encouraging the client to push with the unaffected leg on the bed mattress for repositioning may cause skin breakdown on the unaffected heel area. Although a draw sheet is helpful and client movement may be more easily facilitated with four nurses, these actions will not promote repositioning by the client. Strategy: Focus on the strategic words to best assist the client with self-positioning. Eliminate options 2 and 3 first because they are comparative or alike. Next, eliminate option 1 because this action may cause an alteration in skin integrity. If you had difficulty with this question, review care of the client in skeletal traction. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 637). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2458) A nurse provides discharge instructions to a client after patch testing. Which of the following instructions will be included on the discharge sheet for the client? a. Return to the clinic in 2 weeks for the initial reading. b. Reapply the patch if it comes off. c. All activities can be continued. d. Keep the test sites dry. Source: Saunders 4th

ANS: D Rationale: The nurse instructs the client to keep the test sites dry at all times. The nurse also discourages excessive physical activity that will result in sweating. If the client reapplies patches that come loose, this can interfere with an accurate interpretation of the allergic reactions. The nurse reinforces the necessity of removing loose or nonadherent test patches for reapplication at a later date. The initial reading is performed 2 days after application, and the final reading is performed 2 to 5 days later. Strategy: Use the process of elimination. Eliminate option 1 because of the time frame. Eliminate option 3 because of the word all. Regarding the remaining options, recalling that the test site needs to remain dry will assist in directing you to option 4. If you had difficulty with this question, review the client teaching points after a patch test. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 462). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

41) The nurse is giving a bed bath to an assigned client when a nursing assistant enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The appropriate nursing action is which of the following? a. Finish the bed bath and then administer the pain medication to the other client. b. Ask the nursing assistant to find out when the last pain medication was given to the client. c. Ask the nursing assistant to tell the client in pain that medication will be administered as soon as the bed bath is complete. d. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. Source: Saunders 4th

ANS: D Rationale: The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the nursing assistant. Strategy: Use the process of elimination and principles related to priorities of care. Options 1 and 3 delay the administration of pain medication, and option 2 is not a responsibility of the nursing assistant. The appropriate action is to plan to administer the medication. Review principles related to priorities of care if you had difficulty with this question. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., p. 4). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 267-268, 1030). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

1536) The nurse provides instructions regarding home care to the parents of a 3-year-old child hospitalized with hemophilia. Which statement, if made by the parent, indicates a need for further instructions? a. "We will supervise the child closely." b. "We will pad corners of the furniture." c. "We will remove household items that can easily fall over." d. "We will avoid having the child receive immunizations and cancel the scheduled dental appointments." Source: Saunders 4th

ANS: D Rationale: The nurse needs to stress the importance of immunizations, dental hygiene, and routine well-child care. Options 1, 2, and 3 are appropriate. The parents are also instructed in the measures to implement in the event of blunt trauma, especially trauma involving the joints, and to apply prolonged pressure to superficial wounds until the bleeding has stopped. Strategy: Use the process of elimination. Note the strategic words indicates a need for further instructions. These words indicate a negative event query and ask you to select an option that is incorrect. Knowledge that bleeding is a concern in this disorder will assist in eliminating options 1, 2, and 3, which include measures of protection and safety for the child. If you had difficulty with this question, review home care instructions for the child with hemophilia. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1319). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

953) The client has undergone esophagogastroduodenoscopy. The nurse places highest priority on which item as part of the client's care plan? a. Monitoring the temperature b. Monitoring complaints of heartburn c. Giving warm gargles for a sore throat d. Assessing for the return of the gag reflex Source: Saunders 4th

ANS: D Rationale: The nurse places highest priority on assessing for return of the gag reflex. This assessment addresses the client's airway. The nurse also monitors the client's vital signs and for a sudden increase in temperature, which could indicate perforation of the gastrointestinal tract. This complication would be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the client's airway is the priority. Strategy: Use the ABCs—airway, breathing, and circulation. Note the strategic words highest priority. Option 4 addresses the airway. Review care of the client following esophagogastroduodenoscopy if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1244). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 963). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

2048) A nurse is developing a plan of care for a client with dysphagia following a brain attack (stroke). Which of the following is an inappropriate intervention to include in the plan of care for this client? a. Thicken liquids. b. Provide ample time for the client to chew and swallow. c. Assess for the presence of a swallow reflex. d. Place the food on the affected side of the mouth. Source: Saunders 4th

ANS: D Rationale: The nurse should assess for gag and swallowing reflexes before the client with dysphagia is started on a diet. The nurse should assist the client with eating and place food on the unaffected side of the mouth. The client should be allowed ample time to chew and swallow to prevent choking. Liquids are thickened to prevent aspiration. Strategy: Use the process of elimination, noting the strategic word inappropriate in the question. This indicates a negative event query and directs you to select an incorrect intervention. Recalling that the client is at risk for aspiration will assist in directing you to the correct option. If you had difficulty with this question, review care of the client with dysphagia. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2129). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

134) A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that the client has developed phlebitis. The nurse avoids which action in the care of this client? a. Notifies the physician. b. Applies warm moist packs to the site. c. Discontinues the IV catheter at that site. d. Starts a new IV line in a proximal portion of the same vein. Source: Saunders 4th

ANS: D Rationale: The nurse should discontinue the IV at the phlebitic site and apply warm moist compresses to the area to speed resolution of the inflammation. Because phlebitis has occurred, the nurse also notifies the physician about the IV complication. The nurse should restart the IV in a vein other than the one that has developed phlebitis. Strategy: Use the process of elimination and note the strategic word avoids. This tells you that the correct option is an incorrect nursing action. Recalling that the nurse should restart the IV in a vein other than the one that has developed phlebitis will direct you to option 4. Review nursing interventions related to phlebitis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 260). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1173). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1208) Phenazopyridine hydrochloride (Pyridium) is prescribed for a client for symptomatic relief of pain resulting from a lower urinary tract infection. The nurse teaches the client: a. To take the medication at bedtime b. To take the medication before meals c. To discontinue the medication if a headache occurs d. That a reddish orange discoloration of the urine may occur Source: Saunders 4th

ANS: D Rationale: The nurse should instruct the client that a reddish-orange discoloration of urine may occur. The nurse also should instruct the client that this discoloration can stain fabric. The medication should be taken after meals to reduce the possibility of gastrointestinal upset. A headache is an occasional side effect of the medication and does not warrant discontinuation of the medication. Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are comparative or alike in that they address time schedules for the administration of the medication. From the remaining options, eliminate option 3 because the nurse would not advise the client to discontinue this medication. Review client instructions regarding this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 919). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1689) The nurse has provided instructions for the mother at risk for thrombosis regarding measures to prevent its occurrence. Which of the following statements, if made by the mother, indicates a need for further education? a. "I should perform regularly scheduled exercise such as walking." b. "I should avoid prolonged standing or sitting in one position." c. "I should avoid using pillows under my knees to prevent pressure in the back of my knee area." d. "I should apply my antiembolism stockings two hours after arising in the morning." Source: Saunders 4th

ANS: D Rationale: The nurse should instruct the client to apply antiembolism stockings before the client rises in the morning to prevent the venous congestion that will begin as soon as the mother gets up. Circulation can be improved with a regular schedule of activity, preferably walking, and the mother should be instructed to avoid prolonged standing or sitting in one position. The mother should also be encouraged to maintain a fluid intake of at least 2500 mL/day to prevent dehydration and consequent sluggish circulation. Strategy: Use the process of elimination. Note the strategic words need for further education. These words indicate a negative event query and ask you to select an option that is incorrect. Knowledge regarding the application of antiembolism stockings will assist in directing you to option 4. If you had difficulty with this question, review measures to prevent thrombosis in the postpartum woman. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 743). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

1889) A home care nurse is providing safety instructions to the mother of a child with hemophilia. Which of the following instructions should the nurse provide to the mother to promote a safe environment for the child? a. Allow the child to play indoors only and to avoid any outdoor play or playgrounds. b. Place a helmet and elbow pads on the child every day as soon as the child awakens. c. Allow the child to use play equipment only when a parent is present. d. Eliminate any toys with sharp edges from the child's play area. Source: Saunders 4th

ANS: D Rationale: The nurse should instruct the mother to remove toys with sharp edges that may cause potential injury. Requiring that the child wear a helmet and elbow pads immediately on awakening and throughout the day is not necessary; however, these items should be worn during activities that could cause injury. It is not necessary that the child be restricted from outdoor play activity, but the activities that the child participates in should be monitored. It is not necessary to restrict play if safety measures have been implemented. Strategy: Use the process of elimination. Eliminate options 1 and 3 first because of the close-ended word only. Next, eliminate option 2 because of the close-ended word every. If you had difficulty with this question, review safety measures for the child with hemophilia. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 954). St. Louis: Mosby. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1319). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

167) A nurse is giving a report to a nursing assistant who will be caring for a client who has hand restraints. The nurse instructs the nursing assistant to assess the skin integrity of the restrained hands every: a. 2 hours b. 3 hours c. 4 hours d. 30 minutes Source: Saunders 4th

ANS: D Rationale: The nurse should instruct the nursing assistant to assess restraints and skin integrity every 30 minutes. Agency guidelines regarding the use of restraints should always be followed. Strategy: Use the process of elimination. In this situation, selecting the option that identifies the most frequent time frame is best. Review the guidelines related to the use of restraints if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 45). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Leadership and Management Alternate Question Types -> Multiple Choice

1025) A nurse is teaching a client with tuberculosis about dietary elements that should be increased in the diet. The nurse suggests that the client increase intake of: a. Potatoes and fish b. Eggs and spinach c. Grains and broccoli d. Meats and citrus fruits Source: Saunders 4th

ANS: D Rationale: The nurse teaches the client with tuberculosis to increase intake of protein, iron, and vitamin C. Foods rich in vitamin C include citrus fruits, berries, melons, pineapple, broccoli, cabbage, green peppers, tomatoes, potatoes, chard, kale, asparagus, and turnip greens. Food sources that are rich in iron include liver and other meats. Less than 10% of iron is absorbed from eggs, and less than 5% is absorbed from grains and vegetables. Strategy: Use the process of elimination. Recall that the diet in tuberculosis should be high in protein, vitamin C, and iron. Knowing which types of foods contain these various nutrients will direct you to option 4. If you had difficulty with this question, review these nutritional concepts. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 644). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1101) A nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse immediately would assess which of the following items based on priority? a. Anxiety level of the client and family b. Presence of a Medic-Alert card for the client to carry c. Knowledge of restrictions of postdischarge physical activity d. Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver Source: Saunders 4th

ANS: D Rationale: The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device settings, similar to after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the device is activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver. Options 1, 2, and 3 are also nursing interventions but are not the priority. Strategy: Use Maslow's Hierarchy of Needs theory. Option 4 is the option that identifies the physiological need. Review care to the client following insertion of an automatic internal cardioverter-defibrillator if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 743, 746). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

1704) The maternity nurse is describing the ovarian cycle to a group of nursing students. The instructor asks a nursing student to identify the phases of the cycle. Which of the following, if identified as a phase of the cycle by the nursing student, indicates a need to further research this area? a. Follicular phase b. Ovulatory phase c. Luteal phase d. Proliferative phase Source: Saunders 4th

ANS: D Rationale: The ovarian cycle consists of three phases, the follicular, ovulatory, and luteal phases. The proliferative phase is a phase of the endometrial cycle. Strategy: Use the process of elimination. Note the strategic words indicates a need to further research. Also, focus on the subject of the question, the ovarian cycle. Review the phases of the ovarian cycle if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 62). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1558) The client with acute pancreatitis is experiencing severe pain from the disorder. The nurse determines that the client understands suggestions for positioning to reduce pain if the client avoids: a. Leaning forward. b. Drawing the legs up to the chest. c. Sitting up. d. Lying flat. Source: Saunders 4th

ANS: D Rationale: The pain of pancreatitis is aggravated by lying supine or by walking. This is because the pancreas is located retroperitoneally, and the edema and inflammation intensify the irritation of the posterior peritoneal wall with these positions or movements. The fetal position (with the legs drawn up to the chest) may decrease the abdominal pain of pancreatitis. Positions such as sitting up, leaning forward, and flexing the legs (especially the left leg) will also alleviate some of the pain associated with pancreatitis. Strategy: Use the process of elimination and note the strategic word avoids. Use your critical thinking skills to visualize the anatomy of the pancreas and the potential effects from stretching associated with the various positions identified in the options. Also, remember that options that are comparative or alike are not likely to be correct. This will help you eliminate options 1, 2, and 3. Review care of the client with pancreatitis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1405). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2051) A nurse is providing instructions to the client with trigeminal neuralgia regarding measures to take to prevent the episodes of pain. The nurse should instruct the client to: a. Prevent stressful situations. b. Avoid contact with people with an infection. c. Avoid activities that may cause fatigue. d. Avoid activities that may cause pressure near the face. Source: Saunders 4th

ANS: D Rationale: The pain that accompanies trigeminal neuralgia is triggered by stimulation of the trigeminal nerve. Symptoms can be triggered by pressure such as from washing the face, brushing the teeth, shaving, eating, and drinking. Symptoms also can be triggered by stimulation by a draft or cold air. Options 1, 2, and 3 are not associated with triggering episodes of pain. Strategy: Use the process of elimination and knowledge regarding the precipitating factors to answer this question. Recalling that the pain is triggered by stimulation of the trigeminal nerve will direct you to option 4. If you are unfamiliar with this disorder and the precipitating factors, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2154). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

924) The nurse instructs the ileostomy client to include which action as part of essential care of the stoma? a. Massage the area below the stoma. b. Limit fluid intake to prevent diarrhea. c. Take in high-fiber foods such as nuts. d. Cleanse the peristomal skin meticulously. Source: Saunders 4th

ANS: D Rationale: The peristomal skin must receive meticulous cleansing because ileostomy drainage has more enzymes and is more caustic to the skin than colostomy drainage. Foods such as nuts and those with seeds will pass through the ileostomy. The client should be taught that these foods will remain undigested. The area below the ileostomy may be massaged if needed if the ileostomy becomes blocked by high-fiber foods. Fluid intake should be at least six to eight glasses of water per day to prevent dehydration. Strategy: Focus on the subject and note the strategic words essential care and stoma. This tells you that the correct option deals with the stoma directly. This will direct you to option 4. Review client instructions regarding ileostomy care if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1326). Philadelphia: W.B. Saunders. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills and techniques (6th ed., pp. 1157, 1160). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2370) A client with glaucoma is given a prescription for a pilocarpine ocular system (Ocusert Pilo). The nurse plans to include which of the following instructions to the client on how to use the medication? a. Apply 1 drop of the solution four times a day. b. Remove and replace the ocular system every 48 hours. c. Apply ½ inch into the eye at bedtime. d. Check the eye each morning to make sure that the system is in place. Source: Saunders 4th

ANS: D Rationale: The pilocarpine ocular system has a bilayered membrane surrounding a reservoir of pilocarpine solution. The tiny unit, which is placed in the conjunctival sac, slowly releases medication. The unit should be changed once a week. Because the unit may fall out during sleep, the client should check the eye each morning for its presence. Strategy: Use the process of elimination. Knowing that the system remains in the eye for a period of 1 week will direct you to the correct option. If you had difficulty with this question, review this treatment for glaucoma. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 729). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

2489) A nurse is performing an assessment on a client suspected of having herpes zoster. The nurse would expect to note which type of lesions on inspection of the client's skin? a. A generalized body rash b. Small blue-white spots with a red base c. A fiery red edematous rash on the cheeks d. Clustered skin vesicles Source: Saunders 4th

ANS: D Rationale: The primary lesion of herpes zoster is a vesicle. The classic presentation is grouped vesicles on an erythematous base along a dermatome. Because they follow nerve pathways, the lesions do not cross the body's midline. Options 1, 2, and 3 are incorrect. Strategy: Use the process of elimination. Remembering that these lesions occur as grouped vesicles along a nerve pathway will direct you to option 4. If you had difficulty with this question, review the characteristics of herpes zoster lesions. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., p. 1150). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

1796) The nurse instructs a client with diabetes mellitus about blood glucose monitoring and monitoring for signs of hypoglycemia. The nurse informs the client that hypoglycemia is a blood glucose level lower than: a. 120 mg/dL b. 110 mg/dL c. 90 mg/dL d. 60 mg/dL Source: Saunders 4th

ANS: D Rationale: The principle adverse effect of insulin therapy is hypoglycemia, a blood glucose level lower than 50 to 60 mg/dL. Strategy: Use the process of elimination. Recalling the normal blood glucose level will assist in eliminating options 1, 2, and 3. If you are unfamiliar with the normal blood glucose level or the concept of hypoglycemia, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1276). Philadelphia: W.B. Saunders. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 599). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1539). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

1800) A client presents to the emergency department with upper gastrointestinal (GI) bleeding and is in moderate distress. In planning care, which nursing action would be the first priority for this client? a. Thorough investigation of precipitating events b. Insertion of a nasogastric tube and Hematest of emesis c. Complete abdominal examination d. Assessment of vital signs Source: Saunders 4th

ANS: D Rationale: The priority nursing action is to assess the vital signs. This would indicate the amount of blood loss that has occurred and also provides a baseline by which to monitor the progress of treatment. The client may not be able to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority. Strategy: Note the strategic words first priority. Use the process of elimination and the ABCs, airway, breathing, and circulation. This will direct you to option 4. Review care of the client with a GI bleed if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1024). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1946) A nurse has developed a plan of care for a client diagnosed with anorexia nervosa. Which of the following nursing diagnoses would the nurse select as the priority in the plan of care? a. Disturbed body image b. Pain related to inflamed gastric mucosa c. Deficient knowledge regarding self-care measures d. Imbalanced nutrition Source: Saunders 4th

ANS: D Rationale: The priority nursing diagnosis for the client with anorexia nervosa is imbalanced nutrition. Although the nursing diagnoses identified in options 1, 2, and 3 may be considerations in the plan of care for the client with anorexia nervosa, imbalanced nutrition is the priority. Strategy: Use the process of elimination and Maslow's Hierarchy of Needs theory to answer the question. Recalling that physiological needs are the priority will assist in eliminating options 1 and 3. From the remaining options, select option 4 over option 2 because the question presents no data indicating the presence of an inflamed gastric mucosa. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 714). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2131) A nurse teaches a client who is going to have a plaster cast applied about the procedure. Which statement by the client indicates a need for further teaching? a. "A stockinette will be placed over the leg area to be casted." b. "The cast edges may be trimmed with a cast knife." c. "The cast will give off heat as it dries." d. "I can bear weight on the cast in one half-hour." Source: Saunders 4th

ANS: D Rationale: The procedure for casting involves washing and drying the skin and placing a stockinette material over the area to be casted. A roll of padding is then applied smoothly and evenly. The plaster is rolled onto the padding, and the edges are trimmed or smoothed as needed. A plaster cast gives off heat as it dries. A plaster cast can tolerate weight bearing once it is dry, which takes from 24 to 72 hours depending on the nature and thickness of the cast. Strategy: Use the process of elimination. Note the strategic words need for further teaching. This phrasing indicates a negative event query and asks you to select an incorrect statement. Noting that the client is having a plaster cast applied will direct you to option 4. Review client instructions after application of a plaster cast if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1198). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1130) A nurse is caring for a client receiving a heparin intravenous (IV) infusion. The nurse anticipates that which laboratory study will be prescribed to monitor the therapeutic effect of heparin? a. Hematocrit b. Hemoglobin c. Prothrombin time d. Activated partial thromboplastin time Source: Saunders 4th

ANS: D Rationale: The prothrombin time will assess for the therapeutic effect of warfarin sodium (Coumadin), and the activated partial thromboplastin time (aPTT) will assess the therapeutic effect of heparin. Hematocrit and hemoglobin values assess red blood cell concentrations. Baseline assessment, including an aPTT value, should be completed, as well as ongoing daily aPTT values while the client is taking heparin. Heparin doses are determined based on the result of the aPTT. Strategy: Use the process of elimination. Eliminate options 1 and 2 because they are comparative or alike and are unrelated to heparin therapy. From the remaining options, recall the relationship between the prothrombin time and warfarin and the aPTT and heparin. Review care of a client on heparin infusion if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 intravenous medications (22nd ed., p. 637). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1458) The nurse is discharging a client with a history of command hallucinations to harm self or others. The nurse provides instructions to the client about interventions for hallucinations and anxiety and determines that the client understands the instructions if the client states: a. "My medications won't make me anxious." b. "I'll go to support group and talk so that I don't hurt anyone." c. "I won't get anxious or hear things if I get enough sleep and eat well." d. "I can call my therapist when I'm hallucinating so that I can talk about my feelings and plans and not hurt anyone." Source: Saunders 4th

ANS: D Rationale: The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. The nurse should ask the client whether he or she has intentions to hurt himself or herself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. Options 1, 2, and 3 will aid in wellness but are not specific interventions for hallucinations, if they occur. Strategy: Use the process of elimination. Options 1, 2, and 3 are interventions that a client can carry out to aid wellness. Option 4 is a specific agreement to seek help and evidences self-responsible commitment and control over one's own behavior. Review teaching points for a client with a history of hallucinations if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 211). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 402-403). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1077) A client with pulmonary edema has been on diuretic therapy. The client has an order for additional furosemide (Lasix) in the amount of 40 mg intravenous push. Knowing that the client will also be started on digoxin (Lanoxin), the nurse should review which laboratory result? a. Sodium level b. Digoxin level c. Creatinine level d. Potassium level Source: Saunders 4th

ANS: D Rationale: The serum potassium level is measured in the client receiving digoxin and furosemide. Heightened digoxin effect leading to digoxin toxicity can occur in the client with hypokalemia. Hypokalemia also predisposes the client to ventricular dysrhythmias. Strategy: Use the process of elimination. Eliminate option 2 because the client will just be beginning digoxin therapy. No data indicate the presence of renal insufficiency; therefore, eliminate option 3. Furosemide therapy can cause hyponatremia and hypokalemia, but remember that the risk of hypokalemia has more severe consequences in this situation. Review the nursing considerations related to administering furosemide if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1658). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 227, 762). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2193) A client who is on lithium carbonate (Eskalith) complains of nausea. Later that day, the client complains of drowsiness, muscle weakness, and lack of coordination. It is time for the client's 4:00 <sc>PM</sc> dose of lithium. The best nursing action is: a. Give the 4:00 <sc>PM</sc> dose as scheduled and re-educate the client that these are normal side effects of the medication. b. Give the 4:00 <sc>PM</sc> dose and document the client's complaints. c. Give the 4:00 <sc>PM</sc> dose and notify the physician of the client's complaints. d. Hold the 4:00 <sc>PM</sc> dose and notify the physician of the client's complaints. Source: Saunders 4th

ANS: D Rationale: The side effects of lithium include fine hand tremors, polyuria, mild thirst, and mild nausea. Diarrhea, vomiting, nausea, drowsiness, muscle weakness, and lack of coordination may be early signs of toxicity. The medication is withheld and the physician notified so that the client can be further evaluated to determine the presence of toxicity. Strategy: Use the process of elimination. Eliminate options 1, 2, and 3 because they are comparative or alike in that all indicate administering the medication. Review the content for this medication and the signs of toxicity if you had difficulty with this question. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 373). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2094) A home health nurse is planning to make a home visit to a client who has undergone surgical creation of an ileal conduit. The nurse plans to include which of the following considerations in ostomy care in discussions with the client? a. Cut an opening in the faceplate of the appliance that is slightly smaller than the stoma. b. Plan to do appliance changes in the late evening hours. c. Appliance odor from urine breakdown to ammonia can be minimized by limiting fluids. d. Cleanse the skin around the stoma, using gentle soap and water, and then rinse and dry well. Source: Saunders 4th

ANS: D Rationale: The skin around the stoma is cleansed at each appliance change using a gentle, nonresidue soap and water. The skin is rinsed and then dried thoroughly. The appliance should be changed early in the morning, because urine production is slowest from no fluid intake during sleep. The appliance is cut so that the opening is not more than 3 mm larger than the stoma. An opening smaller than the stoma will prevent application of the appliance. Generous fluid intake is encouraged to dilute the urine, decreasing the intensity of odor. Strategy: Use the process of elimination. Begin to answer this question by eliminating option 3. Fluid limitation will not limit ammonia odor; in fact; decreased fluids will increase the concentration of the urine, making it stronger. Option 1 is eliminated next, because an appliance cut in this way will be too small to fit over the stoma. Regarding the remaining options, recall that urine flow is slowest in early morning as a result of decreased intake during the night. Review client teaching points related to ostomy care if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 837). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2034) A client with a diagnosis of depression has been meeting with the mental health nurse for therapy sessions for the past 6 weeks. During the session the client says to the nurse, "I lost my job this week and I'm going to be evicted from my apartment if I can't pay my bill. The only person that I have is my daughter, but I don't want to burden her with my problems." Which response by the nurse would be therapeutic? a. "If you get evicted from your apartment, we will commit you to the hospital so you will have a place to eat and sleep." b. "Why did you lose your job?" c. "There are homeless shelters available, and we will get you into one if you are evicted from your apartment." d. "Let's talk about contacting your daughter. Wouldn't you want to know if your daughter was having difficulty and try to help her if you could?" Source: Saunders 4th

ANS: D Rationale: The therapeutic communication technique is clarification that attempts to put vague ideas into words. It helps the client to view the explicit correlation between the client's feelings and actions. Asking why a client lost a job is not directly related to the client's feelings and concerns. Offering to provide a homeless shelter or to commit the client to the hospital does not address the issue at hand and places the client's concerns and feelings on hold. Strategy: Use the process of elimination and knowledge regarding therapeutic communication techniques to assist in answering the question. Eliminate options 1 and 3 first because they are comparative or alike. Next, eliminate option 2 because of the word Why. If you had difficulty with this question, review therapeutic communication techniques. Reference: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed., pp. 30-34, 632). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2035) During a therapy session with a client with paranoid disorder, the client says to the nurse, "You look so nice today. I love how you do your hair, and I love that perfume that you're wearing." Which response by the nurse would be therapeutic? a. "Thank you for noticing. I just bought this new perfume." b. "My hair has been a mess. I really needed to have it done." c. "Your comment is inappropriate." d. "We are not here to discuss how I look or smell. We are here to talk about you." Source: Saunders 4th

ANS: D Rationale: The therapeutic response by the nurse is the one that clarifies the content of the client's statements and directs the client to the purpose of the session. The nurse should confront the client verbally regarding the inappropriate statements and refocus the client back to the issue of the session. Strategy: Knowledge regarding therapeutic communication techniques and how to respond to clients who make personal statements is required to answer this question. Option 3 may be judgmental and may provide an opening for a verbal struggle. Options 1 and 2 are social responses and could be misinterpreted by the client. Review therapeutic communication techniques if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed., pp. 30-34). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 280). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1530) A client receiving lithium carbonate (Eskalith) complains of loose watery stools and difficulty walking. The nurse would expect the serum lithium level to be which of the following? a. 0.7 mEq/L b. 1 mEq/L c. 1.3 mEq/L d. 1.8 mEq/L Source: Saunders 4th

ANS: D Rationale: The therapeutic serum level of lithium is 0.6 to 1.2 mEq/L. A serum lithium level of 1.8 mEq/L indicates moderate toxicity. Serum lithium concentrations of 1.5 to 2.5 mEq/L may produce vomiting, diarrhea, ataxia, incoordination, muscle twitching, and slurred speech. Strategy: Focusing on the client's symptoms will assist in answering this question. Also, note that option 4 identifies the highest lithium level. Review the normal lithium level and signs of toxicity if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 479). St. Louis: Mosby. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., pp. 215, 218). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1304) The nurse is planning to test the function of the trigeminal nerve (cranial nerve V). The nurse would gather which of the following items to perform the test? a. Tuning fork and audiometer b. Snellen chart, ophthalmoscope c. Flashlight, pupil size chart or millimeter ruler d. Safety pin, hot and cold water in test tubes, cotton wisp Source: Saunders 4th

ANS: D Rationale: The trigeminal nerve has motor and sensory divisions. The motor division innervates the muscles for chewing (mastication). The sensory division innervates the entire face, scalp, cornea, and nasal and oral cavities. The sensations of pain, temperature, and touch can be assessed using each of the respective items noted in option 4. The corneal reflex (motor division) also can be tested using the cotton wisp. The supplies noted in options 1, 2, and 3 are used for testing cranial nerves III, VIII, and II, respectively. Strategy: Use the process of elimination. Recalling the function of cranial nerve V will direct you to option 4. Review the function of this nerve if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2012, 2028). Philadelphia: W.B. Saunders. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills and techniques (6th ed., pp. 591-592). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1035) A nurse is caring for a client with exacerbation of sarcoidosis who is receiving corticosteroids. A nurse teaches the client about adverse effects of medication therapy, which would include: a. Pruritus b. Weight loss c. Hyperkalemia d. Hyperglycemia Source: Saunders 4th

ANS: D Rationale: The usual treatment for exacerbations of sarcoidosis includes systemic corticosteroids. Side effects of this therapy include weight gain, changes in mood, and hyperglycemia. Hyperkalemia and pruritus are unrelated findings. Strategy: Recall that sarcoidosis is a restrictive lung disease and that exacerbations are treated with corticosteroids. Knowing that corticosteroids cause hyperglycemia will direct you to the correct option. Review the medication therapy used in the treatment of sarcoidosis if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1872). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2215) A nurse provides home care instructions to a client with hepatitis B. Which statement made by the client indicates the best understanding of how to prevent transmission of the disease? a. "I should be vaccinated as soon as possible." b. "I never will share towels with anyone else." c. "It is all right to kiss my wife." d. "My wife should get the vaccine." Source: Saunders 4th

ANS: D Rationale: The vaccine is recommended for both sexual and household contacts of the person with hepatitis B. Hepatitis B can be transmitted through intimate contact, such as kissing. The vaccine is used for prevention. This disease is not transmitted through the use of towels. Strategy: Use the process of elimination and focus on the subject, preventing hepatitis B. Eliminate option 2 because of the close-ended word never. Next, eliminate option 1 because the vaccine is used for prevention. From the remaining options, eliminate option 3 because the disease can be transmitted by intimate contact. Review the methods of transmission of hepatitis B if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1327, 1330). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1385). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1567) On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urinalysis is done and the results indicate the presence of a urinary tract infection. The nurse instructs the new mother regarding measures to take for the treatment of the infection. Which of the following statements, if made by the mother, would indicate a need for further instructions? a. "The prescribed medication must be taken until it is finished." b. "My fluid intake should be increased to at least 3000 mL daily." c. "I need to urinate frequently throughout the day." d. "Foods and fluids that will increase urine alkalinity should be consumed." Source: Saunders 4th

ANS: D Rationale: The woman with a urinary tract infection must be encouraged to take the medication for the entire time it is prescribed. The women should also be instructed to drink at least 3000 mL of fluid each day to flush the infection from the bladder and to urinate frequently throughout the day. Foods and fluids that acidify the urine need to be encouraged. Strategy: Use the process of elimination. Note the strategic words indicate a need for further instructions. These words indicate a negative event query and ask you to select an option that is incorrect. Recall that foods and fluids that acidify the urine should be consumed rather than foods and fluids that cause urine alkalinity. If you had difficulty with this question, review nursing considerations for the client with a urinary tract infection. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 860). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1684). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Maternity—Postpartum Alternate Question Types -> Multiple Choice

999) Theophylline is prescribed for a client with acute bronchitis. A nurse administers the medication, knowing that the primary action of this medication is to: a. Prevent infection. b. Suppress the cough. c. Promote expectoration. d. Relax smooth muscles of the bronchial airway. Source: Saunders 4th

ANS: D Rationale: Theophylline is a bronchodilator that directly relaxes the smooth muscles of the bronchial airway. Options 1, 2, and 3 are not direct actions of this medication. Strategy: Use the process of elimination. Recalling that this medication is a bronchodilator will direct you to option 4. Review this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 41). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2523) Betaxolol (Betoptic) eye drops have been prescribed for a client with glaucoma. The home health nurse preparing to visit the client develops a plan of care that includes monitoring for the side effects of this medication by: a. Assessing the glucose level b. Assessing peripheral pulses c. Monitoring body temperature d. Monitoring body weight Source: Saunders 4th

ANS: D Rationale: This medication is an antiglaucoma medication and a β adrenergic blocker. The nurse assesses for evidence of heart failure manifested by dizziness, night cough, peripheral edema, and distended neck veins. Intake greater than output, weight gain, and decreased urine output also may indicate heart failure. Hypotension (manifested as dizziness), nausea, diaphoresis, headache, fatigue, and constipation or diarrhea also are potential systemic effects of the medication. Nursing interventions include monitoring body weight, periodic evaluation of blood pressure for hypotension, and assessing the apical or radial pulse for strength, weakness, irregular heart rate, and bradycardia. Strategy: Use the process of elimination. Recalling that this medication causes heart failure will direct you to option 4. Review the side effects of betaxolol if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 134). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

199) A nurse attempts to relieve an airway obstruction on a 3-year-old conscious child. The nurse performs this maneuver by placing his or her hands between the: a. Groin and the abdomen. b. Umbilicus and the groin. c. Lower abdomen and the chest. d. Umbilicus and the xiphoid process. Source: Saunders 4th

ANS: D Rationale: To perform the Heimlich maneuver on a child, the rescuer stands behind the victim and places the arms directly under the victim's axillae and around the victim. The rescuer places the thumb side of one fist against the victim's abdomen in the midline, slightly above the umbilicus and well below the tip of the xiphoid process. The rescuer grasps the fist with the other hand and delivers up to five thrusts. One must take care not to touch the xiphoid process or the lower margins of the rib cage because force applied to these structures may damage internal organs. Options 1, 2, and 3 are incorrect hand placements. Strategy: Use the process of elimination, noting the age of the child. Eliminate options 1 and 2 first because they are comparative or alike. From the remaining options, considering the anatomical location and the effect of the maneuver in dislodging an obstruction will direct you to option 4. If you had difficulty with this question, review the correct hand placement for the Heimlich maneuver. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 836). St. Louis: Mosby. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 570). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Child Health Alternate Question Types -> Multiple Choice

1564) Cortisone acetate (Cortone Acetate) is prescribed for a client with adrenal insufficiency. The nurse provides instructions to the client regarding the medication. Which statement, if made by the client, indicates a need for further instruction? a. "I will eat a good breakfast every day." b. "I will avoid people with colds." c. "I will limit my sodium intake." d. "I will stop the medication when I feel better." Source: Saunders 4th

ANS: D Rationale: To prevent acute adrenal insufficiency, glucocorticoids should not be abruptly discontinued. These medications can cause sodium and water retention and the loss of potassium, and clients should be instructed to limit sodium intake and consume potassium-rich foods. Additionally, adequate dietary intake is important. These medications can increase the risk of infection and the client should avoid contact with persons who are ill. Strategy: Use the process of elimination. Note the strategic words indicates a need for further instruction. These words indicate a negative event query and ask you to select an option that is incorrect. You should easily be able to eliminate options 1, 2, and 3, remembering that the client should not stop these medications, or any medication, without physician approval. Review the administration of glucocorticoids if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 223). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2008) A client arrives to the surgical unit after nasal surgery. The client has nasal packing in place. The nurse reviews the physician's orders and anticipates that which of the following client positions would be prescribed to reduce swelling? a. Sims b. Prone c. Supine d. Semi-Fowler's position Source: Saunders 4th

ANS: D Rationale: To reduce swelling, the client would be placed in the semi-Fowler's position. The supine and prone positions would not decrease swelling because the client would be lying flat. Sims position, which is side-lying, also would not decrease swelling. Strategy: Use the process of elimination. Recall that in order for gravity to reduce swelling, the part must be elevated. Option 4 is the only option that identifies elevation of the affected body part. Review care of the client after nasal surgery if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 564). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1621) The nurse is assessing for Kernig's sign in a child with a suspected diagnosis of meningitis. The nurse performs this test by: a. Bending the head towards the knees and hips and assessing for pain. b. Tapping the facial nerve and assessing for spasm. c. Compressing the upper arm and assessing for tetany. d. Raising the leg with the knee flexed and then extending the leg at the knee and assessing for pain. Source: Saunders 4th

ANS: D Rationale: To test for Kernig's sign, the leg is raised with the knee flexed. Then, the leg is extended at the knee. If any resistance is noted or pain is felt, the result is a positive Kernig's sign. This is a common finding in meningitis. Brudzinski's sign occurs when flexion of the head causes flexion of the hips and knees. Chvostek's sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Trousseau's sign is a sign for tetany in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally. Strategy: Knowledge regarding the appropriate procedure to elicit Kernig's sign is required to answer the question. Use the process of elimination and assessment techniques to direct you to option 4. If you had difficulty with this question, review these signs, their significance, and the procedure to elicit these signs. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1524). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Child Health Alternate Question Types -> Multiple Choice

2603) A client is started on tolbutamide (Orinase) once daily. The nurse instructs the client to monitor for which intended effect of this medication? a. Weight loss b. Resolution of infection c. Decreased blood pressure d. Decreased blood glucose Source: Saunders 4th

ANS: D Rationale: Tolbutamide is an oral hypoglycemic agent. It is not used to enhance weight loss, treat infection, or decrease blood pressure. Strategy: Use the process of elimination. Recalling that this medication is an oral hypoglycemic will direct you to option 4. Review the intended effects of this medication if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 788 ). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed.). Philadelphia: W.B. Saunders, p. 661. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1211) Oxybutynin chloride (Ditropan) is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication? a. Pallor b. Drowsiness c. Bradycardia d. Restlessness Source: Saunders 4th

ANS: D Rationale: Toxicity (overdosage) of this medication produces central nervous system excitation, such as nervousness, restlessness, hallucinations, and irritability. Other signs of toxicity include hypotension or hypertension, confusion, tachycardia, flushed or red face, and signs of respiratory depression. Drowsiness is a frequent side effect of the medication but does not indicate overdosage. Strategy: Knowledge regarding the manifestations related to toxicity is required to answer this question. Remember restlessness is a sign of toxicity. Review the signs that indicate toxicity if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 882). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1885) A community health nurse is performing a safety assessment in the home of a mother with two children. The ages of the children are 1 and 3 years. Which of the following if noted during the assessment would present the greatest hazard to the children? a. Hot water heater set above 120° F b. Small dog as a house pet c. Gate placed at the stairs of the second floor d. Toys with small loose parts in the play room Source: Saunders 4th

ANS: D Rationale: Toys with small loose parts would be the priority concern. Children at this age are likely to place the small toy parts in their mouth, which could lead to aspiration and choking. The water temperature of the hot water heater is a concern but is not the greatest hazard. The mother should be aware of and taught safety measures related to safe water temperatures for bathing the children. A gate placed at the stairs of the second floor is a safety measure. A small dog as a house pet is not necessarily a hazard. Strategy: Focus on the subject of the question, the child's age, the home, and items that would present a safety hazard to the children and note the strategic words greatest hazard. Use the ABCs—airway, breathing, and circulation—to assist in answering the question. Option 4 specifically relates to airway. If you had difficulty with this question, review safety related to children ages 1 and 3. Reference: Wong, D., Perry, S. Hockenberry, M., Lowdermilk, D., & Wilson, D. (2006). Maternal child nursing care (3rd ed., p. 951). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Assessment Content Area -> Child Health Alternate Question Types -> Multiple Choice

2190) A client with depression who is taking tranylcypromine sulfate (Parnate) has been instructed on appropriate diet. The nurse determines that the client understands the diet if the client selects which foods from the dietary menu? a. Pepperoni pizza, salad, and a cola drink b. Roasted chicken, roasted potatoes, and beer c. Pickled herring, French fries, and milk d. Fried haddock, baked potato, and a cola drink Source: Saunders 4th

ANS: D Rationale: Tranylcypromine sulfate (Parnate) is an monoamine oxidase inhibitor (MAOI) that is used to treat depression. A tyramine-restricted diet is required while on this medication to avoid hypertensive crisis, a life-threatening side effect of the medication. Foods to be avoided are meats prepared with tenderizer, smoked or pickled fish, beef or chicken liver, and dry sausage (salami, pepperoni, bologna). In addition, figs, bananas, aged cheese, yogurt and sour cream, beer, red wine, alcoholic beverages, soy sauce, yeast extract, chocolate, caffeine, and aged, pickled, fermented, or smoked foods need to be avoided. Many over-the-counter medications also include tyramine and must be avoided as well. Strategy: Use the process of elimination. Recall that tranylcypromine sulfate is an MAOI and that tyramine-containing items need to be avoided. Recalling the foods that contain tyramine will direct you to option 4. Review this medication and the foods high in tyramine if you had difficulty with this question. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 349-350). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1254) The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which of the following cranial nerves would identify a complication specifically associated with this surgery? a. Cranial nerve I, olfactory b. Cranial nerve IV, trochlear c. Cranial nerve III, oculomotor d. Cranial nerve VII, facial nerve Source: Saunders 4th

ANS: D Rationale: Treatment for acoustic neuroma is surgical removal via a craniotomy. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve. Acoustic neuromas rarely recur following surgical removal. Strategy: Use the process of elimination and knowledge regarding the anatomical location of an acoustic neuroma to direct you to option 4. If you had difficulty with this question, review the complications associated with this surgical procedure. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1133). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1519). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

1710) A client with a small bowel obstruction asks the nurse to explain the purpose of the nasogastric tube and continuous gastric suction. After the teaching is completed, the nurse determines that the client understands if the client states that the purpose of the continuous gastric suction is to: a. Provide nourishment. b. Relieve the bronchi of mucus. c. Withdraw gastric contents for laboratory analysis. d. Remove gas and fluids from the stomach and intestine. Source: Saunders 4th

ANS: D Rationale: Treatment of intestinal obstruction is directed toward decompression of the intestine by removal of gas and fluid. Nasogastric tubes may be used to decompress the bowel. Continuous gastric suction does not provide nourishment. Option 2 is the purpose for tracheal suctioning. Although gastric contents may be sent for laboratory analysis, it is not the main purpose for continuous gastric suction. Strategy: Use the process of elimination. Option 2 can be eliminated first because it is unrelated to a gastrointestinal disorder. Eliminate option 1 next, recalling that a client with a bowel obstruction is NPO. From the remaining options, focusing on the client's diagnosis will direct you to option 4. Review the treatment for a client with a bowel obstruction if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1328-1329). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1405). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2594) The home care nurse is preparing to visit a client with a diagnosis of trigeminal neuralgia (tic douloureux). When performing the assessment, the nurse should plan to ask the client which question to elicit the most specific information regarding this disorder? a. "Do you have any visual problems?" b. "Are you having any problems hearing?" c. "Do you have any tingling in the face region?" d. "Is the pain experienced a stabbing type of pain?" Source: Saunders 4th

ANS: D Rationale: Trigeminal neuralgia is characterized by spasms of pain that start suddenly and last for seconds to minutes. The pain often is characterized as stabbing or as similar to an electric shock. It is accompanied by spasms of facial muscles that cause twitching of parts of the face or mouth, or closure of the eye. Options 1, 2, and 3 would not elicit data specifically related to this disorder. Strategy: Use the process of elimination. Note the strategic word neuralgia and the relationship of this word to pain noted in option 4. Review the manifestations of trigeminal neuralgia if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1023). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2050) A nurse is performing an assessment on a client suspected of having trigeminal neuralgia (tic douloureux). Which of the following assessment questions would elicit data specific to this disorder? a. "Have you had any numbness and tingling in your face?" b. "Have you noticed that your eyelid has been drooping?" c. "Have you had any facial paralysis?" d. "Have you had any sharp pain or any twitching in any part of your face?" Source: Saunders 4th

ANS: D Rationale: Trigeminal neuralgia is characterized by spasms of pain that start suddenly and last from seconds to minutes. The pain often is described as either stabbing or similar to an electric shock. It is accompanied by spasms of the facial muscles that cause twitching of parts of the face or mouth, or causes closure of the eye. Strategy: Use the process of elimination. Note the word tic in the name of the disorder. Recalling that a tic is a nervous twitch will assist in directing you to option 4. If you had difficulty with this question, review the clinical manifestations of trigeminal neuralgia Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1023). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

968) The client has just taken a dose of trimethobenzamide hydrochloride (Tigan). What indicates that this client has had a therapeutic response to the medication? a. Relief of constipation b. Decrease in heartburn c. Absence of abdominal pain d. Relief of nausea and vomiting Source: Saunders 4th

ANS: D Rationale: Trimethobenzamide (Tigan) is an antiemetic agent used to treat nausea and vomiting. The other options are incorrect. Strategy: Use the process of elimination. Recalling that this medication is an antiemetic will direct you to option 4. Review this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1179). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2241) A client with active tuberculosis demonstrates less-than-expected interest in learning about the prescribed medication therapy. The nurse assesses that this client may ultimately need: a. More medication instructions b. Involvement of the family in teaching c. Reinforcement by the physician d. Directly observed therapy Source: Saunders 4th

ANS: D Rationale: Tuberculosis is a highly communicable disease that is reportable to the local public health department. This agency has regulations that may be enforced to ensure compliance with tuberculosis therapy. The client may be required to have directly observed therapy to reduce the risk to the general public. This involves having a responsible person actually observe the client taking the medication each day. Strategy: Note the word ultimately. This implies an action that would be taken as a last resort. Knowing that tuberculosis is a highly communicable, reportable disease, you would eliminate options 1, 2, and 3. This leaves directly observed therapy, which is closely overseen and enforced through the public health department. Review the interventions that will ensure medication compliance if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 643-644). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1095) A nurse is preparing to defibrillate a client in ventricular fibrillation. After placing the paddles on the client's chest and before discharging them, which of the following should be done? a. Ensure that the client has been intubated. b. Set the defibrillator to the "synchronize" mode. c. Administer lidocaine hydrochloride (Xylocaine). d. Confirm that the rhythm is actually ventricular fibrillation. Source: Saunders 4th

ANS: D Rationale: Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections. A nitroglycerin patch, if present, is removed. The client does not have to be intubated to be defibrillated. Lidocaine may be given subsequently but is not required before defibrillation. The machine is not set to the synchronous mode because there is no underlying rhythm with which to synchronize. Strategy: Use the process of elimination, focusing on the subject, ventricular fibrillation. Note that option 4 directly addresses this subject and also addresses assessment of the client. Review the procedure for defibrillation if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1687). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 732, 741-742). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1169) The male client has a tentative diagnosis of urethritis. The nurse assesses the client for which of the following manifestations of the disorder? a. Hematuria and pyuria b. Dysuria and proteinuria c. Hematuria and urgency d. Dysuria and penile discharge Source: Saunders 4th

ANS: D Rationale: Urethritis in the male client often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear to mucopurulent discharge. Because this disorder often coexists with gonorrhea, diagnostic tests are done for both and include culture and rapid assays. Strategy: Use the process of elimination. Recalling that urethritis generally is accompanied by dysuria in the male client will assist you in eliminating options 1 and 3. Knowing that the problem originates in the urethra, not the kidney, will assist you in eliminating option 2, because proteinuria indicates a problem with kidney function. Review the clinical manifestations of urethritis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1685). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1640) A nursing instructor asks the nursing student to describe the definition of a critical path. Which of the following statements, if made by the student, indicates a need for further understanding regarding critical paths? a. "They are developed through the collaborative efforts of all members of the health care team." b. "They provide an effective way for monitoring care and for reducing or controlling the length of hospital stay for the client." c. "They are developed based on appropriate standards of care." d. "They are nursing care plans and use the steps of the nursing process." Source: Saunders 4th

ANS: D Rationale: Use the process of elimination and knowledge regarding the definition and purpose of critical paths to direct you to option 4. Note the strategic words in the question, a need for further understanding. These words indicate a negative event query and ask you to select an option that is incorrect. If you had difficulty with this question, review critical paths. Strategy: Use the process of elimination and knowledge regarding the definition and purpose of critical paths to direct you to option 4. Note the strategic words in the question, a need for further understanding. These words indicate a negative event query and ask you to select an option that is incorrect. If you had difficulty with this question, review critical paths. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., pp. 342-343). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Leadership and Management Alternate Question Types -> Multiple Choice

2585) A nurse is documenting information in a client's chart when the ECG telemetry alarm sounds and the nurse notes that the client is in ventricular tachycardia (VT). The nurse rushes to the client's bedside and performs which assessment first? a. Blood pressure b. Cardiac rate c. Respiratory rate d. Responsiveness of the client Source: Saunders 4th

ANS: D Rationale: VT is associated with a significant decrease in cardiac output. Assessing for unresponsiveness determines whether the client is affected by the decreased cardiac output. Although options 1, 2, and 3 may be a component of the assessment, the first action would be to determine responsiveness of the client. Strategy: Use the steps of basic life support (BLS) to answer the question. Determining unresponsiveness is the first assessment to make in an emergency. Review the initial actions for care of the client with VT if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1685). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 729-730). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2444) Vasopressin (Pitressin) is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse should prepare to administer this medication by which of the following routes? a. Orally b. Through the Sengstaken-Blakemore tube c. By intramuscular route d. By intravenous infusion Source: Saunders 4th

ANS: D Rationale: Vasopressin is a synthetic antidiuretic hormone. Administration of this hormone into the bloodstream reduces bleeding. It acts directly on gastrointestinal smooth muscle as a vasoconstrictor. To take advantage of these effects, it should be administered intravenously. Strategy: Use the process of elimination. Focusing on the client's diagnosis will direct you to option 4. If you had difficulty with this question, review care of the client with esophageal varices. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1345). Philadelphia: W.B. Saunders. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 1218). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1117) A client is admitted to the hospital with a venous stasis leg ulcer. Which of the following characteristics would be an expected finding of this type of ulcer? a. Pale-colored base b. Deep, with even edges c. Has little granulation tissue d. Has brown pigmentation surrounding it Source: Saunders 4th

ANS: D Rationale: Venous leg ulcers, also called stasis ulcers, tend to be more superficial than arterial ulcers, and the ulcer bed is pink. The edges of the ulcer are uneven, and granulation tissue is evident. The skin has a brown pigmentation from accumulation of metabolic waste products resulting from venous stasis. The client also exhibits peripheral edema. Strategy: Use the process of elimination and focus on the strategic word venous. Knowing that the information in options 1, 2, and 3 is based on the presence of tissue malnutrition (and thus an arterial problem) will direct you to option 4. Review the assessment findings in arterial and venous conditions if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 817). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1232) The client with glaucoma asks the nurse if complete vision will return. The most appropriate response is: a. "Your vision will never return to normal." b. "Your vision will return as soon as the medication begins to work." c. "Your vision loss is temporary and will return in about 3 to 4 weeks." d. "Although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan." Source: Saunders 4th

ANS: D Rationale: Vision loss to glaucoma is irreparable. The client should be reassured that although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan. Option 1 does not provide reassurance to the client. Strategy: Use the process of elimination and therapeutic communication techniques. Also, note that option 4 is an umbrella option, addressing the importance of compliance with the treatment plan. Review the effects of glaucoma and therapeutic communication techniques if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1945-1946). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Communication and Documentation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1251) The client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. The nurse interprets this as: a. The client is legally blind. b. The client's vision is normal. c. The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet. d. The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet. Source: Saunders 4th

ANS: D Rationale: Vision that is 20/20 is normal—that is, the client is able to read from 20 feet what a person with normal vision can read from 20 feet. A client with a visual acuity of 20/60 can only read at a distance of 20 feet what a person with normal vision can read at 60 feet. Strategy: Use the process of elimination. Focus on the test result, 20/60, to direct you to option 4. If you had difficulty with this question, review interpretation of visual acuity test results. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1078). Philadelphia: W.B. Saunders. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., pp. 306-307). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1692) The clinic nurse is teaching a pregnant client about the warning signs in pregnancy. Which of the following, if identified as a warning sign by the client, would indicate a need for further education? a. Visual disturbances b. Rapid weight gain c. Generalized or facial edema d. Presence of irregular painless contractions Source: Saunders 4th

ANS: D Rationale: Visual disturbances, rapid weight gain, and generalized or facial edema are warning signs in pregnancy. Braxton Hicks contractions are the normal, irregular, painless contractions of the uterus that may occur throughout pregnancy. Additional warning signs in pregnancy include vaginal bleeding, premature rupture of the membranes, preterm uterine contractions that are normal and regular, change in or absence of fetal activity, severe headache, epigastric pain, persistent vomiting, abdominal pain, and signs of infection. Strategy: Use the process of elimination, noting the strategic words need for further education. These words indicate a negative event query and ask you to select an option that is incorrect. Recalling that Braxton Hicks contractions are irregular painless contractions will assist in directing you to option 4. If you had difficulty with this question, review the warning signs in pregnancy. Reference: Lowdermilk, D., & Perry, A. (2004). Maternity and woman's health care (8th ed., pp. 438-439). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1679) Oral iron supplements are prescribed for the 6-year-old child with iron deficiency anemia (IDA). The nurse instructs the mother to administer the iron with which of the following food items? a. Water b. Milk c. Apple juice d. Orange juice Source: Saunders 4th

ANS: D Rationale: Vitamin C (ascorbic acid) increases the absorption of iron by the body. The mother should be instructed to administer the medication with a citrus fruit or juice high in vitamin C. From the options presented, option 4 is the option that identifies the food highest in vitamin C. Strategy: Use the process of elimination. Recalling that vitamin C increases the absorption of iron will assist in eliminating options 1 and 2. From the remaining options, select option 4 because this food item contains the highest amount of vitamin C. Review foods high in vitamin C if you had difficulty with this question. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 943). St. Louis: Mosby. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., pp. 1305-1306). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

1977) A client is being discharged on warfarin (Coumadin) and the nurse provides instructions to the client regarding the medication. Which of the following statements if made by the client indicates to the nurse that the client understands the teaching provided? a. "I'll stop my medication if I see bruising." b. "Stiff joints are common while taking warfarin." c. "This medication will prevent me from having a stroke." d. "If I notice blood-tinged urine, I will call the doctor immediately." Source: Saunders 4th

ANS: D Rationale: Warfarin (Coumadin) is an anticoagulant, which is used as long-term prophylaxis of thrombosis. Clients must receive detailed instructions regarding the signs of bleeding. Hematuria is a sign of bleeding, which the client should report. Bruising is a common side effect associated with anticoagulant therapy and is almost unavoidable. The client, however, should not stop the medication if bruising occurs. Option 2 is unrelated to the use of warfarin, and option 3 is not completely accurate regarding prevention of a stroke. Strategy: Use the process of elimination and knowledge regarding the purpose and action of warfarin to answer the question. Eliminate option 1 first, recalling that bruising is a common side effect and that the client should not stop the medication. Eliminate option 2 next, because it is unrelated to the use of anticoagulants. Eliminate option 3 because it is inaccurate and may offer false hope to a client about stroke prevention. Review the client teaching points related to warfarin if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1222). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2496) A client who is intubated and receiving mechanical ventilation has a nursing diagnosis of risk for infection. The nurse should avoid doing which of the following in the care of this client? a. Monitor the client's temperature. b. Monitor sputum characteristics and amounts. c. Use the closed-system method of suctioning. d. Drain water from the ventilator tubing into the humidifier bottle. Source: Saunders 4th

ANS: D Rationale: Water in the ventilator tubing should be emptied, not drained back into the humidifier bottle. This puts the client at risk of acquiring infection, especially Pseudomonas. Monitoring temperature and sputum production is indicated in the care of the client. A closed-system method of suctioning does not harm the client and decreases the risk of infection associated with suctioning. Strategy: Use the process of elimination. Note the strategic word avoid and focus on the subject, infection. Use basic principles related to the prevention of infection to answer this question. Options 1, 2, and 3 do not place the client at risk for infection. Review these principles if you had difficulty with the question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 663). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2548) A nurse is developing a plan of care for a client in Buck's traction. The plan of care will include assessing the client for which finding indicating a complication associated with the use of this type of traction? a. Hypotension b. Drainage at the pin sites c. Redness at the pin sites d. Weak pedal pulses Source: Saunders 4th

ANS: D Rationale: Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage used to secure the traction system. This type of traction does not use pins; rather, elastic bandages or a prefabricated boot is worn by the client. Therefore, options 2 and 3 are incorrect. Hypotension is not directly associated with the use of this type of traction. Strategy: Use the process of elimination. Eliminate options 2 and 3 first because they are comparative or alike and because this type of traction does not use pins. From the remaining options, visualizing the mechanics of this type of traction will direct you to option 4. Review the complications of Buck's traction if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 644). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2038) A nurse is planning care for a client with bipolar disorder who is experiencing psychomotor agitation. Which of the following activities should the nurse plan for this client? a. Reading letters and books in a quiet environment b. Involving the client in a card game with other clients on the unit c. Providing an activity such as checkers for the client d. Include the client in a clay-molding class that is scheduled for today Source: Saunders 4th

ANS: D Rationale: When a client is experiencing psychomotor agitation, it is best to provide activities that involve the use of hands and gross motor movements. Such activities can include Ping-Pong, volleyball, finger-painting, drawing, and working with clay. These activities will provide an appropriate way for the client to discharge motor tension. Simple card games and reading are sedentary activities. Playing checkers requires concentration and more intensive use of thought processes. Strategy: Note the client's diagnosis and behavior to assist you in answering this question. Eliminate options 1 and 2 because they are comparative or alike. Next, eliminate option 3 because it requires concentration. Also, recalling that activities requiring the use of hands and gross motor movements are best for the client experiencing psychomotor agitation will direct you to option 4. Review care of the client with psychomotor agitation if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed., p. 355). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 334). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2129) A nurse witnesses a client sustain a fall and suspects that the right leg may be broken. The nurse takes which priority action? a. Take a set of vital signs. b. Call the radiology department. c. Reassure the client that everything will be fine. d. Immobilize the right leg before moving the client. Source: Saunders 4th

ANS: D Rationale: When a fracture is suspected, it is imperative that the area be splinted before the client is moved. Emergency help should be called for if the client is not hospitalized, and a physician is called for the hospitalized client. The nurse should remain with the client and provide realistic reassurance. The nurse does not order radiographs. Telling the client that everything will be fine is nontherapeutic. Although vital signs will be taken, the priority is to immobilize the leg. Strategy: Use the process of elimination. In this situation, eliminate option 2 because the nurse does not order radiographs. Option 3 is eliminated next because the nurse never tells a client that "everything will be fine." Regarding the remaining options, immobilizing the limb is imperative for the client's safety, which makes it a better choice than taking vital signs. Review care of the client with a fracture if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1197). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2315) Which action by the parent of an infant with respiratory syncytial virus (RSV) infection who is receiving ribavirin (Virazole) would indicate a knowledge deficit regarding the management of the disease process? a. Telling a family member who has asthma that he should not visit the infant b. Wearing a gown, gloves, mask, and hair covering when visiting the infant c. Before leaving the infant's room, washing the hands d. Telling the infant's aunt who is pregnant that it is acceptable to visit the infant Source: Saunders 4th

ANS: D Rationale: When an infant is receiving ribavirin, exposure precautions need to be observed. Anyone entering the infant's room should wear a gown, mask, gloves, and hair covering. Anyone who is pregnant or considering pregnancy and anyone with a history of respiratory problems or airway disease should not care for or visit the infant who is receiving ribavirin. Hand washing is absolutely necessary before leaving the room to prevent the spread of germs. Strategy: Use the process of elimination, noting the strategic words indicate a knowledge deficit. Reading each option carefully and noting the word pregnant in option 4 will direct you to this option. Review care of the infant receiving ribavirin if you had difficulty with this question. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., p. 1337). St. Louis: Mosby. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1214). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

1794) The nurse is reviewing the results of a test on a sample drawn from a child who is receiving carbamazepine (Tegretol) for the control of seizures. The results indicate a serum carbamazepine level of 10 mcg/mL. The nurse analyzes the results and anticipates that the physician will prescribe: a. An increased dose of the medication. b. A decreased of the dose of the medication. c. Discontinuation of the medication. d. Continuation of the presently prescribed dosage. Source: Saunders 4th

ANS: D Rationale: When carbamazepine (Tegretol) is administered, blood levels need to be tested periodically to check for the child's absorption of the medication. The amount of the medication prescribed is based on the blood level achieved. Carbamazepine's therapeutic serum range is 3 to 14 mcg/mL. The nurse would anticipate that the physician would continue the presently prescribed dosage. Strategy: It is necessary to know the therapeutic serum drug level of carbamazepine to answer the question. Recalling that the therapeutic level is 3 to 14 mcg/mL will direct you to option 4 because a result of 10 mcg/mL is within the therapeutic range. If you had difficulty with this question, learn the therapeutic serum drug level of carbamazepine. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 137). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1639) The registered nurse (RN) is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has a registered nurse, a licensed practical (vocational) nurse, and two nursing assistants on a nursing team. Which of the following clients would the nurse most appropriately assign to the licensed practical (vocational) nurse? a. The client who requires a 24-hour urine collection b. An elderly client requiring assistance with a bed bath and frequent ambulation c. A client on a mechanical ventilator requiring frequent assessment and suctioning d. A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours Source: Saunders 4th

ANS: D Rationale: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Collecting a 24-hour urine and frequent ambulation can most appropriately be provided by the nursing assistant, considering the clients identified in each option. The client on the mechanical ventilator requiring frequent assessment and suctioning should most appropriately be cared for by the registered nurse. The licensed practical (vocational) nurse is skilled in wound irrigation and dressing changes, so this client would be assigned to this staff member. Strategy: Use the principles related to delegations and assignment and consider the education and job position as described by the nurse practice act and employee guidelines. Note the strategic word assessment in option 3. This should alert you that this client should be assigned to the registered nurse. Options 1 and 2 can easily be eliminated because a nursing assistant can easily perform these tasks. This should assist in directing you to option 4. If you had difficulty with this question, review the principles related to a delegation and assignment making. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., pp. 551-552). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

38) The RN employed in a long-term care facility is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has a licensed practical (vocational) nurse and three nursing assistants on a nursing team. Which of the following clients would the nurse most appropriately assign to the licensed practical (vocational) nurse? a. The client who requires a bed bath b. An older client requiring frequent ambulation c. A client who requires a 24-hour urine collection d. A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours Source: Saunders 4th

ANS: D Rationale: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Collecting a 24-hour urine sample, giving a bed bath, and assisting with frequent ambulation can be provided most appropriately by the nursing assistant. The licensed practical (vocational) nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care. Strategy: Use the process of elimination and knowledge regarding the principles of delegation and assignment making. Focus on the subject, assignment to a licensed practical/vocational nurse. Recall that education and job position as described by the nurse practice act and employee guidelines need to be considered when delegating activities and making assignments. Options 1, 2, and 3 easily can be eliminated because a nursing assistant can perform these tasks. If you had difficulty with this question, review the principles of delegation and assignment making. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., pp. 545-546). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 41-42, 378). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

1032) A nurse is evaluating the respiratory status of a client with carbon dioxide narcosis who is being ventilated mechanically. On evaluation of a set of arterial blood gases, the nurse notes that the client's carbon dioxide level has dropped significantly. The nurse then evaluates the client for which adverse effect of this rapid change? a. Tachypnea b. Confusion c. Hyponatremia d. Seizure activity Source: Saunders 4th

ANS: D Rationale: With a rapid drop in carbon dioxide levels, the kidneys are unable to excrete bicarbonate ions at the same rate. The client can experience rebound metabolic alkalosis, with resulting seizure activity. The nurse evaluates the client's status carefully during this period. Options 1, 2, and 3 are not adverse effects. Strategy: Use the process of elimination and knowledge regarding how the body maintains acid-base balance. Because a rapid decline in the carbon dioxide level often results in metabolic alkalosis, the client is at risk for seizure activity. Review the basic acid-base abnormalities and their manifestations if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 669). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1338) A nurse is one of several persons who witness a vehicle hit a pedestrian at fairly low speed on a small street. The person is dazed and tries to get up. The leg appears fractured. The nurse would plan to: a. Try to reduce the fracture manually. b. Assist the person to get up and walk to the sidewalk. c. Leave the person for a few moments to call an ambulance. d. Stay with the person and encourage the person to remain still. Source: Saunders 4th

ANS: D Rationale: With a suspected fracture, the client is not moved unless it is dangerous to remain in that spot. The nurse should remain with the client and have someone else call for emergency help. A fracture is not reduced at the scene. Before the client is moved, the site of fracture is immobilized to prevent further injury. Strategy: Use the process of elimination. Eliminate options 1 and 2 first because either of these options could result in further injury to the client. Of the remaining options, the more prudent action would be for the nurse to remain with the client and have someone else call for emergency assistance. Review care of the client with a fracture if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1197). St. Louis: W.B. Saunders. Reference: Monahan, F., Sands, J., Neighbors, M., et al. (2007). Phipps' medical-surgical nursing: Health and illness perspectives (8th ed., p. 1526). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2639) A client who has been receiving theophylline by the intravenous (IV) route has the medication order changed to an immediate-release oral form of the medication. After discontinuing the IV medication, the nurse schedules the first dose of the oral medication: a. Just before the next meal b. Just after the next meal c. Immediately on discontinuing the IV form d. 4 hours after discontinuing the IV form Source: Saunders 4th

ANS: D Rationale: With immediate-release preparations, oral theophylline should be administered 4 to 6 hours after discontinuing the IV form of the medication. If the sustained-release form is used, the first oral dose should be administered immediately on discontinuation of the IV infusion. Strategy: Use the process of elimination. The strategic words immediate-release tell you that delayed absorption of this medication will not occur. Coupled with this knowledge, a review of the options will assist in directing you to option 4. If this question was difficult for you, review the concepts related to the administration of theophylline. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 84). St. Louis: Mosby. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 43). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1404) The client who is human immunodeficiency virus seropositive has been taking zalcitabine (ddC, Hivid) as a component of treatment. The nurse plans to monitor which of the following most closely while the client is taking this medication? a. Platelet count b. Glucose level c. Red blood cell count d. Liver function studies Source: Saunders 4th

ANS: D Rationale: Zalcitabine (ddC, Hivid) is an antiretroviral (nucleoside reverse transcriptase inhibitor) used to manage human immunodeficiency virus infection in combination with other antiretrovirals. Zalcitabine also has been used as a single agent in clients who are intolerant of other regimens. Zalcitabine can cause serious liver damage, and liver function studies should be monitored closely. Options 1, 2, and 3 are not associated specifically with the use of this medication. Strategy: Focus on the name of the medication. Recalling that this medication is hepatotoxic will direct you to option 4. If you are unfamiliar with this medication, review this content. Reference: Mosby. (2007). Mosby's 2007 nursing drug reference (20th ed., p. 1050). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1895) A client reports to the health care clinic and says that it has been 6 weeks since her last menstrual period. The nurse performs a pregnancy test and would expect to note the presence of which of the following in the blood test results if the client is pregnant? a. Estrogen b. Progesterone c. Follicle-stimulating hormone (FSH) d. Human chorionic gonadotropin (hCG) Source: Saunders 4th

ANS: D Rationale: hCG can be detected in the blood as early as 6 days after conception or 20 days after the last menstrual period. Options 1, 2, and 3 are unrelated to determining the presence of a pregnant state. Strategy: Knowledge regarding the blood test used to determine pregnancy is required to answer this question, as well as knowledge regarding the various hormonal changes that occur during pregnancy. If you are unfamiliar with the hormonal changes that occur during pregnancy, review this content. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 103). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1123) A client develops atrial fibrillation with a ventricular rate of 140 beats/min and signs of decreased cardiac output. Which of the following medications should the nurse first anticipate administering? a. Atropine sulfate b. Warfarin (Coumadin) c. Lidocaine (Xylocaine) d. Metoprolol (Lopressor) Source: Saunders 4th

ANS: D Rationale: β-Blockers such as metoprolol slow conduction of impulses through the AV node and decrease the heart rate. In rapid atrial fibrillation, the goal first is to slow the ventricular rate and improve the cardiac output and then attempt to restore normal sinus rhythm. Strategy: Use the process of elimination. Eliminate option 1 because atropine sulfate will further increase the heart rate and will further decrease the cardiac output. Eliminate option 3 because lidocaine is only useful in suppressing ventricular dysrhythmias. Although warfarin (Coumadin) is administered to clients with atrial fibrillation to prevent clots from forming in the atria it will have no effect in decreasing the ventricular rate or restoring normal sinus rhythm. Review these medications if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, L. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed., pp. 722, 725, 728). St. Louis: W.B. Saunders. Reference: Skidmore-Roth, L. (2006). Mosby's 2006 nursing drug reference (20th ed., p. 641). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1314) The client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, select from the list in order of priority of the nurse's actions, with the first selected option being of highest priority and the last selected option of lowest priority. a. Contact the physician. b. Raise the head of the bed. c. Check for bladder distention. d. Loosen tight clothing on the client. e. Administer an antihypertensive medication. f. Document the occurrence, treatment, and response. Source: Saunders 4th

ANS: D ANS: A ANS: C ANS: B ANS: E ANS: F Rationale: Autonomic dysreflexia is characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing. The cause is a noxious stimulus, most often a distended bladder or constipation. Autonomic dysreflexia is a neurological emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing actions are to sit the client up in bed in a high-Fowler's position and remove the noxious stimulus. The nurse would loosen any tight clothing and then check for bladder distention. If the client has a Foley catheter, the nurse would check for kinks in the tubing. The nurse also would check for a fecal impaction and disimpact the client, if necessary. The physician is contacted, especially if these actions do not relieve the signs and symptoms. Antihypertensive medication may be prescribed by the physician to minimize cerebral hypertension. Finally, the nurse documents the occurrence, treatment, and client response. Strategy: Recalling that this syndrome causes severe hypertension will assist you in determining that elevating the head of the bed is the first action. Next, recalling that the syndrome is caused by a noxious stimulus will assist you in determining that loosening tight clothing and checking for bladder distention would be the next actions. Because loosening any tight clothing would take less time than checking for bladder distention, this action would be taken next. Antihypertensives require a physician's order; therefore, calling the physician would be the next action. Review immediate nursing interventions for the client experiencing autonomic dysreflexia if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2215, 2229). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Prioritize

128) A nurse is monitoring a client receiving parenteral nutrition. The client suddenly develops respiratory distress, dyspnea, and chest pain, and the nurse suspects air embolism. Number the actions that the nurse would take in order of priority. (Number 1 is the first action and number 6 is the last action.) a. Administer oxygen. b. Contact the physician. c. Document the occurrence. d. Take the client's vital signs. e. Clamp the intravenous catheter. f. Position the client in left Trendelenburg position. Source: Saunders 4th

ANS: D ANS: C ANS: F ANS: E ANS: A ANS: B Rationale: If air embolism is suspected, the nurse would first clamp the intravenous catheter to prevent the embolism from traveling through the heart to the pulmonary system. The nurse would next place the client in a left side-lying position with the head lower than the feet (to trap air in right side of the heart). The nurse would notify the physician and administer oxygen as prescribed. The nurse would monitor the client closely and take the client's vital signs. Finally, the nurse documents the occurrence. Strategy: Think about the pathophysiology and effects of an air embolism. Recalling that a primary concern is that the embolism will travel to the pulmonary system will assist in determining that the catheter needs to be clamped first and that the client needs to be positioned to trap the air in the right side of the heart. Because this event is an emergency, the nurse notifies the physician next and the physician will provide an order for oxygen, if necessary. The nurse monitors the client and takes the client's vital signs frequently. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., p. 1050). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1315-1316). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Delegating and Prioritizing Alternate Question Types -> Prioritize

1155) A client with coronary artery disease complains of substernal chest pain. After assessing the client&#39;s heart rate and blood pressure, a nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, &quot;My chest still hurts.&quot; Select the appropriate actions that the nurse should take. Select all that apply. a. Call a Code Blue. b. Contact the physician. c. Contact the client's family. d. Assess the client's pain level. e. Check the client&#39;s blood pressure. f. Administer a second nitroglycerin, 0.4 mg, sublingually. Source: Saunders 4th

ANS: D ANS: E ANS: F Rationale: The usual guidelines for administering nitroglycerin tablets for chest pain include administering one tablet every 5 minutes PRN for chest pain, for a total dose of three tablets. If the client does not obtain relief after taking a third dose of nitroglycerin, the physician is notified. Because the client is still complaining of chest pain, the nurse would administer a second nitroglycerin tablet. The nurse would assess the client's pain level and check the client's blood pressure before administering each nitroglycerin dose. There are no data in the question that indicate the need to call a Code Blue. Additionally, it is not necessary to contact the client's family unless the client has requested this. Strategy: Focus on the data in the question. Use the steps of the nursing process to determine that assessing the client's pain level and checking the client&#39;s blood pressure are appropriate actions. Next, recalling the usual guidelines for administering nitroglycerin tablets will assist in determining that an appropriate action is to administer a second nitroglycerin tablet, 0.4 mg, sublingually. Review care of the client with chest pain and the guidelines for the administration of nitroglycerin if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed., p. 847). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Multiple

43) Client assignment and nursing activities include the following: (see image)<br />The home health care nurse is planning client visits and nursing activities for the day. The nurse begins the visits at 9 <sc>AM</sc>. All clients live within a 5-mile radius. List in order of priority how the nurse should plan the order of the assignments for the day? (Number 1 is the first client and/or nursing activity for the day and number 6 is the last.) a. A client requiring twice daily abdominal dressing changes. b. A client with diabetes mellitus who needs a fasting blood glucose level drawn. c. A client who will be visited by home health aide at 10 AM, and the nurse needs to orient the aide and provide supervision of client care. d. A client whose spouse is performing daily dressing changes, and the nurse needs to supervise the spouse in performing the dressing change. e. A client who was discharged yesterday from the hospital following a diagnosis of pneumonia who needs to admitted to home health care. Source: Saunders 4th

ANS: E ANS: C ANS: D ANS: B ANS: F ANS: A Rationale: The nurse would plan to visit the client with diabetes mellitus first and draw the fasting blood glucose level because this client needs to remain NPO until the blood is drawn. This client would also not be able to take any medication, such as insulin, until the blood is drawn. The nurse would plan to see the client requiring twice-daily dressing changes next because the dressing changes should be spaced as far apart as possible. The nurse then would plan to see the client being visited by the home health aide and provide instructions and directions to the home health aide regarding care to the client. The nurse then would visit the client regarding supervision of the dressing change and would perform the admission last because that may take more time than the other clients. The nurse then would return to the client requiring the second twice-daily dressing change. Strategy: Note the needs of the client and the role of the nurse in caring for each of the clients. Noting that the client with diabetes mellitus needs to remain NPO until the blood is drawn will assist in determining that this client needs to be visited first. Noting that the client requiring twice-daily dressing changes will need to be seen twice will assist in determining the next and last client visit of the day, because dressing changes should be spaced as far apart as possible. Next, note that the home health aide will be with the client at 10 <sc>AM</sc>; this client will be seen next. From the remaining clients, select the client requiring a supervised dressing change to be seen next because the client admission may take time. If you had difficulty with this question, review the process of planning care and time management. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., p. 83). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 377-378). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Delegating and Prioritizing Alternate Question Types -> Prioritize Chart

75) A nurse is preparing to obtain an arterial blood gas specimen from a client and plans to perform the Allen's test on the client. Number in order of priority the steps for performing the Allen's test. (Number 1 is the first step and number 6 is the last step.) a. Document the findings. b. Explain the procedure to the client. c. Release pressure from the ulnar artery. d. Apply pressure over the ulnar and radial arteries. e. Ask the client to open and close the hand repeatedly. f. Assess the color of the extremity distal to the pressure point. Source: Saunders 4th

ANS: F ANS: A ANS: D ANS: B ANS: C ANS: E Rationale: The Allen's test is performed before obtaining an arterial blood specimen from the radial artery to determine the presence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. The nurse first would explain the procedure to the client. To perform the test, the nurse applies direct pressure over the client's ulnar and radial arteries simultaneously. While applying pressure, the nurse asks the client to open and close the hand repeatedly; the hand should blanch. The nurse then releases pressure from the ulnar artery while compressing the radial artery and assesses the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used for obtaining a blood specimen. Finally, the nurse documents the findings. Strategy: Recalling that the procedure needs to be explained to the client will assist in determining the first action. Next, think about the purpose and reason for performing this test and visualize the procedure. This will assist in determining the steps for performing the Allen's test. Remember, the nurse would document the findings last. Review this test if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 731-732). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Delegating and Prioritizing Alternate Question Types -> Prioritize

32) A client involved in a head-on automobile crash has awakened from a coma and asks for her husband, who was killed in the same accident. The family does not want the client to know at this time that her husband has died. The family wants all nursing staff to tell the client that the husband was taken by helicopter to another hospital, has a head injury, and is in the intensive care unit. Because the American Nurses Association Code of Ethics requires the nurse to preserve integrity, but the nurse wants to follow the family's instruction, the nurse faces an ethical dilemma. Number in order the steps for systematic processing of the ethical dilemma. Number 1 is the first step and number 6 is the last step. a. Evaluate the action. b. Verbalize the problem. c. Negotiate the outcome. d. Consider possible courses of action. e. Gather all of the information relevant to the case. f. Examine and determine one's own values on the issues. Source: Saunders 4th

ANS: F ANS: C ANS: E ANS: D ANS: A ANS: B Rationale: Ethical reasoning is the process of thinking through what one ought to do in an orderly and systematic manner to provide justification for actions based on principles. First, the nurse determines whether or not the issue involves an ethical dilemma and gathers information that is relevant to the case. Next, the nurse undertakes personal value clarification and identifies his or her own values regarding the issue. Third, the nurse verbalizes the problem in a simple sentence. Fourth, the nurse considers possible courses of action. In this case, the nurse may choose to seek the counsel of the agency's ethicist regarding the issue. Fifth, the nurse negotiates the outcome by developing a confidence in her or his own point of view with deep respect for the opinions of others. In this case, the nurse may negotiate with the family to determine a course of action that will allow the nurse to preserve integrity and yet allow the family to determine when the client should be informed of the tragic loss. Finally, the nurse evaluates the action. Strategy: Focus on the subject, the systematic processing of an ethical dilemma. Use the steps of the nursing process to assist in determining the correct order of action. Review the steps for systematic processing of an ethical dilemma if you had difficulty with this question.<br /> Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 398). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Prioritize

165) A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit levels. The nurse notifies the blood bank of the order, and a blood specimen is drawn from the client for typing and crossmatching. The nurse receives a telephone call from the blood bank and is informed that the unit of blood is ready for administration. Number the actions in order of priority that the nurse should take to administer the blood. (Number 1 is the first action and number 6 is the last action.) a. Hang the bag of blood. b. Obtain the unit of blood from the blood bank. c. Ensure that an informed consent has been signed. d. Verify the physician's order for the blood transfusion. e. Insert an 18- or 19-gauge IV catheter into the client. f. Ask a licensed nurse to assist in confirming blood compatibility and verifying client identity. Source: Saunders 4th

ANS: F ANS: D ANS: B ANS: A ANS: C ANS: E Rationale: The nurse would first verify the physician's order for the blood transfusion and ensure that the client has been informed about the procedure and has signed an informed consent. Once this has been done, the nurse would ensure that at least an 18- or 19-gauge intravenous needle is inserted into the client. Blood has a thicker and stickier consistency than intravenous solutions and using an 18- or 19-gauge catheter ensures that the bore of the catheter is large enough to prevent damage to the blood cells. Next, the blood is obtained from the blood bank, once the nurse is sure that the client has been informed and has an adequate access for administering the blood. Once the blood has been obtained, two registered nurses, or one registered and a licensed practical nurse (depending on agency policy), must together check the label on the blood product against the client's identification number, blood group, and complete name. This minimizes the risk of error in checking information on the blood bag and thereby minimizes the risk of harm or injury to the client. The nurse should measure vital signs and assess lung sounds and then hang the transfusion. Strategy: Remember that a physician's order is needed for treatments and procedures. This will direct you to the first nursing action. Recalling that the client needs to be informed about a procedure will assist in determining that the next action would be to ensure that the client has signed a consent form. Next, remember that client preparation for the procedure is important. You would not obtain the blood from the blood bank unless the client was prepared; therefore, the nurse would ensure that the client had an adequate intravenous access. Once blood is obtained, remember that verifying compatibility and client identity is critical before hanging the blood. Review the procedure for administering blood if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 914). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1190-1191). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Delegating and Prioritizing Alternate Question Types -> Prioritize

2325) A community health nurse is providing a session to community members about the risks associated with laryngeal cancer. Which statement by a person attending the session indicates correct understanding of the risk factors? a. "Cigarette smoking does not contribute to the development of this type of cancer." b. "Alcohol consumption is not associated with this type of cancer." c. "Exposure to airborne carcinogens can cause this type of cancer." d. "Overuse of the voice is not associated with this type of cancer unless it causes spitting up of blood." Source: Saunders 4th

ANS: C Rationale: To decrease the risk of laryngeal cancer, the client should be instructed to avoid cigarette smoking, alcohol consumption, exposure to airborne carcinogens, and vocal abuse. The client is instructed to schedule routine physical examinations. The client also should be instructed to seek medical care if difficulty in swallowing, persistent hoarseness, enlarged lymph nodes in the neck, or unexplained weight loss occurs. Strategy: Note the strategic words indicates an understanding. Focusing on the anatomical location of this condition will assist in directing you to option 3. Also, note that options 1, 2, and 4 are comparative or alike in that they all contain the word not. Review the risk factors associated with this type of cancer if you had difficulty with this question. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., p. 781). St. Louis: Mosby. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 572). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

1722) The nurse is preparing to insert a nasogastric tube (NG) into a client. What nursing measure will best facilitate easy insertion of the tube? a. Placing the NG tube in warm water b. Removing the tube if any resistance to insertion is met c. Asking the client to swallow as the tube is being advanced d. Hyperextending the head to insert the tube Source: Saunders 4th

ANS: C Rationale: To facilitate insertion best, when the tube reaches the pharynx, the client is encouraged to lower his or her head slightly, swallow and, if allowed, take sips of water. The nasogastric (NG) tube would be iced to stiffen it, which eases insertion. If resistance is met, the tube is withdrawn and repassed. Option 3 is the only option that would facilitate insertion. Strategy: Use the process of elimination. Focus on the subject, facilitating easy insertion of the NG tube. Next, visualize the procedure to direct you to option 3. Review this procedure if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1405). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2189) A home care nurse provides instructions to a client with systemic lupus erythematosus (SLE) about measures to manage fatigue. Which statement by the client indicates the need for further instruction? a. "I need to avoid long periods of rest." b. "I need to sit whenever possible." c. "I should take a hot bath every evening." d. "I should engage in moderate low-impact exercise when I am not tired." Source: Saunders 4th

ANS: C Rationale: To help reduce fatigue in the client with SLE, the nurse should instruct the client to sit whenever possible, to avoid hot baths, to schedule moderate low-impact exercises when not fatigued, and to maintain a balanced diet. The client is instructed not to rest for long periods because it promotes joint stiffness. Strategy: Use the process of elimination. Note the strategic words manage fatigue and need for further instruction. This phrasing indicates a negative event query and asks you to select an incorrect statement. By the process of elimination, you should easily be directed to option 3 as the action that would exacerbate fatigue. If you had difficulty with this question, review measures to prevent fatigue. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2354). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 1743-1744). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1191) The nurse is caring for a client following kidney transplantation. The client develops oliguria. Which of the following would the nurse anticipate to be prescribed as the treatment for the oliguria? a. Restricting fluids b. Encourage fluid intake c. Administration of diuretics d. Irrigation of the Foley catheter Source: Saunders 4th

ANS: C Rationale: To increase urinary output, diuretics and osmotic agents are administered. The client should be monitored closely because fluid overload can cause hypertension, congestive heart failure, and pulmonary edema. Fluid intake would not be encouraged or restricted. Irrigation of the Foley catheter will not assist in alleviating this oliguria. Strategy: Use the process of elimination. Recalling the definition of oliguria will direct you easily to option 3 as the treatment for this occurrence. If you are unfamiliar with the treatment of oliguria following kidney transplantation, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1762). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2105) A nurse is planning care for a client with intracranial pressure (ICP) monitoring. Which of the following interventions would be contraindicated in the plan of care? a. Using strict aseptic technique when touching the monitoring system b. Assessing the insertion site for signs and symptoms of infection c. Leveling the transducer at the lowest point of the ear d. Checking all stopcocks and connections for leaks Source: Saunders 4th

ANS: C Rationale: To obtain accurate ICP pressure readings, the transducer is zeroed at the level of the foramen of Monro, which is approximated by placing the transducer 1 inch above the level of the ear. Serial ICP readings should be done with the client's head in the same position. Options 1, 2, and 4 are accurate interventions. Strategy: Use the process of elimination, noting the strategic word contraindicated. This indicates a negative event query and asks you to select an incorrect intervention. Begin by eliminating options 1 and 2. Because there is a foreign body embedded in the client's brain, vigilant aseptic technique must be carried out. Regarding the remaining options, it makes sense to ensure that there are no leaks in the system, because bacteria could enter the system, or incorrect pressure readings could be obtained. Review the procedure related to ICP monitoring if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2195-2197, 2201). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2027) A nurse is conducting a health screening clinic for glaucoma. A client reports to the clinic for an eye examination, and the nurse performs a tonometry test on the client. The results of the test indicate an intraocular pressure of 24 mm Hg. On the basis of this finding, what information should the nurse provide to the client? a. The pressure is normal. b. The pressure is low. c. The pressure is elevated, necessitating follow-up treatment. d. The test will need to be repeated because the findings are inconclusive. Source: Saunders 4th

ANS: C Rationale: Tonometry is an effective screening test to detect glaucoma in its early stages. The normal intraocular pressure is 12 to 22 mm Hg. An intraocular pressure of 24 mm Hg is an elevated finding, and the client should be referred for follow-up treatment. Strategy: Knowing that normal intraocular pressure is 12 to 22 mm Hg will easily direct you to the correct option. If you are unfamiliar with this test, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1080-1081). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1210) A nurse who is administering bethanechol chloride (Urecholine) is monitoring for acute toxicity associated with the medication. The nurse checks the client for which sign of toxicity? a. Dry skin b. Dry mouth c. Bradycardia d. Signs of dehydration Source: Saunders 4th

ANS: C Rationale: Toxicity (overdose) produces manifestations of excessive muscarinic stimulation such as salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension. Treatment includes supportive measures and the administration of atropine sulfate subcutaneously or intravenously. Strategy: Use the process of elimination. Noting the similarity in options 1, 2, and 4 will assist in eliminating these options. Review these signs if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 135). Philadelphia: W.B. Saunders. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 284). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1198) The client with prostatitis following kidney infection has received instructions on management of the condition at home and prevention of recurrence. The nurse determines that the client understands the instructions if the client verbalizes that he will: a. Stop antibiotic therapy when pain subsides. b. Exercise as much as possible to stimulate circulation. c. Use warm tub baths and analgesics to increase comfort. d. Keep fluid intake to a minimum to decrease the need to void. Source: Saunders 4th

ANS: C Rationale: Treatment of prostatitis includes medication with antibiotics, analgesics, and stool softeners. The nurse also teaches the client to rest, increase fluid intake, and use sitz baths for comfort. Antimicrobial therapy is always continued until the prescription is finished. Strategy: Use the process of elimination. Eliminate option 1 first because stopping medication therapy before the end of the course is contraindicated. Also, eliminate option 4 because fluid intake should be increased. From the remaining options, recall that sitz baths provide comfort and that rest is helpful in the healing process. Review home care instructions for the client with prostatitis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1880). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1395) The nurse is assigned to care for a client admitted to the hospital with a diagnosis of systemic lupus erythematosus. The nurse reviews the physician's orders, expecting to note that which type of medication is prescribed? a. Antibiotic b. Antidiarrheal c. Corticosteroid d. Opioid analgesic Source: Saunders 4th

ANS: C Rationale: Treatment of systemic lupus erythematosus is based on the systems involved and symptoms. Treatment normally consists of anti-inflammatory drugs, corticosteroids, and immunosuppressants. Options 1, 2, and 4 are not standard components of medication therapy. Strategy: Use the process of elimination. Recalling that systemic lupus erythematosus is an inflammatory disorder will direct you to option 3. If you are unfamiliar with the treatments normally prescribed in this disease, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2355). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1741). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

983) A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including metronidazole (Flagyl), omeprazole (Prilosec), and clarithromycin (Biaxin). Which statement by the client indicates the best understanding of the medication regimen? a. "My ulcer will heal because these medications will kill the bacteria." b. "These medications are only taken when I have pain from my ulcer." c. "The medications will kill the bacteria and stop the acid production." d. "These medications will coat the ulcer and decrease the acid production in my stomach." Source: Saunders 4th

ANS: C Rationale: Triple therapy for Helicobacter pylori infection usually includes two antibacterial drugs and a proton pump inhibitor. Metronidazole and clarithromycin are antibacterials. Omeprazole is a proton pump inhibitor. These medications will kill the bacteria and decrease acid production. Strategy: Focus on the name of the medications and their actions. Eliminate option 1 because the medications do more than kill the bacteria. These medications are taken not only when there is pain but continually until gone, usually for 1 to 2 weeks. This will eliminate option 2. These medications do not coat the ulcer, eliminating option 4. Review the medication regimens for treatment of H. pylori and their actions if you had difficulty with this question. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 708-709). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

80) A client arrives in the emergency room complaining of chest pain that began 4 hours ago. A troponin T blood specimen is obtained, and the results indicate a level of 0.6 ng/mL. The nurse interprets that this result indicates a: a. Normal level b. Low value that indicates possible gastritis c. Level that indicates a myocardial infarction d. Level that indicates the presence of possible angina Source: Saunders 4th

ANS: C Rationale: Troponin is a regulatory protein found in striated muscle. The troponins function together in the contractile apparatus for striated muscle in skeletal muscle and in the myocardium. Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. A troponin T value that is higher than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction. A normal troponin I level is lower than 0.6 ng/mL. Strategy: Note that the subject of the question relates to the troponin T. Knowing that a level higher than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction will direct you to option 3. Review this diagnostic test if you are unfamiliar with it. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 1094). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 694). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

159) The nurse has just obtained a unit of blood from the blood bank to transfuse into a client as ordered. Before preparing the blood for transfusion, the nurse next looks for which of the following members of the health care team to assist in checking the unit of blood? a. Phlebotomist b. Medical student c. Registered nurse d. Blood bank technician Source: Saunders 4th

ANS: C Rationale: Two registered nurses (RNs) or one RN and a licensed practical nurse (LPN) (depending on agency policy) must check the label on the blood product together against the client's identification number, blood group, and complete name. This minimizes the risk of error in checking information on the blood bag and thereby minimizes the risk of harm or injury to the client. A blood bank technician will verify data with the nurse when the blood is obtained from the blood bank, but will not verify information on the nursing unit or at the client's bedside. The other options are also incorrect. Strategy: Use the process of elimination and specific knowledge of blood administration methods and techniques. Remember that two RNs or one RN and a licensed practical nurse (depending on agency policy) must check the blood product together. Review the procedures related to checking blood before administration if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 914). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1191). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2141) An older client is brought to the hospital emergency department by ambulance after sustaining a fall. The client's left leg is shortened, adducted, and externally rotated. The nurse interprets these signs as consistent with: a. Fractured knee b. Dislocated knee c. Fracture of the femoral neck d. Fracture of the midshaft of the femur Source: Saunders 4th

ANS: C Rationale: Typical signs and symptoms after femoral neck fracture include shortening of the affected leg, adduction, and external rotation. The client may report slight groin pain, or pain in the medial side of the knee. Moving the fractured extremity increases the pain significantly. These signs and symptoms are not associated with a fractured or dislocated knee or a fractured femur. Strategy: Use the process of elimination and recall the signs and symptoms of hip fracture. Remember that older clients are much more likely to fracture the hip after sustaining a fall than to dislocate it. On this basis alone, you could choose option 3 as the correct answer. Review the signs of a hip fracture if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 638-639). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1172) The nurse is assessing the client with epididymitis. The nurse anticipates which of the following findings on physical examination? a. Fever, diarrhea, groin pain, and ecchymosis b. Nausea, vomiting, scrotal edema, and ecchymosis c. Fever, nausea, vomiting, and painful scrotal edema d. Diarrhea, groin pain, testicular torsion, and scrotal edema Source: Saunders 4th

ANS: C Rationale: Typical signs and symptoms of epididymitis include scrotal pain and edema, which often are accompanied by fever, nausea and vomiting, and chills. Epididymitis most often is caused by infection, although sometimes it can be caused by trauma. Epididymitis needs to be distinguished correctly from testicular torsion. Strategy: Use the process of elimination. A disorder that ends in -itis results from inflammation or infection. Therefore, an expected finding would be elevated temperature. With this in mind, eliminate options 2 and 4 because they do not contain fever as part of the option. Knowing that ecchymosis results from bleeding, which is not part of this clinical picture, directs you to option 3. Review the clinical manifestations of epididymitis if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1039). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1880). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2275) A nurse has formulated the nursing diagnosis risk for impaired skin integrity for an unconscious client. Which of the following interventions would be inappropriate to include in the plan of care for this client? a. Reposition every 2 hours. b. Apply protective pads to heels and elbows. c. Add a small amount of alcohol to the daily bath water. d. Provide perineal care every 8 hours and after incontinence. Source: Saunders 4th

ANS: C Rationale: Unconscious clients are completely immobile, having lost the protective reflexes to shift body weight. It is up to the nurse to minimize the risk of prolonged pressure that could cause skin ischemia and breakdown. This is accomplished by repositioning the client every 2 hours. Protective pads can be applied to the heels and elbows to reduce friction and shear. Appropriate perineal care is essential to keep waste products from excoriating the skin. The nurse can reduce skin dryness and irritation by adding a superfatty solution (such as baby oil or castile soap) to the daily bath water. Drying agents such as alcohol are avoided, because dry skin can crack and break down. Strategy: Use the process of elimination, noting the strategic word inappropriate. This indicates a negative event query and asks you to select an incorrect action. Using knowledge of the basic concepts related to maintaining skin integrity will direct you to option 3. Review these basic concepts if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2061). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1921) A nurse instructs a female client to obtain a clean catch urine specimen for culture and sensitivity testing. Which statement by the client indicates that she understands the procedure for collecting the specimen? a. "I should empty my bladder into a container so that the full amount of urine can be determined." b. "A urine specimen will be obtained from a catheter." c. "I need to cleanse the labia using cleansing towels, void into the toilet, and then void into the sterile specimen container." d. "I need to clean the labia with toilet paper and void into the sterile specimen container." Source: Saunders 4th

ANS: C Rationale: Urine specimens for culture and sensitivity need to be obtained using proper cleansing and voiding techniques to avoid contamination from external sources. The use of toilet paper will contaminate the specimen. The procedure described in option 1 would not provide a clean specimen. It is not necessary to obtain the specimen via a catheter. Strategy: Use the process of elimination. Knowledge of principles of asepsis and measures to prevent infection will assist in eliminating option 2. Regarding the remaining options, noting the strategic words clean catch will assist in eliminating options 1 and 4. Review the procedure for this type of urine collection if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1666). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1834) An ambulatory care nurse is providing discharge instructions to a female client who underwent cryosurgery with laser therapy because of a positive Papanicolaou smear. Which of the following statements if made by the client indicates an understanding of the instructions? a. "If I note any odor to the vaginal discharge, I should call the physician immediately." b. "I should take sitz baths every 4 hours for the next week." c. "I should expect the vaginal discharge to be clear and watery." d. "Narcotics will be needed to relieve any discomfort that I may have." Source: Saunders 4th

ANS: C Rationale: Vaginal discharge should be clear and watery after the procedure. The client should be told that the vaginal discharge may be odorous as a result of the sloughing of dead cell debris. This vaginal odor takes about 8 weeks to resolve. The client should be instructed to avoid any sitz baths or tub baths while the area is healing, which takes approximately 10 weeks. Narcotic analgesics would not be prescribed because pain is mild after this procedure. The client should understand that the medication prescribed is not likely to be a narcotic analgesic. Strategy: Use the process of elimination, thinking about the anatomical location and the effects of the procedure. This will direct you to option 3. If you had difficulty with this question, review the client teaching points related to cryosurgery. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1074). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1846). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

2646) A client with diabetes insipidus asks the nurse about the purpose of a new medication, vasopressin (Pitressin). The nurse explains that this medication works by which of the following mechanisms? a. Inhibiting contraction of smooth muscle b. Producing vasodilation c. Decreasing urinary output d. Decreasing peristalsis Source: Saunders 4th

ANS: C Rationale: Vasopressin is a vasopressor and an antidiuretic. It increases reabsorption of water by the renal tubules, resulting in a decreased urinary flow rate. It also directly stimulates contraction of smooth muscle, causing vasoconstriction, and stimulating peristalsis. Strategy: Use the process of elimination. Eliminate options 1 and 4 first because they are comparative or alike. Regarding the remaining options, recall the pathophysiology of diabetes insipidus to direct you to option 3. Review the actions of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1199). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1094) A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How would the nurse correctly interpret this rhythm? a. Asystole b. Atrial fibrillation c. Ventricular fibrillation d. Ventricular tachycardia Source: Saunders 4th

ANS: C Rationale: Ventricular fibrillation is characterized by irregular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles. Strategy: Use the process of elimination and knowledge regarding the characteristics of ventricular fibrillation. The lack of visible QRS complexes eliminates atrial fibrillation and ventricular tachycardia. Recalling that asystole is lack of any electrical activity of the heart will direct you to option 3. Review the characteristics of ventricular fibrillation if you had difficulty with this question. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., p. 681). St. Louis: Mosby. Reference: Ignatavicius, D. & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 731-732). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1086) A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over 100 beats/min. The nurse determines that the client is experiencing which of the following dysrhythmias? a. Sinus tachycardia b. Ventricular fibrillation c. Ventricular tachycardia d. Premature ventricular contractions Source: Saunders 4th

ANS: C Rationale: Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 second), and typically a rate between 140 and 180 impulses/min. The rhythm is regular. Strategy: Use the process of elimination. Eliminate option 1 first because there are no P waves. Premature ventricular contractions are isolated ectopic beats superimposed on an underlying rhythm, so option 4 is eliminated next. Recalling that there are no true QRS complexes with ventricular fibrillation will direct you to option 3 from the remaining options. Review the characteristics of ventricular tachycardia if you are unfamiliar with it. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 716, 729-731). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2422) A nurse is preparing to teach a client how to safely use crutches. Before initiating the teaching, the nurse performs an assessment on the client. The priority nursing assessment should include which of the following? a. The client's fear related to the use of crutches b. The client's understanding of the need for increased mobility c. The client's vital signs, muscle strength, and previous activity level d. The client's feelings about the restricted mobility Source: Saunders 4th

ANS: C Rationale: Vitals signs provide a baseline to determine how well the client will tolerate activity. Assessing muscle strength will help determine if the client has enough strength for crutch walking and if muscle-strengthening exercises are necessary. Previous activity level will provide information related to the tolerance of activity. Options 1, 2, and 4 also are a component of the assessment, but physiological needs take precedence over psychosocial needs. Strategy: Note the strategic word priority in the question. Use Maslow's Hierarchy of Needs theory to prioritize. Remember that physiological needs take precedence over psychosocial needs. This should direct you to option 3. Review physiological assessment of a client requiring crutches if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills and techniques (6th ed., pp. 283-284). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1620) The nurse is preparing to teach a client how to use crutches safely. Prior to initiating the teaching, the nurse performs an assessment on the client. The priority nursing assessment should include which of the following? a. The client's fear related to the use of the crutches b. The client's understanding of the need for increased mobility c. The client's vital signs, muscle strength, and previous activity level of the client d. The client's feelings about the restricted mobility Source: Saunders 4th

ANS: C Rationale: Vitals signs provide a baseline to determine how well the client will tolerate activity. Assessing muscle strength will help determine whether the client has enough strength for crutch walking and if muscle-strengthening exercises are necessary. The previous activity level will provide information related to the tolerance of activity. Options 1, 2, and 4 are also a component of the assessment but physiological needs take precedence over psychosocial needs. Strategy: Note the strategic word priority in the question. Use Maslow's Hierarchy of Needs theory to prioritize. Remember that physiological needs take precedence over psychosocial needs. This should easily direct you to option 3. Review assessment of the client's readiness to use crutches if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills and techniques (6th ed., pp. 284-287). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1980) A nurse is caring for a client who is taking an oral anticoagulant. The nurse notes the presence of gross hematuria and large areas of bruising on the client's body. The nurse notifies the physician and prepares to administer which medication if prescribed? a. Oral potassium supplements b. Heparin sulfate c. Phytonadione (vitamin K) d. Protamine sulfate Source: Saunders 4th

ANS: C Rationale: Warfarin (Coumadin) is an oral anticoagulant. The effects of warfarin (Coumadin) overdose can be reversed with phytonadione (vitamin K). Vitamin K is an antagonist to the action of warfarin that can reverse warfarin-induced inhibition of clotting factor synthesis. For mild bleeding, vitamin K should be administered orally; a dose of 10 to 20 mg will cause prothrombin levels to normalize within 24 hours. If bleeding is severe, parenteral vitamin K is indicated. Protamine sulfate is the antidote for heparin sulfate. Heparin sulfate is an anticoagulant and would cause increased bleeding. The question presents no data indicating that potassium supplements are indicated. Strategy: Knowledge regarding the antidote for warfarin is required to answer this question. Remember that the antidote for warfarin is vitamin K. If you had difficulty with this question, review this medication and its antidote. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 595). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1148) A client who has been receiving heparin therapy also is started on warfarin sodium (Coumadin). The client asks a nurse why both medications are being administered. Which of the following statements reflects appropriate teaching by the nurse? a. Warfarin sodium stimulates production of the body's own thrombolytic substances, but it takes 2 to 4 days for this to begin. b. Warfarin sodium stimulates breakdown of specific clotting factors by the liver, and it takes 2 to 3 days for this to exert an anticoagulant effect. c. Warfarin sodium inhibits synthesis of specific clotting factors in the liver, and it takes 3 to 4 days for this medication to exert an anticoagulant effect. d. Warfarin sodium has the same mechanism of action as heparin, and the crossover time is needed for the serum level of warfarin sodium to be therapeutic. Source: Saunders 4th

ANS: C Rationale: Warfarin sodium works in the liver and inhibits synthesis of four vitamin K-dependent clotting factors (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of warfarin is exhibited. Strategy: Use the process of elimination. Heparin and warfarin sodium do not act in the same way, so eliminate option 4 first. Warfarin is an anticoagulant, not a thrombolytic, so eliminate option 1 next. From the remaining options, recalling that the liver synthesizes clotting factors will direct you to option 3. Review the action of warfarin sodium if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 814). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2198) A nurse is reviewing the medical record of a client who received electroconvulsive therapy (ECT) in the past. Which of the following assessment data would indicate to the nurse the presence of long-term retrograde amnesia in the client? a. After the procedure, the client has difficulty recalling newly learned information. b. The client has a memory loss for 2 days after the procedure. c. The client had difficulty remembering information learned for 4 months before ECT. d. The client has difficulty recalling newly learned information for 2 weeks following the procedure. Source: Saunders 4th

ANS: C Rationale: When ECT is performed, the client may experience disorientation, attention difficulty, and transient neurological abnormalities, which usually resolve within a few hours or days. The most prominent adverse reaction is short-term anterograde and retrograde amnesia. Anterograde amnesia is defined as the loss of the client's ability to retain newly learned information. This kind of amnesia usually resolves within the first few weeks after ECT treatments. Retrograde amnesia is defined as difficulty recalling information learned before ECT. This kind of amnesia may be long-term. Option 1 describes short-term anterograde amnesia. Options 2 and 4 describe short-term retrograde amnesia. Strategy: Use the process of elimination. Focus on the subject, long-term retrograde amnesia. Eliminate options 1 and 4 first because they are comparative or alike. Regarding the remaining options, noting the relationship between the words long-term retrograde and 4 months before will direct you to option 3. Review the side effects associated with ECT if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 608). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 351-352). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2012) A nurse is providing instructions to a client being discharged from the hospital following removal of a chest tube that was inserted following thoracic surgery. Which of the following statements if made by the client indicates a need for further instruction? a. "If I note any signs of infection, I should contact the physician." b. "If I have any difficulty in breathing, I should call the physician." c. "I should remove the chest tube site dressing when I get home." d. "I should avoid heavy lifting for at least 4 to 6 weeks." Source: Saunders 4th

ANS: C Rationale: When a chest tube is removed, an occlusive dressing consisting of petrolatum gauze covered by a dry sterile dressing usually is placed over the chest tube site. This dressing is maintained in place until the physician says that it may be removed. The client is taught to monitor and report any signs of respiratory difficulty or any signs of infection or increased temperature. The client should avoid heavy lifting for 4 to 6 weeks after discharge to facilitate continued wound healing. Strategy: Note the strategic words need for further instruction. This phrasing indicates a negative event query and directs you to select an incorrect statement. Reading each option carefully and use of the process of elimination will assist in directing you to option 3. Review client teaching points after removal of a chest tube if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1866). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1744) A nasogastric (NG) tube has been inserted into a client and the physician prescribes that the tube be attached to intermittent suction. The nurse attaches the suction noting that the pressure should not exceed: a. 10 mm Hg b. 20 mm Hg c. 25 mm Hg d. 30 mm Hg Source: Saunders 4th

ANS: C Rationale: When a nasogastric (NG) tube is attached to suction, it may be continuous or intermittent, with a pressure not exceeding 25 mm Hg. The specific pressure and intervals are prescribed by the physician. Options 1, 2, and 4 are incorrect. Strategy: Knowledge regarding the restrictions related to the amount of pressure with suction on a GI tube is required to answer this question. Remember that when an NG tube is attached to suction, the pressure should not exceed 25 mm Hg. If you are unfamiliar with the care of a client with an NG tube attached to suction, review this content. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1778). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2484) A community health nurse is providing a yearly summer educational session to parents in a local community. The topic of the session is prevention and treatment measures for poison ivy. The nurse instructs the parents that if the child comes in contact with poison ivy to: a. Immediately report to the emergency department. b. Avoid becoming concerned if a rash is not noted on the skin. c. Shower the child immediately, lathering and rinsing the exposed skin several times. d. Apply calamine lotion immediately to the exposed skin areas. Source: Saunders 4th

ANS: C Rationale: When a person comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the human skin. The client should be instructed to shower immediately; the skin should be lathered several times and rinsed each time in running water. Application of calamine lotion is a treatment that is used if dermatitis develops. It is not necessary for the client to be seen in the emergency department at the time of initial contact with the poison ivy. Strategy: Use the process of elimination. Knowing that dermatitis can develop from contact with an allergen will assist in selecting the correct option. Also, recalling that contact with poison ivy results in an invisible film will assist in directing you to option 3. Review the immediate treatment for contact with poison ivy if you had difficulty with this question. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., p. 779). St. Louis: Mosby. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 1113). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

2057) A nursing student is performing a respiratory assessment on a female adult client and is assessing for tactile fremitus. The nurse observing the student intervenes if the student performs which incorrect technique? a. Palpating over the lung apices in the supraclavicular area b. Asking the client to repeat the word "ninety-nine" during palpation c. Palpating over the breast tissue to assess and compare vibrations from one side to the other d. Comparing vibrations from one side to the other as the client repeats the word "ninety-nine" Source: Saunders 4th

ANS: C Rationale: When assessing for tactile fremitus, the nurse should begin palpating over the lung apices in the supraclavicular area. The nurse should compare vibrations from one side to the other as the client repeats the word "ninety-nine." The nurse should avoid palpating over female breast tissue because breast tissue usually blocks the sound. Strategy: Note the strategic word incorrect in the question. This indicates a negative event query and directs you to select an incorrect technique. Eliminate options 2 and 4 first, because they are comparative or alike. Regarding the remaining options, recalling that breast tissue blocks sound will direct you to this option. Review the technique of performing assessment for tactile fremitus if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1753-1754). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 635-636). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1711) The client with a history of lung disease is at risk for developing respiratory acidosis. The nurse assesses this client for which signs and symptoms characteristic of this disorder? a. Bradycardia and hyperactivity b. Decreased respiratory rate and depth c. Headache, restlessness, and confusion d. Bradypnea, dizziness, and paresthesias Source: Saunders 4th

ANS: C Rationale: When the client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache, restlessness, mental status changes, such as drowsiness and confusion, visual disturbances, diaphoresis, cyanosis as the hypoxia becomes more acute, hyperkalemia, a rapid, irregular pulse, and dysrhythmias. Strategy: Use the process of elimination and knowledge of the signs and symptoms of respiratory acidosis to answer the question. Remember that restlessness and confusion occur in respiratory acidosis. If this question was difficult, review the clinical manifestations associated with respiratory acidosis. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1145). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

118) A client receiving parenteral nutrition (PN) suddenly spikes a fever. A nurse notifies the physician, and the physician initially orders that the solution and tubing be changed. The nurse should do which of the following with the discontinued materials? a. Discard them in the unit trash. b. Return them to the hospital pharmacy. c. Send them to the laboratory for culture. d. Save them for return to the manufacturer. Source: Saunders 4th

ANS: C Rationale: When the client who is receiving PN spikes a temperature, a catheter-related infection should be suspected. The solution and tubing should be changed, and the discontinued materials should be cultured for infectious organisms. The other options are incorrect. Strategy: Use the process of elimination. Identifying the subject of the question, infection, and correlating the elevated temperature with infection associated with the IV should direct you to option 3. Review the procedure when infection is suspected in the client receiving PN if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 989). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1671) The client with diabetes mellitus calls the clinic and tells the nurse that he has been nauseated during the night. The client asks the nurse if the morning insulin should be administered. Which of the following is the appropriate nursing response? a. Omit the insulin. b. Administer half the prescribed dose. c. Administer the full dose as prescribed. d. Wait until noon before making a decision. Source: Saunders 4th

ANS: C Rationale: When the client with diabetes mellitus becomes ill, control is more difficult. Insulin is not omitted and the client is encouraged to consume liquid carbohydrates if unable to eat regular meals. The client is instructed to notify the physician if vomiting or diarrhea occurs, or if the illness progresses past 2 days. Strategy: Use the process of elimination. You can easily eliminate options 1, 2, and 4 because it is not within the legal parameters of nursing responsibilities to adjust or alter medication dosages. If you had difficulty with this question, review the client teaching points related to the administration of insulin on "sick days." Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1545). Philadelphia: W.B. Saunders. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 788). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1968) A nurse is reviewing the laboratory test results for a client with a diagnosis of leukemia who is receiving chemotherapy. The nurse notes that the client's platelet count is 20,000 cells/μL. The nurse should prepare to implement which of the following? a. Remove the fresh flowers from the client's room. b. Call the dietary department to report that the client will be on a low-bacteria diet. c. Remove the rectal thermometer from the client's room. d. Instruct family members to wear a mask when entering the client's room. Source: Saunders 4th

ANS: C Rationale: When the client's platelet count is low, the client is at risk for bleeding. Options 1, 2, and 4 relate to the risk for infection. Rectal temperatures should not be taken on the client who is at risk for bleeding because the thermometer could cause an alteration in the delicate rectal membranes and lead to bleeding. Strategy: Use the process of elimination, focusing on the subject, a low platelet count. Recalling that a low platelet count places the client at risk for bleeding will assist in directing you to option 3. Also, note that options 1, 2, and 4 are comparative or alike in that they all relate to the risk of infection. Review the normal platelet count and nursing interventions for the client with a low count if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2409). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

1488) The emergency room nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which of the following is the priority nursing action? a. Adhering to the mandatory abuse reporting laws b. Notifying the case worker of the family situation c. Removing the client from any immediate danger d. Obtaining treatment for the abusing family member Source: Saunders 4th

ANS: C Rationale: Whenever the abused client remains in the abusive environment, priority must be placed on ascertaining whether the person is in any immediate danger. If so, emergency action must be taken to remove the person from the abusing situation. Options 1, 2, and 4 may be appropriate interventions but are not the priority. Strategy: Use Maslow's Hierarchy of Needs theory, remembering that if a physiological need is not present, then safety is the priority. This should direct you to option 3, the only option that directly addresses client safety. Review care of the client who is a victim of physical abuse if you had difficulty with this question. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 521). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

2431) A client is brought to the emergency department immediately after a smoke inhalation injury. The initial nursing action should be to prepare the client to receive: a. Pain medication b. Oxygen via nasal cannula c. 100% humidified oxygen by face mask d. Endotracheal intubation Source: Saunders 4th

ANS: C Rationale: With a smoke inhalation injury, the client is immediately treated with 100% humidified oxygen delivered by face mask. Endotracheal intubation is needed if the client exhibits respiratory stridor, which indicates airway obstruction. Pain medication may be needed but would not be the initial intervention. Strategy: Note the strategic word initial in the question. No data in the question indicate that the client would require endotracheal intubation. Therefore, eliminate option 4. Regarding the remaining options, use the ABCs—airway, breathing, and circulation—to assist in directing you to option 3. Oxygen delivered at 100% concentration is the initial action. Review care to the client who sustained a burn injury, if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1445). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1627). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

2152) A nurse in the hospital emergency department is assessing a client with an open leg fracture. The nurse inquires about the date of the client's last: a. Physical examination b. Chest radiograph c. Tetanus vaccine d. Tuberculin test Source: Saunders 4th

ANS: C Rationale: With an open fracture, the client is at risk for the development of osteomyelitis, gas gangrene, and tetanus. The nurse assesses for the date of the last tetanus immunization to ensure that the client has tetanus prophylaxis. Strategy: Use the process of elimination. With an open leg fracture, the client is at risk for infection. Therefore, look for the option that is somehow related to this complication. Thus, the answer is to inquire about the date of the last tetanus vaccine. Review care of the client with an open leg fracture if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2501, 2503). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2180) A client receiving therapy with carbidopa/levodopa (Sinemet) is upset and tells the home health nurse that his urine has turned a darker color since he started taking this medication. The client wants to discontinue its use. In formulating a response to the client's concerns, the nurse interprets that this change is: a. Indicative of developing toxicity b. A sign of interaction with another medication c. A harmless side effect of the medication d. A result of taking the medication with milk Source: Saunders 4th

ANS: C Rationale: With carbidopa/levodopa therapy, a darkening of the urine or sweat may occur. The client should be reassured that this is a harmless effect of the medication, and its use should be continued. Options 1, 2, and 4 are incorrect. Strategy: Use the process of elimination. Recalling the side effects that occur with this medication will direct you to option 3. Review the side effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 186). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2053) A nurse is performing an assessment on a client with a diagnosis of Cushing's syndrome. Which of the following would the nurse expect to note on assessment of the client? a. Drooping on one side of the face b. Skin atrophy c. A rounded "moon-like" appearance to the face d. The presence of sunken eyes Source: Saunders 4th

ANS: C Rationale: With excessive secretion of corticotropin hormones (ACTH) and chronic corticosteroid use, the person with Cushing's syndrome develops a rounded moon-like face, prominent jowls, red cheeks, and hirsutism on the upper lip, lower cheek, and chin. Options 1, 2, and 4 are not associated with the assessment findings in Cushing's syndrome. Strategy: Use the process of elimination. Recall that in Cushing's syndrome there is an excessive secretion of ACTH. This will assist in directing you to option 3. If you had difficulty with this question, review the assessment findings in the client with Cushing's syndrome. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1474). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

151) The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The nurse determines that this client most likely is experiencing which complication of blood transfusion therapy? a. Bacteremia b. Hypovolemia c. Fluid overload d. Transfusion reaction Source: Saunders 4th

ANS: C Rationale: With fluid overload, the client has the presence of crackles in addition to dyspnea. An allergic reaction, which is one type of blood transfusion reaction, would produce symptoms such as flushing, dyspnea, itching, and a generalized rash. Hypovolemia is not a complication of a blood transfusion. With bacteremia, the client would have a fever, which is not part of the clinical picture presented. Strategy: Use the process of elimination, noting the strategic words most likely. Read the question carefully and focus on the symptoms identified in the question. Eliminate option 2 first because it is not a complication of a blood transfusion. Next, eliminate option 1 because no information in the question indicates that the client has an elevated temperature. From the remaining options, focusing on the strategic words crackles in the lung bases will direct you to option 3. Review the complications of blood transfusion therapy if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., p. 977). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1938) A nurse tests the urine of a client with acute renal failure (ARF) with a multitest reagent strip. The strip tests highly positive for proteinuria. The nurse analyzes that this result is consistent with which of the following types of renal failure? a. Atypical renal failure b. Prerenal failure c. Intrinsic renal failure d. Postrenal failure Source: Saunders 4th

ANS: C Rationale: With intrinsic renal failure, there is a fixed specific gravity and the urine tests definitely positive for proteinuria. In prerenal failure, the specific gravity is high, and there is very little or no proteinuria. In postrenal failure, there is a fixed specific gravity and little or no proteinuria. There is no disorder known as atypical renal failure. Strategy: Use the process of elimination. Begin to answer this question by eliminating option 1 because there is no known disorder with this name. Regarding the remaining options, knowing that proteinuria occurs because of leakage at the basement membrane of the glomerulus helps you to choose option 3. Review the types of ARF and the characteristics associated with ARF if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 944). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1729). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2264) An unconscious client has an impaired corneal reflex on one side. The nurse should demonstrate the best understanding of how to protect the client's eye by: a. Placing an eye patch b. Taping the eye shut during the day c. Using sterile saline drops every few hours to keep the eye moist d. Wiping inside the lower eyelid with a cotton-tipped applicator three times a day Source: Saunders 4th

ANS: C Rationale: With loss of the corneal (blink) reflex, the client is at risk for the eyes' becoming dry, and also for corneal abrasions if foreign matter comes in contact with the eye. Use of sterile saline drops is indicated to keep the eyes lubricated. An eye patch would have to be used carefully, because corneal abrasion could result if the cornea comes in contact with the patch. Introduction of a cotton-tipped applicator (foreign object) inside the lower eyelid also risks corneal abrasion. Taping the eye shut is inappropriate, does not follow assessment, and could impair the conscious client's vision, putting the client at risk for other injury, such as falls. Strategy: Use the process of elimination. The best way to answer this question is from the standpoint of potential trauma to the client. Each of the incorrect options carries some degree of risk to the client. Additionally, options 1 and 2 are comparative or alike in that they both address covering the eye. Review care of the client with an impaired corneal reflex if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2035). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2488) A clinic nurse notes that the physician has documented a suspected diagnosis of herpes zoster in the client's chart. The nurse should prepare the client for which of the following diagnostic tests to confirm this diagnosis? a. Skin biopsy b. Wood's lamp examination c. Culture of the lesion d. Patch test Source: Saunders 4th

ANS: C Rationale: With the classic presentation of herpes zoster, the clinical examination is diagnostic. A viral culture of the lesion provides the definitive diagnosis. Herpes zoster is caused by a reactivation of the varicella-zoster virus, the cause of chickenpox. In a Wood's lamp examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin. A patch test is a skin test that involves the administration of an allergen to the skin's surface to identify specific allergies. A biopsy identifies tissue type. Strategy: Recalling that herpes zoster is caused by a virus will assist in eliminating options 2 and 4 first. Regarding the remaining options, remember that a biopsy will determine tissue type, whereas a culture will identify an organism. Review diagnostic tests for herpes zoster if you had difficulty with this question. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., p. 1149). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

1593) The mother arrives at the clinic with her 3-year-old child. The mother tells the nurse that the child has had a fever and a cough for the past 2 days, and that this morning the child began to wheeze. Viral pneumonia is diagnosed. Based on the diagnosis, nurse anticipates that which of the following will be a component of the treatment plan? a. Oral antibiotics b. Hospitalization and IV antibiotics c. Supportive treatment d. IV fluid administration Source: Saunders 4th

ANS: C Rationale: With viral pneumonia, treatment is supportive. More severely ill children may be hospitalized and given oxygen, chest physiotherapy, and IV fluids. Antibiotics are not given. Bacterial pneumonia however, is treated with antibiotic therapy. Strategy: Use the process of elimination. Note the strategic word viral in the question. Recalling that antibiotics are not effective in treating viruses will assist in eliminating options 1 and 2. There are no data in the question to support the need for IV fluid administration. Option 3 is also the umbrella response. Review the care of a child with viral pneumonia if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1217). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Child Health Alternate Question Types -> Multiple Choice

1825) The community health nurse is conducting a breast cancer screening clinic in a local neighborhood and is providing sessions regarding breast self-examination (BSE). A postmenopausal woman arrives at the clinic for information on BSE. Which of the following information should the nurse give to the client? a. "It is not necessary to do BSE because you are postmenopausal." b. "You are not at risk for breast cancer because you are in the postmenopausal phase." c. "You need to perform BSE on the same day of every month." d. "Mammograms performed every 5 years are sufficient in the postmenopausal phase." Source: Saunders 4th

ANS: C Rationale: Women who are in the postmenopausal phase are taught to do BSE on the same day of every month. Before menopause, woman should do the procedure 7 days after the start of the menstrual cycle when the breasts are less tender. Options 1, 2, and 4 are incorrect regarding breast cancer and BSE in a woman who is postmenopausal. Strategy: Use the process of elimination. Eliminate options 1 and 2 first because of the close-ended word not. From the remaining options, eliminate option 4 because 5 years is too infrequent to have a mammogram. Recall that a woman who is postmenopausal should perform BSE on the same day of every month. Review BSE for the postmenopausal woman if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 735-736). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

1057) Zafirlukast (Accolate) is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication? a. Platelet count b. Neutrophil count c. Liver function tests d. Complete blood count Source: Saunders 4th

ANS: C Rationale: Zafirlukast (Accolate) is a leukotriene receptor antagonist used in the prophylaxis and long-term treatment of bronchial asthma. Zafirlukast is used with caution in clients with impaired hepatic function. Liver function laboratory tests should be performed to obtain a baseline, and the levels should be monitored during administration of the medication. Strategy: Use the process of elimination, eliminating options 2 and 4 first because a complete blood count would include a neutrophil count. From the remaining options, you would need to know that this medication would affect hepatic function. If you had difficulty with this question, review this medication. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1225). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2606) A client is receiving zalcitabine (Hivid). The nurse plans to monitor the results of which study to determine the effectiveness of this medication? a. Enzyme-linked immunosorbent assay (ELISA) b. Western blot c. CD4⁺ cell count d. Complete blood cell (CBC) count with differential Source: Saunders 4th

ANS: C Rationale: Zalcitabine slows the progression of acquired immunodeficiency syndrome (AIDS) by improving the CD4⁺ cell count. A CBC with differential may be done as part of an ongoing monitoring of the status of the client with AIDS, and to detect adverse effects of other medications. The ELISA and the Western blot are performed to diagnose AIDS initially. Strategy: Note the strategic words determine the effectiveness. Knowledge of the purpose and action of this medication and recalling that it improves the CD4⁺ cell count will direct you to option 3. Review the purpose and action of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 1225-1226). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1674) Select all interventions that apply to the care of a child who is having a seizure. a. Insert an oral airway. b. Place the child in a supine position. c. Loosen clothing around the child's neck. d. Restrain the child. e. Time the seizure. f. Stay with the child. Source: Saunders 4th

ANS: C ANS: E ANS: F Rationale: During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side will prevent aspiration because saliva will drain out the corner of the child's mouth. The child is not restrained because this could cause injury to the child. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this could injure the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure. Strategy: Visualize this clinical situation. Recalling that airway patency and safety is the priority will assist in determining the appropriate interventions. Review care of the child experiencing a seizure if you had difficulty with this question. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., pp. 1051-1052). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Child Health Alternate Question Types -> Multiple Multiple

1513) A nurse is preparing to care for a dying client, and several family members are at the client's bedside. Select the therapeutic techniques that the nurse will use when communicating with the family. Select all that apply. a. Discourage reminiscing. b. Make the decisions for the family. c. Encourage expression of feelings, concerns, and fears. d. Explain everything that is happening to all family members. e. Extend touch and hold the client's or family member's hand if appropriate. f. Be honest and truthful and let the client and family know that you will not abandon them. Source: Saunders 4th

ANS: C ANS: E ANS: F Rationale: The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears, as well as reminiscing. The nurse needs to be honest and truthful and let the client and family know that they will not be abandoned. Extend touch and hold the client's or family member's hand, if appropriate. Strategy: Recalling therapeutic communication techniques and client and family rights will assist you in answering this question. Review these techniques and care of the dying client if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 586-587). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 606). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Mental Health Alternate Question Types -> Multiple Multiple

1883) A nurse is admitting a 10-month-old infant who is being hospitalized for a respiratory infection. The nurse develops a plan of care for the infant and appropriately includes which of the following? a. Keeping the infant as quiet as possible. b. Placing small toys in the crib to provide stimulation for the infant. c. Restraining the infant to prevent dislodging of tubes. d. Providing a consistent routine with touching, rocking, and cuddling throughout hospitalization. Source: Saunders 4th

ANS: D Rationale: A 10-month-old is in the Trust versus Mistrust stage of psychosocial development according to Erikson. The infant is developing a sense of self, and the nurse should appropriately provide a consistent routine for the child. Hospitalization may have an adverse effect, and the nurse should touch, rock, and cuddle the infant to promote a sense of trust and provide sensory stimulation. Option 2 is an unsafe action. Option 1 will not provide sensory stimulation. The infant should not be restrained. Strategy: Knowledge regarding the psychosocial stages of development for the 10-month-old infant is required to answer this question. Focus on the age of the child to assist in directing you to option 4. If you had difficulty with this question, review the effects of hospitalization on a 10-month-old. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 57). St. Louis: W.B. Saunders. Reference: Wong, D., Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2006). Maternal child nursing care (3rd ed., pp. 1428-1429). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Planning Content Area -> Child Health Alternate Question Types -> Multiple Choice

1805) A 15-year-old is injured and sustains a fractured jaw. The fractured jaw has been surgically wired, and the physician has ordered a full liquid diet. Which of the following nursing actions would best promote compliance and provide an adequate nutrient value with the full liquid diet for this teenager? a. Offer chocolate milkshakes between meals. b. Explain to the teenager the importance of good nutrition. c. Offer commercial nutritional supplements four to six times per day. d. Ask the teenager for food preferences and blenderize these foods into liquids. Source: Saunders 4th

ANS: D Rationale: A 15-year-old may find difficulty maintaining compliance with a diet that is only liquids. To encourage compliance, it is important to have the teenager participate in as much decision making in the diet as possible. Although blenderized foods may be unappealing under many circumstances, the nutrient value is unchanged. The teenager will have an opportunity to "eat" the same foods that he or she was eating before the jaw fracture. Option 1 may be beneficial but does not offer the teenager any choices. Teenagers may or may not respond to reasoning and explanations as with option 2. Commercial supplements also are beneficial nutritional sources but will not be effective unless the client is willing to drink them. Strategy: Focus on the age of the client and apply knowledge regarding the theories of growth and development to assist in answering the question. Note the dual subject, compliance and nutrient value. Recall that a teenager generally will be more compliant with a difficult regimen if the teenager has some impact on his or her own choices. Review the theories of growth and development and the considerations related to the adolescent age group if you had difficulty with this question. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., pp. 506-507). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1298). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2281) A nurse is assessing fluid balance in a client after a craniotomy. The nurse should assess for which of the following as a sign of overhydration, which would aggravate cerebral edema? a. Shift intake 950 mL, output 900 mL b. Unchanged weight c. Blood urea nitrogen (BUN) 10 mg/dL d. Serum osmolality 280 mOsm/kg H₂O Source: Saunders 4th

ANS: D Rationale: A 50-mL difference in intake and output for an 8-hour shift is insignificant. Stable weight indicates that there is neither fluid excess nor fluid deficit. The BUN of 10 mg/dL is within normal range and does not indicate overhydration or underhydration. The normal serum osmolality is 285 to 295 mOsm/kg H₂O. A higher value indicates dehydration; a lower value indicates overhydration. After craniotomy, the goal is to keep the serum osmolality on the high side of normal. This would minimize excess body water and control cerebral edema. Strategy: Use the process of elimination. Options 1 and 2 can be easily eliminated first. Recalling the normal BUN and serum osmolality will direct you to option 4. Also, an easy way to remember serum osmolality trends is "high is dry." Because the converse also is true, a low value indicates excess body water (overhydration). Review the signs of overhydration if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2092). Philadelphia: W.B. Saunders. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 827). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1042) A client has an order to receive purified protein derivative, 0.1 mL, intradermally. A nurse administers the medication by using a tuberculin syringe with a: a. 20-gauge, 1-inch needle inserted at a 30-degree angle, with the bevel side down b. 26-gauge, ⅝-inch needle inserted at a 45-degree angle, with the bevel side down c. 20-gauge, 1-inch needle inserted almost parallel to the skin, with the bevel side up d. 26-gauge, ⅝-inch needle inserted almost parallel to the skin, with the bevel side up Source: Saunders 4th

ANS: D Rationale: A Mantoux skin test is administered by giving 0.1 mL of purified protein derivative (PPD) intradermally. Administration involves drawing the medication into a tuberculin syringe with a 25- to 27-gauge, ⅝-inch needle. The injection is given by inserting the needle as close as possible to a parallel position with the skin and with the needle bevel facing up. This results in formation of a wheal when the PPD is administered correctly. Strategy: Remember that a tuberculin syringe is small and measures small amounts of medication dosages. Use the process of elimination, eliminating options 1 and 3 first because these options indicate the use of larger needles. Remembering that the bevel side is up during administration of PPD will assist in directing you to the correct option from the remaining choices. If this question was difficult, review the basics of this injection technique. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 766). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1378) A female client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which of the following nursing actions is most appropriate? a. Refer the client for a blood test immediately. b. Inform the client that there is no test available for Lyme disease. c. Tell the client that testing is not necessary unless arthralgia develops. d. Instruct the client to return in 4 to 6 weeks to be tested because testing before this time is not reliable. Source: Saunders 4th

ANS: D Rationale: A blood test is available to detect Lyme disease; however, the test is not reliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following manner. Immunoglobulin M is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, and then gradually disappears; immunoglobulin G is detected 2 to 3 months after infection and may remain elevated for years. Options 1, 2, and 3 are incorrect. Strategy: Use the process of elimination. Eliminate option 1 first. The word immediately should indicate that this is potentially an incorrect option. A blood test is available; therefore, eliminate option 2. Eliminate option 3 because treatment should begin before the arthralgia develops. If you had difficulty with this question, review the method of diagnosing Lyme disease. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 418). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

2443) A nurse is developing a plan of care for a newborn infant with spina bifida (meningomyelocele type). The nurse includes assessment measures in the plan to monitor for increased intracranial pressure. Which of the following assessment techniques should be performed that will best detect the presence of an increase in intracranial pressure? a. Assess blood pressure for signs of hypotension. b. Monitor for signs of dehydration. c. Check urine for specific gravity. d. Assess anterior fontanel for bulging. Source: Saunders 4th

ANS: D Rationale: A bulging or taut anterior fontanel would indicate the presence of increased intracranial pressure. Blood pressure is difficult to assess during the newborn period and is not the best indicator of intracranial pressure. Urine concentrating ability also is not well developed at the newborn stage of development. Monitoring for signs of dehydration will not provide data related to increased intracranial pressure. Strategy: Focus on the subject of the question, monitoring for increased intracranial pressure. Use the process of elimination and recall the assessment findings in the newborn infant that would indicate the presence of increased intracranial pressure. Review these assessment techniques if you had difficulty with this question. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., p. 433). St. Louis: Mosby. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., p. 1197). St. Louis: Mosby. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1500). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Child Health Alternate Question Types -> Multiple Choice

1348) A nurse is admitting a client with multiple trauma to the nursing unit. The client has a leg fracture and had a plaster cast applied. In positioning the casted leg, the nurse should: a. Keep the leg in a level position. b. Elevate the leg for 3 hours and put it flat for 1 hour. c. Keep the leg level for 3 hours and elevate it for 1 hour. d. Elevate the leg on pillows continuously for 24 to 48 hours. Source: Saunders 4th

ANS: D Rationale: A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and promote venous drainage. Options 1, 2, and 3 are incorrect. Strategy: Use the process of elimination. Recalling that edema is a concern and knowledge of the effects of gravity on edema will direct you to option 4. Review care of the client with a new cast if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby. Reference: Monahan, F., Sands, J., Neighbors, M., et al. (2007). Phipps' medical-surgical nursing: Health and illness perspectives (8th ed., p. 1536). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1234) The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which of the following is associated with this eye disorder? a. Total loss of vision b. Pain in the affected eye c. A yellow discoloration of the sclera d. A sense of a curtain falling across the field of vision Source: Saunders 4th

ANS: D Rationale: A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options 1 and 3 are not characteristics of this disorder. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal. Strategy: Use the process of elimination, focusing on the diagnosis. Thinking about the pathophysiology associated with this disorder will direct you to option 4. Review the manifestations associated with this condition if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1952). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

2633) A client taking albuterol (Salbutamol) by inhalation cannot cough up secretions. The nurse suggests that the client do which of the following to assist in expectoration of secretions? a. Get more exercise each day. b. Use a dehumidifier in the home. c. Take an extra dose of albuterol before bedtime. d. Drink increased amounts of fluids every day. Source: Saunders 4th

ANS: D Rationale: A client should drink increased fluids (2000 to 3000 mL/day) to decrease viscosity and increase expectoration of secretions. This is standard advice for clients receiving any of the adrenergic bronchodilators, unless the client has another health problem that contraindicates an increased fluid intake. A dehumidifier will dry secretions, making the situation worse. The client should not take additional medication. Additional exercise will not effectively clear bronchial secretions. Strategy: Focus on the subject, assistance in expectorating secretions. Recalling basic respiratory principles will help direct you to option 4. Review these basic principles if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 27-28). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2037) A nurse in the mental health unit is assigned to care for a female client with a diagnosis of acute depression. In communicating with the client, which of the following statements would be appropriate for the nurse to make? a. "You will feel better when your medication starts to work." b. "Don't worry—everyone gets depressed once in a while." c. "You look lovely today." d. "You're wearing a new blouse." Source: Saunders 4th

ANS: D Rationale: A client who is depressed sees the negative side of everything. Telling the client that she looks lovely today can be interpreted as "I didn't look lovely last time we met." Neutral comments such as that identified in option 4 will avoid negative interpretations. These clients should not be told not to worry, that they will feel better, or that everyone gets depressed once in a while because such statements are inappropriate. Strategy: Focus on the diagnosis of the client and therapeutic communication techniques to assist in answering the question. Avoid statements that may cause negative interpretations by the client. Neutral statements such as that identified in option 4 will avoid negative interpretations. Review therapeutic communication techniques for the depressed client if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed., pp. 30-34). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 338). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2235) A nurse reads a client's Mantoux skin test as positive and notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse's response is based on the understanding that the client has: a. No evidence of tuberculosis b. Systemic tuberculosis c. Pulmonary tuberculosis d. Exposure to tuberculosis Source: Saunders 4th

ANS: D Rationale: A client who tests positive on a Mantoux skin test either has been exposed to tuberculosis or has inactive (dormant) tuberculosis. The client must then undergo chest radiography and sputum culture to confirm the diagnosis. Strategy: Use the process of elimination, eliminating options 2 and 3 first because they are comparative or alike in that both indicate the presence of tuberculosis. Regarding the remaining options, note that the result on Mantoux skin testing is positive. Therefore, eliminate option 1. Because of the importance of this test, review this content if the question was difficult for you. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1846). Philadelphia: W.B. Saunders. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., pp. 766-767). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1462) A client is admitted to the mental health unit with a diagnosis of depression. The nurse develops a plan of care for the client and includes which appropriate activity in the plan? a. Reading and writing most of the day b. Several activities from which the client can choose c. Nothing, until the client asks to participate in milieu d. A structured program of activities in which the client can participate Source: Saunders 4th

ANS: D Rationale: A client with depression often suffers a depressed mood and is withdrawn. The person also experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. Options 1, 2, and 3 are too "restrictive" and offer little or no structure and stimulation. Strategy: Use the process of elimination. Recall that the depressed client requires a structured and stimulating program in a safe environment. Option 4 is the only option that will provide a safe and effective environment. Review care of the client with depression if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 221). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 353). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2693) A client has been prescribed pindolol (Visken) for hypertension. The nurse provides anticipatory guidance, knowing that which common side effect of this medication may decrease client compliance? a. Difficulty swallowing b. Mood swings c. Increased appetite d. Impotence Source: Saunders 4th

ANS: D Rationale: A common side effect of β-adrenergic blocking agents such as pindolol is impotence. Other common side effects include fatigue and weakness. Central nervous system side effects are rarer and include mental status changes, nervousness, depression, and insomnia. Increased appetite, difficulty swallowing, and mood swings are not side effects of this medication. Strategy: Medication names that end in -lol are β-adrenergic blocking agents. Recalling the common side effects associated with this classification will direct you to option 4. Review the side effects of this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 693). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2109) A client was seen and treated in the hospital emergency department for treatment of a concussion. The nurse determines that the family needs reinforcement of the discharge instructions if they verbalize to call the physician for which client sign or symptom? a. Difficulty speaking b. Difficulty awakening c. Vomiting d. Minor headache Source: Saunders 4th

ANS: D Rationale: A concussion after head injury is a temporary loss of consciousness (from a few seconds to a few minutes) without evidence of structural damage. After concussion, the family is taught to monitor the client and to call the physician or return the client to the emergency department for several signs and symptoms. These include confusion, difficulty awakening or speaking, one-sided weakness, vomiting, and severe headache. Minor headache is expected. Strategy: Use the process of elimination, noting the strategic words needs reinforcement. Focusing on the client's diagnosis and recalling the signs of increased intracranial pressure will direct you to option 4. Review client instructions for home care after a concussion if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2104). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1738) The nurse is caring for a suicidal client. The appropriate nursing intervention in dealing with this client is to: a. Demonstrate confidence in the client's ability to deal with stressors. b. Provide hope and reassurance that the problems will resolve themselves. c. Display an attitude of detachment, confrontation, and efficiency. d. Provide authority, action, and participation. Source: Saunders 4th

ANS: D Rationale: A crisis is an acute, time-limited state of disequilibrium resulting from situational, developmental, or societal sources of stress. A person in this state is temporarily unable to cope with or adapt to the stressor by using previous coping mechanisms. The person who intervenes in this situation (the nurse) "takes over" for the client who is not in control and devises a plan (action) to secure and maintain the client's safety. Once this has occurred, the nurse works collaboratively with the client (participates) in developing new coping and problem-solving strategies. Strategy: Use the process of elimination. The client who experiences a suicidal crisis is in a state of acute disequilibrium. Remember, in a crisis, an authority figure must emerge to take action. Review care of the client in crisis if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 515-517). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2019) A nurse provides discharge instructions to a client after a prostatectomy. The nurse instructs the client to: a. Avoid lifting any objects greater that 30 pounds. b. Contact the physician if small clots are noticed in the urine. c. Avoid driving a car for at least 1 week. d. Increase fluid intake to at least 2.5 L/day. Source: Saunders 4th

ANS: D Rationale: A daily intake of 2.5 L of fluid should be maintained to limit clot formation and prevent infection. Passing small pieces of tissue or blood clots in the urine for up to 2 weeks after surgery is expected and does not necessitate contacting the physician. The client should be instructed to avoid lifting objects heavier than 20 pounds for at least 6 weeks. Driving a car and sitting for long periods are restricted for at least 3 weeks. Strategy: Use the process of elimination and principles related to general postoperative client instructions to answer the question. Focusing on the type of surgical procedure will direct you to option 4. If you had difficulty with this question, review client teaching points related to prostatectomy. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1864). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

142) A physician has written an order to discontinue an intravenous line. The nurse obtains which of the following supplies from the unit supply area for applying pressure to the site after removing the intravenous (IV) catheter? a. Alcohol swab b. Betadine swab c. Adhesive bandage d. Sterile 2 × 2 gauze Source: Saunders 4th

ANS: D Rationale: A dry sterile dressing, such as a sterile 2 × 2, is used to apply pressure to the discontinued IV site. This material is absorbent, sterile, and nonirritating. A Betadine swab or an alcohol swab would irritate the opened puncture site and would not stop the blood flow. An adhesive bandage may be used to cover the site once hemostasis has occurred. Strategy: Use the process of elimination and note the strategic words applying pressure. Visualize this procedure, thinking about each of the items identified in the options to direct you to option 4. Review this basic procedure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 258). Philadelphia: W.B. Saunders. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., pp. 937-938). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1190). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1339) A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when the client will be able to walk using the casted leg. The nurse replies that the client will be able to bear weight on the casted leg: a. In 48 hours b. In 24 hours c. In about 8 hours d. Within 20 to 30 minutes of application Source: Saunders 4th

ANS: D Rationale: A fiberglass cast is made of water-activated polyurethane materials that are dry to the touch within minutes and reach full rigid strength in about 20 minutes. Because of this, the client can bear weight on the cast within 20 to 30 minutes. Strategy: Use the process of elimination. Note the strategic word nonplaster. Options 1 and 2 should be eliminated first because these time frames are similar to the drying times for plaster casts. Recalling that the nonplaster type of cast is lighter and dries quickly may help you choose the 20- to 30-minute time frame as correct. Review client teaching points related to a nonplaster cast if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1198). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

931) The client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? a. Folate deficiency b. Malabsorption of fat c. Intestinal obstruction d. Fluid and electrolyte imbalance Source: Saunders 4th

ANS: D Rationale: A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period. Strategy: Use the process of elimination and note the strategic words ileostomy, immediate postoperative period, and complication. This tells you that the correct option occurs early in the postoperative course, with relative frequency. Remember that ileostomy drainage is liquid, placing the client at risk for fluid and electrolyte imbalance. If you had difficulty with this question, review the postoperative complications following this surgical procedure. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1324). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1228) The nurse is performing an assessment on a client with a suspected diagnosis of cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is: a. Diplopia b. Eye pain c. Floating spots d. Blurred vision Source: Saunders 4th

ANS: D Rationale: A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception. Options 1, 2, and 3 are not signs of a cataract. Strategy: Use the process of elimination. Remember the pathophysiology related to cataract development. As a cataract develops, the lens of the eye becomes opaque. This description will assist in directing you to the correct option. If you had difficulty with this question, review the assessment signs associated with cataract development. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1093). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

2450) A nurse is caring for a client with an endotracheal tube attached to a mechanical ventilator. The high-pressure alarm sounds, and the nurse assesses the client. The nurse determines that the cause of the alarm is most likely to be due to which of the following? a. A leak in the endotracheal tube cuff b. Displacement of the endotracheal tube c. A disconnection of the ventilator tubing d. A kink in the ventilator circuit Source: Saunders 4th

ANS: D Rationale: A high-pressure alarm occurs if the amount of pressure needed for ventilating a client exceeds the preset amount. Causes of high-pressure alarm activation include excess secretions, mucous plugs, the client's biting on the endotracheal tube, kinks in the ventilator tubing, and the client's coughing, gagging, or attempting to talk. Strategy: Focus on the strategic words high pressure. Thinking about this concept will direct you to option 4. If you had difficulty with this question, review the causes of the high-pressure alarm activation on a ventilator. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 667). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2491) A nurse is performing a skin assessment on a client diagnosed with malignant melanoma. The nurse would expect to note which of the following characteristics of this type of skin lesion? a. A small papule with a dry, rough scale b. A firm nodular lesion topped with crust c. A pearly papule with a central crater and a waxy border d. An irregularly shaped lesion Source: Saunders 4th

ANS: D Rationale: A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough adherent yellow or brown scale. Squamous cell carcinoma is a firm nodular lesion topped with a crust or a central area of ulceration. Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Strategy: Focus on the client's diagnosis, malignant melanoma. Remembering that irregularly shaped lesions are a cause for concern will assist you in answering the question. If you had difficulty with this question, review the characteristics of malignant skin lesions. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1416). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

1229) In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nurse reviews the physician's orders, expecting which type of eye drops to be prescribed? a. A miotic agent b. A thiazide diuretic c. An osmotic diuretic d. A mydriatic medication Source: Saunders 4th

ANS: D Rationale: A mydriatic medication produces mydriasis or dilation of the pupil. Mydriatic medications are used preoperatively in the cataract client. These medications act by dilating the pupils. They also constrict blood vessels. An osmotic diuretic may be used to decrease intraocular pressure. A miotic medication constricts the pupil. A thiazide diuretic is not likely to be prescribed for a client with a cataract. Strategy: Use the process of elimination. Read the question carefully, noting that the client is being prepared for eye surgery. Dilation of the eye is necessary before cataract extraction. Recalling that a mydriatic dilates will direct you to option 4. Review preoperative care for cataract surgery if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1950). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1094). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

90) An adult client with a history of gastrointestinal bleeding has a platelet count of 300,000 cells/mm³. Which action by the nurse is most appropriate after seeing the laboratory results? a. Report the abnormally low count. b. Report the abnormally high count. c. Place the client on bleeding precautions. d. Place the normal report in the client's medical record. Source: Saunders 4th

ANS: D Rationale: A normal platelet count ranges from 150,000 to 400,000 cells/mm³. The nurse should place the report containing the normal laboratory value in the client's medical record. A platelet count of 300,000 cells/mm³ is not an elevated count. The count also is not low; therefore, bleeding precautions are not needed. Strategy: Use the process of elimination. Remember that options that are comparative or alike are not likely to be correct. With this in mind, eliminate options 1 and 3 first. From the remaining options, you must be familiar with the normal range for this laboratory test. Review this normal laboratory value if you had difficulty with this question. Reference: Pagana, K., & Pagana, T. (2006). Mosby's manual of diagnostic and laboratory tests (3rd ed., p. 409). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

918) The client with ascites is scheduled for a paracentesis and the nurse is assisting the physician in performing the procedure. Which position will the nurse help the client assume? a. Supine b. Left side-lying c. Right side-lying d. Upright position Source: Saunders 4th

ANS: D Rationale: A paracentesis is the transabdominal removal of fluid from the peritoneal cavity for analysis. An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion. Options 1, 2, and 3 are incorrect positions. Strategy: Attempt to visualize this procedure in selecting the correct option. Recalling that fluid will be aspirated from the abdominal cavity will assist in directing you to option 4. If you had difficulty with this question, review this procedure. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 843). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1375, 1377). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

168) A nurse is planning care for a client with an internal radiation implant. Which of the following is an inappropriate component for the nurse to include in the plan of care? a. Wearing gloves when emptying the client's bedpan b. Keeping all linens in the room until the implant is removed c. Wearing a lead apron when providing direct care to the client d. Placing the client in a semiprivate room at the end of the hallway Source: Saunders 4th

ANS: D Rationale: A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent accidental exposure of other clients to radiation. Options 1, 2, and 3 are accurate interventions for a client with a radiation implant. Strategy: Use the process of elimination and note the strategic words inappropriate component. Option 1 can be eliminated first because this is a component of standard precautions for all clients. Options 2 and 3 can be eliminated next because they directly relate to radiation safety. Review radiation safety principles if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 490). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1839) A nurse is caring for a client after abdominal surgery and creation of a colostomy. The nurse is assessing the client for a prolapsed stoma and would expect to note which of the following if this was present? a. A sunken and hidden stoma b. A stoma that is dusky or bluish in color c. A narrow and flattened stoma d. A protrusion of the bowel with an elongated, swollen appearance of the stoma Source: Saunders 4th

ANS: D Rationale: A prolapsed stoma is one in which the bowel protrudes, causing an elongated and swollen appearance to the stoma. A retracted stoma is characterized by sinking of the stoma. Ischemia of the stoma would be associated with a dusky or bluish color. A stoma with a narrow opening is described as being stenosed. Strategy: Use the process of elimination. Focus on the strategic words prolapsed stoma in the question. The word prolapsed should make you think of a protusion. If you had difficulty with this question, review assessment findings noted in the client after creation of a colostomy. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1326). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

905) The client with peptic ulcer disease is scheduled for a pyloroplasty and the client asks the nurse about the procedure. Which response by the nurse best describes what is involved with a pyloroplasty? a. Cutting the vagus nerve b. Removing the distal portion of the stomach c. Removal of the ulcer and a large portion of the cells that produce hydrochloric acid d. An incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum Source: Saunders 4th

ANS: D Rationale: A pyloroplasty involves making an incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum. A vagotomy involves cutting the vagus nerve. A subtotal gastrectomy involves removing the distal portion of the stomach. A Billroth II procedure involves removal of the ulcer and a large portion of the tissue that produces hydrochloric acid. Strategy: Use the process of elimination. Note the relationship between the words pyloroplasty in the question and pylorus in the correct option. Review this procedure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1298). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1040). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2068) A female client calls the nurse at the clinic and reports that ever since the vein ligation and stripping procedure was performed, she has been experiencing a sensation as though the affected leg is falling asleep. Which response to the client is appropriate? a. "Keep the leg elevated as much as possible." b. "Apply warm packs to the leg." c. "This normally occurs after surgery and will subside when the edema goes down." d. "Contact your physician right away to report this problem." Source: Saunders 4th

ANS: D Rationale: A sensation of pins and needles, or feeling as though the surgical limb is falling asleep, may indicate temporary or permanent nerve damage after surgery. The saphenous vein and the saphenous nerve run close together, and damage to the nerve will produce paresthesias. Options 1, 2, and 3 are inaccurate responses. Strategy: Use the process of elimination, focusing on the client's complaint. Knowing that the client's complaint may indicate nerve irritation or damage will assist in directing you to option 4. If you had difficulty with this question, review the complications related to this type of surgery. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1540). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

53) A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a potassium value at this level? a. The client with colitis b. The client with Cushing's syndrome c. The client who has been overusing laxatives d. The client who has sustained a traumatic burn Source: Saunders 4th

ANS: D Rationale: A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia. Strategy: Use the process of elimination. Eliminate options 1 and 3 first because they are comparative or alike, with both reflecting a gastrointestinal loss. From the remaining options, recalling that cell destruction causes potassium shifts will assist in directing you to the correct option. Remember that Cushing's syndrome presents a risk for hypokalemia and that Addison's disease presents a risk for hyperkalemia. If you had difficulty with this question, review the risk factors associated with hyperkalemia. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1141-1142). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

54) A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value? a. ST depression b. Inverted T wave c. Prominent U wave d. Tall peaked T waves Source: Saunders 4th

ANS: D Rationale: A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Electrocardiographic changes include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. Strategy: From the information in the question, you need to determine that this condition is a hyperkalemic one. From this point, you must know the electrocardiographic changes that are expected when hyperkalemia exists. If you had difficulty with this question, review the normal serum potassium level and the electrocardiographic changes that occur in hyperkalemia. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 343). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2574) A nurse is caring for a client in skeletal traction. On assessing the pin sites, the nurse notes the presence of purulent drainage. Which nursing action would be appropriate? a. Document the findings. b. Clean the pin sites more frequently than prescribed. c. Apply antibiotic ointment to the pin sites. d. Notify the physician. Source: Saunders 4th

ANS: D Rationale: A small amount of clear fluid drainage is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin sites are not expected findings and should be reported to the physician. Options 1, 2, and 3 are inappropriate nursing actions for this client. Strategy: Focus on the strategic words purulent drainage in the question. Recalling the signs of infection and knowledge of the expected findings at pin sites will assist in directing you to option 4. Review the signs of infection related to the client in skeletal traction if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1201). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2064) A nurse is preparing to perform pin site care for a client in skeletal traction. On assessment of the pin site, the nurse notes the presence of serous drainage. Which of the following nursing actions would be appropriate? a. Notify the physician. b. Lift the weights and place them on the bed so that the physician can assess the client. c. Remove 2 pounds of weight from the traction. d. Document the findings. Source: Saunders 4th

ANS: D Rationale: A small amount of serous oozing is expected at the pin insertion site. The nurse would document the findings. It is not necessary to notify the physician. The nurse would not add or remove any weight from the client's traction setup because this would disrupt the alignment of the fracture. Strategy: Use the process of elimination. Recalling that weights should never be added or removed from a traction setup will assist in eliminating options 2 and 3. Knowing that serous drainage is expected at the pin site will easily direct you to the correct option from those remaining. If you had difficulty with this question, review pin site care and the expected findings. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1201). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

140) A client is hypovolemic and plasma expanders are not available. The nurse anticipates that which of the following solutions available on the nursing unit will be prescribed by the physician? a. 5% dextrose in water b. 0.9% sodium chloride c. 0.45% sodium chloride d. 5% dextrose in 0.45% sodium chloride Source: Saunders 4th

ANS: D Rationale: A solution of 5% dextrose in 0.45% sodium chloride is hypertonic. An advantage of hypertonic solutions is that they may be used to treat hypovolemia when plasma expanders are not readily available. Options 1 and 2 are isotonic solutions. Option 3 is a hypotonic solution. Strategy: Use the process of elimination. Noting the strategic word hypovolemic will assist in directing you to option 4 if you are familiar with the IV solutions that are hypertonic. If this question was difficult, review the nature and purposes of hypertonic, isotonic, and hypotonic IV solutions. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 213, 247). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1136, 1396). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1617) The nurse has developed a plan of care for a client who is in traction and documents a nursing diagnosis of self-care deficit. The nurse evaluates the plan of care and determines that which of the following observations indicates a successful outcome? a. The client allows the nurse to complete the care on a daily basis. b. The client allows the family to assist in the care. c. The client refuses care. d. The client assists in self-care as much as possible. Source: Saunders 4th

ANS: D Rationale: A successful outcome for the nursing diagnosis of self-care deficit is for the client to do as much of the self-care as possible. The nurse should promote independence in the client and allow the client to perform as much self-care as is optimal, considering the client's condition. The nurse would determine that the outcome is unsuccessful if the client refuses care or allows others to do the care. Strategy: Use the process of elimination. Focusing on the strategic words successful outcome will assist in eliminating the incorrect options. Additionally, note that options 1 and 2 are comparative or alike and should be eliminated. Review successful outcomes related to the nursing diagnosis of self-care deficit if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 636, 643). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1014-1015). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1504) The nursing care plan indicates a nursing diagnosis of Violence, self-directed, risk for suicidal ideations with a plan. An expected outcome of this plan of care would be that the client: a. Displays less anxiety and agitation b. Establishes a relationship with staff and peers c. Develops adequate coping and problem-solving skills d. Denies suicidal ideation and identifies options to deal with stressors Source: Saunders 4th

ANS: D Rationale: A suicidal client may have numerous diagnoses that encompass inadequate coping skills, anxiety, and strained interpersonal relationships. The question, however, directly and clearly designates that the problems that need to be dealt with are the "Risk for self-directed violence" and the client's "suicidal ideations with a plan." The expected outcome is that the client no longer has suicidal ideations and has identified options to deal with stress. Options 1, 2, and 3 are not related directly to the nursing diagnosis as stated in the question. Strategy: When presented with a question that identifies a nursing diagnosis, use the information in the question to assist in directing you to the correct option. Option 4 is the only option that offers a resolution to the problem of "suicidal ideations with a plan" in that the client denies the "suicidal ideation and identifies options to deal with stressors." Review the appropriate plan of care for a suicidal client if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 377, 381). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2133) A nurse is giving a client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed touch-down of the affected leg. The nurse tells the client to advance the: a. Left leg along with the right crutch, and then the right leg and left crutch b. Crutches along with both legs simultaneously c. Crutches along with the right leg, and then advance the left leg d. Crutches along with the left leg, and then advance the right leg Source: Saunders 4th

ANS: D Rationale: A three-point gait requires good balance and arm strength. The crutches are advanced with the affected leg, and then the unaffected leg is moved forward. Option 1 describes a two-point gait. Option 2 describes a swing-through gait. Option 3 describes the three-point gait used for a right leg problem. Strategy: Use the process of elimination. First, note the strategic words left leg, three-point gait, and touch-down. Then visualize the descriptions in each option to direct you to option 4. Review the three-point gait for crutch-walking if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2501). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1204). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2155) A client is complaining of pain underneath a cast in the area of a bony prominence. The nurse interprets that this client may need: a. To have the cast replaced with an air splint b. To have extra padding put over this area of the cast c. To have the cast bivalved d. To have a window cut in the cast Source: Saunders 4th

ANS: D Rationale: A window may be cut in a dried cast to relieve pressure, assess pulses, relieve discomfort, or remove drains. Bivalving the cast involves splitting the cast along both sides to allow space for swelling or to facilitate taking radiographs, or to make a half-cast for use as an intermittent splint. Padding is not placed on top of a cast. The use of an air splint is not indicated. Strategy: Use the process of elimination. Note the strategic words bony prominence. Wherever there is a bony prominence, there is a risk of pressure and skin breakdown. If the pressure area is under a cast, the cast must be removed in that area to relieve the pressure. Therefore, options 1 and 3 can be eliminated. Because extra padding over the area of the cast does no good either, that option can be eliminated next. Putting a window in the cast will relieve the pressure in that one area without disrupting the cast. Review the purpose of a window cut in a cast if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 632-633). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1393) The nurse is assisting in administering immunizations at a health care clinic. The nurse understands that an immunization will provide: a. Protection from all diseases b. Innate immunity from disease c. Natural immunity from disease d. Acquired immunity from disease Source: Saunders 4th

ANS: D Rationale: Acquired immunity can occur by receiving an immunization that causes antibodies to a specific pathogen to form. Natural (innate) immunity is present at birth. No immunization protects the client from all diseases. Strategy: Use the process of elimination and knowledge regarding immunity to disease to answer the question. Eliminate option 1 first because of the close-ended word all. Next, eliminate options 2 and 3 because they are comparative or alike. Review natural and acquired immunity if you had difficulty with this question. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., pp. 130, 210). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1275) The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which of the following activities? a. Blowing the nose b. Isometric exercises c. Coughing vigorously d. Exhaling during repositioning Source: Saunders 4th

ANS: D Rationale: Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed, opens the glottis, which prevents intrathoracic pressure from rising. Strategy: Use the process of elimination. Evaluate each option in terms of the tension it puts on the body. Doing so will help you eliminate each incorrect option systematically. Review the measures that will reduce or prevent increased intracranial pressure if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2201, 2293). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1049, 1051). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2559) The home care nurse is preparing to visit a client who has undergone renal transplantation. The nurse develops a plan of care that includes monitoring the client for signs of acute graft rejection. The nurse documents in the plan to assess the client for which signs of acute graft rejection? a. Hypotension, graft tenderness, and hypothermia b. Hypertension, polyuria, and thirst c. Fever, hypotension, and polyuria d. Fever, hypertension, and graft tenderness Source: Saunders 4th

ANS: D Rationale: Acute rejection usually occurs within the first 3 months after transplantation, although it can occur for up to 2 years after transplantation. The client exhibits fever, hypertension, malaise, and graft tenderness. Treatment with corticosteroids, and possibly also with monoclonal antibodies and antilymphocyte agents, is begun immediately. Strategy: Use the process of elimination. Note the strategic word acute. Eliminate options 1 and 2 first, recognizing fever as a sign of acute graft rejection. Recalling that hypertension rather than hypotension also would be a sign of an acute graft rejection will assist in directing you to option 4. Review the signs of acute graft rejection if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1762). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2366) A client is receiving acyclovir (Zovirax) by the intravenous (IV) route for treatment of cytomegalovirus (CMV) infection. After reconstituting the powder dispensed by the pharmacy, the nurse administers this medication by: a. Continuous IV infusion over 12 hours b. Continuous IV infusion over 24 hour c. Rapid IV bolus over 5 minutes d. Slow IV infusion over 1 hour Source: Saunders 4th

ANS: D Rationale: Acyclovir is dispensed as a powder to be reconstituted for IV administration and is administered by slow IV infusion over 1 hour. It is not given as an IV bolus or continuous infusion or by intramuscular or subcutaneous injection. To minimize the risk of renal damage, the client should be hydrated during the infusion and for 2 hours after the infusion. Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are comparative or alike and because the medication is not given as a continuous infusion. Regarding the remaining options, use medication safety principles to direct you to option 4. Review this medication if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 14). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

2568) A nurse is caring for a client with a diagnosis of Addison's disease. The nurse is monitoring the client for signs of addisonian crisis. The nurse should assess the client for which manifestation that would be associated with this crisis? a. Diaphoresis b. Agitation c. Restlessness d. Severe abdominal pain Source: Saunders 4th

ANS: D Rationale: Addisonian crisis is a serious, life-threatening response to acute adrenal insufficiency that most commonly is precipitated by a major stressor. The client in addisonian crisis may demonstrate any of the signs and symptoms of Addison's disease, but the primary problems are sudden profound weakness; severe abdominal, back, and leg pain; hyperpyrexia followed by hypothermia; peripheral vascular collapse; coma; and renal failure. Options 1, 2, and 3 do not identify clinical manifestations associated with addisonian crisis. Strategy: Focus on the subject of the question, addisonian crisis. Use the process of elimination, noting the strategic word severe in the correct option. Review the manifestations associated with addisonian crisis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1471). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

2341) A client with trigeminal neuralgia who is receiving carbamazepine (Tegretol) 400 mg orally (PO) daily has a white blood cell (WBC) count of 2800/μL, blood urea nitrogen (BUN) of 17 mg/dL, sodium of 141 mEq/L, and uric acid of 5.0 ng/dL. On the basis of these laboratory values, the clinic nurse would make which of the following interpretations? a. The sodium level is low, indicating an electrolyte imbalance. b. The uric acid level is elevated, indicating the risk for renal calculi. c. The BUN is elevated, indicating nephrotoxicity. d. The WBC is low, indicating a blood dyscrasia. Source: Saunders 4th

ANS: D Rationale: Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, and leukopenia; cardiovascular disturbances; thrombophlebitis; dysrhythmias; and dermatological effects. The incorrect options identify laboratory values that are within normal range. Strategy: Use the process of elimination and knowledge regarding normal laboratory values. The WBC count is the only abnormal value. Review the signs of adverse reactions related to this medication if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., pp. 223-224). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1328) A client with trigeminal neuralgia is being treated with carbamazepine (Tegretol), 400 mg PO daily. Which of the following indicates that the client is experiencing an adverse reaction to the medication? a. Uric acid level, 5 mg/dL b. Sodium level, 140 mEq/L c. Blood urea nitrogen level, 15 mg/dL d. White blood cell count, 3000/mm³ Source: Saunders 4th

ANS: D Rationale: Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, leukopenia, cardiovascular disturbances, thrombophlebitis, dysrhythmias, and dermatological effects. Strategy: Use the process of elimination. If you are familiar with normal laboratory values, you will note that the only option that indicates an abnormal value is option 4. Review the signs of adverse reactions related to this medication if you had difficulty with this question. Reference: Mosby. (2007). 2007 Mosby's nursing drug reference (20th ed., p. 220). St. Louis: Mosby. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 137). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1013) A client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of the following nursing interventions for this client? a. Administering atropine intravenously b. Administering small doses of midazolam (Versed) c. Encouraging additional fluids for the next 24 hours d. Ensuring the return of the gag reflex before offering food or fluids Source: Saunders 4th

ANS: D Rationale: After bronchoscopy, the nurse keeps the client on NPO status until the gag reflex returns because the preoperative sedation and local anesthesia impair swallowing and the protective laryngeal reflexes for a number of hours. Additional fluids are unnecessary because no contrast dye is used that would need flushing from the system. Atropine and midazolam would be administered before the procedure, not after. Strategy: Use the process of elimination. Recall that the client has lost the protective cough, gag, and swallow reflexes during this procedure. Knowledge of this implication helps you choose option 4 as the only possible answer. Review nursing care measures following a bronchoscopy if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 297). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2284) A nurse has formulated a nursing diagnosis of body image disturbance for a client after craniotomy. The nurse would evaluate that the client has not met the outcome criteria by discharge if the client: a. Wears a turban to cover the incision b. States an intention to purchase a hairpiece until hair has grown back c. Verbalizes that periorbital bruising will disappear over time d. Indicates that facial puffiness will be a permanent problem Source: Saunders 4th

ANS: D Rationale: After craniotomy, clients may experience difficulty with altered personal appearance. The nurse can help by listening to client concerns and by clarifying any misconceptions about facial edema, periorbital bruising, and hair loss (which are temporary). The nurse can encourage the client to participate in self-grooming and to use personal articles of clothing. Finally, the nurse can suggest the use of a turban, followed by a hairpiece, to help the client adapt to the temporary change in appearance. Strategy: Use the process of elimination, noting the strategic words has not met. Look for the option that indicates a maladaptive response. Options 1 and 2 both indicate adaptive responses and are therefore eliminated. Knowing that facial edema and bruising are temporary will help you to choose option 4 over option 3. Review the manifestations associated with a disturbed body image after craniotomy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2089). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2032) A nurse is providing discharge instructions to the client being discharged after a fenestration procedure for the treatment of otosclerosis. Which statement if made by the client indicates a need for further instruction? a. "I should take stool softeners to avoid straining when having a bowel movement." b. "I need to avoid washing my hair and showering for at least 1 week." c. "I should avoid movements requiring bending over for at least 3 weeks." d. "I should use a straw to drink liquids for the next 2 to 3 weeks." Source: Saunders 4th

ANS: D Rationale: After ear surgery, clients need to be instructed to avoid drinking with a straw for 2 to 3 weeks, to avoid air travel, and to avoid coughing excessively. The client also should be instructed to avoid straining when having a bowel movement and should be instructed to take stool softeners as prescribed. The client should avoid getting the head wet, washing the hair, or showering for at least 1 week, and to avoid rapidly moving the head, bouncing, and bending over for at least 3 weeks. Strategy: Use the process of elimination and note the strategic words need for further instruction. This phrasing indicates a negative event query and directs you to select an incorrect statement. Consider the anatomical area for this surgical procedure and the effects of each option on pressure within the ear to assist in directing you to option 4. If you had difficulty with this question, review client instructions after ear surgery. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1130). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

2090) A client is receiving intravesical chemotherapy for cancer of the bladder. The nurse should plan to do which of the following after the completion of each treatment? a. Provide increased doses of opioid analgesics. b. Keep the client on nothing-by-mouth (nil per os [NPO]) status for 6 hours. c. Place the client on contact isolation for 24 hours. d. Encourage increased intake of oral fluids. Source: Saunders 4th

ANS: D Rationale: After intravesical chemotherapy, the nurse increases fluids to help flush the medication out of the bladder after the period of retention. The chemotherapy agent and the urine are treated as biohazards, but the client does not need to be placed on contact isolation. The client does not have a need for opioid analgesics as a result of the chemotherapy treatment, nor does the client need to be NPO. Strategy: Use the process of elimination. Eliminate option 1 first, knowing that the client would not have a need for higher doses of opioids as a result of this treatment. Knowing that the urine is the only biohazard will help you to eliminate option 3 next. Regarding the remaining options, recalling that increased urine flow will flush the residual chemotherapeutic agent from the bladder will direct you to option 4. Review care of the client after intravesical chemotherapy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 870-871). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2018) A nurse is assigned to care for a client after a mastoidectomy. Which nursing intervention would be appropriate in the care of this client? a. Maintain a supine position. b. Position the client on the affected side to promote drainage. c. Change the ear dressing daily. d. Monitor for signs of facial nerve injury. Source: Saunders 4th

ANS: D Rationale: After mastoidectomy, the nurse should monitor vital signs and inspect the dressing for drainage or bleeding. The nurse also should assess for signs of facial nerve injury (cranial nerve VII). The nurse also should monitor for signs of pain, dizziness, or nausea. The head of the bed should be elevated at least 30 degrees, and the client should be instructed to lie on the unaffected side. The client probably will have sutures, an outer ear packing, and a bulky dressing, which is removed on approximately the sixth day postoperatively. Strategy: Use the process of elimination. Note the anatomical location for this procedure. Recalling that the client should lie on the unaffected side to avoid disruption of the surgical site and that the head of the bed should be elevated to prevent edema will assist in directing you to option 4. Review postoperative care of the client after mastoidectomy if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1131). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

2085) A nurse is urging a client to cough and deep breathe after nephrectomy. The client tells the nurse: "That's easy for you to say! You don't have to do this." The nurse interprets that the client's statement is most likely to be a result of: a. A stress response to the ordeal of surgery b. A latent fear of needing dialysis if the surgery is unsuccessful c. Effects of circulating metabolites that have not been excreted by the remaining kidney d. Pain that is intensified because of the location of the incision near the diaphragm Source: Saunders 4th

ANS: D Rationale: After nephrectomy, the client may be in considerable pain. This is due to the size of the incision and its location near the diaphragm, which makes coughing and deep breathing very uncomfortable. For this reason, opioids are used liberally and may be most effective when provided as patient-controlled analgesia or through epidural analgesia. Strategy: Use the process of elimination. The question asks for the most likely reason for the client's statement. Begin to answer the question by eliminating options 2 and 3 because data to supporting these options are lacking. Recalling that coughing and deep breathing will intensify pain after many surgical procedures helps you to choose option 4 over option 1. Review care of the client following nephrectomy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 924). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1312) The nurse is caring for the client who suffered a spinal cord injury 48 hours ago. The nurse monitors for gastrointestinal complications by assessing for: a. A history of diarrhea b. A flattened abdomen c. Hyperactive bowel sounds d. Hematest-positive nasogastric tube drainage Source: Saunders 4th

ANS: D Rationale: After spinal cord injury, the client can develop paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. Development of a stress ulcer can be detected by Hematest-positive nasogastric tube aspirate or stool. A history of diarrhea is irrelevant. Strategy: Use the process of elimination, focusing on the client's diagnosis and the signs of a gastrointestinal complication. This will direct you to option 4. Review this information if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2148). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2150) A client is being transferred to the nursing unit from the postanesthesia care unit after spinal fusion with rod insertion. The nurse should prepare to transfer the client from the stretcher to the bed by using: a. A bath blanket and the assistance of three people b. A bath blanket and the assistance of four people c. A transfer (slider) board and the assistance of two people d. A transfer (slider) board and the assistance of four people Source: Saunders 4th

ANS: D Rationale: After spinal fusion, with or without instrumentation, the client is transferred from the stretcher to bed using a transfer (slider) board and the assistance of 4 people. This strategy permits optimal stabilization and support of the spine while allowing the client to be moved smoothly and gently. Strategy: This question can be answered by analyzing the level of comfort and stability provided to the client's spine with the amounts of assistance given in each option. Using this approach, you can eliminate each of the incorrect options. Review care of the client after spinal fusion if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2147, 2225-2226). Philadelphia: W.B. Saunders. Reference: Perry, A., & Potter, P. (2006). Clinical nursing skills and techniques (6th ed., pp. 236-237, 335-336). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2043) A nurse in the ambulatory care unit is caring for a child after a tonsillectomy. The child's mother tells the nurse that the child is complaining of a dry throat and would like something to relieve the dryness. Which of the following should the nurse provide for the mother to give to the child? a. Cool cherry Kool-Aid b. A glass of milk c. Cola with ice d. Yellow noncitrus Jell-O Source: Saunders 4th

ANS: D Rationale: After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and extremely hot or cold liquids should be avoided because they may irritate the throat. Red liquids should be avoided because they give the appearance of blood if the child vomits. Milk and milk products including pudding are avoided because they coat the throat, which causes the child to clear the throat, thereby increasing the risk of bleeding. Strategy: Use the process of elimination. The subject of the question is the foods and fluids that should be avoided after tonsillectomy. Avoiding foods and fluids that may irritate or cause bleeding is the concern. This will assist in eliminating options 2 and 3. The word cherry in option 1 should be the clue that this is not an appropriate food item. Review dietary measures after tonsillectomy if you had difficulty with this question. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., pp. 1322-1323). St. Louis: Mosby. Reference: Hockenberry, M., Wilson, D., & Winkelstein, M. (2005). Wong's essentials of pediatric nursing (7th ed., pp. 796-797). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Child Health Alternate Question Types -> Multiple Choice

2320) A nurse has completed giving discharge instructions to a client who has had total knee replacement with a metal prosthesis. The nurse determines that the client understands the instructions if the client verbalizes that: a. Fever, redness, or increased pain is expected. b. Changes in the shape of the knee are expected. c. Bleeding gums or black-colored stools may occur, but this is normal. d. Other caregivers should be told about the metal implant. Source: Saunders 4th

ANS: D Rationale: After total knee replacement, the client should report signs and symptoms of infection and any changes in the shape of the knee. These could indicate developing complications. With a metal implant, the client must be on anticoagulant therapy and should report adverse effects of this therapy, including bleeding from a variety of sources. With a metal implant, the client must inform other caregivers of its presence, because certain tests and procedures will need to be avoided, and the client will need antibiotic prophylaxis for invasive procedures. Strategy: Use the process of elimination. The question refers to a metal prosthesis, which indicates that anticoagulant therapy is indicated. Therefore, eliminate options 2 and 3. It is important to report signs and symptoms of infection, so option 1 also is eliminated. Review client teaching points after total knee replacement if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 596). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 392). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

40) The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? a. A client scheduled for a chest x-ray b. A client requiring daily dressing changes c. A postoperative client preparing for discharge d. A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift Source: Saunders 4th

ANS: D Rationale: Airway is always a highest priority, and the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options 1, 2, and 3 have needs that would be identified as intermediate priorities. Strategy: Use Maslow's Hierarchy of Needs theory and the ABCs—airway, breathing, and circulation—to answer the question. Remember that airway is always the highest priority. This will direct you to option 4. Review principles related to prioritizing if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 267-268, 1247). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

1064) A nurse is preparing to administer albuterol (Proventil) to a client. The nurse assesses which of the following parameters before and during therapy? a. Nausea and vomiting b. Urine output and blood urea nitrogen level c. Headache and level of consciousness d. Lung sounds and presence of dyspnea Source: Saunders 4th

ANS: D Rationale: Albuterol is an adrenergic bronchodilator. The nurse assesses respiratory pattern, lung sounds, pulse, and blood pressure before and during therapy. The nurse also notes the color, character, and amount of sputum. Strategy: Use the process of elimination. Knowing that this medication is a bronchodilator allows you to eliminate each of the incorrect options. Use the ABCs—airway, breathing, and circulation—to answer the question. Option 4 is the only option that addresses airway. Review this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 27). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1582) Prior to administering an intermittent tube feeding through a nasogastric tube, the nurse assesses for gastric residual. The nurse understands that this procedure is important to: a. Confirm proper nasogastric tube placement. b. Observe the digestion of formula. c. Assess fluid and electrolyte status. d. Evaluate absorption of the last feeding. Source: Saunders 4th

ANS: D Rationale: All stomach contents are aspirated and measured prior to administering a tube feeding. This procedure measures the gastric residual. The gastric residual is assessed to confirm whether undigested formula from a previous feeding remains, thereby evaluating absorption of the last feeding. It is important to assess gastric residual because administration of a tube feeding to a full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration. Options 1, 2, and 3 do not relate to the purpose of assessing residual. Strategy: Use the process of elimination. Focusing on the subject, the purpose of assessing residual, will direct you to option 4. Review the purpose of this procedure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1246). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 984). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1497) The nurse is developing a plan of care for the client in a crisis state. When developing the plan, the nurse considers which of the following? a. A crisis state indicates that the individual is suffering from a mental illness. b. A crisis state indicates that the individual is suffering from an emotional illness. c. Presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis. d. A client's response to a crisis is individualized and what constitutes a crisis for one person may not constitute a crisis for another person. Source: Saunders 4th

ANS: D Rationale: Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one person may not constitute a crisis for another person, because each is a unique individual. Being in the crisis state does not mean that the client is suffering from an emotional or mental illness. Strategy: Use the process of elimination. Eliminate option 3 because of the word all. Next, eliminate options 1 and 2 because a crisis does not indicate "illness." Review the characteristics of a crisis state if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 509). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 459-461). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

974) The nurse is giving the client directions for proper use of aluminum hydroxide tablets (Alu-Tabs). What should the nurse tell the client? a. Swallow the tablets whole with a full glass of water. b. Take the tablets at the same time as other medications. c. Take each dose with a laxative to prevent constipation. d. Chew the tablets thoroughly and follow with 4 oz of water. Source: Saunders 4th

ANS: D Rationale: Aluminum hydroxide tablets should be chewed thoroughly before swallowing. This prevents them from entering the small intestine undissolved. They should not be swallowed whole. Antacids should be taken at least 1 hour apart from other medications to prevent interactive effects. Constipation is a side effect of the use of aluminum products, but it is not correct for the client to take a laxative with each dose. This promotes laxative abuse; the client should first try other means to prevent constipation. Strategy: Use the process of elimination. Eliminate option 3 first because this action does not promote healthy bowel function. Next, eliminate option 2, using general knowledge of antacid interactive effects. From the remaining options, use principles of digestion and medication use to direct you to option 4. Review this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 46). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

3) A nurse is preparing a plan of care for a client who is a Jehovah's Witness. The client has been told that surgery is necessary. The nurse considers the client's religious preferences in developing the plan of care and documents that: a. Faith healing is practiced primarily. b. Medication administration is not allowed. c. Surgery is prohibited in this religious group. d. The administration of blood and blood products is forbidden. Source: Saunders 4th

ANS: D Rationale: Among Jehovah's Witnesses, surgery is not prohibited, but the administration of blood and blood products is forbidden. Faith healing is forbidden in this religious group. Administration of medication is an acceptable practice, except if the medication is derived from blood products. Strategy: Use the process of elimination, recalling that the administration of blood and any associated blood products is forbidden in this religious group. Review the characteristics of this religious group if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 133). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1878) A nurse reviews the laboratory results for a client with a suspected ectopic pregnancy. The nurse would expect that the results of the beta subunit of human chorionic gonadotropin (β-hCG) to be which of the following if the client had an ectopic pregnancy? a. Within normal limits b. Not present c. Present in high levels d. Present in low levels Source: Saunders 4th

ANS: D Rationale: An abnormal pregnancy (ectopic) is suspected if β-hCG is present but at lower levels than expected. The absence of β-hCG would indicate no pregnancy, whereas normal limits could indicate a normal pregnancy. High levels could indicate a molar pregnancy. Strategy: Use the process of elimination. Eliminate options 1 and 2 first. In an ectopic pregnancy, β-hCG levels would be present but would not be normal. Regarding the remaining options, it is necessary to know that the level would be low. Review the expected findings in ectopic pregnancy if you had difficulty with this question. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 621). St. Louis: W.B. Saunders. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 628). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

1161) The client with an external arteriovenous shunt in place for hemodialysis is at risk for bleeding. The priority nurse action would be to: a. Check the shunt for the presence of bruit and thrill. b. Observe the site once as time permits during the shift. c. Check the results of the prothrombin time as they are determined. d. Ensure that small clamps are attached to the arteriovenous shunt dressing. Source: Saunders 4th

ANS: D Rationale: An arteriovenous shunt is a less common form of access site but carries a risk for bleeding when it is used because two ends of an external cannula are tunneled subcutaneously into an artery and a vein, and the ends of the cannula are joined. If accidental disconnection occurs, the client could lose blood rapidly. For this reason, small clamps are attached to the dressing that covers the insertion site for use if needed. The shunt site also should be assessed at least every 4 hours. Strategy: Use the process of elimination. Focus on the subject, preventing bleeding. Visualize this type of access device. Recalling that the risk of disconnection can occur will direct you to option 4. Review care of the client with an arteriovenous shunt if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 959-960). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1316) The client with myasthenia gravis has become increasingly weaker. The physician prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium (Tensilon) is administered. Which of the following would indicate that the client is in cholinergic crisis? a. No change in the condition b. Complaints of muscle spasms c. An improvement of the weakness d. A temporary worsening of the condition Source: Saunders 4th

ANS: D Rationale: An edrophonium injection makes the client in cholinergic crisis temporarily worse. This is known as a negative Tensilon test. Strategy: Use the process of elimination. Recalling that a cholinergic crisis indicates an overdose of medication, it seems reasonable that a worsening of the condition will occur when medication is administered. Review cholinergic crisis if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., pp. 1035-1036). Philadelphia: W.B. Saunders. Reference: Mosby. (2007). Mosby's 2007 nursing drug reference (20th ed., p. 400). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1109) A client with angina has a 12-lead electrocardiogram taken during an episode of chest pain. A nurse examines the tracing for which electrocardiographic change caused by myocardial ischemia? a. Tall peaked T waves b. Prolonged PR interval c. Widened QRS complex d. ST segment elevation or depression Source: Saunders 4th

ANS: D Rationale: An electrocardiogram taken during a chest pain episode captures ischemic changes, which include ST segment elevation or depression. Tall, peaked T waves may indicate hyperkalemia. A prolonged PR interval indicates first-degree heart block. A widened QRS complex indicates delay in intraventricular conduction, such as a bundle branch block. Strategy: Use the process of elimination. Recalling that myocardial ischemia causes cellular derangements that alter the processes of depolarization will direct you to option 4. Review the electrocardiographic changes that occur with myocardial ischemia if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1704). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 232, 732, 735, 845-846). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1922) A client is scheduled for a excretory urogram. Which of the following would the nurse expect to be prescribed as a component of preparation for this test? a. NPO status after midnight b. Administration of a sedative before the test c. Administration of intravenous fluids d. Bowel preparation to remove fecal contents Source: Saunders 4th

ANS: D Rationale: An excretory urogram is an invasive test that uses contrast radiopaque dye to assess the ability of the kidneys to excrete dye in the urine. Bowel preparation is necessary to permit adequate visualization of the kidneys, ureters, and bladder. Options 1, 2, and 3 usually are not components of preparation for this test. Strategy: Use the process of elimination. Focus on the name of the test, excretory urogram. The name of the procedure may provide you with the clue that visualization of the renal system is necessary. Review test preparation for this procedure if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1669, 1671). Philadelphia: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 562). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1611) The nurse is caring for an older client who has been placed in Buck's extension traction following a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. The appropriate nursing intervention is to: a. Ask the family to stay with the client. b. Apply restraints to the client. c. Ask the laboratory to perform electrolyte studies. d. Reorient the client frequently and place a clock and calendar in the client's room. Source: Saunders 4th

ANS: D Rationale: An inactive older adult may become disoriented because of lack of sensory stimulation. The most appropriate nursing intervention would be to reorient the client frequently and to place objects such as a clock and a calendar in the client's room to maintain orientation. The family can assist with orientation of the client but it is not appropriate to ask the family to stay with the client. It is not the within the scope of nursing practice to prescribe laboratory studies. Restraints may cause further disorientation and should not be applied unless specifically prescribed; agency policies and procedures should be followed prior to the application of restraints. Strategy: Use the process of elimination. Eliminate option 3 first because it is not within the realm of nursing practice to prescribe laboratory studies. Next, eliminate option 2 because restraints may add to the disorientation that the client is experiencing. It is not appropriate to place the responsibility of the client on the family, so eliminate option 1. Note the relationship between the words disoriented in the question and reorient in the correct option. Review the measures related to caring for a client who is disoriented if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 641). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1847) A nurse is preparing to administer a tuberculin test to a client via the intradermal route. Which of the following actions should the nurse perform when administering this test to the client? a. Inject the medication and place a pressure dressing over the medication site. b. Massage the area with an alcohol swab after injection to ensure that the medication is absorbed. c. Administer the injection with the needle bevel facing downward at a 10- to 15-degree angle. d. Make a circular mark around the injection site after administration of the tuberculin test. Source: Saunders 4th

ANS: D Rationale: An intradermal injection is administered with the needle bevel facing upward at a 10- to 15-degree angle. The medication is injected slowly, and a bleb should form under the skin with injection. After withdrawing the needle, the area may be patted dry with a 2 × 2 sterile gauze pad, but pressure should not be applied. The area should not be rubbed because this would cause the medication to spread beyond the area of injection. The area of injection is outlined or circled for later reference. Strategy: Use the process of elimination and knowledge regarding the procedure for administering intradermal injections. Visualizing this procedure and recalling its purpose will direct you to option 4. If you had difficulty with this question, review the procedure for administering a tuberculin test. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 766). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1157) The client with chronic renal failure who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). The nurse should plan to administer this medication: a. During dialysis b. Just before dialysis c. The day after dialysis d. On return from dialysis Source: Saunders 4th

ANS: D Rationale: Antihypertensive medications such as enalapril are given to the client following hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from having the medication removed from the bloodstream by dialysis. No rationale exists for waiting an entire day to resume the medication. This would lead to ineffective control of the blood pressure. Strategy: Use the process of elimination. Begin to answer this question by thinking about the effects of an antihypertensive medication on the blood pressure when fluid is being removed from the body. Because hypotension is much more likely to occur in this circumstance, eliminate options 1 and 2. Eliminate option 3, because this action would lead to ineffective blood pressure control. Review preprocedure hemodialysis measures if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1755). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2002) A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain, and appendicitis is suspected. Laboratory tests are performed, and the nurse notes that the client's white blood cell (WBC) count is elevated. On the basis of these findings, the nurse would question which of the following physician's orders documented in the client's medical record? a. Maintain nothing-by-mouth (nil per os [NPO]) status. b. Initiate an intravenous (IV) line for the administration of IV fluids. c. Apply a cold pack to the abdomen. d. Administer 30 mL of Milk of Magnesia (MOM). Source: Saunders 4th

ANS: D Rationale: Appendicitis should be suspected in a client with an elevated WBC count complaining of acute right lower abdominal quadrant pain. The client would be NPO and given IV fluids in preparation for possible surgery. Cold packs may be ordered for comfort. Laxatives are never ordered, because if appendicitis is present, the effect of the laxative may cause a rupture with resultant peritonitis. Strategy: Use the process of elimination and knowledge regarding the treatment measures for appendicitis to assist in answering this question. Recalling that the client will require surgery will assist in eliminating options 1 and 2. Regarding the remaining options, recall that a concern with a client with appendicitis is rupture of the appendix. With this in mind, use knowledge regarding the principles of heat and cold to assist in directing you to option 4. Laxatives are contraindicated for an inflamed appendix. Review treatment measures for the client with appendicitis if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 813). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1267) The nurse is providing instructions to a client who will be self-administering eye drops. To minimize the systemic effects that eye drops can produce, the nurse instructs the client to: a. Eat before instilling the drops. b. Swallow several times after instilling the drops. c. Blink vigorously to encourage tearing after instilling the drops. d. Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling the drops. Source: Saunders 4th

ANS: D Rationale: Applying pressure on the nasolacrimal duct prevents systemic absorption of the medication. Options 1, 2, and 3 will not prevent systemic absorption. Strategy: Use the process of elimination. Eating and swallowing are comparative options and are not related to the systemic absorption of an eye medication. Blinking vigorously to produce tearing may result in the loss of the administered medication. Review the procedure for administering eye drops to prevent systemic absorption if you had difficulty with this question. Reference: Kee, J., Hayes, E., McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 34). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

2539) A nurse is developing a plan of care for a client with cirrhosis and ascites. Which of the following nursing actions will be avoided in the care plan for this client? a. Measure abdominal girth. b. Monitor respiratory status. c. Monitor daily weight. d. Place the client in a supine position. Source: Saunders 4th

ANS: D Rationale: Ascites is a problem because as more fluid is retained, it pushes up on the diaphragm, thereby impairing the client's breathing patterns. The client should be placed in a semi-Fowler's position to allow for free diaphragm movement. Options 1, 2, and 3 identify appropriate nursing interventions to be included in the plan of care for the client with ascites. Strategy: Focus on the diagnosis of the client and note the strategic word avoided in the question. Recalling that a supine position would further impair the client's breathing patterns will direct you to option 4. Review care of the client with cirrhosis and ascites if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1349-1350, 1353). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

46) A nurse caring for a client who has been receiving intravenous diuretics suspects that the client is experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this condition? a. Lung congestion b. Decreased hematocrit c. Increased blood pressure d. Decreased central venous pressure (CVP) Source: Saunders 4th

ANS: D Rationale: Assessment findings in a client with a deficient fluid volume include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 cm H₂O. A client with dehydration has a low CVP. The assessment findings in options 1, 2, and 3 are seen in a client with excess fluid volume. Strategy: Use the process of elimination and focus on the subject, deficient fluid volume. Eliminate options 1 and 3 first. Lung congestion is noted in excess fluid volume, as is increased blood pressure. From the remaining options, recall that central venous pressure reflects the pressure under which blood is returned to the superior vena cava and right atrium. Therefore, pressure (volume) would be decreased in a deficient fluid volume. If you had difficulty with this question, review the assessment findings noted in deficient fluid volume. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 339). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1144). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2552) A nurse is reviewing the record of a client admitted to the hospital with a diagnosis of Hodgkin's disease. Which assessment data finding noted in the client's record is unassociated with this diagnosis? a. Night sweats b. Enlarged, painless lymph nodes c. Weight loss d. Visual changes Source: Saunders 4th

ANS: D Rationale: Assessment of a client with Hodgkin's disease most often reveals enlarged, painless lymph nodes along with fever, malaise, and night sweats. Weight loss may be a feature in metastatic disease. Visual changes are not specifically associated with Hodgkin's disease. Strategy: Use the process of elimination. Note the strategic word unassociated in the question. Recalling the physiology associated with Hodgkin's disease will direct you to option 4. Review the assessment findings in Hodgkin's disease if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 909-910). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

2352) Auranofin (Ridaura) has been prescribed for a client with rheumatoid arthritis. The nurse provides instructions to the client about the medication and tells the client to notify the physician if which of the following occurs? a. Nausea b. Loss of appetite c. Diarrhea d. Metallic taste in the mouth Source: Saunders 4th

ANS: D Rationale: Auranofin is the one gold preparation that is given orally, rather than by injection. Gastrointestinal (GI) reactions including diarrhea, abdominal pain, nausea, and loss of appetite are common early in therapy but usually subside in the first 3 months. Early signs and symptoms of toxic reactions include a rash, purple blotches, pruritus, mouth lesions, and a metallic taste in the mouth. Signs and symptoms of toxic reactions are reported to the physician. Strategy: Note the strategic words notify the physician. Recalling that auranofin is a gold preparation will direct you to option 4. Also, options 1, 2, and 3 are comparative or alike in that they all are GI signs and symptoms. If you had difficulty with this question, review toxicity related to gold compounds. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 108). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2375) A client has been diagnosed with chlamydial infection, and azithromycin (Zithromax) has been prescribed. The nurse instructs the client to take the medication: a. With a magnesium-containing antacid b. With an aluminum-containing antacid c. With meals d. 1 hour before meals Source: Saunders 4th

ANS: D Rationale: Azithromycin should be taken 1 hour before or 2 hours after meals. It is not administered with meals, and it should not be taken with either aluminum- or magnesium-containing antacids. Strategy: Use the process of elimination. Eliminate options 1, 2, and 3 because they are comparative or alike in that they all indicate administration of the medication with another substance. If you are unfamiliar with how this medication is administered, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 114). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1947) A nurse teaches the mother of a child diagnosed with bacterial conjunctivitis regarding measures to prevent the transmission of the infection. Which statement by the mother indicates a need for further teaching? a. "Hands need to be washed frequently." b. "A clean wash cloth can be used to wipe my child's eyes." c. "The eye drops must be given as prescribed and hands need to be washed before and after instillation." d. "It is all right to share towels and washcloths as long as they are bleached after use." Source: Saunders 4th

ANS: D Rationale: Bacterial conjunctivitis is highly contagious, and infection control measures should be taught. These measures include frequent hand washing and not sharing towels and washcloths regardless of the bleaching process. Options 2 and 3 are correct treatment measures. Strategy: Note the strategic words need for further teaching. This phrasing indicates a negative event query and directs you to select an incorrect statement. Recalling that bacterial conjunctivitis is highly contagious will assist in eliminating options 1, 2, and 3. If you had difficulty with this question, review infection control measures for bacterial conjunctivitis. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1588). St. Louis: W.B. Saunders. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., pp. 677, 1106-1107). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

2621) A client diagnosed with schizophrenia has a new order for risperidone (Risperdal). The nurse reviews baseline laboratory results for which of the following studies before administering the first dose of this medication? a. Blood clotting tests b. Platelet count c. Complete blood count d. Liver function studies Source: Saunders 4th

ANS: D Rationale: Baseline assessment of renal and liver function should be done before the initiation of therapy with risperidone. The medication is used with caution in clients with renal or hepatic impairment, in those with underlying cardiovascular disorders, and in geriatric or debilitated clients. These clients are started on the medication at a reduced dosage level. Strategy: Use the process of elimination. Recalling that the medication is used cautiously in clients with renal or hepatic impairment will direct you to the correct option. If you are unfamiliar with the nursing considerations with the use of this medication, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1028). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1701) The physician orders a 24-hour urine collection for VMA (vanillylmandelic acid). The community health nurse visits the client at home and instructs the client in the procedure for the collection of the urine. Which statement, if made by the client, would indicate a need for further instruction? a. "I will start the collection in 2 days. Starting now, I cannot eat or drink any tea, chocolate, vanilla, or fruit until the test is completed." b. "When I start the collection, I will urinate and discard that specimen." c. "I will pour the urine in the collection bottle each time I urinate and refrigerate the urine." d. "I can take medication if I need to during the collection." Source: Saunders 4th

ANS: D Rationale: Because a 24-hour urine collection is a timed quantitative determination, it is essential that the client start the test with an empty bladder. Therefore, the client is instructed to void, discard the first urine, note the time, and start the test. The 24-hour urine specimen collection bottle must be kept on ice or refrigerated. For a vanillylmandelic acid (VMA) determination, the client is instructed to avoid tea, chocolate, vanilla, and all fruits for 2 days before urine collection begins. Also, clients are reminded not to take medications for 2 to 3 days before the test. Strategy: Use the process of elimination. Note the strategic words need for further instructions. These words indicate a negative event query and ask you to select an option that is incorrect. Use knowledge regarding the basic procedure for collecting a 24-hour urine sample to answer the question. Review this procedure if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 1130). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1666). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

2237) A nurse has instructed a client diagnosed with tuberculosis about how to prevent the spread of infection after discharge from the hospital. The nurse evaluates that the client needs further reinforcement of information if the client makes which of the following statements? a. "It's very important to wash my hands after I touch my mask, tissues, or body fluids." b. "I should cough into tissues and throw them away carefully." c. "It's important to cover my mouth if I laugh, sneeze, or cough." d. "I should use disposable plates, forks, and knives." Source: Saunders 4th

ANS: D Rationale: Because tuberculosis is transmitted by droplet, it cannot be carried on clothing, eating utensils, or other possessions. It is not necessary to discard any of these. It is important to perform proper hand washing after contact with body substances, tissues, or face masks. The client should cover the mouth with a tissue when laughing, coughing, or sneezing and dispose of tissues carefully. The client also may need to wear a mask as advised by the physician. Strategy: Note the strategic words needs further reinforcement. This phrasing indicates a negative event query and asks you to select an incorrect statement. Recall that tuberculosis is an airborne disease, so the organisms cannot be carried on inanimate objects. Review client teaching points related to the prevention of the spread of tuberculosis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 644). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 606). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2580) The physician orders Intralipids fat emulsion, given intravenously, for a client. The nurse should consult with the physician before administering the fat emulsion solution if which of the following is noted in the client's record? a. The client is receiving parenteral nutrition (PN). b. The client has an allergy to iodine. c. The client has a blood glucose level of 120 mg/dL. d. The client has an allergy to egg yolks. Source: Saunders 4th

ANS: D Rationale: Before administering any medication, the nurse must assess for allergy or hypersensitivity to substances used in producing the medication. Fat emulsions such as Intralipids may contain an emulsifying agent obtained from egg yolks. Clients sensitive to eggs are at risk for developing hypersensitivity reactions. Options 1, 2, and 3 are not contraindications to the administration of fat emulsions. Strategy: Use the process of elimination. Eliminate options 1 and 3 first, knowing that fat emulsions can be administered concurrently with PN and that a blood glucose level of 120 mg/dL is a normal value. From the remaining options, recalling that fat emulsion may contain an emulsifying agent obtained from egg yolks will direct you to option 4. Review the contraindications associated with the administration of fat emulsion if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 540). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1014) A client has an order to have radial arterial blood gases drawn. Before drawing the sample, a nurse occludes the: a. Ulnar artery and observes for color changes in the affected hand b. Radial artery and observes for color changes in the affected hand c. Brachial and radial arteries, releases them, and then observes the circulation to the hand d. Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the process with the other artery Source: Saunders 4th

ANS: D Rationale: Before drawing a sample for arterial blood gas analysis, the nurse assesses the collateral circulation to the hand with Allen's test. This involves compressing the radial and ulnar arteries and asking the client to close and open the fist, which should cause the hand to become pale. The nurse then releases pressure on one artery and observes whether circulation is restored quickly. The nurse repeats the process, releasing the other artery. The blood sample may be taken safely if collateral circulation is adequate. Strategy: Use the process of elimination, recalling that the nurse must ensure collateral circulation to the hand before drawing a sample for arterial blood gas testing. Consider the anatomy of the blood vessels that lead to the hand to direct you to option 4. If you are unfamiliar with Allen's test, review this procedure. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., pp. 248-249). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1039) A client has been taking benzonatate (Tessalon Perles) as prescribed. A nurse concludes that the medication is having the intended effect if the client experiences: a. Decreased anxiety level b. Increased comfort level c. Reduction in nausea and vomiting d. Decreased frequency and intensity of cough Source: Saunders 4th

ANS: D Rationale: Benzonatate is a locally acting antitussive and its effectiveness is measured by the degree to which it decreases the intensity and frequency of cough without eliminating the cough reflex. Options 1, 2, and 3 are not effects of this medication. Strategy: Focus on the name of the medication. Recalling that the medication is an antitussive will direct you to option 4. Review this medication if you are unfamiliar with it. Reference: Kee, J. Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 584). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2608) A client has been given a prescription for benzonatate (Tessalon). The nurse evaluates the effectiveness of the medication by noting whether it has: a. Decreased the client's anxiety level b. Increased the client's comfort level c. Eliminated the client's nausea and vomiting. d. Calmed the client's persistent cough Source: Saunders 4th

ANS: D Rationale: Benzonatate is a locally acting antitussive that decreases the intensity and frequency of cough without eliminating the cough reflex. The other options are incorrect. Strategy: Use the process of elimination. Recalling that benzonatate is a locally acting antitussive will direct you to the correct option. If the question was difficult or if you are unfamiliar with this medication, review its intended effect. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 127). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2698) A client has been prescribed betaxolol (Betoptic) eye drops for the treatment of glaucoma. The ambulatory care nurse determines that the client understands proper medication use if the client states the need to return to the office for monitoring of: a. Blood glucose level b. Hearing acuity c. Calf pain d. Blood pressure and apical pulse Source: Saunders 4th

ANS: D Rationale: Betaxolol is an antiglaucoma medication and a β-adrenergic blocker. Systemic effects of this medication are hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea. The client should have the blood pressure monitored for hypotension and the pulse assessed for strength, weakness, irregular rate, and bradycardia. Bowel activity and evidence of congestive heart failure also should be assessed. The other options are incorrect. Strategy: Noting the -lol in the name of the medication will assist you to recall that this medication is a β-adrenergic blocker. This knowledge and use of the ABCs—airway, breathing, and circulation—will direct you to option 4. Review the client teaching points related to this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 132). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

15) The nurse understands that which of the following statements regarding herbal therapies is true? a. Zinc is used for insomnia. b. Ginger is used to improve memory. c. Echinacea is used for erectile dysfunction. d. Black cohosh produces estrogen-like effects. Source: Saunders 4th

ANS: D Rationale: Black cohosh produces estrogen-like effects. Zinc stimulates the immune system and is used for its antiviral properties. Echinacea stimulates the immune system and ginger is used for nausea and vomiting. Strategy: Note the strategic word true and use the process of elimination and knowledge regarding herbal therapies. Options 1, 2 and 3 can be eliminated because the herb identified does not correlate with the correct therapeutic property. If you had difficulty with this question, review commonly used herbs and their therapeutic properties. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 145, 1261). Philadelphia: W.B. Saunders. Reference: Mahan, L.K., & Escott-Stump, S. (2004). Krause's food, nutrition, & diet therapy (11th ed., pp. 482-487). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1957) A nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is appropriate? a. Insert nasal packing. b. Document the findings. c. Monitor the client's blood pressure and monitor for signs of increased intracranial pressure. d. Contact the physician. Source: Saunders 4th

ANS: D Rationale: Bloody or clear drainage from either the nasal or the auditory canal after trauma could indicate a cerebrospinal fluid leak. The appropriate nursing action is to notify the physician because this finding requires immediate intervention. Options 1, 2, and 3 are inappropriate nursing actions in this situation. Strategy: Use the process of elimination. Recalling that the presence of bloody or clear drainage could indicate the presence of a cerebrospinal fluid leak will assist in directing you to option 4. If you had difficulty with this question, review the complications following a head injury and the appropriate nursing interventions. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1050-1051). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1255) The nurse assesses the client with a blunt head injury sustained from a motor vehicle accident. Which assessment sign would indicate a basal skull fracture as a result of the injury? a. Epistaxis b. Periorbital edema c. Purulent drainage from the auditory canal d. Bloody or clear drainage from the auditory canal Source: Saunders 4th

ANS: D Rationale: Bloody or clear watery drainage from the auditory canal indicates a cerebrospinal fluid leak following trauma and suggests a basal skull fracture. This warrants immediate attention. Options 1, 2, and 3 are not specific to a basal skull fracture. Strategy: Use the process of elimination. Recalling the concern related to leakage of cerebrospinal fluid will direct you to option 4. If you had difficulty with this question, review these assessment signs. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1044, 1050). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

2401) A nurse is reviewing the progress notes for a client admitted to the nursing unit with a suspected diagnosis of leukemia. The nurse notes that the diagnosis of leukemia has been confirmed. The nurse interprets that results have been reported to the physician for which of the following diagnostic tests? a. Complete blood cell count b. Platelet count c. White blood cell count d. Bone marrow biopsy Source: Saunders 4th

ANS: D Rationale: Bone marrow aspiration or biopsy allows examination of blast cells and other hypercellular activity. Blood studies will not provide a definitive diagnosis of leukemia. Strategy: Note the strategic word confirmed. Recall that in leukemia, infiltration of leukemic cells occurs in the bone marrow. From this point on, use the process of elimination. Also, note that options 1, 2, and 3 are comparative or alike and identify blood studies. Review diagnostic procedures for leukemia if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 897). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

1807) A nurse has instructed a client in the foods that are best to consume on a low-fat diet. The nurse determines that the client understands this diet if the client indicates that which food item is lowest in fat? a. Bran muffin b. Cheese omelet c. Bagel with cream cheese d. Dry toast and strawberry jelly Source: Saunders 4th

ANS: D Rationale: Bread (toast without butter or margarine) contains the least amount of fat among the items in the options provided. Strawberry jelly contains calories but nominal fats. Bran muffins, although they may be high in residue, are high in fat. Cheese contains significant amounts of fat. Strategy: Use the process of elimination. Eliminate options 2 and 3 first because they are comparative or alike in that they both include cheese. Regarding the remaining options, awareness of the differences between healthful foods and low-fat foods will assist in directing you to option 4. A bran muffin may be "healthier" than a doughnut; however, it still may contain saturated fats. Review the food items lowest in fat if you had difficulty with this question. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed., p. 594). St. Louis: Mosby. Reference: Nix, S. (2005). Williams' basic nutrition & diet therapy (12th ed., p. 344). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2652) Neuroleptic malignant syndrome develops in a client taking chlorpromazine (Thorazine). The nurse checks the nursing unit medication cart to see if which of the following medications is available to treat this adverse reaction? a. Enalapril maleate (Vasotec) b. Protamine sulfate c. Phytonadione (vitamin K) d. Bromocriptine (Parlodel) Source: Saunders 4th

ANS: D Rationale: Bromocriptine, an antiparkinsonian prolactin inhibitor, is used in the treatment of neuroleptic malignant syndrome. Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. Phytonadione is the antidote for warfarin (Coumadin) overdose. Protamine sulfate is the antidote for heparin overdose. Strategy: Knowledge of the treatment for neuroleptic malignant syndrome is needed to answer this question. Recall that bromocriptine is used in the treatment of neuroleptic malignant syndrome. If you are unfamiliar with the various medications used as antidotes or treatments for various syndromes, review this content. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 317). Philadelphia: W.B. Saunders. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 183). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1341) A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction primarily: a. Allows bony healing to begin before surgery b. Provides rigid immobilization of the fracture site c. Lengthens the fractured leg to prevent severing of blood vessels d. Provides comfort by reducing muscle spasms and provides fracture immobilization Source: Saunders 4th

ANS: D Rationale: Buck's extension traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps immobilize the fracture. Traction does not lengthen the leg for the purpose of preventing blood vessel severance. Traction also does not allow for bony healing to begin. Strategy: Use the process of elimination. Focus on the client's diagnosis, hip fracture. Read each option carefully. Noting the words provides fracture immobilization will direct you to option 4. Review the purpose of Buck's traction if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1200). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1930) Which of the following clients is most at risk for developing a Candida urinary tract infection (UTI)? a. A man with diabetes insipidus b. An obese woman c. A male paraplegic on intermittent catheterization d. A young woman on antibiotic therapy Source: Saunders 4th

ANS: D Rationale: Candida infections, which are fungal infections, develop in persons who are on long-term antibiotic therapy because an alteration of normal flora occurs. These infections also are commonly seen in clients with blood dyscrasias, diabetes mellitus, cancer, or immunosuppression and in clients with a drug addiction. Strategy: Use the process of elimination. Recalling that women are more susceptible to UTIs will assist in eliminating options 1 and 3. Regarding the remaining options, recalling that antibiotics alter normal flora will direct you to option 4. Review the risk factors associated with Candida infections if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1679). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2386) A client is scheduled to begin therapy with carbamazepine (Tegretol). The nurse assesses the results of which of the following tests before administering the first dose of this medication to the client? a. Renal function tests b. Pancreatic enzyme studies c. Liver function tests d. Complete blood cell count Source: Saunders 4th

ANS: D Rationale: Carbamazepine can cause leukopenia, anemia, thrombocytopenia, and, very rarely, fatal aplastic anemia. To reduce the risk of serious hematological effects, a complete blood cell count should be done before treatment and periodically thereafter. This medication should be avoided in clients with pre-existing hematological abnormalities. The client also is told to report the occurrence of fever, sore throat, pallor, weakness, infection, easy bruising, and petechiae. Options 1, 2, and 3 are not associated with the use of this medication. Strategy: Recalling that carbamazepine causes hematological effects will direct you to option 4. To help answer questions similar to this one, remember that carbamazepine and complete blood count begin with C. If you are unfamiliar with the adverse effects of this medication, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 182). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2576) The home care nurse is visiting a client who sustained a severe muscle sprain to the back. Carisoprodol (Soma) is prescribed for the client, and the nurse provides instructions to the client regarding the medication. The nurse teaches the client: a. That muscle spasms will be reduced but the pain may increase b. To try to avoid missing doses, but if a dose is missed to take it as soon as it is remembered c. To limit alcohol consumption to two drinks daily while taking the medication d. To avoid driving until the reaction to the medication is known Source: Saunders 4th

ANS: D Rationale: Carisoprodol, a centrally acting skeletal muscle relaxant, may cause central nervous system (CNS) side effects of drowsiness and dizziness. For this reason, the client avoids other CNS depressants, such as alcohol, while taking this medication. Driving or other activities requiring mental alertness should also be avoided until the client's reaction to the medication is known. The medication is used to reduce muscle spasticity and pain. Missed doses should be taken if remembered within 1 hour. Strategy: Focus on the client's diagnosis, severe muscle sprain. Recalling that this medication is a skeletal muscle relaxant will assist in directing you to option 4. Review client teaching points related to this medication if you had difficulty with this question. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 240). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

961) The client is taking cascara sagrada and develops abdominal cramps. What interpretation by the nurse is most likely correct? a. The client has peptic ulcer disease. b. The client is experiencing a case of influenza. c. The client may have a partial bowel obstruction. d. This is a common side effect of this medication. Source: Saunders 4th

ANS: D Rationale: Cascara sagrada is a laxative that causes nausea and abdominal cramps as the most frequent side effects. Other health problems (options 1, 2, and 3) are not determined based on a single symptom. Strategy: Use the process of elimination. Remember that options that are comparative or alike are not likely to be correct. This will allow you to eliminate the two gastrointestinal disorders (options 1 and 3). From the remaining options, choose option 4 over option 2, knowing that laxatives can cause abdominal cramping. Review the effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 193). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1568) The registered nurse is beginning a new job in a clinic and is attending an orientation session. Following the orientation session, another new employee asks the registered nurse to describe case management, a component of the discussions in the orientation session, because the employee did not clearly understand the concept. The registered nurse responds that: a. "Case management requires an experienced nurse, because it represents a primary health prevention focus and is managed by a single nurse." b. "Case management saves money for the institution because clients with similar problems are all treated in the same manner." c. "Case management is an important concept but it doesn't promote appropriate use of personnel." d. "Case management will maximize hospital revenues and at the same time provide optimal outcome of client care." Source: Saunders 4th

ANS: D Rationale: Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources to maximize hospital revenues while providing for optimal outcome of client care. Options 1, 2, and 3 are inaccurate statements regarding case management. Strategy: Use the process of elimination and knowledge regarding the characteristics of case management. Also, note that option 4 is the umbrella option. Review the characteristics of case management if you had difficulty with this question. Reference: Cohen, E., & Cesta, T., (2005). Nursing case management: From essentials to advanced practice applications (4th ed., p. 33). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2046) A nurse is performing an assessment on a client with a diagnosis of thrombotic brain attack (stroke). Which of the following assessment questions would elicit data specific to this type of stroke? a. "Have you had any headaches in the past few days?" b. "Have you had any sudden episodes of passing out in the past few days?" c. "Have you recently been having difficulty with seeing at night time?" d. "Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?" Source: Saunders 4th

ANS: D Rationale: Cerebral thrombosis does not occur suddenly. In the few days or hours preceding the thrombotic stroke, the client may experience a transient loss of speech, hemiparesis, or parasthesias on one side of the body. Signs and symptoms of this type of stroke vary but may include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage. In addition, most clients do not have repeated episodes of loss of consciousness. The client does not complain of difficulty with night vision as part of this clinical problem. Strategy: Use the process of elimination and knowledge regarding the signs and symptoms that are associated with a thrombotic stroke to answer this question. If you had difficulty with this question or are unfamiliar with these clinical manifestations, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2111). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1029). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1517) A hospitalized client is prescribed chloral hydrate (Somnote). The nurse includes which action in the plan of care? a. Monitor blood pressure every 4 hours. b. Monitor apical heart rate every 2 hours. c. Clear a path to the bathroom at bedtime. d. Instruct the client to call for ambulation assistance. Source: Saunders 4th

ANS: D Rationale: Chloral hydrate (Somnote) is a sedative. This medication does not affect cardiac function. Blood pressure changes are not significant with the use of this medication. The client should call for assistance to the bathroom at night. Additionally, the client may experience residual daytime sedation; therefore, the nurse also should instruct the client to call for ambulation assistance during the daytime hours. Strategy: Use the process of elimination. Recalling that this medication is a sedative will direct you easily to option 4. Review nursing considerations related to this medication if you had difficulty with this question. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., pp. 343-344). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1526) The 26-year-old female client with schizophrenia has been prescribed chlorpromazine hydrochloride (Thorazine). The client calls the mental health clinic and tells the nurse that her urine has become dark. The client has no other urinary symptoms. The nurse tells the client: a. That this indicates medication toxicity b. To seek treatment for urinary tract infection c. To increase intake of acid-ash foods and liquids d. That this is an expected side effect of the medication Source: Saunders 4th

ANS: D Rationale: Chlorpromazine hydrochloride (Thorazine) is an antipsychotic medication. A side effect of this medication is that the color of urine may darken. The client should be aware that this effect is harmless. The other options are incorrect. Strategy: Use the process of elimination. Eliminate options 2 and 3 first because the question states that the client exhibits no other symptoms of urinary tract infection. From the remaining options, remember that dark urine is a side effect of this medication. Review the side effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 242). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

904) The nurse provides medication instructions to a client with peptic ulcer disease. Which statement, if made by the client, indicates the best understanding of the medication therapy? a. "Antacids will coat my stomach." b. "Sucralfate (Carafate) will change the fluid in my stomach." c. "Omeprazole (Prilosec) will coat the ulcer and help it heal." d. "The cimetidine (Tagamet) will cause me to produce less stomach acid." Source: Saunders 4th

ANS: D Rationale: Cimetidine (Tagamet), a histamine (H₂) receptor antagonist, will decrease the secretion of gastric acid. Antacids neutralize acid in the stomach. Sucralfate (Carafate) promotes healing by coating the ulcer. Omeprazole (Prilosec) inhibits gastric acid secretion. Strategy: Use the process of elimination and knowledge regarding the actions of the medications identified in the options. Remember that cimetidine decreases the secretion of gastric acid. If you are unfamiliar with these medications or their actions, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 754). Philadelphia: W.B. Saunders. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., p. 715). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

129) A client recently diagnosed with a myocardial infarction and impaired renal function is recuperating on the step-down cardiac unit. The client's blood pressure has been borderline low and intravenous (IV) fluids have been infusing at 100 mL/hr via a central line catheter in the right internal jugular for approximately 24 hours to increase renal output and maintain the blood pressure. On entering the client's room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determines that the client is most likely experiencing which complication of intravenous therapy? a. Hematoma b. Systemic infection c. Electrolyte overload d. Circulatory overload Source: Saunders 4th

ANS: D Rationale: Circulatory (fluid overload) is a complication of intravenous therapy. Signs include rapid breathing, dyspnea, a moist cough, and crackles. When circulatory overload is present, the client's blood pressure would also increase. Hematoma is characterized by ecchymosis, swelling and leakage at the IV insertion site, and hard and painful lumps at the site. Systemic infection is characterized by chills, fever, malaise, headache, nausea, vomiting, backache, and tachycardia. Signs of electrolyte imbalance depend on the specific electrolyte. Strategy: Focus on the data in the question. Noting that the client is experiencing rapid breathing and is coughing will assist in directing you to the correct option. Review the signs of complications of IV therapy if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p.749). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1340) A nurse has given a client with a leg cast instructions on cast care at home. The nurse would evaluate that the client needs further instruction if the client makes which of the following statements? a. "I should avoid walking on wet, slippery floors." b. "I'm not supposed to scratch the skin underneath the cast." c. "It's okay to wipe dirt off the top of the cast with a damp cloth." d. "If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting." Source: Saunders 4th

ANS: D Rationale: Client instructions should include avoiding walking on wet slippery floors to prevent falls. Surface soil on a cast can be removed with a damp cloth. If the cast gets wet, it can be dried with a hair dryer set to a cool setting to prevent skin breakdown. If the skin under the cast itches, cool air from a hair dryer may be used to relieve it. The client should never scratch under a cast because of the risk of skin breakdown and ulcer formation. Strategy: Use the process of elimination. Note the strategic words needs further instruction. These words indicate a negative event query and ask you to select an option that is incorrect. Remember never to use a hair dryer on a cast or on the skin under a cast with the dryer set at the warmest setting; only cool settings are used to prevent burns. Review client teaching points about a cast if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1169). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1286) The nurse is assessing the adaptation of the client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client: a. Gets angry with family if they interrupt a task b. Experiences bouts of depression and irritability c. Has difficulty with using modified feeding utensils d. Consistently uses adaptive equipment in dressing self Source: Saunders 4th

ANS: D Rationale: Clients are evaluated as coping successfully with lifestyle changes after a brain attack (stroke) if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions. Options 1, 2, and 3 are not adaptive behaviors. Strategy: Use the process of elimination, focusing on the strategic words adapting most successfully. Options 1 and 2 are behaviors that may be expected in the client with a brain attack (stroke), but they are not adaptive responses. Instead, they are a result of the insult to the brain. Options 3 and 4 indicate that the client is trying to adapt, but option 4 has the best outcome. Review care of the client with a brain attack (stroke) if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2131-2132). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1044). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1004) A client exposed to tuberculosis is taking isoniazid (INH) and develops signs and symptoms of the disease. The client is instructed to add rifampin (Rifadin) to the medication regimen. A nurse explains to the client that the purpose of adding this second medication is: a. That these medications potentiate each other b. That rifampin offsets the side effects of isoniazid c. That isoniazid offsets the side effects of rifampin d. To be certain that resistant organisms are eliminated Source: Saunders 4th

ANS: D Rationale: Clients diagnosed with active tuberculosis usually are started on more than one medication to be certain that the resistant organisms are eliminated. The doses of some medications initially may be large because the bacilli are difficult to kill. Options 1, 2, and 3 are inaccurate. Strategy: Use the process of elimination and focus on the subject, multidrug therapy for tuberculosis. Recalling the concern related to multidrug-resistant tuberculosis will direct you to option 4. If you are unfamiliar with this therapy, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1847-1848). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 643-644). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

65) A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 6 breaths/min. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/min. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which of the following? a. A decreased pH and an increased CO₂ b. An increased pH and a decreased CO₂ c. A decreased pH and a decreased HCO₃^- d. An increased pH with an increased HCO₃^- Source: Saunders 4th

ANS: D Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO₃^- to increase. Symptoms experienced by the client would include hypoventilation and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition. Option 3 reflects a metabolic acidotic condition. Strategy: Focus on the data in the question and note that the client is vomiting. Recalling that vomiting would most likely cause metabolic alkalosis will assist in directing you to option 4. Review the causes of metabolic alkalosis if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 351-352). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2156) A client is fearful about having an arm cast removed. Which of the following actions by the nurse would be the most helpful? a. Telling the client that the saw makes a frightening noise b. Reassuring the client that no one has had an arm lacerated yet c. Stating that the hot cutting blades cause burns only very rarely d. Showing the client the cast cutter and explaining how it works Source: Saunders 4th

ANS: D Rationale: Clients may be fearful of having a cast removed because of misconceptions about the cast cutting blade. The nurse should show the cast cutter to the client before it is used and explain that the client may feel heat, vibration, and pressure. The cast cutter resembles a small electric saw with a circular blade. The nurse should reassure the client that the blade does not cut like a saw but instead cuts the cast by vibrating side to side. Strategy: Use the process of elimination. Note the strategic words most helpful. Option 4 provides the client the most reassurance because it best prepares the client for what will occur when the cast is removed. Review therapeutic nursing interventions if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1200). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1144) A client with a diagnosis of congestive heart failure is seen in a clinic. The client is being treated with a variety of medications, including digoxin (Lanoxin) and furosemide (Lasix). Which of the following assessment findings would lead the nurse to suspect that the client is hypokalemic? a. Diarrhea b. Tingling of fingers and toes c. Intermittent intestinal colic d. Muscle weakness and leg cramps Source: Saunders 4th

ANS: D Rationale: Clients on potassium-wasting diuretics are at high risk for hypokalemia. Clinical manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesias, and dysrhythmias. Strategy: Use the process of elimination and knowledge regarding the signs of electrolyte imbalances. Diarrhea and intestinal colic are signs of hyperkalemia. Tingling of the fingers and toes are signs of hypocalcemia. If you had difficulty with this question, review the signs of hypokalemia. Reference: Ignatavicius, D., & Workman, M., (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 228). St. Louis: W.B. Saunders. Reference: Lilley, L., Harrington, S., & Snyder, J. (2005). Pharmacology and the nursing process (4th ed., pp. 444-445). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2425) A client has been on parenteral nutrition (PN) for 8 weeks at home. The physician orders that the PN be weaned by 50 mL per hour per day until discontinued. The client asks the nurse why the PN cannot just be stopped. The nurse explains that unless the PN infusions are tapered gradually, the client is at risk for development of which of the following? a. Dehydration b. Hypokalemia c. Hypernatremia d. Hypoglycemia Source: Saunders 4th

ANS: D Rationale: Clients receiving PN are receiving high concentrations of glucose. To give the pancreas time to adjust to decreasing glucose loads, the infusion rate is tapered downward. Before discontinuation of PN, the body must adjust to the lowered glucose levels. If the PN was suddenly withdrawn, the client could experience rebound hypoglycemia. Options 1, 2, and 3 are not associated with the discontinuation of the PN. Strategy: Use the process of elimination. Recalling that PN solutions contain high concentrations of glucose will direct you to option 4. Review the components of a PN solution and the considerations related to weaning if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 708). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1433). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2499) A young adult client has never had a chest x-ray examination before and expresses to the nurse a fear of experiencing some form of harm from the test. Which of the following statements by the nurse would provide valid reassurance to the client? a. "You'll wear a lead shield to partially protect your organs from harm." b. "The amount of x-ray exposure is not sufficient to cause DNA damage." c. "The test isn't harmful at all. The most frustrating part is the long wait in radiology." d. "The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation." Source: Saunders 4th

ANS: D Rationale: Clients should be taught that the amount of exposure to radiation is minimal, and that the test itself is painless. The wording in each of the other options is only partly true and therefore cannot provide valid reassurance to the client. Strategy: Use the process of elimination, focusing on the dual subject, client fear and providing reassurance. Use knowledge regarding this basic procedure to direct you to option 4. Also note the words partially protect, not, and at all in the incorrect options. Review the procedure and basic information regarding chest radiography if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., pp. 360-361). Philadelphia: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., pp. 254-255). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

2350) A client with gout has begun taking allopurinol (Zyloprim). The home health nurse provides which of the following instructions to the client for use of the medication? a. Take the medication 1 hour before eating. b. Put ice on the upper and lower lips if they swell. c. Use an antihistamine lotion if an itchy rash develops. d. Drink at least 8 glasses of fluid every day. Source: Saunders 4th

ANS: D Rationale: Clients taking allopurinol are encouraged to drink 3000 mL of fluid a day to prevent formations of crystals in the urine. Allopurinol is given with or immediately after meals or milk. If the client notes development of a rash, irritation of the eyes, or swelling of the lips or mouth, the physician should be notified because this may indicate hypersensitivity. Strategy: Use the process of elimination. Options 2 and 3 can be easily eliminated because they indicate a hypersensitivity reaction, which is not a normal expected response. Knowing either that the medication should be taken with food or milk or that insufficient fluid can cause the formation of crystals and renal stones will direct you to the correct option. If you had difficulty with this question, review client instructions related to allopurinol. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 37). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1207) Trimethoprim-sulfamethoxazole (TMP-SMZ; Bactrim) is prescribed for a client. A nurse would instruct the client to report which symptom if it developed during the course of this medication therapy? a. Nausea b. Diarrhea c. Headache d. Sore throat Source: Saunders 4th

ANS: D Rationale: Clients taking trimethoprim (TMP)-sulfamethoxazole (SMZ) should be informed about early signs of blood disorders that can occur from this medication. These include sore throat, fever, and pallor, and the client should be instructed to notify the physician if these symptoms occur. The other options do not require physician notification. Strategy: Use the process of elimination. Knowledge that this medication can cause blood dyscrasias will direct you to option 4. If you are unfamiliar with this medication, review this content. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 877). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1436) The nurse is caring for a client who is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Based on this information, the nurse determines that: a. The physician will provide the informed consent. b. An informed consent does not need to be obtained. c. An informed consent should be obtained from the family. d. An informed consent needs to be obtained from the client. Source: Saunders 4th

ANS: D Rationale: Clients who are admitted involuntarily do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The informed consent needs to be obtained from the client. Strategy: Knowledge regarding the hospital admission processes and client's rights are necessary to answer this question. If you had difficulty with this question, focus on the subject of client rights to direct you to option 4. Review client rights if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 54). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 150, 605). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Analysis Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1499) During a conversation with a depressed client on an inpatient unit, the client says to the nurse, "My family would be better off without me." The nurse's best response is: a. "Have you talked to your family about this?" b. "Everyone feels this way when they are depressed." c. "You will feel better once your medication begins to work." d. "You sound very upset. Are you thinking of hurting yourself?" Source: Saunders 4th

ANS: D Rationale: Clients who are depressed may be at risk for suicide. For the nurse to assess suicidal ideation and plan is critical. Ask the client directly whether a plan for self-harm exists. Options 1, 2, and 3 do not deal directly with the client's feelings. Strategy: Using therapeutic communication techniques will assist in directing you to the correct option. Option 4 is the only option that deals directly with the client's feelings. Additionally, clients at risk for suicide need to be assessed directly regarding the potential for self-harm. Review care of the client at risk for suicide if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-34, 367). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 330). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1482) The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa, and a nursing student will be observing the nurse. The nurse asks the student about the expected assessment findings and determines that the student needs to research the disorder further if the student states that which of the following is a characteristic finding? a. Dental decay b. Loss of tooth enamel c. Electrolyte imbalances d. Body weight well below ideal range Source: Saunders 4th

ANS: D Rationale: Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, the client demonstrates dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present. Strategy: Focus on the subject, bulimia nervosa, and note the strategic words needs to research. Eliminate options 1 and 2 because they are comparative or alike. From the remaining options, recall that in anorexia nervosa the body weight is normally below 85% of ideal body weight. Option 4 is a characteristic sign of anorexia nervosa, not bulimia nervosa. Review the characteristics of these disorders if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 380-381, 383). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Teaching and Learning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2265) A nurse is planning care for a client who displays confusion secondary to a neurological problem. Which of the following approaches by the nurse would be least helpful in assisting this client? a. Giving simple, clear directions b. Providing a stable environment c. Providing sensory cues d. Encouraging multiple visitors at one time Source: Saunders 4th

ANS: D Rationale: Clients with cognitive impairment from neurological dysfunction respond best to a stable environment, which is limited in amount and type of sensory input. The nurse can provide sensory cues and give clear, simple directions in a positive manner. Confusion can be minimized by reducing environmental stimuli (such as television or multiple visitors) and keeping familiar personal articles (such as family pictures) at the bedside. Strategy: Use the process of elimination and note the strategic words least helpful. Remember that the client who is confused can handle limited amounts of information at one time. Review care of the confused client if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2067-2068). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1356) A client with diabetes mellitus has had a right below-knee amputation. The nurse would assess specifically for which of the following signs and symptoms because of the history of diabetes? a. Hemorrhage b. Edema of the stump c. Slight redness of incision d. Separation of wound edges Source: Saunders 4th

ANS: D Rationale: Clients with diabetes mellitus are more prone to wound infection and delayed wound healing because of the disease. Postoperative stump edema and hemorrhage are complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long as it is dry and intact. Strategy: Use the process of elimination. Recalling that diabetes mellitus increases the client's chances of developing infection and delayed wound healing will direct you to option 4. Review the complications associated with an amputation in the client with diabetes mellitus if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1299). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1293) The nurse is teaching the client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by: a. Eating large, well-balanced meals b. Doing muscle-strengthening exercises c. Doing all chores early in the day while less fatigued d. Taking medications on time to maintain therapeutic blood levels Source: Saunders 4th

ANS: D Rationale: Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress. Strategy: Use the process of elimination. Recalling that the common causes of myasthenic and cholinergic crises are undermedication and overmedication, respectively, will assist you in eliminating each of the incorrect options. No other option would prevent both of those complications. Review measures to prevent myasthenic and cholinergic crises if you are unfamiliar with them. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1015-1017). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1927) A nurse is caring for a client with acute renal failure (ARF). When performing an assessment, the nurse would expect to note which of the following breathing patterns? a. Decreased respirations b. Apneic c. Cheyne-Stokes d. Kussmaul's Source: Saunders 4th

ANS: D Rationale: Clinical manifestations associated with ARF occur as a result of metabolic acidosis. The nurse would expect to note Kussmaul's respirations as a result of the metabolic acidosis because the bodily response is to exhale excess carbon dioxide. Options 1, 2, and 3 are not characteristic of ARF. Strategy: Use the process of elimination. Recalling that the client with ARF experiences metabolic acidosis will easily direct you to option 4. Review the clinical manifestations associated with ARF if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1741). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2550) A female client is suspected of having a vaginal infection caused by the organism Candida albicans. Which assessment question would elicit data associated with this infection? a. "Do you have any blood in your urine?" b. "Have you noticed any swelling in your feet?" c. "Have you had any flank pain or headaches?" d. "Have you had any vaginal discharge?" Source: Saunders 4th

ANS: D Rationale: Clinical manifestations of a Candida infection include vaginal pain, itching, and a thick, white vaginal discharge. Hematuria, edema, flank pain, and headache are clinical manifestations associated with urinary tract infections. Strategy: Use the process of elimination and focus on the subject. Note the relationship between the word vaginal in the question and in the correct option. If you had difficulty with this question, review the signs associated with Candida infection. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1831). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1971) A nurse is reviewing the record of a client who was admitted to the hospital with a diagnosis of ovarian cancer. The nurse understands that which assessment finding is unassociated with this disorder? a. Abdominal distention b. Urinary frequency and urgency c. Pain d. Frequent diarrhea Source: Saunders 4th

ANS: D Rationale: Clinical manifestations of ovarian cancer include abdominal distention, urinary frequency and urgency, pain from pressure caused by the growing tumor, and urinary or bowel obstruction and constipation. Diarrhea is not likely to be seen in the client with ovarian cancer. Strategy: Use the process of elimination, noting the strategic word unassociated in the question. Think about the anatomical location of ovarian cancer and the effects of tumor growth to assist in directing you to option 4. If you had difficulty with this question, review the clinical manifestations associated with ovarian cancer. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1080). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

2538) A nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of portal hypertension. Which initial sign, if noted in the client, indicates the presence of portal hypertension? a. Flat neck veins b. Hypotension c. Weak pulse d. Crackles on auscultation of the lungs Source: Saunders 4th

ANS: D Rationale: Clinical signs and symptoms of portal hypertension are identical to those of heart failure and include jugular vein distention, lung crackles, and decreased perfusion to all organs. Initially, the client may have hypertension, flushed skin, and a bounding pulse. Strategy: Use the process of elimination and focus on the subject, portal hypertension. Recalling that the signs of this disorder are identical to those of heart failure will direct you to option 4. Review these signs if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1344). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1369). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1518) The home health nurse visits the client. The client gives the nurse a bottle of clomipramine (Anafranil). The nurse notes that the medication has not been taken by the client in 2 months. What behaviors observed in the client would validate noncompliance with this medication? a. Complaints of insomnia b. Complaints of hunger and fatigue c. A pulse rate less than 60 beats/min d. Frequent hand washing with hot soapy water Source: Saunders 4th

ANS: D Rationale: Clomipramine (Anafranil) is a tricyclic antidepressant used to treat obsessive-compulsive disorder. Weight gain and tachycardia are side effects of this medication. Sedation sometimes occurs and insomnia is a seldom side effect. Strategy: Recalling that this medication is a tricyclic antidepressant used to treat obsessive-compulsive disorder will direct you to option 4. Review the purpose and use of this medication if you had difficulty with this question. Reference: Keltner, N., & Folks, D. (2005). Psychotropic drugs (4th ed., p. 160). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1445) An 18-year-old woman is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa. A cognitive behavioral approach is used as part of her treatment plan. The nurse understands that the purpose of this approach is to: a. Provide a supportive environment. b. Examine intrapsychic conflicts and past issues. c. Emphasize social interaction with clients who withdraw. d. Help the client identify and examine dysfunctional thoughts and beliefs. Source: Saunders 4th

ANS: D Rationale: Cognitive behavioral therapy is used to help the client identify and examine dysfunctional thoughts and to identify and examine values and beliefs that maintain these thoughts. Options 1, 2, and 3 are incorrect. Strategy: Use the process of elimination and note the strategic words cognitive behavioral. Focusing on these words should direct you to option 4. If you are unfamiliar with this type of therapy and its purpose, review this content. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 389, 422). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1446) A client with major depression is considering cognitive therapy. The client asks the nurse, "How does this treatment work?" The nurse responds and tells the client that: a. "This type of treatment will help you relax and develop new coping skills." b. "This type of treatment helps you confront your fears by gradually exposing you to them." c. "This type of treatment helps you examine how your past life has contributed to your problems." d. "This type of treatment helps you examine how your thoughts and feelings contribute to your difficulties." Source: Saunders 4th

ANS: D Rationale: Cognitive therapy frequently is used for clients with depression. This type of therapy is based on exploring the client's subjective experience. Cognitive therapy includes examining the client's thoughts and feelings about situations and how these thoughts and feelings contribute to and perpetuate the client's difficulties and mood. Strategy: Focusing on the word cognitive will assist you in selecting the correct option. Look for a similar word used in the question and repeated in one of the options. Note the relationship of the word cognitive in the question and thoughts in option 4. Review this form of therapy if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 201-202, 221, 231). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 333). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2158) A client has skeletal traction applied to the right leg, and has an overhead trapeze available for use. The nurse should assess which of the following as a high-risk area for pressure and breakdown? a. Scapulae b. Back of the head c. Right heel d. Left heel Source: Saunders 4th

ANS: D Rationale: Common areas that are under pressure and are at risk for breakdown include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the good leg (which is used as a brace when pushing up in bed). Other pressure points caused by the traction include the ischial tuberosity, popliteal space, and Achilles tendon. Strategy: Use the process of elimination. The question asks for an area at high risk for breakdown. Visualize the client described in the question to direct you to option 4. Remember that the client would use the unaffected heel to push into the mattress during repositioning. With repeated use, this could cause the left heel to become reddened and break down. Review care of the client in skeletal traction if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 640-641). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2099) A nurse is caring for a client with epididymitis. The nurse should avoid using which of the following treatment modalities in the care of the client? a. Bedrest b. Scrotal elevation c. Sitz bath d. Use of a heating pad Source: Saunders 4th

ANS: D Rationale: Common interventions used in the treatment of epididymitis include bedrest, elevation of the scrotum, ice packs, sitz baths, analgesics, and antibiotics. A heating pad would not be used because direct application of heat would enhance blood flow to the area, thereby increasing the swelling. Strategy: Use the process of elimination. Note the strategic word avoid. Recalling that direct heat will increase inflammation in tissue that is already at risk will direct you to option 4. Review interventions for the client with epididymitis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1880). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

950) The nurse is participating in a health screening clinic and is preparing teaching materials about colorectal cancer. Which risk factor for colorectal cancer should the nurse include? a. Age older than 30 years b. High-fiber, low-fat diet c. Distant relative with colorectal cancer d. Personal history of ulcerative colitis or gastrointestinal polyps Source: Saunders 4th

ANS: D Rationale: Common risk factors for colorectal cancer include age older than 40 years, first-degree relative with colorectal cancer, high-fat, low-fiber diet, and history of bowel problems, such as ulcerative colitis or familial polyposis. Strategy: Use the process of elimination, reading each option carefully. Eliminate option 1 because of the age. Eliminate option 2 because this diet is healthful. Eliminate option 3 because of the word distant. Review risk factors for colorectal cancer if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 830-831). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1318). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

7) The role of the nurse regarding complementary and alternative medicine (CAM) should include: a. Recommending herbal remedies that the client should use b. Educating the client about "good" versus "bad" therapies c. Discouraging the client from using any alternative therapies d. Educating the client about therapies that he or she is using or is interested in using Source: Saunders 4th

ANS: D Rationale: Complementary (alternative) therapies include a wide variety of treatment modalities that are used in addition to conventional therapy to treat a disease or illness. Educating the client about therapies that he or she uses or is interested in using is the nurse's role. Options 1, 2, and 3 are all inappropriate actions for the nurse to take. Strategy: Use therapeutic communication techniques. Eliminate options 1, 2, and 3 because they are nontherapeutic. Option 4 is the only option that is appropriate. Review therapeutic communication techniques if you had difficulty with this question. Reference: Mahan, L.K., & Escott-Stump, S. (2004). Krause's food, nutrition, & diet therapy (11th ed., pp. 491-492, 1227). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2221) Which of the following outcomes would the nurse expect to note in the client who has not developed complications from viral hepatitis? a. Decreased absorption of vitamin K in intestine b. Increasing prothrombin time values c. Presence of asterixis d. Decrease in AST (aspartate aminotransferase) Source: Saunders 4th

ANS: D Rationale: Complications from viral hepatitis include bleeding tendencies with increasing prothrombin time values as well as abnormalities on liver function tests. Clients also can develop encephalopathy. A characteristic sign of encephalopathy is asterixis. Serum transaminase levels such as the AST decrease and vitamin K becomes absorbed as liver cells heal and regenerate. Strategy: Focus on the strategic words has not developed. Knowledge of the diagnostic findings along with complications of viral hepatitis will direct you to option 4. Review laboratory values related to hepatitis if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., pp. 206-209). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1386). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

36) The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. A nursing assistant is resistant to the change and is not taking an active part in facilitating the process of change. Which of the following is the best approach in dealing with the nursing assistant? a. Ignore the resistance. b. Exert coercion with the nursing assistant. c. Provide a positive reward system for the nursing assistant. d. Confront the nursing assistant to encourage verbalization of feelings regarding the change. Source: Saunders 4th

ANS: D Rationale: Confrontation is an important strategy to meet resistance head on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Option 1 will not address the problem. Option 2 may produce additional resistance. Option 3 may provide a temporary solution to the resistance but will not address the concern specifically. Strategy: Use the process of elimination. Options 1 and 2 easily can be eliminated first. From the remaining options, select option 4 over option 3 because this option specifically addresses the subject and would provide problem-solving measures. If you had difficulty with this question, review the strategies associated with dealing with resistance to change. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., p. 527). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 440). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Leadership and Management Alternate Question Types -> Multiple Choice

2026) A clinic nurse is providing instructions to a client with a diagnosis of conjunctivitis. Which statement by the client indicates a need for further instruction? a. "I should apply warm compresses before instilling the antibiotic drops if purulent drainage is present in my eye." b. "I can use saline eye irrigations before instilling the antibiotics in my eye if drainage is present." c. "If I have any eye discomfort, I can use the eye analgesic ointment that my physician has prescribed." d. "Sharing wash cloths and towels is acceptable because this condition is not contagious." Source: Saunders 4th

ANS: D Rationale: Conjunctivitis should be considered highly contagious, and the client should be instructed not to share wash cloths or towels or other linens and items with other members of the family. Antibiotic drops usually are administered four times a day. If the client has purulent drainage present in the eye, saline eye irrigations or applications of warm compresses may be necessary before instilling the antibiotic ointment. Ophthalmic analgesics, ointments, or drops may be instilled for discomfort that may occur. Strategy: Use the process of elimination. Note the strategic words need for further instruction. This phrasing indicates a negative event query and directs you to select an incorrect statement. Recalling that this disorder is highly contagious will direct you to option 4. If you had difficulty with this question, review client instructions for the treatment for conjunctivitis. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1090). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1399) The home care nurse is ordering dressing supplies for a client who has an allergy to latex. The nurse asks the medical supply personnel to deliver which of the following? a. Elastic bandages b. Adhesive bandages c. Brown Ace bandages d. Cotton pads and silk tape Source: Saunders 4th

ANS: D Rationale: Cotton pads and plastic or silk tape are latex-free products. The items identified in options 1, 2, and 3 are products that contain latex. Strategy: Use the process of elimination and knowledge regarding products that contain latex to answer this question. Eliminate options 1 and 3 first because they are comparative or alike. Noting the strategic words cotton and silk in option 4 will assist in answering correctly from the remaining options. Review the list of products that contain latex if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 461). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 253). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1089) A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the following, if prescribed, during an episode of ventricular tachycardia? a. Lie down flat in bed. b. Remove any metal jewelry. c. Breathe deeply, regularly, and easily. d. Inhale deeply and cough forcefully every 1 to 3 seconds. Source: Saunders 4th

ANS: D Rationale: Cough cardiopulmonary resuscitation (CPR) sometimes is used in the client with unstable ventricular tachycardia. The nurse tells the client to use cough CPR, if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented. Options 1, 2, and 3 will not assist in terminating the dysrhythmia. Strategy: To answer this question, you must be familiar with the treatment for unstable ventricular tachycardia. Remember that cough CPR sometimes is used in the client with unstable ventricular tachycardia. Review the concept of cough CPR if you are not familiar with it. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 731). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1302) The client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client safety? a. Speak loudly to the client. b. Test the temperature of the shower water. c. Check the temperature of the food on the dietary tray. d. Provide a clear path for ambulation without obstacles. Source: Saunders 4th

ANS: D Rationale: Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Testing the shower water temperature would be useful if there were an impairment of peripheral nerves. Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). Cranial nerve VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior third of the tongue, respectively. Strategy: Use the process of elimination. Recalling that cranial nerve II is the optic nerve will direct you to option 4. Review the function of this nerve if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2027). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1108). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1055) A cromolyn sodium (Intal) inhaler is prescribed for a client with allergic asthma. A nurse provides instructions regarding the side effects of this medication. Which of the following undesirable side effects is associated with this medication? a. Insomnia b. Constipation c. Hypotension d. Bronchospasm Source: Saunders 4th

ANS: D Rationale: Cromolyn sodium (Intal) is an inhaled nonsteroidal antiallergy agent and a mast cell stabilizer. The most common undesired side effects associated with inhalation therapy of cromolyn sodium are bronchospasm, cough, nasal congestion, throat irritation, and wheezing. Clients receiving this medication orally may experience pruritus, nausea, diarrhea, and myalgia. Strategy: Use the process of elimination and note the strategic words undesirable side effects. This should assist in directing you to option 4. In addition, use the ABCs—airway, breathing, and circulation—to select the correct option. Option 4 addresses the airway. Review the undesirable side effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 295). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

101) The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client understands the dietary modifications if she selects which of the following from her menu? a. Nuts and milk b. Coffee and tea c. Cooked rolled oats and fish d. Oranges and dark green leafy vegetables Source: Saunders 4th

ANS: D Rationale: Dark green leafy vegetables are a good source of iron and oranges are a good source of vitamin C, which enhances iron absorption. All other options are not food sources that are high in iron and vitamin C. Strategy: Use knowledge of foods high in iron and vitamin C and recall that vitamin C enhances iron absorption. Use the process of elimination to eliminate options 1, 2, and 3 because they do not contain sources of iron and vitamin C. Review food sources of vitamins and minerals if you had difficulty with this question. Reference: Mahan, L.K., & Escott-Stump, S. (2004). Krause's food, nutrition, & diet therapy (11th ed., p. 544). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1175) The nurse is taking the history of a client who has had benign prostatic hyperplasia in the past. To determine whether the client currently is experiencing difficulty, the nurse asks the client about the presence of which early symptom? a. Nocturia b. Urinary retention c. Urge incontinence d. Decreased force in the stream of urine Source: Saunders 4th

ANS: D Rationale: Decreased force in the stream of urine is an early sign of benign prostatic hyperplasia. The stream later becomes weak and dribbling. The client then may develop hematuria, frequency, urgency, urge incontinence, and nocturia. If untreated, complete obstruction and urinary retention can occur. Strategy: Use the process of elimination and note the strategic word early. If you know that benign prostatic hyperplasia can lead to urinary obstruction, look for the option that identifies the least severe symptom. Review early signs of benign prostatic hyperplasia if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1014-1016). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2347) A nurse has an order to give dexamethasone (Decadron) by the intravenous (IV) route to a client with cerebral edema. The nurse prepares this medication correctly by: a. Diluting the medication in 500 mL of 5% dextrose b. Diluting the medication in 10% dextrose in water and administering it as a direct injection c. Diluting the medication in 1 mL of lactated Ringer's solution for direct injection d. Preparing an undiluted direct injection of the medication Source: Saunders 4th

ANS: D Rationale: Dexamethasone may be given by direct IV injection or IV infusion. For IV infusion, it may be mixed with 50 to 100 mL of 0.9% sodium chloride or 5% dextrose in water. It is not mixed with lactated Ringer's solution or 10% dextrose in water. Strategy: Use the process of elimination. Knowing that the volume to be administered should be small, eliminate option 1. Eliminate options 2 and 3 next because these are solutions that are not normally used. If you had difficulty with this question, review the administration of dexamethasone. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 375). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2636) A nurse gives a dose of diazepam (Valium) to an assigned client. The most important action to be taken by the nurse before leaving the room is: a. Giving the client the remote control for the television set b. Lowering the volume on the television set c. Closing the curtains in the room d. Raising the side rails on the bed Source: Saunders 4th

ANS: D Rationale: Diazepam is a sedative-hypnotic that also has anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client's room to prevent injury as a result of medication side effects, which include dizziness, drowsiness, and lethargy. The other options listed are useful but not essential to the client's safety in this situation. Strategy: Note the strategic words most important. First, recall the action and effects of this medication. Next, use Maslow's Hierarchy of Needs theory to prioritize: If a physiological need is not addressed, safety is the priority. Review nursing considerations with administration of diazepam if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 345). Philadelphia: W.B. Saunders. Reference: Kee, J., Hayes, E., & McCuistion, L. (2006). Pharmacology: A nursing process approach (5th ed., pp. 388-389). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 990). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1837) Dicyclomine hydrochloride (Bentyl) has been prescribed for a client with irritable bowel syndrome, and the nurse provides instructions to the client about how to take this medication. Which statement if made by the client best indicates an understanding of how to take this medication? a. "I should take the pill with food and at meal times." b. "I should take the pill after I have finished eating my meal." c. "I should take the pill when I first wake up in the morning and right before I go to bed." d. "I should take the pill 30 minutes to 1 hour before each meal." Source: Saunders 4th

ANS: D Rationale: Dicyclomine hydrochloride is an anticholinergic, antispasmodic agent often used to treat irritable bowel syndrome that is unresponsive to diet therapy. In order to be effective in decreasing bowel motility, antispasmodic medication should be administered 30 minutes before meals. The other options are incorrect. Strategy: Use the process of elimination. Eliminate options 1 and 2 because they are comparative or alike. Eliminate option 3 because it does not correspond to meal times. Also, recalling that this medication is an antispasmodic and will slow down gastrointestinal motility will direct you to option 4. Review this medication if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1314). Philadelphia: W.B. Saunders. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 130). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1694) The nurse is providing instructions to a client with hypophosphatemia. The nurse instructs the client to avoid: a. Fish. b. Chicken. c. Organ meats. d. Cheese. Source: Saunders 4th

ANS: D Rationale: Diet therapy for hypophosphatemia consists primarily of an increased intake of phosphorus-rich foods while decreasing the intake of calcium-rich foods. Options 1, 2, and 3 identify food items allowed, whereas option 4 should be avoided because it is a calcium-rich food. Strategy: Note the strategic word avoid. Recalling that the client with hypophosphatemia needs to decrease the intake of calcium-rich foods will direct you to option 4. If you had difficulty with the question, review the dietary measures for the client with hypophosphatemia. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 242). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1955) A nurse is providing diet instructions to a client with Ménière's disease who is being discharged from the hospital after admission for an acute attack. Which statement if made by the client indicates an understanding of the dietary measures to take to prevent further attacks? a. "I need to drink at least 3 liters of fluid per day." b. "I need to restrict my carbohydrate intake." c. "I need to maintain a low-fat and low-cholesterol diet." d. "I need to be sure to consume foods that are low in sodium." Source: Saunders 4th

ANS: D Rationale: Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed for the client with Ménière's disease. The client should be instructed to consume a low-sodium diet and restrict fluids as prescribed. Low-fat, low-carbohydrate, and low-cholesterol diets are not specifically prescribed for the client with Ménière's disease. Strategy: Use the process of elimination and knowledge regarding the pathophysiology related to Ménière's disease to answer this question. Recalling that the goal of treatment is to reduce the endolymphatic fluid will assist in directing you to option 4. If you had difficulty with this question, review the treatment measures for Ménière's disease. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1132). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Ear Alternate Question Types -> Multiple Choice

922) The client with peptic ulcer disease needs dietary modification to reduce episodes of epigastric pain. The nurse tells the client that which item does not need to be limited or eliminated with this disease? a. Wine b. Coffee c. Fresh fruit d. Baked chicken Source: Saunders 4th

ANS: D Rationale: Dietary modification for the client with peptic ulcer disease includes eliminating foods that are irritating to the client. Items that generally are eliminated or avoided are highly spiced foods, alcohol, caffeine, chocolate, and fresh fruits. Other foods may be taken according to the client's tolerance of that specific food. Strategy: Use the process of elimination, noting the strategic words does not need to be limited. Recalling which types of foods and beverages are irritating to the gastrointestinal mucosa will direct you to option 4. If this question was difficult, review this content. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed., p. 508). St. Louis: Mosby. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1294). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2645) A client with rapid-rate atrial fibrillation has a new order for diltiazem hydrochloride (Cardizem) by intravenous bolus followed by a continuous intravenous infusion of the same medication. The nurse administers this medication safely, knowing that: a. This medication is one of the most effective b. This medication increases myocardial contractility and thus decreases oxygen demand. c. A bolus needs to be pushed very rapidly over 2 to 3 seconds. d. A continuous infusion should not infuse for more than 24 hours. Source: Saunders 4th

ANS: D Rationale: Diltiazem hydrochloride is a calcium channel blocker used in the treatment of atrial flutter and fibrillation. It decreases myocardial contractility and workload, thereby decreasing the need for oxygen. A bolus of 0.25 mg/kg is given slowly over 2 minutes, and a continuous infusion of 5 to 10 mg/hour may be continued for up to 24 hours. Strategy: Knowledge of the classification, action, and administration by the intravenous route of this medication will assist in eliminating options 1, 2, and 3. Also, option 3 can be eliminated because of the words very rapidly. If you had difficulty selecting the correct option, review the administration of this medication by the intravenous route. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 408). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2276) A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to: a. Stay in a cool environment when possible. b. Increase fluid intake. c. Monitor voiding for adequacy of urine output. d. Resume full activity level. Source: Saunders 4th

ANS: D Rationale: Discharge instructions for the client hospitalized for hyperthermia includes prevention of heat-related disorders, increased fluid intake for 24 hours, self-monitoring of voiding, and the importance of staying in a cool environment and resting. Strategy: Use the process of elimination, noting the strategic words needs clarification. This phrasing indicates a negative event query and asks you to select an incorrect statement. Options 2 and 3 relate to maintaining and monitoring fluid balance and are therefore eliminated. A cool environment is appropriate to prevent hyperthermia, so this is eliminated also. Resumption of full activity is not helpful; rather, rest periods are indicated, so this is the correct option. Review home care instructions for the client with hyperthermia if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1853). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1176) The client newly diagnosed with chronic renal failure recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse assesses the client during dialysis for: a. Hypertension, tachycardia, and fever b. Hypotension, bradycardia, and hypothermia c. Restlessness, irritability, and generalized weakness d. Headache, deteriorating level of consciousness, and twitching Source: Saunders 4th

ANS: D Rationale: Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates. Strategy: Use the process of elimination. Focus on the name, disequilibrium syndrome, to assist in directing you to option 4. Review the manifestations of this syndrome if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1756). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2097) A client with epididymitis is upset about the extent of scrotal edema. Attempts to reassure the client that this condition is temporary have not been effective. The nurse formulates which of the following nursing diagnoses for this client in addressing this problem? a. Anxiety related to inability to reduce scrotal swelling b. Acute pain related to fluid accumulation in scrotum c. Fear related to possibility of sterility secondary to scrotal swelling d. Disturbed body image related to change in appearance of the scrotum Source: Saunders 4th

ANS: D Rationale: Disturbed body image can be diagnosed when the client has either a verbal or a nonverbal response to a change in the structure or the function of a body part. Anxiety is a nonspecific feeling of unease. The diagnosis of fear can be used when the client has an identifiable concern; however, sterility is not mentioned as a concern by the client. Acute pain may apply but does not correlate with the information in the question. Strategy: Use the process of elimination. Begin to answer this question by eliminating options 2 and 3, because neither either pain nor a fear of sterility is mentioned in the question. From the remaining options, eliminate option 3 because the question presents no data indicating an inability to reduce scrotal swelling. Review the manifestations associated with a disturbed body image if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1039, 1423). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

22) The nurse gives an inaccurate dose of a medication to a client. Following assessment of the client, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication dose understands that: a. The error will result in suspension. b. The incident will be reported to the board of nursing. c. The incident will be documented in the personnel file. d. An incident report needs to be completed and is a method of promoting quality care and risk management. Source: Saunders 4th

ANS: D Rationale: Documentation of unusual occurrences, incidents, and accidents and of the nursing actions taken as a result of the occurrence is internal to the institution or agency and allows the nurse and administration to review the quality of care and determine any potential risks present. Based on the information provided in the question, the nurse's error will not result in suspension, nor will it be documented in the personnel file. The error and the situation presented in the question are not a reason for notifying the board of nursing. Strategy: Focus on the information provided in the question. Use the process of elimination and knowledge regarding the purpose of incident reports to assist in eliminating options 1, 2, and 3. Note that the correct option is also the umbrella option. If you had difficulty with this question, review the purpose of incident reports. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 419, 497). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2667) A nurse has administered a dose of docusate (Colace). The nurse later evaluates that the medication has the intended effect if the client experiences which of the following? a. Relief of sharp abdominal pain b. Decreased heartburn c. Decrease in fatty stools d. Bowel movement with soft formed stool Source: Saunders 4th

ANS: D Rationale: Docusate is a stool softener that relieves constipation because it promotes absorption of water into the stool, producing a softer consistency of stool. The other options are not effects of this medication. Strategy: Recalling that docusate is a stool softener will direct you to option 4. Review the action and use of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 378). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1371) A nurse is analyzing the laboratory studies on a client receiving dantrolene sodium (Dantrium). Which of the following laboratory tests would identify an adverse effect associated with the administration of this medication? a. Creatinine level determination b. Platelet count determination c. Blood urea nitrogen level determination d. Liver function tests Source: Saunders 4th

ANS: D Rationale: Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce the risk of liver damage, tests of liver function should be performed before treatment and throughout the treatment interval. Dantrolene is administered in the lowest effective dosage for the shortest time necessary. Strategy: Use the process of elimination. Eliminate options 1 and 3 because these tests assess kidney function and are comparative or alike. From the remaining options, you must recall that this medication affects liver function. Review this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 313). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2665) A client in the postanesthesia care unit (PACU) complains of postoperative nausea. The unit nurse obtains an order for droperidol (Inapsine). The nurse anticipates that which of the following routes will be ordered for the medication? a. Oral b. Subcutaneous c. Rectal d. Intravenous Source: Saunders 4th

ANS: D Rationale: Droperidol may be administered by the intramuscular or the intravenous (IV) route. The IV route is the route used when relief of nausea is needed. The other options are incorrect. Strategy: Specific knowledge regarding the routes of administration of this medication is needed to answer this question. Noting that the client is postoperative will direct you to option 4. Review the methods of administration of this medication if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 458). St. Louis: Mosby. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 395). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1036) A nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client reports which of the following early signs of exacerbation? a. Fever b. Fatigue c. Weight loss d. Shortness of breath Source: Saunders 4th

ANS: D Rationale: Dry cough and dyspnea are typical signs and symptoms of pulmonary sarcoidosis. Others include chest pain, hemoptysis, and pneumothorax. Systemic signs and symptoms include weakness and fatigue, malaise, fever, and weight loss. Strategy: Use the process of elimination and note the strategic word early. Because sarcoidosis is a pulmonary problem, eliminate options 1 and 3 first. Select option 4 over option 2 because the shortness of breath (and impaired ventilation) appears first and would cause the fatigue as a secondary symptom. Review the early signs of exacerbation in sarcoidosis if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1871). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

1842) A nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client regarding the signs and symptoms associated with dumping syndrome. Which of the following signs and symptoms if identified by the client would indicate an understanding of this potential complication after gastrointestinal (GI) surgery? a. Hiccups and diarrhea b. Fatigue and abdominal pain c. Constipation and fever d. Diaphoresis and diarrhea Source: Saunders 4th

ANS: D Rationale: Dumping syndrome occurs after gastric surgery because food is not held as long in the stomach and is dumped into the intestine as a hypertonic mass. This causes fluid to shift into the intestine causing cardiovascular as well as GI symptoms. Symptoms can typically include weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain and distention, hyperactive bowel sounds, and diarrhea. Options 1, 2, and 3 are incorrect and are not signs of dumping syndrome. Strategy: Focus on the name of the diagnosis to assist in eliminating options 2 and 3. Regarding the remaining options, use the process of elimination recalling that when an option contains more than one part, all parts need to be correct for the option to be correct. If you had difficulty with this question, review the manifestations of dumping syndrome. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1303). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

939) The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Where should the nurse anticipate the location of the pain? a. Right lower quadrant, radiating to the back b. Right lower quadrant, radiating to the umbilicus c. Right upper quadrant, radiating to the left scapula and shoulder d. Right upper quadrant, radiating to the right scapula and shoulder Source: Saunders 4th

ANS: D Rationale: During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula and shoulder. This is determined by the pattern of dermatomes in the body. The other options are incorrect. Strategy: Use the process of elimination. Recalling the anatomical location of the gallbladder will direct you to option 4. Review the characteristics of the pain associated with cholecystitis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1398). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1493) Which of the following is the best approach for the nurse to use in crisis counseling? a. Reassuring b. Passive listening c. Explore early life experiences d. Active, with focus on current situation Source: Saunders 4th

ANS: D Rationale: During crisis counseling, the best approach for the nurse to use is an active one, with a focus on the current situation. Options 1, 2, and 3 would be inconsistent with the acute needs that emerge in a crisis. Passive listening would be contrary to the individual's acute stress and disorganization. Exploring the past would be insensitive to the current crisis and would be exploitative of a person in acute distress. Although reassurance may be needed, what is most associated with the nurse's response in a crisis is the need for a direct focus on immediate needs. Strategy: Focus on the subject, crisis counseling. Noting the words current situation in option 4 will direct you to this option. If you had difficulty with this question, review the principles of crisis intervention and counseling. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., pp. 515, 631). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1318) Carbidopa-levodopa (Sinemet) is prescribed for the client with Parkinson's disease. The nurse monitors the client for adverse reactions to the medication. Which of the following would indicate that the client is experiencing an adverse reaction? a. Pruritus b. Tachycardia c. Hypertension d. Impaired voluntary movements Source: Saunders 4th

ANS: D Rationale: Dyskinesia and impaired voluntary movement may occur with high levodopa dosages. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia (the temporary muscle weakness that lasts 1 minute to 1 hour, also known as "on-off phenomenon") is a frequent side effect of the medication. Strategy: Use the process of elimination. Options 2 and 3 are comparative or alike and are cardiac-related options, so these options can be eliminated first. Note that the question asks for an adverse reaction; therefore, select option 4 over option 1 because it is related neurologically. Review the adverse effects of levodopa if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 186). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1125) A nurse provides discharge instructions to a postoperative client who is taking warfarin sodium (Coumadin). Which statement, if made by the client, reflects the need for further teaching? a. "I will take my pills every day at the same time." b. "I will be certain to limit my alcohol consumption." c. "I have already called my family to pick up a Medic-Alert bracelet." d. "I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated." Source: Saunders 4th

ANS: D Rationale: Ecotrin is an aspirin-containing product and should be avoided. Excessive alcohol consumption should be avoided by a client taking warfarin sodium. Taking prescribed medication at the same time each day increases client compliance. The Medic-Alert bracelet provides health care personnel emergency information. Strategy: Use the process of elimination and note the strategic words need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Recalling that warfarin (Coumadin) is an anticoagulant and that Ecotrin is an aspirin-containing product will direct you to option 4. Review client teaching points related to warfarin if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1222). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 877). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1324) The client is suspected of having myasthenia gravis. Edrophonium (Tensilon) 2 mg is administered intravenously to determine the diagnosis. Which of the following indicates that the client has myasthenia gravis? a. Joint pain following administration of the medication b. Feelings of faintness, dizziness, hypotension, and signs of flushing in the client c. A decrease in muscle strength within 30 to 60 seconds following administration of the medication d. An increase in muscle strength within 30 to 60 seconds following administration of the medication Source: Saunders 4th

ANS: D Rationale: Edrophonium is a short-acting acetylcholinesterase inhibitor used as a diagnostic agent. When a client with suspected myasthenia gravis is given 2 mg of the medication intravenously, an increase in muscle strength should be seen in 30 to 60 seconds. If no response occurs, another 4 to 10 mg of edrophonium is given over the next 2 minutes, and muscle strength is tested again. If no increase in muscle strength occurs with this higher dose, the muscle weakness is not caused by myasthenia gravis. Clients receiving injections of this medication commonly demonstrate a drop in blood pressure, feel faint and dizzy, and are flushed. Strategy: Use the process of elimination. Recalling that the client with myasthenia gravis is treated with medication to improve muscle strength will assist in directing you to option 4. Review this medication as a diagnostic tool for suspected myasthenia gravis if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., pp. 1035-1036). Philadelphia: W.B. Saunders. Reference: Gahart, B., & Nazareno, A. (2006). 2006 intravenous medications (22nd ed., p. 470). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1317) The client with myasthenia gravis verbalizes complaints of feeling much weaker than normal. The physician plans to implement a diagnostic test to determine whether the client is experiencing a myasthenic crisis. The physician administers edrophonium (Tensilon). Which of the following would indicate that the client is experiencing a myasthenic crisis? a. Increasing weakness b. No change in the condition c. An increase in muscle spasms d. A temporary improvement in the condition Source: Saunders 4th

ANS: D Rationale: Edrophonium is administered to determine whether the client is reacting to an overdose of a medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). When the edrophonium injection is given and the condition improves temporarily, the client is in myasthenic crisis. This is known as a positive Tensilon test. Strategy: Use the process of elimination. Recall that myasthenic crisis is treated with medication. It seems reasonable that the client's condition will improve when medication is administered. Review this diagnostic test and the differences between cholinergic and myasthenic crises if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2183). Philadelphia: W.B. Saunders. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., pp. 1035-1036). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1423) The supervisor reprimands the nurse in charge of the nursing unit because the charge nurse has not adhered to the unit budget. Later that afternoon, the charge nurse accuses the nursing staff of wasting supplies. This behavior is an example of: a. Denial b. Repression c. Suppression d. Displacement Source: Saunders 4th

ANS: D Rationale: Ego defense mechanisms are operations outside of a person's awareness that the ego calls into play to protect against anxiety. Displacement is the discharging of pent-up feelings on persons less threatening than those who initially aroused the emotion. Denial is the blocking out of painful or anxiety-inducing events or feelings. Repression is unconsciously keeping unacceptable feelings out of awareness. Suppression is consciously keeping unacceptable feelings and thoughts out of awareness. Strategy: Use the process of elimination. Read the behavior identified in the question to assist you in determining the type of ego defense mechanism or behavior used. Remember that displacement is the discharging of pent-up feelings on persons less threatening than those who initially aroused the emotion. If you had difficulty with this question, review defense mechanisms. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 9). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 269). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1511) An older male client who is a victim of elder abuse and the family have been attending weekly counseling sessions. Which of the following statements, if made by the abusive family member, would indicate that the abuser has learned positive coping skills? a. "I will be more careful to make sure that my father's needs are met." b. "Now that my father is moving into my home, I will need to change my ways." c. "I am so sorry and embarrassed that the abusive event occurred. It won't happen again." d. "I feel better able to care for my father now that I know where to obtain assistance." Source: Saunders 4th

ANS: D Rationale: Elder abuse is sometimes caused by family members who are being expected to care for their aging parents. This can cause the family to become overextended, frustrated, or financially depleted. Knowing where to turn in the community for assistance in caring for aging family members can bring much needed relief. These alternatives are a positive alternative coping strategy, which many families use. Strategy: Use the process of elimination. Note the strategic words positive coping skills. Option 4 identifies a means of coping with the issues. The other options identify statements of good faith or promises, which may or may not be kept in the future. Only option 4 outlines a definitive plan for how to handle the pressure associated with the father's care. Review coping mechanisms if you had difficulty with this question. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 810-811). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 519). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1239) The client arrives in the emergency room after sustaining a chemical eye injury from a splash of battery acid. The initial nursing action is to: a. Begin visual acuity testing. b. Cover the eye with a pressure patch. c. Swab the eye with antibiotic ointment. d. Irrigate the eye with sterile normal saline. Source: Saunders 4th

ANS: D Rationale: Emergency care following a chemical burn to the eye includes irrigating the eye immediately with sterile normal saline or ocular irrigating solution. In the emergency department, the irrigation should be maintained for at least 10 minutes. Following this emergency treatment, visual acuity is assessed. Options 2 and 3 are not a component of initial care. Strategy: Read the question carefully, noting the type of injury to the eye. Noting the strategic word splash will direct you to option 4. Review emergency eye care if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1446). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1106). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Eye Alternate Question Types -> Multiple Choice

1150) A client is on enalapril (Vasotec) for the treatment of hypertension. The nurse teaches the client that he should seek emergent care if he experiences which adverse effect? a. Nausea b. Insomnia c. Dry cough d. Swelling of the tongue Source: Saunders 4th

ANS: D Rationale: Enalapril (Vasotec) is an angiotensin-converting enzyme inhibitor. Angioedema is an adverse effect. Swelling of the tongue and lips can result in airway occlusion. Nausea, insomnia, and a cough can occur as side (not adverse) effects of the medication. Strategy: Note the strategic word adverse. Use the ABCs—airway, breathing, and circulation—to direct you to option 4. Review the adverse effects of this medication if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, L. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed., pp. 459, 762). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2070) A nurse is preparing a client for electroconvulsive therapy (ECT), which is scheduled for the next morning. Which of the following is unnecessary in the pre-procedural period? a. Withhold food and fluids for 6 hours before the treatment. b. Have the client void before the procedure. c. Remove dentures and contact lenses before the procedure. d. Administer tap water enemas on the evening before the procedure. Source: Saunders 4th

ANS: D Rationale: Enemas are not a component of the pretreatment care for a client scheduled for ECT. Options 1, 2, and 3 are a part of the pretreatment plan. Additionally, an informed consent is required, and the nurse should teach the client and family what to expect with ECT and allow the client to discuss his or her feelings regarding the procedure. Strategy: Use the process of elimination and knowledge regarding the pretreatment care for the client scheduled for ECT. Noting the strategic word unnecessary and focusing on the purpose of the procedure will direct you to option 4. If you had difficulty with this question, review the content for this procedure. Reference: Stuart, G., & Laraia, M. (2005). Principles & practice of psychiatric nursing (8th ed., pp. 606-607). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2691) A client is being discharged to home with enoxaparin (Lovenox) for short-term therapy. The nurse explains to the family that this medication is needed to: a. Relieve joint pain b. Stop progression of multiple sclerosis c. Dissolve urinary calculi d. Reduce the risk of deep vein thrombosis Source: Saunders 4th

ANS: D Rationale: Enoxaparin is an anticoagulant that is administered to prevent deep vein thrombosis and thromboembolism in clients at risk. It is not used to treat the conditions listed in options 1, 2, or 3. Strategy: Recalling that this medication is an anticoagulant will direct you to option 4. Review the action and use of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 412). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1810) A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The physician orders an enteral tube feeding of a standard formula to run at 40 mL/hr. A nursing student is assigned to care for the client and the nursing instructor asks the student to describe the nursing considerations related to a tube feeding. Which of the following statements if made by the student indicates an understanding of this dietary treatment? a. "Enteral tube feedings are a frequent causes of sepsis." b. "Enteral feedings should be refrigerated until just before use." c. "The caloric value of enteral feedings is generally 5.0 to 10.0 cal/mL." d. "Enteral feedings require the normal digestive capabilities of the GI tract." Source: Saunders 4th

ANS: D Rationale: Enteral nutrition includes offering nutrients by mouth, nasogastric (NG) tube, gastrostomy tubes (G-tubes), or percutaneous endoscopic gastrostomy (PEG). The common element with these methods of delivery is the fact that the client must have normal GI digestive capabilities. If the client does not have a normal GI tract, other methods of nutrient delivery must be sought, such as parenteral nutrition. Enteral tube feedings may cause aspiration pneumonia from regurgitation of formula into the lungs; however, they generally are not associated with sepsis. Enteral tube feedings should be given at room temperature to avoid problems with diarrhea. The caloric value of most standard enteral feeding formulas is 1.0 to 2.0 cal/mL. Strategy: Focus on the subject of the question as it relates to enteral tube feedings. Note the relationship between the subject and option 4. If you are unfamiliar with the characteristics of these types of feedings, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 703-704). Philadelphia: W.B. Saunders. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed., pp. 418-419). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2253) A nurse is evaluating the results of laboratory studies for a client receiving epoetin alfa (Epogen, Procrit). The nurse would expect to note a therapeutic effect of this medication: a. After 1 week of therapy b. Immediately c. 3 days after therapy d. 2 weeks after therapy Source: Saunders 4th

ANS: D Rationale: Epoetin alfa stimulates erythropoiesis. It takes 2 to 6 weeks after initiation of therapy before a clinically significant increase in hematocrit is observed. Therefore, this medication is not intended for clients who require immediate correction of severe anemia, and it is not a substitute for emergency blood transfusions. Strategy: Use the process of elimination. Knowing that the medication stimulates bone marrow production of red blood cells (erythropoiesis) will assist in directing you to option 4. If you are unfamiliar with this medication and its therapeutic effects, review this content. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 319). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2174) A client with vascular headaches is taking ergotamine (Cafergot). The home health nurse should periodically assess the client for: a. Hypotension b. Dependent edema c. Constipation d. Cool, numb fingers and toes Source: Saunders 4th

ANS: D Rationale: Ergotamine produces vasoconstriction by stimulating α-adrenergic receptors, which suppresses vascular headaches when the medication is given in the therapeutic dose range. The nurse periodically assesses for hypertension, cool, numb fingers and toes, muscle pain, and nausea and vomiting. Strategy: Use the process of elimination and note the client's diagnosis. Recall that vascular headaches are due to vasodilation of the blood vessels in the head. Following this train of thought, recall that this medication must cause vasoconstriction. The only side effect consistent with vasoconstriction is option 4. Review the side effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 431). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2390) An ambulatory care nurse notes that a client taking ergotamine tartrate (Cafergot) is having the intended effects of therapy if the client states relief from which of the following symptoms? a. Diarrhea b. Cough c. Backache d. Headaches Source: Saunders 4th

ANS: D Rationale: Ergotamine tartrate is used to stop an ongoing migraine attack and also is used to treat cluster headaches. The other options are unrelated to the use of this medication. Strategy: Knowledge regarding the use of ergotamine is required to answer this question. Remember that this medication is used to treat headaches. If you are unfamiliar with use of this medication, review this content. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 431). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2618) Etanercept (Enbrel) is prescribed for a client with rheumatoid arthritis. The nurse monitors the client for which adverse effects of the medication following administration? a. Headache b. Abdominal discomfort c. Dizziness d. Dyspnea Source: Saunders 4th

ANS: D Rationale: Etanercept (Enbrel) is an antiarthritic medication that is administered via the subcutaneous route. Adverse effects include heart failure (noted by manifestations of dyspnea and congested lung sounds on auscultation), hypertension or hypotension, pancreatitis, or gastrointestinal hemorrhage. Headache, abdominal discomfort, and dizziness are not side effects of the medication. Strategy: Note the strategic words adverse effects. Use the ABCs—airway, breathing, and circulation—to direct you to option 4. Review the side effects and adverse effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2006). Saunders nursing drug handbook 2006 (p. 420). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed., p. 405). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1061) A nurse has given a client taking ethambutol (Myambutol) information about the medication. The nurse determines that the client understands the instructions if the client states to report immediately: a. Impaired sense of hearing b. Gastrointestinal side effects c. Orange-red discoloration of body secretions d. Difficulty in discriminating the color red from green Source: Saunders 4th

ANS: D Rationale: Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when a client is driving a motor vehicle. The client is taught to report this symptom immediately. The client also is taught to take the medication with food if gastrointestinal upset occurs. Impaired hearing results from antitubercular therapy with streptomycin. Orange-red discoloration of secretions occurs with rifampin (Rifadin). Strategy: Use the process of elimination. Option 2 is the least likely symptom to report; instead, it should be managed by taking the medication with food. To select among the other options, you must know that this medication causes optic neuritis, resulting in difficulty with red-green discrimination. If this question was difficult, review antitubercular medications because the incorrect options for this question are typical side effects of other antitubercular medications. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 451). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2160) A nurse is evaluating goal achievement for a client in traction with impaired physical mobility. The nurse determines that the client has not successfully met all of the goals formulated if which of the following outcomes was noted? a. Absence of Homans' sign b. Active range of motion of uninvolved joints c. Intact skin surfaces d. Bowel movement every 4 days Source: Saunders 4th

ANS: D Rationale: Expected outcomes for impaired physical mobility for the client in traction include absence of thrombophlebitis (as confirmed by absence of Homans' sign), active range of motion to uninvolved joints, clear lung sounds, intact skin, and bowel movement every other day. Strategy: Note the strategic words has not successfully met. This question can be answered by evaluating the degree of normalcy of each option. The only abnormal option is option 4. A bowel movement every 4 days is insufficient. Also, constipation is a known complication of immobility. Review expected outcomes for a client with impaired physical mobility if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 644). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2270) A nurse has formulated a nursing diagnosis of imbalanced nutrition with less than body requirements for an unconscious client. Which of the following outcomes indicates to the nurse that the goals have not yet been fully met? a. Stable weight b. Intake equaling output c. Blood urea nitrogen (BUN) level of 12 mg/dL d. Total protein concentration of 4.5 g/dL Source: Saunders 4th

ANS: D Rationale: Expected outcomes for this nursing diagnosis in an unconscious client include stable weight, intake equaling output, evidence of wound healing, and normal BUN, total protein, and hemoglobin levels. The only abnormal finding is the protein level. Strategy: Use the process of elimination, noting the strategic words has not been fully met. Because stable weight and equal intake and output are satisfactory indicators, these can be eliminated. Regarding the remaining options, knowing that the BUN is normal will allow you to select total protein as the answer to this question. Review normal values for these laboratory tests if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2062). Philadelphia: W.B. Saunders. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 913). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2213) A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states: "I'm not sure I can avoid alcohol." The appropriate response from the nurse is: a. "Everything will be all right." b. "I think you should talk more with the doctor about this." c. "I don't believe that." d. "I'm not sure that I understand. Would you please explain?" Source: Saunders 4th

ANS: D Rationale: Explaining what is vague or clarifying the meaning of what has been said increases the understanding for both the client and the nurse. False reassurance devalues the client's feelings. Refusing to consider the client's ideas may cause the client to discontinue interaction with the nurse for fear of further rejection. Placing the client's feelings on hold, by referring the client to the doctor for further information, is a block to communication. Strategy: Use therapeutic communication techniques. Providing false reassurance in option 1, giving advice and placing the client's feelings on hold in option 2, and showing disapproval in option 3 are blocks to communication and are eliminated. Remember to always focus on the client's feelings. Review therapeutic communication techniques if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1331). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 437). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2586) A nurse is reviewing the laboratory test results for a client admitted to the burn unit 3 hours after an explosion that occurred at a work site. The client has a severe burn injury that covers 35% of the total body surface area (TBSA). The nurse is most likely to note which of the following on the laboratory report? a. White blood cell (WBC) count 9,000/μL b. Serum sodium 144 mEq/L c. Serum albumin 4.8 g/dL d. Hematocrit 60% Source: Saunders 4th

ANS: D Rationale: Extensive burns greater than 25% of the TBSA result in generalized body edema in both burned and unburned tissues and a decrease in circulating intravascular blood volume. Hematocrit levels are elevated in the first 24 hours after injury owing to hemoconcentration from the loss of intravascular fluid. Options 1, 2, and 3 identify normal laboratory values. Strategy: Use knowledge regarding physiological alterations and fluid and electrolyte balance during the first 24 hours after burn injury to answer this question. Also, use the process of elimination and knowledge of normal laboratory values. The only abnormal laboratory value is option 4. Review the physiological changes that occur during the first 24 hours after burn injury if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1446). Philadelphia: W.B. Saunders. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., pp. 635-636). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Integumentary Alternate Question Types -> Multiple Choice

2553) A nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function by the nurse will yield the best information about these cranial nerves? a. Response to verbal stimuli b. Insight, judgment, and planning c. Affect, feelings, or emotions d. Eye movements Source: Saunders 4th

ANS: D Rationale: Eye movements are under the control of cranial nerves III, IV, and VI. Insight, judgment, and planning are part of the function of the frontal lobe in conjunction with association fibers that connect to other areas of the cerebrum. Level of consciousness (response to verbal stimuli) is controlled by the reticular activating system and both cerebral hemispheres. Feelings are part of the role of the limbic system and involve both hemispheres. Strategy: Focus on the subject, cranial nerves III, IV, and VI. Recalling that these nerves control eye movement will direct you to option 4. If you are unfamiliar with neurological assessment and cranial nerve function, review this content. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2012, 2027-2028). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2314) A nurse is reviewing the instillation technique for both eye ointment and eyedrops with the parent of a pediatric client diagnosed with bacterial conjunctivitis. Which of the following statements if made by the parent would indicate that learning has taken place? a. "I will administer the eye ointment and then wait 5 minutes and administer the eyedrops." b. "I will place my child on the left side to administer drops in the right eye." c. "I will have my child blink after the instillation to encourage thorough distribution of the eyedrops." d. "I'll be careful not to touch the eye or eyelid during administration." Source: Saunders 4th

ANS: D Rationale: Eyedrops should be administered before eye ointment is administered. The child should be placed in a supine position with the neck slightly hyperextended for administration. Blinking will increase the loss of medication. Touching the eye or eyelid during medication administration can contaminate the dropper and also cause eye injury. Strategy: Use the process of elimination, noting the strategic words learning has taken place. Use knowledge of the principles related to the administration of both eyedrops and ointments to direct you to option 4. Review these basic principles if you had difficulty with this question. Reference: Hockenberry, M., & Wilson, D. (2007). Nursing care of infants and children (8th ed., p. 1129). St. Louis: Mosby. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 981). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Child Health Alternate Question Types -> Multiple Choice

1583) A 4-year-old child is diagnosed with otitis media. The mother asks the nurse about the causes of this illness. The nurse responds, knowing that which of the following is an unassociated risk factor related to otitis media? a. Household smoking b. Bottle-feeding c. Exposure to illness in other children d. A history of urinary tract infections (UTIs) Source: Saunders 4th

ANS: D Rationale: Factors that increase the risk of otitis media include exposure to illness in other children in day care centers, household smoking, bottle-feeding, and congenital conditions such as Down syndrome and cleft palate. The use of a pacifier beyond age 6 months has also been identified as a risk factor. Allergies are also thought to precipitate otitis media. Strategy: Use the process of elimination. Note the strategic word unassociated in the question. Careful reading of each option will quickly direct you to option 4. If you had difficulty with this question, review the risk factors associated with otitis media. Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed., p. 1196). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Child Health Alternate Question Types -> Multiple Choice

1437) The client was admitted involuntarily to the mental health unit because of episodes of extremely violent behavior. The client is demanding to be discharged from the hospital and the nurse does not allow the client to leave. Which of the following represents the legal ramifications associated with the nurse's behavior? a. The nurse will be charged with assault. b. The nurse will be charged with slander. c. The nurse will be charged with imprisonment. d. No charge will be made against the nurse because the nurse's actions are reasonable. Source: Saunders 4th

ANS: D Rationale: False imprisonment is an act with the intent to confine a person to a specific area. A nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital if the client has been admitted voluntarily and if no agency or legal policies exist for detaining the client. However, if the client has been admitted involuntarily or had agreed to an evaluation before discharge, the nurse's actions are reasonable. Strategy: Noting the strategic words admitted involuntarily will assist you in eliminating option 3 and direct you to option 4. Options 1 and 2 are unrelated to the subject of the question and can be eliminated easily. Review the subjects related to false imprisonment and hospital admission if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 56). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 128-129). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Analysis Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2238) A client is being discharged to home after 2 weeks with a diagnosis of tuberculosis and is worried about the possibility of infecting family and others. The nurse provides the reassurance by telling the client that: a. The family does not need therapy, and the client will not be contagious after 1 month of drug therapy. b. The family does not need therapy, and the client will not be contagious after 6 consecutive weeks of drug therapy. c. The family will receive prophylactic therapy, and the client will not be contagious after 1 continuous week of drug therapy. d. The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive weeks of drug therapy. Source: Saunders 4th

ANS: D Rationale: Family members or others who have been in close contact with a client diagnosed with tuberculosis are placed on prophylactic therapy with isoniazid (INH) for 6 to 12 months. The client usually is not contagious after taking medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or drug-resistant tuberculosis. Strategy: Use the process of elimination. Recalling that the family requires prophylactic therapy helps you to eliminate options 1 and 2. Regarding the remaining options, recall that the client is not contagious after 2 to 3 weeks of therapy. Review the concepts related to the prevention of the spread of tuberculosis if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 606). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Caring Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

21) The registered nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which action first? a. Call the hospital lawyer. b. Refuse to float to the ICU. c. Call the nursing supervisor. d. Report to the ICU and identify tasks that can be performed safely. Source: Saunders 4th

ANS: D Rationale: Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally, a nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Calling the hospital lawyer is a premature action. Strategy: Use the process of elimination, noting the strategic word first. Eliminate option 2 first because of the word refuse. Next, eliminate options 1 and 3 because they are premature actions. Review nursing responsibilities related to floating if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 418-419). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1137) A client is on nicotinic acid (niacin) for hyperlipidemia and the nurse provides instructions to the client about the medication. Which statement by the client would indicate an understanding of the instructions? a. "It is not necessary to avoid the use of alcohol." b. "The medication should be taken with meals to decrease flushing." c. "Clay-colored stools are a common side effect and should not be of concern." d. "Ibuprofen (Motrin) taken 30 minutes before the nicotinic acid should decrease the flushing." Source: Saunders 4th

ANS: D Rationale: Flushing is a side effect of this medication. Aspirin or a nonsteroidal anti-inflammatory drug can be taken 30 minutes prior to taking the medication to decrease flushing. Alcohol consumption needs to be avoided because it will enhance this side effect. The medication should be taken with meals but this will decrease gastrointestinal upset; taking the medication with meals has no effect on the flushing. Clay-colored stools are a sign of hepatic dysfunction and should be immediately reported to the physician. Strategy: Use the process of elimination. Option 1 can be eliminated because alcohol must be abstained from. Option 2 can be eliminated because taking the medication with meals helps decrease the gastrointestinal symptoms. The clay-colored stools in option 3 is a sign of hepatic dysfunction and should be immediately reported to the physician. Review the client teaching points related to this medication if you had difficulty with this question. Reference: Skidmore-Roth, L. (2006). Mosby's 2006 nursing drug reference (20th ed., pp. 689-690). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

902) The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is appropriate? a. Clamp the T tube. b. Irrigate the T tube. c. Notify the physician. d. Document the findings. Source: Saunders 4th

ANS: D Rationale: Following cholecystectomy, drainage from the T tube is initially bloody and then turns to a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output. Strategy: Use the process of elimination. Options 1 and 2 can be eliminated because a T tube is not irrigated and would not be clamped with this amount of drainage. From the remaining options, you must know normal expected findings following this surgical procedure. Review postoperative assessment findings following cholecystectomy if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1401). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1114) A nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which of the following observations would indicate that the procedure was unsuccessful? a. Rising blood pressure b. Clearly audible heart sounds c. Client expressions of relief d. Rising central venous pressure Source: Saunders 4th

ANS: D Rationale: Following pericardiocentesis, a rise in blood pressure and a fall in central venous pressure are expected. The client usually expresses immediate relief. Heart sounds are no longer muffled or distant. Strategy: Use the process of elimination and note the strategic word unsuccessful. Successful therapy is measured by the disappearance of the original signs and symptoms of cardiac tamponade. Therefore, look for the option that identifies a sign consistent with continued tamponade. Review signs of cardiac tamponade and the expected effects of pericardiocentesis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 771). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

1342) A client returns to the nursing unit following the application of skeletal leg traction. Upon assessment, the nurse notes a small amount of bleeding around the pin insertion sites. The nurse should take which action? a. Notify the surgeon. b. Recheck the site in 1 hour. c. Check the client&#39;s vital signs. d. Place a small pressure dressing at the bleeding site. Source: Saunders 4th

ANS: D Rationale: Following pin insertion for skeletal traction, a small amount of bleeding is expected. This can be controlled with small pressure dressings; however, bleeding that continues for more than 24 hours should be brought to the surgeon&#39;s attention. It is not necessary to notify the surgeon immediately. Rechecking the site in 1 hour delays necessary intervention. Although vital signs may be checked in the immediate post-operative period, this action is unrelated to the small amount of bleeding. Strategy: Use the process of elimination. Focusing on the strategic words small amount and recalling that pressure is the immediate intervention for bleeding will direct you to the correct option. Review post-operative care to the client following the application of skeletal leg traction if you had difficulty with this quesiton. Reference: Black, J., & Hawks, J., (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 636). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

1162) The nurse develops a postprocedure plan of care for a client who had a renal biopsy. The nurse avoids documenting which intervention in the plan? a. Administering analgesics as needed b. Encouraging fluids to at least 3 L in the first 24 hours c. Testing serial urine samples with dipsticks for occult blood d. Ambulating the client in the room and hall for short distances Source: Saunders 4th

ANS: D Rationale: Following renal biopsy, the nurse ensures that the client remains in bed for at least 24 hours. Vital signs and puncture site assessments are done frequently during this time. Encouraging fluids is done to reduce possible clot formation at the biopsy site. Serial urine samples are assayed by Hematest with urine dipsticks to evaluate bleeding. Analgesics often are needed to manage the renal colic pain that some clients feel after this procedure. Strategy: Use the process of elimination and note the strategic word avoids. Eliminate options 1 and 3 by recalling that pain and bleeding are potential concerns after this procedure. From the remaining options, recall that fluids will reduce clotting at the site, whereas ambulation could initiate or enhance bleeding at the biopsy site. Therefore, eliminate option 2. Review postprocedure care if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1672-1673). Philadelphia: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., pp. 794-795). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1721) The client is scheduled for an upper gastrointestinal (GI) endoscopy. Which of the following assessments is essential to include in the plan of care following the procedure? a. Monitoring for rectal bleeding b. Assessing pulses c. Monitoring urine output d. Assessing for the presence of the gag reflex Source: Saunders 4th

ANS: D Rationale: Following the procedure, the client remains NPO until the gag reflex returns, which is usually in 1 to 2 hours. Options 1, 2, and 3 are not specific assessments related to this procedure. Strategy: Use the process of elimination. Note the strategic words upper GI endoscopy. The only option that relates to the anatomical location of this procedure is option 4. Review postprocedure care following endoscopy if you had difficulty with this question. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 412). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1855) A nurse in the hospital emergency department is preparing to administer fomepizole (Antizol) to a client with ethylene glycol (antifreeze) intoxication. The nurse should plan to administer this medication by which of the following routes? a. Oral route b. Through a nasogastric tube c. Intramuscular route d. Intravenous (IV) route Source: Saunders 4th

ANS: D Rationale: Fomepizole is a medication that is used to treat known or suspected ethylene glycol (antifreeze) intoxication. It is administered via the IV route. Options 1, 2, and 3 are incorrect. Strategy: Use the process of elimination. Eliminate options 1 and 2 because they are comparative or alike. Knowledge that the medication is administered via the IV route is necessary to answer this question. Additionally, note the strategic word intoxication. It would be necessary to administer a medication that would work most rapidly in such a situation. This will assist in directing you to option 4. If you had difficulty with this question, review the administration of this medication. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., pp. 574-575). St. Louis: Mosby. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., pp. 1248-1249). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1857) An emergency department nurse is preparing to administer fomepizole (Antizol) to a client suspected of having ethylene glycol (antifreeze) intoxication. The nurse obtains the vial of medication and notes that the medication has solidified. Which of the following actions should the nurse take? a. Discard the vial. b. Call the pharmacy and request another vial of medication. c. Contact the physician. d. Run the vial under warm water. Source: Saunders 4th

ANS: D Rationale: Fomepizole is used in the treatment of known or suspected ethylene glycol (antifreeze) intoxication. It is administered via the intravenous (IV) route. It is not administered undiluted and is not administered by rapid IV infusion. It is diluted in at least 100 mL of 0.9% normal saline or 5% dextrose in water and administered over a 30-minute period. If the medication solidifies in the vial, the nurse should run the vial under warm water. Options 1 and 2 are inappropriate actions and option 3 is unnecessary. Strategy: Use the process of elimination. Eliminate options 1 and 2 because they are comparative or alike. Knowledge that the medication may solidify and that it can be run under warm water before administering will assist in directing you to the correct option. Review the administration procedure of this medication if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., pp. 574-575). St. Louis: Mosby. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., pp. 1248-1249). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2185) A nurse is providing instructions to a client with osteoporosis regarding appropriate food items to include in the diet. The nurse tells the client that which food item provides the least amount of calcium? a. Plain yogurt b. Seafood c. Sardines d. Pork Source: Saunders 4th

ANS: D Rationale: Foods high in calcium include plain yogurt, dairy products, seafood, sardines, green vegetables, calcium-fortified orange juice, and cereal. Of the items listed, option 4 contains the least amount of calcium. Strategy: Use the process of elimination and note the strategic word least in the question. Eliminate options 2 and 3 first because they are comparative or alike. Regarding the remaining options, recalling that dairy products are high in calcium will direct you to option 4. Review foods high in calcium if you had difficulty with this question. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed., pp. 210-211). St. Louis: Mosby. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1167). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

99) A client with hypertension has been told to maintain a diet low in sodium. A nurse who is teaching this client about foods that are allowed would plan to include which food item in a list provided to the client? a. Tomato soup b. Boiled shrimp c. Instant oatmeal d. Summer squash Source: Saunders 4th

ANS: D Rationale: Foods that are lower in sodium include fruits and vegetables (option 4), because they do not contain physiological saline. Highly processed or refined foods (options 1 and 3) are higher in sodium unless their food labels specifically state "low sodium." Saltwater fish and shellfish are high in sodium. Strategy: Use the process of elimination. Begin to answer this question by eliminating option 2, recalling that saltwater fish and shellfish are high in sodium. Next, eliminate options 1 and 3 because they are processed foods. Review the foods that are high in sodium if you had difficulty with this question. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed., p. 609). St. Louis: Mosby. Reference: Nix, S. (2005). Williams' basic nutrition and diet therapy (12th ed., p. 359). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

952) The nurse is planning to teach the client with gastroesophageal reflux disease about substances that will increase the lower esophageal sphincter pressure. Which item should the nurse include on this list? a. Coffee b. Chocolate c. Fatty foods d. Nonfat milk Source: Saunders 4th

ANS: D Rationale: Foods that increase lower esophageal sphincter (LES) pressure will decrease reflux and lessen the symptoms of gastroesophageal reflux disease (GERD). The food that will increase LES pressure is nonfat milk. The other substances listed decrease LES pressure, thus increasing reflux symptoms. Aggravating substances include chocolate, coffee, fatty foods, and alcohol. Strategy: Use the process of elimination and knowledge of the effect of various foods on LES pressure and GERD. However, if you were unsure, select the option that identifies the most healthful food item. Review the dietary regimen for a client with GERD if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1263). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

2338) A nurse is providing information to a client who is scheduled for an electromyogram (EMG). The nurse informs the client that: a. An informed consent form is not required. b. Nothing by mouth (NPO) status must be maintained for 12 hours before the test. c. Medication is injected into the nerve for stimulation. d. Needles will be injected into the skeletal muscles. Source: Saunders 4th

ANS: D Rationale: For an EMG, needle electrodes are inserted into selected skeletal muscles to evaluate changes and electrical potential of the muscles and the nerves that lead to them. The test is useful in evaluating suspected lumbar or cervical disk disease, myasthenia gravis, muscular dystrophy, and other motor neuron diseases. The client should be reassured that the needle will not electrocute him or her and that he or she will experience sensations similar to those for an injection as the needles are inserted. An informed consent form is required. No other special preparation is required for this test. Strategy: Use the process of elimination. Recalling that the test involves insertion of needle electrodes will assist in eliminating options 1, 2, and 3. If you had difficulty with this question, review the procedure for performing an EMG. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 494). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1698) Thyroid replacement therapy is prescribed for the client diagnosed with hypothyroidism. The client asks the nurse when the medication will no longer be needed. The appropriate nursing response is which of the following? a. "You will need to ask your physician." b. "Most clients require medication for about 1 year." c. "It depends on the results of the laboratory tests." d. "The medication will need to be continued for life." Source: Saunders 4th

ANS: D Rationale: For most hypothyroid clients, replacement therapy must be continued for life. Treatment provides symptomatic relief but does not produce a cure. The client should be told that although therapy will cause symptoms to improve, these improvements do not constitute a reason to interrupt or discontinue the medication. Options 2 and 3 are incorrect. Option 1 places the client's question on hold. Strategy: Use the process of elimination. Eliminate option 1 first because it places the client's question on hold. Next, eliminate options 2 and 3 because they are comparative or alike. Review this disorder and the medication therapy associated with it if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1492). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2118) When administering a subcutaneous injection of heparin sodium, the nurse should: a. Use a 21- to 23-gauge, 1-inch needle. b. Aspirate before injection of the medication. c. Apply heat after the injection. d. Use a 25- to 26-gauge, 5/8-inch needle. Source: Saunders 4th

ANS: D Rationale: For subcutaneous heparin sodium injection, a 25- to 26-gauge, 3/8- to 5/8-inch needle is used, to prevent tissue trauma and inadvertent intramuscular injection. A 1-inch needle would inject the heparin sodium into the muscle. The application of heat may affect the absorption of the heparin and cause bleeding. Aspiration before injection is incorrect technique with heparin administration. Strategy: Use the process of elimination. Noting the strategic word subcutaneous will direct you to option 4. If you had difficulty with this question, review the principles related to heparin administration. Reference: Lehne, R. (2007). Pharmacology for nursing care (6th ed., p. 591). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

1916) A nurse is monitoring the fluid balance of an assigned client. The nurse determines that the client has proper fluid balance if which of the following 24-hour intake and output totals is noted? a. Intake 1500 mL, output 800 mL b. Intake 3000 mL, output 2400 mL c. Intake 2400 mL, output 2900 mL d. Intake 1800 mL, output 1750 mL Source: Saunders 4th

ANS: D Rationale: For the client taking a normal diet, the normal fluid intake is approximately 1200 to 1800 mL of measurable fluids per day. The client's output in the same period should be about the same, and not include insensible losses, which are extra. This is offset by the fluid in solid foods, which also is not measured. Strategy: Use the process of elimination. Recalling that intake should approximately equal output will help you to eliminate each of the incorrect options. Review the basic principles related to fluid balance if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 211). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 222). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1549) The nurse reviews the plan of care for a client at 37 weeks of gestation who has sickle cell anemia. The nurse determines that which nursing diagnosis listed on the nursing care plan will receive the highest priority? a. Coping, ineffective b. Body image, disturbed c. Risk for pain, acute d. Fluid volume, deficient Source: Saunders 4th

ANS: D Rationale: For the client with sickle cell anemia, dehydration will precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant woman and for the fetus, such as an interruption of blood flow to the placenta. Options 1, 2, and 3 may also be appropriate nursing diagnoses for the client with sickle cell anemia but are not the priority. Strategy: Use Maslow&#39;s Hierarchy of Needs theory, remembering that physiological needs come first. Using this principle, eliminate options 1 and 2. From the remaining options, select option 4 because it identifies an actual rather than a potential nursing diagnosis. Review sickle cell anemia if you had difficulty with this question. Reference: Murray, S., & McKinney, E. (2006). Foundations of maternal-newborn nursing (4th ed., p. 678). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Maternity—Antepartum Alternate Question Types -> Multiple Choice

2211) A nurse is giving dietary instructions to a client who has a new colostomy. The nurse encourages the client to eat foods representing which of the following diets for the first 4 to 6 weeks postoperatively? a. High protein b. High carbohydrate c. Low calorie d. Low residue Source: Saunders 4th

ANS: D Rationale: For the first 4 to 6 weeks after colostomy formation, the client should take in a low-residue diet. After this period, the client should eat a high-carbohydrate, high-protein diet. The client also is instructed to add new foods, one at a time, to determine tolerance to that food. Strategy: Use the process of elimination. Note the strategic words first 4 to 6 weeks. Recalling the type of diet needed to establish a measure of bowel control will direct you to option 4. Review dietary measures after creation of a colostomy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 827, 835). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

1452) A client who is delusional says to the nurse, "The federal guards were sent to kill me." The nurse's best response is: a. "I don't believe this is true." b. "The guards are not out to kill you." c. "What makes you think the guards were sent to hurt you?" d. "I don't know anything about the guards. Do you feel afraid that people are trying to hurt you?" Source: Saunders 4th

ANS: D Rationale: For the nurse to empathize with the client's experience is most therapeutic. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate. Strategy: Use therapeutic communication techniques. Eliminate options 1 and 2 because they are comparative or alike and are statements that disagree with the client. Option 4 encourages discussion regarding the delusion. Review communication techniques with the client experiencing delusions if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 125). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-34). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., p. 407). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

1194) The client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. Which of the following assessment findings would indicate the need to notify the physician? a. Red bloody urine b. Pain related to bladder spasms c. Urinary output of 200 mL higher than intake d. Blood pressure, 100/50 mm Hg; pulse, 130 beats/min Source: Saunders 4th

ANS: D Rationale: Frank bleeding (arterial or venous) may occur during the first day after surgery. Some hematuria is usual for several days after surgery. A urinary output of 200 mL more than intake is adequate. Bladder spasms are expected to occur following surgery. A rapid pulse with a low blood pressure is a potential sign of excessive blood loss. The physician should be notified. Strategy: Use the process of elimination and focus on the subject, need to notify the physician. Think about the expected findings following this procedure and note that the vital signs noted in option 4 indicate excessive blood loss. Review the expected findings following transurethral resection of the prostate if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1024). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2610) A client who has been receiving pentamidine (Pentam 300) intravenously now has a fever with a temperature of 102° F. Keeping in mind that the client has a diagnosis of acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia, the nurse determines that this manifestation is most compatible with: a. Insufficient medication dosing b. Toxic nervous system effects from the medication c. Inadequate thermoregulation d. Infection due to leukopenic effects of the medication Source: Saunders 4th

ANS: D Rationale: Frequent side effects of pentamidine include leukopenia, thrombocytopenia, and anemia. The client should be routinely assessed for signs and symptoms of infection. Options 1, 2, and 3 are inaccurate interpretations. Strategy: Use the process of elimination. Recalling that leukopenia is a frequent side effect of pentamidine will direct you to the correct option. If you had difficulty with this question or are unfamiliar with this medication, review its side effects. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 970). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1406) The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine (Pentam 300). The client develops a temperature of 101° F. The nurse does further monitoring of the client, knowing that this sign would most likely indicate that the: a. Dose of the medication is too low b. Client is experiencing toxic effects of the medication c. Client has developed inadequacy of thermoregulation d. Result of another infection caused by leukopenic effects of the medication Source: Saunders 4th

ANS: D Rationale: Frequent side effects of this medication include leukopenia, thrombocytopenia, and anemia. The client should be monitored routinely for signs and symptoms of infection. Options 1, 2, and 3 are inaccurate interpretations. Strategy: Use the process of elimination, focusing on the strategic words develops a temperature. Note the relationship between these strategic words and option 4. Review the side effects of this medication if you had difficulty with this question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 913). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

2233) A client with acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci infection has been receiving pentamidine (Pentam 300) intravenously. The client develops a fever with a temperature of 101° F. The nurse does further assessment of the client, knowing that this sign would most likely indicate: a. The dose of the medication is too low. b. The client is experiencing toxic effects of the medication. c. The client has developed inadequacy of thermoregulation. d. This is a result of another infection, caused by leukopenic effects of the medication. Source: Saunders 4th

ANS: D Rationale: Frequent side effects of this medication include leukopenia, thrombocytopenia, and anemia. The client should be routinely assessed for signs and symptoms of infection. The client also should have ongoing monitoring of a number of parameters because of the nature and side effects of the medication, including blood glucose, blood urea nitrogen, serum creatinine, complete blood cell count, liver function, and serum calcium and magnesium levels. Options 1, 2, and 3 are inaccurate interpretations. Strategy: Use the process of elimination. Focusing on the strategic words develops a fever will direct you to option 4. Review the complications associated with AIDS and with use of this medication if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., pp. 969-970). St. Louis: Mosby. Reference: Skidmore-Roth, L. (2005). Mosby's drug guide for nurses (6th ed., p. 671). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1425) The nurse employed in a mental health unit is assigned to care for a client admitted to the unit 2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse anticipates which of the following? a. The client will resist treatment measures. b. The client will be angry and will refuse care. c. The client's family will resist treatment measures. d. The client will participate in the planning of the care and treatment plan. Source: Saunders 4th

ANS: D Rationale: Generally, the client seeks voluntary admission. A voluntary admission permits a client to make a written application for admission. If the client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program. Options 1, 2, and 3 are not characteristics of this type of admission. Strategy: Use the process of admission. Note the strategic words voluntary admission. This should direct you to option 4. Additionally, note that options 1, 2, and 3 are comparative or alike. Review the various types of hospital admission processes if you had difficulty with this question. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 50). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., p. 150). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Mental Health Alternate Question Types -> Multiple Choice

171) A client is diagnosed with a nosocomial infection caused by methicillin-resistant Staphylococcus aureus and contact precautions are initiated. The nurse prepares to provide colostomy care to the client and obtains which of the following protective items needed to perform this procedure? a. Gloves and a gown b. Gloves and goggles c. Gloves, gown, and shoe protectors d. Gloves, gown, goggles, and a face shield Source: Saunders 4th

ANS: D Rationale: Goggles and a face shield are worn to protect the mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, or excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary. Strategy: Note the strategic words contact precautions and colostomy. Use the process of elimination and visualize care for this client to determine the necessary items required in caring for this client. If you had difficulty with this question, review transmission-based precautions. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 513-514). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1300) The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. The nurse inquires during the nursing admission interview if the client has a history of: a. Seizures or trauma to the brain b. Meningitis during the last 5 years c. Back injury or trauma to the spinal cord d. Respiratory or gastrointestinal infection during the previous month Source: Saunders 4th

ANS: D Rationale: Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally, the syndrome can be triggered by vaccination or surgery. Strategy: Use the process of elimination and knowledge regarding the causes related to this disorder. Remember that a recent history of respiratory or gastrointestinal infection are predisposing factors. If you are unfamiliar with Guillain-Barré syndrome, review this disorder. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1006-1008). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2657) A client with a diagnosis of schizophrenia is taking haloperidol (Haldol). The nurse interprets that this medication will exert its therapeutic effect through which of the following mechanisms? a. Blocking serotonin reuptake b. Inhibiting the breakdown of released acetylcholine c. Blocking the uptake of norepinephrine and serotonin d. Blocking dopamine from binding to postsynaptic receptors in the brain Source: Saunders 4th

ANS: D Rationale: Haloperidol acts by blocking the binding of dopamine to the postsynaptic dopamine receptors in the brain. Donepezil hydrochloride (Aricept) inhibits the breakdown of released acetylcholine. Fluoxetine hydrochloride (Prozac) is a potent serotonin reuptake blocker. Imipramine hydrochloride (Tofranil) blocks the reuptake of norepinephrine and serotonin. Strategy: Specific knowledge of the mechanism of action of haloperidol is required to answer this question. Recall that haloperidol acts by blocking the binding of dopamine to the postsynaptic dopamine receptors in the brain. If you are unfamiliar with this medication, review its mechanism of action. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 568). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2073) A home care nurse is making home visits to an older client with urinary incontinence, who is very concerned about the incontinent episodes. The nurse explores the client's home situation to determine environmental barriers to normal voiding. The nurse identifies which of the following assesment findings as a factor that may be contributing to the client's problem? a. Presence of hand railings in the bathroom b. Having one bathroom on each floor of the home c. Nightlight present in the hall between the bedroom and bathroom d. Bathroom located on the second floor, bedroom on the first floor Source: Saunders 4th

ANS: D Rationale: Having a bathroom on the second floor and the bedroom on the first floor may pose a problem for the older client with incontinence. The need to negotiate the stairs and the distance both may interfere with reaching the bathroom in a timely fashion. It is more helpful to the incontinent client to have a bathroom on the same floor with the bedroom, or to have a commode rented for use. The presence of nightlights and hand railings is helpful to the client in reaching the bathroom quickly and safely. Strategy: Use the process of elimination.Noting the subject, environmental barriers to normal voiding, will direct you to option 4. Review the environmental barriers that affect continence if you had difficulty with this question. Reference: Meiner, S., & Leuckenotte, A. (2006). Gerontologic nursing (3rd ed., p. 634). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

2629) A client in the hospital emergency department who received nitroglycerin for chest pain has obtained relief but now complains of a headache. The nurse interprets that this client most likely has: a. An early sign of tolerance to the medication b. A warning that the medication should not be used again c. An allergic reaction to nitroglycerin d. An expected medication side effect Source: Saunders 4th

ANS: D Rationale: Headache is a frequent side effect of nitroglycerin, resulting from its vasodilator action. It often subsides as the client becomes accustomed to the medication and is effectively treated with acetaminophen (Tylenol). The other options are incorrect interpretations. Strategy: Use the process of elimination. Eliminate options 2 and 3 first because they are comparative or alike. Recalling that this medication has a vasodilating effect will direct you to option 4. Review the effects of this medication if you had difficulty with question. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 844). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

2362) A client with acquired immunodeficiency syndrome (AIDS) who is taking zidovudine (Retrovir) 200 mg orally three times daily has severe neutropenia noted on follow-up laboratory studies. The nurse interprets that which of the following is likely to occur at this point? a. Prednisone (Deltasone) probably will be added to the medication regimen. b. Epoetin alfa (Epogen) probably will be added to the medication regimen. c. The medication dose probably will be reduced. d. The medication probably will be discontinued until laboratory results indicate bone marrow recovery. Source: Saunders 4th

ANS: D Rationale: Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or severe neutropenia develops, treatment should be discontinued until evidence of bone marrow recovery is noted. If anemia or neutropenia is mild, a reduction in dosage may be sufficient. The administration of prednisone may further alter the immune function. Epoetin alfa is administered to clients experiencing anemia. Strategy: Use the process of elimination. Focusing on the strategic words severe neutropenia will direct you to the correct option. If you had difficulty with this question, review adverse effects and treatment related to the administration of zidovudine. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (p. 1230). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Immune Alternate Question Types -> Multiple Choice

1907) A nurse is analyzing the posthemodialysis laboratory test results for a client with chronic renal failure (CRF). The nurse interprets that the dialysis is having an expected but nontherapeutic effect if the results indicate a decreased: a. Phosphorus b. Creatinine c. Potassium d. Red blood cell (RBC) count Source: Saunders 4th

ANS: D Rationale: Hemodialysis typically lowers the amounts of fluid, sodium, potassium, urea nitrogen, creatinine, uric acid, magnesium, and phosphate levels in the blood. Hemodialysis also worsens anemia, because RBCs are lost in dialysis from blood sampling and anticoagulation during the procedure, and from residual blood that is left in the dialyzer. Although all of these results are expected, only the lowered RBC count is nontherapeutic and worsens the anemia already caused by the disease process. Strategy: Use the process of elimination. Note the strategic words expected and nontherapeutic. Knowing that decreased laboratory values are expected will guide you to then focus on which of the results is nontherapeutic. Review the effects of hemodialysis if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 961). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

1285) The nurse has instructed the family of a client with brain attack (stroke) that has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will: a. Place objects in the client's impaired field of vision. b. Discourage the client from wearing eyeglasses. c. Approach the client from the impaired field of vision. d. Remind the client to turn the head to scan the lost visual field. Source: Saunders 4th

ANS: D Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available. Strategy: Use the process of elimination. Recalling the definition of homonymous hemianopsia will direct you easily to option 4. Review the concept of homonymous hemianopsia if you are unfamiliar with it. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2114). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1035-1036). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

2055) A nurse is performing an assessment on a client with a diagnosis of hyperthyroidism. Which assessment finding would the nurse expect to note in this client? a. Periorbital edema b. Coarse facial features c. Dry skin d. Bulging eyeballs Source: Saunders 4th

ANS: D Rationale: Hyperthyroidism is clinically manifested by goiter (increase in the size of the thyroid gland) and exophthalmos (bulging eyeballs). Other clinical manifestations include nervousness, fatigue, weight loss, muscle cramps, and heat intolerance. Additional signs found in this disorder include tachycardia, shortness of breath, excessive sweating, fine muscle tremors, thin silky hair and thin skin, infrequent blinking, and a staring appearance. Strategy: Focus on the client's diagnosis, hyperthyroidism, to answer this question. Recall the function of the thyroid hormone and note that options 1, 2, and 3 are signs of hypothyroidism. If you are unfamiliar with the signs of hyperthyroidism, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1482). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

2106) A client is being hyperventilated by a mechanical ventilator to decrease the client's intracranial pressure (ICP). On monitoring arterial blood gas results, the nurse would report values that are outside of which of the following ranges? a. Pa<SC>O</SC> ₂ 60 to 100 mm Hg, Pa<SC>CO</SC> ₂ 25 to 30 mm Hg b. Pa<SC>O</SC> ₂ 60 to 100 mm Hg, Pa<SC>CO</SC> ₂ 30 to 35 mm Hg c. Pa<SC>O</SC> ₂ 80 to 100 mm Hg, Pa<SC>CO</SC> ₂ 35 to 40 mm Hg d. Pa<SC>O</SC> ₂ 80 to 100 mm Hg, Pa<SC>CO</SC> ₂ 25 to 30 mm Hg Source: Saunders 4th

ANS: D Rationale: Hyperventilation with a Pa<SC>CO</SC> ₂ of 25 to 30 mm Hg causes cerebral vasoconstriction, which decreases intracranial blood volume and ICP. The Pa<SC>O</SC> ₂ is not allowed to fall below 80 mm Hg, to prevent cerebral vasodilation from hypoxemia. Strategy: Use the process of elimination, noting the strategic word hyperventilated. Because the bottom parameter of the arterial oxygen values in options 1 and 2 is too low, these options are eliminated first. Recall that the normal Pa<SC>CO</SC> ₂ ranges from 35 to 45 mm Hg, and that hyperventilation should cause these values to drop. Thus, option 4 is the correct answer, because the Pa<SC>CO</SC> ₂ value in option 3 is normal. Review hyperventilation and its relationship to ICP if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 2195). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1673) The nurse is caring for a client following thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to: a. Treat thyroid storm. b. Prevent cardiac irritability. c. Stimulate release of parathyroid hormone. d. Treat hypocalcemic tetany. Source: Saunders 4th

ANS: D Rationale: Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips or toes, muscle spasms, or twitching, the physician is notified immediately. Calcium gluconate should be kept at the bedside. Strategy: Use the process of elimination. Noting the name of the medication (calcium gluconate) should easily direct you to option 4. Calcium would be given if hypocalcemia tetany occurs. Review care of the client following thyroidectomy if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., p. 1205). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1486-1487). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

1071) A client is in sinus bradycardia with a heart rate of 45 beats/min, complains of dizziness, and has a blood pressure of 82/60 mm Hg. Which of the following should the nurse anticipate will be prescribed? a. Defibrillate the client. b. Administer digoxin (Lanoxin). c. Continue to monitor the client. d. Prepare for transcutaneous pacing. Source: Saunders 4th

ANS: D Rationale: Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client. Digoxin will further decrease the client's heart rate. Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular fibrillation. Continuing to monitor the client delays necessary intervention. Strategy: Use the process of elimination. Eliminate option 3 because the client is symptomatic and requires intervention. Option 2 is eliminated because digoxin will further decrease the client's heart rate. Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular fibrillation; therefore, eliminate option 1. Review the indications for transcutaneous pacing if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed., pp. 720, 740). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

2102) A nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs or symptoms of infection. The nurse interprets that the hyperthermia may be related to damage to the client's thermoregulatory center in the: a. Cerebrum b. Cerebellum c. Hippocampus d. Hypothalamus Source: Saunders 4th

ANS: D Rationale: Hypothalamic damage causes persistent hyperthermia, which also may be called "central fever." It is characterized by a persistent high fever with no diurnal variation. Another characteristic feature is absence of sweating. Options 1, 2, and 3 are incorrect. Strategy: Knowledge of the location of the brain's thermoregulatory center is needed to answer this question. Eliminate options 1 and 2 first, because they are responsible for higher mental functions and balance, respectively. A quick trick may be to remember that hyperthermia is due to the hypothalamus. Review the function of the hypothalamus if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 2195, 2201). Philadelphia: W.B. Saunders. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., pp. 335-338, 475-476). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

1442) The nurse is conducting a group therapy session, and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which of the following? a. Ask the client to leave. b. Refer the client to another group. c. Tell the client to stop monopolizing d. Thank the client for the contribution and tell him or her to allow others a chance to contribute. Source: Saunders 4th

ANS: D Rationale: If a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others. Although option 3 may be a direct response, option 4 is a more specific and direct statement. Options 1 and 2 are inappropriate. Strategy: Use the process of elimination. Eliminate options 1 and 2 first because they are comparative or alike. Use therapeutic communication techniques to assist in directing you to option 4. If you had difficulty with this question, review therapeutic communication techniques for the client with a manic disorder. Reference: Fortinash, K., & Holoday-Worret, P. (2004). Psychiatric mental health nursing (3rd ed., p. 445). St. Louis: Mosby. Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed., pp. 30-34). St. Louis: Mosby. Reference: Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing (5th ed., pp. 365-366). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Mental Health Alternate Question Types -> Multiple Choice

2441) A home care nurse visits a client who has a cast applied to the left lower leg. On assessment of the client, the nurse notes the presence of skin irritation from the edges of a cast. Which of the following nursing interventions is appropriate? a. Massage the skin at the edges of the cast. b. Contact the physician. c. Place a small face cloth in the cast around the edges of the cast. d. Petal the cast edges with adhesive tape. Source: Saunders 4th

ANS: D Rationale: If a client with a cast has skin irritation from the edges of the cast, the nurse would petal the edges of the cast with tape to minimize the irritation. Massaging the skin will not eliminate the problem. Placing a small face cloth in the cast around the edges of the cast is not appropriate. It is not necessary to contact the physician. Strategy: Focus on the subject of the question and use the process of elimination. Eliminate option 3 first because this action is inappropriate. Next, eliminate option 2 because this action is unnecessary. Option 1 will not alleviate the problem, which leaves option 4 as the correct option. If you had difficulty with this question, review care of the client with an extremity cast. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1198). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Musculoskeletal Alternate Question Types -> Multiple Choice

2220) A client with viral hepatitis has no appetite, and food makes the client nauseated. Which of the following nursing interventions would be appropriate? a. Explain that high-fat diets usually are better tolerated. b. Encourage foods high in protein. c. Explain that a majority of calories need to be consumed in the evening hours. d. Monitor for fluid and electrolyte imbalance. Source: Saunders 4th

ANS: D Rationale: If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte imbalance. It is important to explain to the client that a majority of calories should be eaten in the morning hours, because nausea is most common in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Protein increases the workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are better tolerated. Strategy: Use the process of elimination. Eliminate options 1, 2, and 3 because they are comparative or alike in that they all relate to diets. Review care of the client with viral hepatitis if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 1329-1330). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

150) A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias? a. Pulse oximetry b. Cardiac monitor c. Infusion controller d. Blood-warming device Source: Saunders 4th

ANS: D Rationale: If several units of blood are to be administered, a blood warmer should be used. Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. To prevent this, the nurse warms the blood as needed, using a blood-warming device. Pulse oximetry and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias. Electronic infusion devices are not helpful in this case because the infusion must be rapid, and infusion devices generally are used to control the flow rate. In addition, not all infusion devices are made to handle blood or blood products. Strategy: Use the process of elimination and note the strategic words rapid and reduce the risk. These words tell you that the infusions will infuse quickly and that the correct option is the one that will minimize the risk of cardiac dysrhythmias. Eliminate options 1 and 2 first because these items are used to assess for rather than reduce the risk of complications. From the remaining options, use knowledge related to the complications of transfusion therapy and note the relationship between the words several units of blood in the question and blood-warming device in the correct option. Review the concepts related to the use of a blood warmer if you had difficulty with this question. Reference: Perry, A., & Potter, P. (2006) Clinical nursing skills & techniques (6th ed., p. 970). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1191). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

1646) The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. The appropriate instruction regarding when the BSE should be performed is: a. 7 to 10 days after menses. b. Just before menses begins. c. At ovulation time. d. At a specific day of the month and on that same day every month thereafter. Source: Saunders 4th

ANS: D Rationale: If the client has had a hysterectomy or is no longer menstruating, the breast self-examination (BSE) should be performed on the same day every month. Options 1 and 2 are inappropriate because the client who had a hysterectomy would not be menstruating. It is best not to perform the BSE at ovulation time because of the hormonal changes that occur. Strategy: Use the process of elimination. Note the strategic word hysterectomy in the question to eliminate options 1 and 2. Eliminate option 3 because of the hormonal changes that occur at this time. If you are unfamiliar with the procedure for performing BSE, review this important self-examination. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 1797-1798). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 736-737). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

2448) A nurse is caring for a client on a mechanical ventilator. The high-pressure alarm sounds. The nurse assesses the client and attempts to determine the cause of the alarm. Which of the following initial nursing actions would be appropriate if the nurse is unable to determine the cause of ventilator alarm? a. Call the physician. b. Call the respiratory therapy department. c. Shut the alarm off. d. Manually ventilate the client with a resuscitation device. Source: Saunders 4th

ANS: D Rationale: If the nurse is unable to troubleshoot an alarm or suspects equipment failure in a mechanical ventilator, the nurse should manually ventilate the client with a resuscitation device. The nurse should never shut off the alarms. It is not necessary to contact the physician, although the respiratory therapist may be notified to assist in troubleshooting the cause of the problem. However, the initial nursing action would be to manually ventilate the client. Strategy: Read the information presented in the question carefully. Note the strategic word initial in the question. Use the ABCs—airway, breathing, and circulation—to direct you to option 4. If you had difficulty with this question or are unfamiliar with the care of the client on a ventilator, review this content. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 666). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

25) The nurse has made an error in documenting an assessment finding on a client and obtains the client's record to correct the error. The nurse corrects the error by: a. Documenting a late entry into the client's record b. Trying to erase the error for space to write in the correct data c. Using Wite-Out to delete the error to write in the correct data d. Drawing one line through the error, initialing and dating the line, and then documenting the correct information Source: Saunders 4th

ANS: D Rationale: If the nurse makes an error in documenting in the client's record, the nurse should follow agency policies to correct the error. This includes drawing one line through the error, initialing and dating the line, and then documenting the correct information. A late entry is used to document additional information not remembered at the initial time of documentation. Erasing data from the client's record and the use of Wite-Out are prohibited. Strategy: Use the process of elimination and principles related to documentation. Recalling that alterations to a client's record are to be avoided will assist in eliminating options 2 and 3. From the remaining options, focusing on the subject of the question and using knowledge regarding the principles related to documentation easily will direct you to option 4. Review these principles if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 836, 841). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Communication and Documentation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

119) A nurse enters the room of a client receiving parenteral nutrition (PN) and discovers that the electronic infusion pump has been shut off. After checking the line for patency and restarting the infusion, the nurse assesses the client for which of the following signs and symptoms? a. Fever and chills b. Dyspnea and hypotension c. Weakness, thirst, and excessive urination d. Weakness, shakiness, diaphoresis, and complaints of hunger Source: Saunders 4th