Testing4

*Question: Implemented treatment measures for a client with a diagnosis of bleeding esophageal varices have been unsuccessful. The primary health care provider states that a Sengstaken-Blakemore tube will be used to control the resulting hemorrhage. The nurse would prepare for insertion of this tube via which route?*

*Answer: Nasogastric* Rationale: A Sengstaken-Blakemore tube is inserted via the nose into the esophagus and stomach. The other options are incorrect, because this tube is not inserted in those manners.

*Question: The nurse employed in a well-baby clinic is reinforcing nutrition instructions to the mother of a 1-month-old infant. Which instruction would the nurse provide the mother?*

*Answer: Offer breast milk or formula as the main food.* Rationale: Breast milk or formula is the main food throughout infancy. Rice cereal mixed with breast milk or formula is introduced at 4 months of age. Strained vegetables, fruits, and meats are introduced one at a time and can begin at 6 months of age.

*Question: The nurse is providing discharge teaching for a post-myocardial infarction (MI) client who will be taking 1 baby aspirin a day. The nurse determines that the client understands the use of this medication if the client makes which statement?*

*Answer: "I will take this medication every day."* Rationale: A single daily dose of 1 baby aspirin (low-dose aspirin) may be a component of the standard treatment regimen for the client after an MI. Aspirin helps prevent clotting and may prevent a thrombosis that could cause a second MI. If the client cannot tolerate aspirin, then another antiplatelet medication may be prescribed. The other three options are unacceptable because the benefit comes in taking the medication on a daily basis.

*Question: A nursing student is caring for a child with increased intracranial pressure. On review of the chart, the student nurse notes that a transtentorial herniation has occurred. A nursing instructor asks the student about this type of herniation. Which statement by the student indicates a need for further research about this condition?*

*Answer: "It involves only the anterior portions of the client's brain."* Rationale: Transtentorial herniation occurs when part of the brain herniates downward and around the tentorium cerebelli. It can be unilateral or bilateral and may involve anterior or posterior portions of the brain. If a large amount of tissue is involved, it can cause death because vital brain structures are compressed and become unable to perform their functions.

*Question: A licensed practical nurse (LPN) is providing follow-up teaching after a client underwent an upper gastrointestinal (GI) series with diatrizoate used for contrast. The nurse instructs the client that which may occur from the diatrizoate?*

*Answer: Diarrhea* Rationale: If diatrizoate is used for contrast, significant diarrhea is possible. It may also cause nausea and vomiting. Excessive flatus, abdominal pain, and gastrointestinal bleeding are not associated with diatrizoate administration.

*Question: An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily available if respiratory depression occurs?*

*Answer: Naloxone* Rationale: Opioid analgesics may be prescribed to relieve moderate to severe pain associated with labor. Opioid toxicity can occur and cause respiratory depression. Naloxone is an opioid antagonist, which reverses the effects of opioids and is given for respiratory depression. Morphine sulfate and meperidine hydrochloride are opioid analgesics. Betamethasone is a corticosteroid administered to enhance fetal lung maturity.

*Question: The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement would the nurse make to the client to try to motivate the client to quit smoking?*

*Answer: "If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years."* Rationale: The risks to the cardiovascular system from smoking are noncumulative and are not permanent. Three to 4 years after cessation, a client's cardiovascular risk is comparable to that of a person who never smoked. Therefore, options 1, 2, and 3 are incorrect.

*Question: The nurse is admitting a child with a diagnosis of lactose intolerance. Which finding does the nurse expect to note?*

*Answer: Frothy stools* Rationale: Lactose intolerance causes frothy stools. Abdominal distention, crampy abdominal pain, and excessive flatus may also occur. Option 2 is a clinical manifestation of Hirschsprung's disease. Option 3 is a clinical manifestation of celiac disease. Option 4 is a symptom of irritable bowel syndrome.

*Question: The nurse is preparing to care for a child with a head injury. On review of the records, the nurse notes that the primary health care provider has documented decorticate posturing. The nurse plans care, knowing that this type of posturing indicates which finding?*

*Answer: Dysfunction in the cerebral hemisphere* Rationale: Decorticate posturing indicates a lesion in the cerebral hemisphere or disruption of the corticospinal tracts. Decerebrate posturing indicates damage in the diencephalon, midbrain, or pons.

*Question: The nurse has reinforced instructions to a client receiving enalapril maleate. Which statement by the client indicates a need for further teaching?*

*Answer: "I need to notify the primary health care provider if nausea occurs."* Rationale: If nausea occurs, it is not necessary to notify the primary health care provider. The client should be instructed to consume noncaffeinated carbonated beverages, unsalted crackers, or dry toast to alleviate the nausea. To reduce the hypotensive effect of this medication, the client is instructed to rise slowly from a lying to a sitting position and to permit the legs to dangle from the bed momentarily before standing. The client should report signs of a sore throat or fever to the health care provider because these may indicate infection. The client should be notified that several weeks may be needed for the full therapeutic effect of blood pressure reduction. The client should also be instructed not to skip doses or discontinue the medication because severe rebound hypertension can occur.

*Question: The nurse has reviewed activity restrictions with a client who is being discharged following hip surgery and insertion of a femoral head prosthesis. The nurse determines that the client understands the material presented if the client makes which statement?*

*Answer: "I will use a raised toilet seat."* Rationale: The postoperative hip surgery client understands the material presented when the client plans to use a raised toilet seat. It is important for clients with an insertion of a femoral head prosthesis to use a raised toilet seat. The client should also maintain the leg in a neutral, straight position when lying, sitting, or walking. The leg should not be adducted, internally rotated, or flexed more than 90 degrees. The client should sit in chairs that have arms so there will be assistance when the client is ready to rise from the sitting position. The client should avoid putting on his or her own socks and shoes for 8 weeks after surgery because it would force the leg into acute flexion.

*Question: The nurse is reviewing instructions to a client diagnosed with otitis media who is prescribed amoxicillin 500 mg orally every 8 hours. The nurse would determine that which statement by the client most indicates an understanding of the adverse effects related to the medication?*

*Answer: "If I get diarrhea, I need to call the doctor."* Rationale: Amoxicillin is a penicillin. Adverse reactions include superinfections such as potentially fatal antibiotic-associated colitis, which results from altered bacterial balance. Symptoms include abdominal cramps, severe watery diarrhea, and fever. The statements "I may become dizzy from the medication," "Constipation means that the medication needs to be stopped," and "A headache may mean that I need to discontinue the medication" are incorrect. The medication does not cause dizziness. The client should not independently stop the medication.

*Question: A 15-year-old client who is pregnant and unwed, says, "My life was unbearable before I met Johnny. My mother beats me up every day and my dad has been sleeping with me since I was 10 years old!" Which response is appropriate for the nurse to make?*

*Answer: "It seems that you needed help to separate from your family. Do you feel you are ready to have a baby with Johnny?"* Rationale: Adolescent pregnancy outside of marriage can arise from female low self-esteem, fears of inadequacy, and desperation to escape from an abusive and dysfunctional family. The most therapeutic communication technique is the one that uses restatement and repeats the main thought that the client expressed. This assures the client that the nurse is listening and is attempting to validate what the client has said. Options 1, 2, and 3 are nontherapeutic responses. Option 1 reflects a knowledge deficit on the nurse's part. Option 2 is insensitive and makes assumptions. Option 3 makes connections that are assumed and imply judgmental bias.

*Question: An adult client is admitted to the emergency department following a burn injury. The burn initially affected the client's upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the entire face (anterior half of the head) and the upper half of the posterior torso. Using the rule of nines, which percentage would characterize the burn injury?

*Answer: 31.5%* Rationale: According to the rule of nines, with the initial burn, the upper half of the anterior torso equals 9% and the lower half of both arms equals 9%. The subsequent burn included the anterior half of the head equaling 4.5% and the upper half of the posterior torso equaling 9%. This totals 31.5%.

*Question: A primary health care provider asks the nurse to obtain a Salem sump tube for gastric intubation. The nurse would correctly select which tube from the unit storage area?*

*Answer: A tube with a larger lumen and an air vent* Rationale: A Salem sump tube is used commonly for gastric intubation and has a larger suction lumen and an air vent. A feeding tube describes a Levin tube. A jejunostomy tube describes a tube used for small intestinal feedings. A Sengstaken-Blakemore tube describes a tube used for gastroesophageal bleeding.

*Question: The nurse is caring for a client at home who has had a tracheostomy tube for several months. The nurse monitors the client for complications associated with the long-term tracheostomy and suspects tracheoesophageal fistula if which observation is noted for the client?*

*Answer: Abdominal distention* Rationale: Necrosis of the tracheal wall can lead to an artificial opening between the posterior trachea and the esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the stomach, causing abdominal distention. It also can cause aspiration of gastric contents. Option 2 may indicate an infection. Option 3 may indicate the need for more frequent suctioning. Option 4 may indicate an obstruction of some sort or the presence of bronchoconstriction.

*Question: A client has had surgery to repair a fractured left hip. The nurse plans to use which important item when repositioning the client from side to side in the bed?*

*Answer: Abductor splint* Rationale: Following surgery to repair a fractured hip, an abductor splint is used to maintain the affected extremity in good alignment. An overhead trapeze and bed pillow are also used, but they are not the priority item to be used in repositioning.

*Question: A client experiences cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style?*

*Answer: Autocratic* Rationale: Autocratic leadership is an approach in which the leader retains all authority and is primarily concerned with task accomplishment. It is an effective leadership style to implement in an emergency or crisis situation. The leader assigns clearly defined tasks and establishes one-way communication with the work group, and he or she makes all decisions independently. Situational leadership is a comprehensive approach that incorporates the leader's style, the maturity of the work group, and the situation at hand. Democratic leadership is a people-centered approach that is primarily concerned with human relations and teamwork. This leadership style facilitates goal accomplishment and contributes to the growth and development of the staff. Laissez-faire leadership is a permissive style in which the leader gives up control and delegates all decision making to the work group.

*Question: A client will undergo a barium swallow to confirm a diagnosis of a hiatal hernia. In preparation for the test, which instruction would the nurse provide the client?*

*Answer: Avoid eating or drinking after midnight before the test.* Rationale: The stomach should be empty at the time of a barium swallow because food and medications can interfere with test results. Smoking increases mucus and acid production and can interfere with the test. For this reason, all foods, liquids, medication, and smoking are avoided before the test.

*Question: The nurse employed in a well-baby clinic is collecting data on the language and communication developmental milestones of a 4-month-old infant. Based on the age of the infant, the nurse expects to note which highest level of developmental milestones?*

*Answer: Babbling sounds* Rationale: Babbling sounds are common between the ages of 3 and 4 months. Additionally, during this age, crying becomes more differentiated. Between the ages of 1 and 3 months, the infant will produce cooing sounds. An increased interest in sounds occurs between 6 and 8 months, and the use of gestures occurs between 9 and 12 months.

*Question: Rho(D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition?*

*Answer: Being affected by Rh incompatibility* Rationale: Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes pregnant with a fetus who is Rh positive. During pregnancy and at delivery, some of the fetus's Rh-positive blood can enter the maternal circulation, causing the mother's immune system to form antibodies against Rh-positive blood. Administration of Rho(D) immune globulin prevents the mother from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen.

*Question: A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and her contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication?*

*Answer: Betamethasone* Rationale: Betamethasone, a glucocorticoid, is given to increase the production of surfactant to stimulate fetal lung maturation. It is administered to clients in preterm labor at 28 to 32 weeks of gestation if the labor can be inhibited for 48 hours. Nalbuphine is an opioid analgesic. Rho(D) immune globulin is given to Rh-negative clients to prevent sensitization. Dinoprostone vaginal insert is a prostaglandin given to ripen and soften the cervix and to stimulate uterine contractions.

*Question: Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority nursing assessment?*

*Answer: Blood pressure* Rationale: Methylergonovine, an ergot alkaloid, is used to prevent or control postpartum hemorrhage by contracting the uterus. Methylergonovine causes continuous uterine contractions and may elevate the blood pressure. A priority assessment before the administration of the medication is to check the blood pressure. The primary health care provider should be notified if hypertension is present. Although options 1, 3, and 4 may be components of the postpartum assessment, the correct option, blood pressure, is related specifically to the administration of this medication.

*Question: The nurse is collecting data on a client complaining of fatigue, weakness, malaise, muscle pain, joint pain at multiple sites, anorexia, and photosensitivity. Systematic lupus erythematosus (SLE) is suspected. The nurse would further check for which manifestation that is also indicative of the presence of SLE?*

*Answer: Butterfly rash on the cheeks and bridge of the nose* Rationale: Systematic lupus erythematosus is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and on the bridge of the nose is a classic sign of SLE. Two hemoglobin S genes are found in sickle cell anemia. Emboli and ascites may be found in many conditions but are not associated with SLE.

*Question: The nurse is visiting an older client whose family has gone out for the day. During the visit, the client experiences chest pain that is unrelieved by nitroglycerin given by the nurse. Which action by the nurse would be appropriate at this time?*

*Answer: Call for an ambulance to transport the client to the emergency department.* Rationale: Chest pain that is unrelieved by rest and nitroglycerin may not be typical anginal pain but may signal myocardial infarction (MI). Because the risk of sudden cardiac death is greatest in the first 24 hours after MI, it is imperative that the client receive emergency cardiac care. A primary health care provider's office is not equipped to treat MI. Communication with the family or home care agency delays client treatment, which is needed immediately.

*Question: A client returning to the medical nursing unit following cardiac catheterization has a stat prescription to receive a dose of procainamide. The licensed practical nurse assisting in caring for the client obtains which piece of equipment to adequately determine the client's response to this medication?*

*Answer: Cardiac monitor* Rationale: Procainamide is an antidysrhythmic medication often used to treat ventricular dysrhythmias that do not adequately respond to lidocaine. The effectiveness of this medication is best determined by evaluating the client's cardiac rhythm. Therefore, a cardiac monitor is of greatest value, although the blood pressure cuff and pulse oximeter would provide general information about the client's cardiovascular status. A glucometer is not needed for this client with the information presented.

*Question: A client with a Sengstaken-Blakemore tube in place to treat esophageal varices suddenly becomes restless, the heart rate and blood pressure increase, and the client's pulse oximetry reading is decreasing. The nurse calls for the registered nurse and plans to take which immediate nursing action?*

*Answer: Cut the tube, and pull it out.* Rationale: Sudden rupture of the esophageal balloon can cause airway obstruction, aspiration, and/or asphyxiation. The tube should be cut and removed to prevent airway obstruction. The remaining options also may be done once the nurse first takes action to safeguard the client's airway.

*Question: The nurse is monitoring a child with a head injury. On data collection, the nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. The nurse documents that the child is experiencing which?*

*Answer: Decorticate posturing* Rationale: Decorticate posturing is an abnormal flexion of the upper extremities and an extension of the lower extremities with possible plantar flexion of the feet. Decerebrate posturing is an abnormal extension of the upper extremities with internal rotation of the upper arms and wrists, and an extension of the lower extremities with some internal rotation.

*Question: The nurse is caring for a client with a tibial fracture who was just diagnosed with acute compartment syndrome (ACS). Which procedure does the nurse anticipate the surgeon will perform?*

*Answer: Fasciotomy* Rationale: If ACS is verified, the surgeon may perform a fasciotomy, or opening in the fascia, by making an incision through the skin and subcutaneous tissues into the fascia of the affected compartment. This procedure relieves the pressure and restores circulation to the affected area. Compartments are areas in the body in which muscles, blood vessels, and nerves are contained within fascia. Arteriotomy is a surgical opening into an artery. A venous thromboectomy is removal of a piece of clot or embolus from a vein. It is indicated in clients with deep vein thrombosis (DVT) whose symptoms are severe and present for fewer than 7 days. External compartment removal is not a surgical procedure.

*Question: A client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting. A gastric ulcer is suspected. The nurse would determine that which data would further support this diagnosis?*

*Answer: History of chronic obstructive pulmonary disease with weight loss* Rationale: History of chronic obstructive pulmonary disease is commonly associated with gastric ulcers, because this disease increases gastric acid secretion. Weight loss is also associated with gastric ulcer disease. The other options do not contain risk factors or symptoms commonly associated with this disorder. The symptoms listed in option 2 may be seen in gastroesophageal reflux disease. Spicy foods often have been blamed for ulcers, but this link has not been proven.

*Question: A client uses the alternative therapy of cascara sagrada, known as Californian buckthorn, for ongoing management of chronic constipation. The nurse would monitor the client's laboratory results for which electrolyte imbalance specifically related to long-term use of this medication?*

*Answer: Hypokalemia* Rationale: Hypokalemia can result from long-term use of cascara sagrada, an alternative therapy laxative. The medication stimulates peristalsis and alters fluid and electrolyte transport, thus helping fluid to accumulate in the colon. Hyperkalemia, hyponatremia, and hypernatremia are not specifically associated with the use of this medication.

*Question: The nurse is reviewing the laboratory results of an infant suspected of having hypertrophic pyloric stenosis. Which acid-base disorder would the nurse expect to note in the infant?*

*Answer: Metabolic alkalosis* Rationale: Laboratory findings in an infant with hypertrophic pyloric stenosis include metabolic alkalosis as a result of the vomiting (depletes acid) that occurs in this disorder. Additional findings include decreased serum potassium and sodium levels, increased pH and bicarbonate, and decreased chloride level.

*Question: A licensed practical nurse (LPN) assisting a registered nurse in the cardiac care unit (CCU) prepares to admit a client with a diagnosis of myocardial infarction (MI). The LPN would be certain to have which item(s) readily available on the unit when the client arrives by stretcher?*

*Answer: Oxygen cannula and flowmeter* Rationale: The client will require oxygen therapy following MI to decrease pain because of ischemia and to help minimize the risk of its recurrence. Oxygen decreases pain to the myocardium by improving oxygen supply. An electrocardiogram machine and bedside commode may be used but are not priorities at this time. An overhead trapeze could actually be harmful by causing the client to use the Valsalva maneuver while pulling up in bed.

*Question: A client receiving total parenteral nutrition (TPN) is demonstrating signs and symptoms of an air embolism. Which action would the nurse take first?*

*Answer: Place the client on the left side with the head lowered.* Rationale: Lying on the left side may prevent air from flowing into the pulmonary veins. Placing the head lower than the body increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during inspiration. The primary health care provider is notified, but this is not the first action. Stopping the TPN will not treat the problem.

*Question: The client with diagnosed peptic ulcer disease has been prescribed misoprostol and sucralfate. The nurse reinforces teaching the client that these two medications will work primarily for which reason?*

*Answer: The medications protect the gastric mucosa.* Rationale: Both of these medications protect the stomach lining. Misoprostol increases mucous production and bicarbonate levels, although sucralfate coats the ulcer surface. Options 1 and 2 reflect histamine antagonists and antibiotics, respectively. Option 3 describes antacids.

*Question: During a nursing interview, a client says, "My daughter was murdered in her New York apartment, and her estranged husband called to tell me. I can't stop myself from wondering if he killed her, but the police have ruled him out as a suspect." Which statement reflects a therapeutic nursing response?*

*Answer: "Have you shared your concerns with the police?"* Rationale: Option 2 addresses the subject of the client's statement. Options 1 and 4 are responses that identify the process of agreeing with the client. Option 3 is not directly related to the subject of the client's statement.

*Question: A client receiving total parenteral nutrition (TPN) has a history of heart failure. The primary health care provider has prescribed furosemide 40 mg orally daily to prevent fluid overload. The nurse is giving instructions about taking furosemide in relation to the client's health plan. Which statement by the client indicates a need for further teaching?*

*Answer: "I need to talk to my doctor about increasing my digoxin."* Rationale: Furosemide is a potassium-losing diuretic. Instructions include a need for a high-potassium diet or potassium replacement, rising slowly from a lying or sitting position because orthostatic hypotension may occur, and taking the medication early in the day to prevent sleeplessness and nocturia. Furosemide can increase the risk of toxicity of lithium, nondepolarizing skeletal muscle relaxants, digoxin, salicylates, aminoglycosides, and cisplatin.

*Question: The nurse is reinforcing home-care instructions to the parents of a 3-year-old child with scabies. Which statement by a parent indicates the need for further teaching?*

*Answer: "I understand that I need to leave the scabicide on for 4 hours before washing it off."* Rationale: The treatment for scabies involves applying a scabicide to cool, dry skin at least 30 minutes after bathing, which needs to be left on the skin for 8 to 14 hours, then washed off. The other statements are correct.

*Question: The nurse determines that a client with coronary artery disease (CAD) needs further teaching about disease management if the client makes which statement?*

*Answer: "I will avoid walking for exercise."* Rationale: Lack of physical exercise contributes to the development of coronary artery disease, and engaging in a regular program of exercise helps retard progression of atherosclerosis by lowering cholesterol levels and developing collateral circulation to heart tissue. Walking should be encouraged for 30 minutes a day. Watching weight gain; monitoring cholesterol; and following a low-fat, low-salt diet are accurate statements.

*Question: The nurse is preparing to administer beractant to a premature infant who has respiratory distress syndrome. The nurse plans to administer the medication by which route?*

*Answer: Intratracheal* Rationale: Respiratory distress syndrome is a serious lung disorder caused by immaturity and the inability to produce surfactant, resulting in hypoxia and acidosis. It is common in premature infants and may occur as a result of lung immaturity caused by surfactant deficiency. The mainstay of treatment is the administration of exogenous surfactant, which is administered by the intratracheal route. Options 1, 3, and 4 are not routes of administration for this medication.

*Question: A child is diagnosed with intussusception. The nurse collects data on the child, knowing that which is a characteristic of this disorder?*

*Answer: Invagination of a section of the intestine into the distal bowel* Rationale: Intussusception is an invagination of a section of the intestine into the distal bowel. It is the most common cause of bowel obstruction in children age 3 months to 6 years. Option 1 describes encopresis. Option 2 describes imperforate anus, and this disorder is diagnosed in the neonatal period. Option 3 describes constipation. Constipation can affect any child at any time, although it peaks at ages 2 to 3 years. Encopresis generally affects preschool and school-age children.

*Question: The nurse who is assisting in the care of a client within the first 24 hours following a total gastrectomy for gastric cancer would avoid which intervention?*

*Answer: Irrigating the nasogastric (NG) tube* Rationale: After gastric surgery the nasogastric tube should not be irrigated. To do so may cause the suture line in the stomach to tear. Bowel sounds should be assessed, the drainage from the NG tube should be measured, and the tube should be kept to suction to be sure the stomach does not become distended.

*Question: The nurse should include which most appropriate information when reinforcing home care instructions for a client who has been diagnosed with peptic ulcer disease?*

*Answer: Learn to use stress reduction techniques.* Rationale: Identifying and reducing stress is essential to a comprehensive ulcer management plan. The client also should avoid intake of foods that aggravate pain, quit smoking, and avoid irritants such as NSAIDs. Antibiotic therapy often cures the client of this problem in many instances.

*Question: The nurse has assisted in the insertion of a Levin tube for gastrointestinal (GI) decompression. The nurse would anticipate a prescription to set the suction to which pressure?*

*Answer: Low and intermittent* Rationale: A Levin tube has no air vent, and the suction must be placed on an intermittent setting to prevent trauma to the gastric mucosa. Low pressure and intermittent suction are safer for the stomach than high pressure and continuous suction.

*Question: After a routine eye examination, a client has been told there are refractive errors in both eyes. The nurse explains to the client that this problem is primarily treated with which intervention?*

*Answer: Prescription of corrective lenses* Rationale: Errors of refraction in vision include astigmatism, presbyopia, myopia, and hyperopia. Corrective lenses, or eyeglasses, are the most common method used to correct errors of refraction. Eye drops would be used for several eye conditions, most commonly glaucoma. The client may or may not need rigid contact lenses, and this is not the most common treatment. A keratoplasty is a surgical procedure for cataracts.

*Question: The nurse is reviewing the record of a newborn infant and notes that the primary health care provider has documented the presence of a cephalhematoma. Based on this documentation, the nurse expects to observe which indications on data collection of the infant? Select all that apply.*

** Rationale: A cephalhematoma indicates edema resulting from bleeding below the periosteum of the cranium. It does not cross the suture line. It is most likely the result of ruptured blood vessels from head trauma during birth. It develops within 24 to 48 hours after birth and may take 2 to 3 weeks to resolve. Option 1 may be associated with premature closure or craniosynostosis and should be investigated further. Option 2 may indicate increased intracranial pressure. Option 3 identifies a caput succedaneum.

*Question: A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. The nurse avoids using which intervention in an effort to relieve the spasm?*

*Answer: Cold* Rationale: Traction, analgesics, and heat may all be used to relieve the pain of muscle spasm in the client with a vertebral fracture. The use of cold is incorrect because ice is applied to a site for only the first 24 hours after an injury. Application of ice to the spine of a client could be uncomfortable, increase spasms, and result in feeling chilled.

*Question: The nurse is caring for a 1-year-old child following a cleft palate repair. Which solution would the nurse use after feedings to cleanse the child's mouth?*

*Answer: Sterile water* Rationale: Following a cleft palate repair, the mouth is rinsed with water after feedings to clean the palate repair site. Rinsing food and residual sugars from the suture line reduces the risk of infection. Diluted hydrogen peroxide, a soft lemon glycerin swab, and half-strength povidone-iodine solution should not be used.

*Question: The nurse receives a call from a mother whose child has a foreign body in the eye. The object is clearly visible and not embedded. When the mother asks for the most effective way to get it out, the nurse would give which response?*

*Answer: Touch the object gently with a moistened sterile cotton swab, and lift it out.* Rationale: Sometimes a speck of foreign matter on the cornea can be removed with a moistened, sterile cotton swab. It should not be allowed to remain and "work its way out." If the foreign body is not deeply embedded in the tissues of the eye, it can be removed by irrigation. Irrigate with clear, lukewarm water or sterile water.

*Question: The client in an emergency department reports right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse should question which prescriptions? Select all that apply.*

** Rationale: A client with right lower quadrant abdominal pain may have appendicitis. This client would be NPO and given intravenous (IV) fluids for hydration. Cold packs may provide comfort. Laxatives are not prescribed; heat might bring enough blood and fluid to the appendix to cause it to rupture and cause peritonitis; therefore, the nurse would question the cathartic prescription and heat application.

*Question: The nurse observes a client following delivery for normal maternal physiological changes that are anticipated. The nurse would document which expected changes? Select all that apply.*

** Rationale: Following delivery of the placenta, the maternal cardiac system begins to make several normal changes, leading to slowing of the pulse rate and an elevation in blood pressure. The client should be alert and oriented.

*Question: A client with heart failure is scheduled to be discharged to home with digoxin and furosemide as ongoing prescribed medications. The nurse teaches the client to report which sign/symptom that indicates the medications are not producing the intended effect?*

*Answer: Weight gain of 2 to 3 pounds in a few days* Rationale: Clients with heart failure should immediately report weight gain, loss of appetite, shortness of breath with activity, edema, persistent cough, and nocturia. An increase in daytime voiding is expected while on diuretic therapy. A cough as a result of respiratory infection does not necessarily indicate that heart failure is exacerbating.

*Question: The nurse is caring for a client with anorexia nervosa. The nurse planning care for the client recognizes that which manifestation is likely to be present?*

*Answer: Amenorrhea* Rationale: Physical symptoms of anorexia nervosa include cessation of menstruation (amenorrhea) in women, loss of sexual drive, cold intolerance, the growth of fine hair on the body and the face (lanugo), hypotension, and heart irregularities. Weight loss and maintenance of weight at or below 85% is a physical sign of anorexia, not 10%.

*Question: The nurse who is reinforcing instructions to a client who has had a gastric resection would include which considerations? Select all that apply.*

** Rationale: After a gastrectomy, small frequent meals are given until the stomach stretches enough to tolerate three regular meals a day. Dumping syndrome occurs in many clients after GI surgery and may occur as an early or late complication. Upper GI hemorrhage also may occur. A diet high in vitamin B12 will not prevent pernicious anemia because the client lacks the intrinsic factor needed for absorption. Instead the client requires injection to supplement this vitamin. Iron supplements are necessary to help absorption of parenteral vitamin B12.

*Question: A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving if which breath sounds are noted?*

*Answer: Crackles in the lung bases* 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 throughout the lung fields. As the client's condition improves, the amount of fluid in the alveoli decreases and may be detected by crackles in the bases. (Clear lung sounds would indicate full resolution of the episode.) Wheezes and rhonchi are not associated with pulmonary edema.

*Question: The nurse is preparing to collect client data by examining the abdomen. The nurse should begin the assessment by performing which action first?*

*Answer: Inspecting the abdomen* Rationale: Examination of the abdomen begins with inspection. Auscultation follows inspection, then palpation and percussion is done last.

*Question: The nurse would document that a client diagnosed with a hiatal hernia is implementing effective health maintenance measures after the client reports doing which action?*

*Answer: Eating low-fat or nonfat foods* Rationale: The use of low-fat or nonfat foods is recommended to reduce gastric pressure and prevent sliding of the hernia through the cardiac sphincter. The client should also elevate the head of the bed during sleep and wait at least 1 hour after meals to perform chores.

*Question: A client with diabetes mellitus decides to exercise an extra 30 minutes. The client is now experiencing hypoglycemia. Hypoglycemia is supported by which noted data? Select all that apply.*

** Rationale: Hypoglycemia is identified by cool, clammy skin; shakiness; and hunger. Diabetic ketoacidotic coma is usually identified with a fruity breath odor; dry, cracked mucous membranes; hypotension; and rapid, deep breathing.

*Question: The nurse is collecting data on a client with a diagnosis of rheumatoid arthritis. The nurse looks at the client's hands and notes characteristic deformities. The nurse would identify this as which deformity? Refer to figure.View Figure*

*Answer: Ulnar drift* Rationale: All of the conditions identified in the options can occur in rheumatoid arthritis. Ulnar drift occurs when synovitis stretches and damages the tendons, and eventually the tendons become shortened and fixed. This damage causes subluxation (drift) of the joints. A hallux valgus deformity is a deformity characterized by lateral deviation of the great toe. It is commonly called a bunion. A swan neck deformity is a deformed position of the finger in which the joint closest to the fingertip is permanently bent toward the palm while the nearest joint to the palm is bent away from it. A boutonniere deformity is a deformed position of the fingers or toes in which the joint nearest the knuckle is permanently bent toward the palm while the farthest joint is bent back away.

*Question: A client with angina pectoris has just been started on medication therapy with nitroglycerin. In planning care for this client, the nurse would place priority on measuring which data?*

*Answer: Vital signs* Rationale: The nurse would place priority on measuring vital signs, especially the blood pressure, because of the vasodilator action of the medication. Drug levels are not measured for nitroglycerin, and the medication does not affect serum glucose level. Intake and output may be measured as part of the general plan of care for the client with heart disease, but it is not directly related to administration of this medication.

*Question: A 1-year-old child is admitted to the hospital for control of tonic-clonic seizures. The nurse would perform which actions in order to protect the child from injury? Select all that apply.*

** Rationale: Attempting to place something in a child's mouth during a seizure is not helpful even if it is padded. The mouth is usually clenched, and one would have to use force to open the mouth. One must attempt to keep the airway clear, which can be done through positioning the client on the side. Keeping the hospital lights on is not helpful in preventing a seizure and can provide unnecessary stimulation, and keeping side rails and other hard objects padded safeguards the client's physical safety. Restricting the client's fluid intake is not necessary and can be harmful.

*Question: The nurse would prepare to give a prescribed oxytocic medication after delivery of which?*

*Answer: Placenta* Rationale: Oxytocics are administered because they stimulate the uterus to contract, thereby helping prevent hemorrhage after the placenta is expelled. If an oxytocic medication is prescribed, the nurse administers the medication after placental delivery.

*Question: The school nurse prepares a list of home care instructions for the parents of school children who have been diagnosed with pediculosis capitis (head lice). Which would be included in the list? Select all that apply.*

** Rationale: Bedding and linens should be washed with hot water and dried on a hot setting. Thorough home cleaning is necessary to remove any remaining lice or nits. Siblings may need to be treated, and combs and brushes may need to be discarded or soaked in boiling water for 10 minutes. Antilice sprays are unnecessary. Additionally, they should never be used on bedding, furniture, or a child. The pediculicide product needs to be used as prescribed, and the parents are instructed to follow package instructions for timing the application and for contraindications for their use in children.

*Question: A client in pulmonary edema has a prescription to receive morphine sulfate intravenously. The licensed practical nurse assisting in caring for the client determines that the client experienced an intended effect of the medication if which is noted?*

*Answer: Relief of apprehension* Rationale: Morphine sulfate reduces anxiety and dyspnea in the client with pulmonary edema. It also promotes peripheral vasodilation and causes blood to pool in the periphery. It decreases pulmonary capillary pressures, which reduces fluid migration into the alveoli. The client receiving morphine sulfate is monitored for signs and symptoms of respiratory depression and extreme drops in blood pressure, especially when administered intravenously. Options 1, 3, and 4 are unrelated to the action of morphine sulfate.

*Question: A client with no history of heart disease has experienced an acute myocardial infarction and been given thrombolytic therapy with tissue plasminogen activator (tPA). The nurse interprets that the client is likely experiencing a complication of this therapy if which occurs?*

*Answer: Tarry stools* Rationale: Thrombolytic agents are used to dissolve existing thrombi, and the nurse must monitor the client for obvious or occult signs of bleeding. This includes assessment for obvious bleeding within the gastrointestinal (GI) tract, urinary system, and skin. It also includes testing secretions for occult blood. Option 1 is the only option that indicates the presence of blood Orange-colored urine is associated with administration of the antibiotic rifampin. Orange-colored urine, nausea and vomiting, and decreased urine output are not complications associated with administration of tPA.

*Question: The nurse assisting in the care of a woman in labor should focus primarily on which client at the time of delivery?*

*Answer: Newborn* Rationale: The nurse's primary responsibility at the time of delivery is focused on the infant. The primary health care provider is primarily responsible for the care of the mother. The support persons are responsible for themselves.

*Question: Enoxaparin sodium is prescribed for the client following hip replacement surgery. The nurse prepares to have which available in the event that an overdose of the medication occurs?*

*Answer: Protamine sulfate* Rationale: Enoxaparin sodium is a low molecular weight heparin anticoagulant. Accidental overdose of this medication may lead to bleeding complications. The antidote is protamine sulfate. Naloxone is the antidote for opioids. Phytonadione is the antidote for warfarin sodium. Epinephrine is used to treat hypersensitivity reactions or acute bronchial asthma attacks and bronchospasms.

*Question: The nurse is collecting data on a newborn infant with a diagnosis of a hiatal hernia. Which findings would the nurse expect to note in the infant? Select all that apply.*

** Rationale: Clinical signs/symptoms associated with hiatal hernia specifically include vomiting, coughing, wheezing, short periods of apnea, and failure to thrive. Excessive oral secretions are a clinical manifestation of esophageal atresia and tracheoesophageal fistula. Bowel sounds heard over the chest are a clinical manifestation associated with a congenital diaphragmatic hernia. Hiccupping and spitting up after a meal is a clinical manifestation of gastroesophageal reflux.

*Question: The nurse is talking with a client with angina about factors that can precipitate an angina attack. Which statement by the client indicates an understanding of the precipitating events?*

*Answer: "I will pay my neighbor to shovel my snow this winter."* Rationale: Excessive exertion and cold frequently trigger angina attacks. Having the neighbor shovel snow will prevent the client from exertion in cold weather. Electronic cigarettes contain nicotine, which causes vasoconstriction.

*Question: The nurse has reinforced dietary instructions to the mother of a child with celiac disease. The nurse determines that the mother understands the dietary instructions if she indicates eliminating which products? Select all that apply.*

** Rationale: Dietary management is the mainstay of treatment for the child with celiac disease. Because gluten occurs mainly in the grains of wheat and rye, but also in smaller quantities in barley and oats, these four foods are eliminated. Corn, rice, and millet are substitute grain foods.

*Question: The nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary in order to control disease progression. Which statements by the client indicate a need for further teaching? Select all that apply.*

** Rationale: Exercise is most effective when done at least 3 times a week for 20 to 30 minutes to reach a target heart rate. Other healthy habits include limiting salt and fat in the diet and using stress management techniques. The client also should be taught to take nitroglycerin before any activity that causes pain, and to take the medication at the first sign of chest discomfort. Electronic cigarettes contain nicotine, which causes vasoconstriction.

*Question: A client who has undergone a subtotal gastrectomy is being prepared for discharge. Which considerations concerning ongoing self-management would the nurse reinforce to the client? Select all that apply.*

** Rationale: Following gastric surgery, the client should eat smaller, more frequent meals to facilitate digestion. Fluids should be taken between meals, not with them, to avoid dumping syndrome. The client should resume activity gradually and should minimize stressors to prevent recurrence of symptoms. The client requires ongoing medical supervision and evaluation.

*Question: The nurse collecting data on a client during the second stage of labor notes a slowing of the fetal heart rate (FHR) with a loss of variability and determines that these are indicators of possible complications. Which priority interventions would the nurse perform?*

*Answer: Turn client to her side and administer oxygen by mask at 8 to 10 L/min.* Rationale: Prompt treatment must be initiated when the FHR begins to slow or a loss of variability is identified during labor. To facilitate oxygenation of the mother and fetus, the mother is turned to her side to reduce uterine pressure on the ascending vena cava and descending aorta. The greater flow rate for oxygen is also indicated.

*Question: The nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. The nurse plans to reinforce which information about this type of angina when teaching the client?*

*Answer: Prinzmetal's angina is generally treated with calcium channel blocking agents.* Rationale: Prinzmetal's angina results from spasm of the coronary arteries and is generally treated with calcium channel blocking agents. The risk factors are unknown, and this type of angina is relatively unresponsive to nitrates. Beta blockers are contraindicated because they may actually worsen the spasm. Diet therapy is not specifically indicated, although a healthy diet consuming foods low in fat and sodium is advocated in cardiac disease.

*Question: The nurse is caring for a client with a Sengstaken-Blakemore tube. To effectively prevent ulceration and necrosis of oral and nasal mucosa, the nurse would plan to implement which action?*

*Answer: Provide frequent oral and nasal care on a regular basis.* Rationale: Frequent oral and nasal care is necessary to prevent irritation to the mucosa. A family member's presence will not prevent this from occurring, nor will the actions taken in options 1 and 2. Keeping scissors at the bedside is a good action; however, these are used to cut the tube if the client begins to have airway maintenance problems.

*Question: A client has been started on cyclobenzaprine for the management of muscle spasms in the cervical spine. The client is experiencing drowsiness, dizziness, and dry mouth. The nurse interprets these signs/symptoms as which response?*

*Answer: These are the common side effects of this medication.* Rationale: Drowsiness, dizziness, and dry mouth are the most common side effects of cyclobenzaprine. This medication is a centrally acting skeletal muscle relaxant used in the management of muscle spasm that accompanies a variety of conditions. The other responses are incorrect.

*Question: An older client complains of chronic constipation. Which instructions would the nurse reinforce with the client? Select all that apply.*

** Rationale: Increase of fluid intake and dietary fiber will help change the consistency of the stool and make it easier for the client to pass. Clients should respond to the feeling of peristalsis involved with the urge to defecate. Some older clients with mobility issues may not respond to the urge. Increasing the intake of rice and bananas will increase constipation. Increasing sugar-free products and potassium in the diet will not be beneficial to the client.

*Question: A preschool child who was admitted to the hospital for a minor surgery develops a rash on the second day after hospitalization and is diagnosed with chicken pox (varicella). The nurse would take which action to provide safety for all children on the unit?*

*Answer: Place the infected child and any immunocompromised children in isolation.* Rationale: The period of communicability for chicken pox is 1 day before the eruption of vesicles to about 1 week, when crusts are formed. The infected child should be isolated until vesicles have dried, and other high-risk children (immunocompromised) should be isolated from the infected client.

*Question: A pediatric nurse is caring for a hospitalized toddler. The nurse determines that which play activity would be appropriate for the toddler?*

*Answer: Playing with a push-pull toy* Rationale: The toddler has increased use of motor skills and enjoys manipulating small objects such as toy people, cars, and animals. Push-pull toys are appropriate for this age. Listening to music is most appropriate for an adolescent. Playing peek-a-boo is most appropriate for an infant. Hand sewing a picture is most appropriate for a school-age child.

*Question: The nurse would reinforce instructions to a client that has had a gastrectomy about the signs and symptoms of pernicious anemia, knowing what information?*

*Answer: Regular monthly injections of vitamin B12 will prevent this complication.* Rationale: Vitamin B12 deficiency occurs from the lack of intrinsic factor normally secreted by specialized cells in the gastric mucosa. Replacement therapy is given by the parenteral route. Symptoms generally occur within 5 years or less. Although not fatal, pernicious anemia can contribute to many other diseases. Not all diets are deficient in all of the B vitamins.

*Question: A client is receiving an enteral feeding that delivers 1.5 calories/mL. The feeding is infusing at 30 mL/hr via a feeding pump. What is the maximal amount of calories the client should receive in an 8-hour period if the tube feeding is not interrupted? Fill in the blank.*

** Rationale: Rationale not found

*Question: A client is to receive 1000 mL of 5% dextrose in water at a rate of 125 mL/hr. The drop (gtt) factor is 10 drops (gtts)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.*

** Rationale: Rationale not found

*Question: A client originally was prescribed oral sertraline 25 mg daily for depression. The dose has been gradually increased in an effort to control the symptoms. The current dose is 75 mg daily. The medication label reads 25 mg/tablet. To receive the correct dose, the nurse instructs the client to take how many tablets once daily? Fill in the blank.*

** Rationale: Rationale not found

*Question: A client with a major burn is admitted to the emergency department. In priority order, which actions would the nurse take? Arrange the actions in the order that they should be used. All options must be used.*

** Rationale: Rationale not found

*Question: The nurse has assisted with the insertion of a Levin tube for gastrointestinal (GI) decompression in a client with a bowel obstruction. Which settings would the nurse anticipate to be prescribed by the primary health care provider? Select all that apply.*

** Rationale: A Levin tube has no air vent, and the suction must be placed on a low and intermittent setting to prevent trauma to the gastric mucosa. A Salem sump tube allows for continuous suction because of the presence of an air vent on that tube. Low suction pressure is safer for the stomach than high pressure.

*Question: Which types of nourishment would the nurse include when initiating a prescribed clear liquid diet for a postoperative client who has a gag reflex after surgery under general anesthesia? Select all that apply.*

** Rationale: A clear liquid diet includes fluids or frozen fluids that are clear at room temperature. These food sources are easy to digest and less likely to cause vomiting in a postoperative client. The nurse should assess for the return of the gag reflex first before initiating any oral intake. Coffee, ice chips, beef broth, plain tea, and gelatins are included in a clear liquid diet. Dairy products such as milk or yogurt are included in a full liquid diet.

*Question: The nurse is preparing a client for a right below-the-knee amputation. The nurse anticipates that the client is likely to experience which psychosocial problems in the perioperative period? Select all that apply.*

** Rationale: A client facing an elective amputation of a lower extremity will experience psychosocial as well as physical challenges during the perioperative period. The client is likely to experience grief because of the loss of the extremity as well as an alteration in body image. The client will also experience anxiety since this will be a new experience and life as an amputee is unknown. Pain is a physical problem influenced by psychosocial factors. There are no data in the question to support a problem of anger.

*Question: A client with a diagnosis of lung cancer returns to the nursing unit after a left pneumonectomy. Which nursing actions would be done? Select all that apply.*

** Rationale: A client with a pneumonectomy can be turned slightly and supported with a pillow, but complete lateral positioning is contraindicated because of pressure on the bronchial stump or shifting of mediastinal contents. In addition, the surgeon's prescription for positioning is always checked and followed. The client needs to receive oxygen and use an incentive spirometer to prevent atelectasis in the remaining lung. Vital signs and pulse oximetry need to be monitored frequently. The client should not be placed in respiratory isolation to prevent infection; this is unnecessary.

*Question: The nurse is reviewing the laboratory results and physical examination of a client with acute glomerulonephritis. Which data would the nurse see? Select all that apply.*

** Rationale: A client with acute glomerulonephritis usually becomes suddenly ill with fever, chills, flank pain, widespread edema, puffiness around the eyes, visual disturbances, and marked hypertension. Diagnosis is based on physical findings. Presence of marked hypertension is a late manifestation. Diagnostic tests include urinalysis, creatinine, blood urea nitrogen (BUN), and complete blood count (CBC). The urine may be smoky, will contain red blood cells and protein, output decreased, and will have an increased specific gravity. Serum creatinine and BUN levels rise above normal. If the condition is severe, hematocrit and hemoglobin will indicate anemia.

*Question: The nurse is caring for a client who just been prescribed alendronate. Which conditions contraindicate this medication being given to the client? Select all that apply.*

** Rationale: A client with hypocalcemia, poor renal function, and gastroesophageal reflux disease (GERD) should not take alendronate. Alendronate is a bisphosphonate. The other conditions do not prevent a client from taking alendronate.

*Question: A client is being advanced to a full liquid diet on the second postoperative day. Which foods are allowed for this client? Select all that apply.*

** Rationale: A full liquid diet consists of the foods on a clear liquid diet plus the addition of smooth dairy products, cream soups, and refined cooked cereals. The client's diet would include tea, ice cream, cream of tomato soup, and cream of wheat cereal. Crackers are on a regular diet. Scrambled eggs are included in a pureed diet.

*Question: A client is scheduled for a myelogram, and the nurse reinforces a list of instructions to the client regarding preparation for the procedure. Which instructions would the nurse include in the list? Select all that apply.*

** Rationale: A myelogram is a diagnostic test that consists of contrast media being injected into the subarachnoid space to determine any pathology of the spine and vertebral column. The client will need to remove jewelry and metal objects from the chest area. An informed consent is required because the procedure is invasive and is therefore performed by the primary health care provider. Increased intake of nonalcoholic fluids is encouraged afterward to prevent any headache after the procedure. A health care professional such as a radiologist, neurologist, or specialized nurse practitioner will perform the test. 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. The client is also told that pretest medications may be prescribed for relaxation. Myelogram is used less frequently as a diagnostic tool since the advent of magnetic resonance imagi

*Question: The nurse is caring for a client with a nasogastric tube in place for gastric decompression. The gastroenterologist prescribes to have the tube irrigated once every 8 hours. Select the correct interventions the nurse would utilize in performing this procedure. Select all that apply.*

** Rationale: A nasogastric tube is usually a Salem sump tube that is inserted through the naris with the end of the tube in the stomach. The tube is connected to low suction to remove gastric secretions and rest the bowel. Irrigation is done to maintain patency of the tube. Normal saline is used to limit loss of electrolytes. The usual amount is 30 mL injected through the tube, not the air vent, and then aspirated back into the syringe. The nurse should follow aseptic technique wearing clean gloves, not sterile technique. The client's serum electrolyte results do not need to be monitored since normal saline is the correct solution for irrigation.

*Question: The nurse is caring for a client with cirrhosis who is experiencing fluid overload. The nurse would determine that this problem is resolving if which data are obtained? Select all that apply.*

** Rationale: A sign that fluid overload is resolving is loss of body weight and a decrease in the abdominal girth. The client with cirrhosis with resolving fluid overload will have less ascites. Assessment findings associated with excess fluid volume include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, elevated central venous pressure, weight gain, edema, neck and hand vein distention, altered level of consciousness, decreased urine output, and a decreased hematocrit. These symptoms must reverse if the fluid overload is to be resolved.

*Question: A client has been prescribed acarbose for treatment of diabetes mellitus. Client teaching regarding this medication would include which instructions? Select all that apply.*

** Rationale: Acarbose (an alpha-glucosidase inhibitor) inhibits digestion and absorption of carbohydrates, and thereby reduces the postprandial rise in blood glucose. To be effective, the medication must be taken with each meal; a full glass of water alone is not enough sustenance. The major adverse effects of acarbose are gastrointestinal disturbances including flatulence, cramps, and abdominal distention. Fatty stools are seen in the client with cystic fibrosis; this is not a side effect of acarbose. Dizziness is an adverse effect and may be a sign of hypoglycemia; it is not an expected side effect of acarbose.

*Question: Which diagnostic tests indicate active tuberculosis? Select all that apply.*

** Rationale: Active tuberculosis is diagnosed by a chest x-ray, sputum smear, and sputum culture. A diagnosis of active TB is established when the tubercle bacillus has been found in the sputum or gastric washings. Interferon gamma release assays (IGRA) is a diagnostic aid that measures a component of cell-mediated immune reactivity to M. tuberculosis much like the tuberculin skin testing. These test results indicate a need for further evaluation.

*Question: The nurse is caring for a client with Addison's disease. The diagnosis is supported by which noted data? Select all that apply.*

** Rationale: Addison's disease is a decreased secretion of the adrenal cortex. Signs and symptoms include orthostatic hypotension, decreased body hair, weight loss, skin hyperpigmentation, and progressive weakness.

*Question: What is included in the treatment of Addison's disease? Select all that apply.*

** Rationale: Addison's disease is treated with replacement therapy to provide the missing hormones, but the patient must continue taking the hormones as lifelong therapy. Prednisone is given to replace glucocorticoids; fludrocortisone is a synthetic adrenocortical steroid to replace the mineralocorticoid aldosterone. Cushing's syndrome treatment includes drug therapy, radiation, and surgery. Bilateral benign tumors more often are treated with an aldosterone antagonist agent (i.e., a drug that reduces aldosterone secretion or blocks its effects such as potassium-sparing diuretic spironolactone.

*Question: Which nursing actions should decrease the discomfort of an episiotomy? Select all that apply.*

** Rationale: After 24 hours, a sitz bath increases circulation and promotes healing. The sitz bath may circulate either cool or warm water over the perineum to cleanse the area and increase comfort. An ice pack is applied for the first 12 to 24 hours to reduce edema and bruising and numb the perineal area. The administration of oxytocin occurs after the third stage of labor to increase uterine contraction. Kegel exercises may be resumed immediately after birth but their purpose is to strengthen perineal muscles. The client is taught to do perineal care after each voiding or bowel movement to cleanse the area without trauma.

*Question: The nurse is caring for a client with a multilumen catheter and is monitoring for signs of an air embolism. Which signs and symptoms would be noted in this complication? Select all that apply.*

** Rationale: All clients with intravenous lines are at risk for air embolism. Because an air embolism can be life threatening, it is essential that the nurse monitor for the presence of chest pain, coughing, hypotension, cyanosis, and hypoxia. In addition, if the client does have an air embolism, auscultation over the right ventricle may reveal a churning "windmill" sound.

*Question: The nurse is completing the laboratory requisition that will accompany an arterial blood gas (ABG) specimen sent to the laboratory for analysis. The nurse understands that which data will be needed by the laboratory for adequate evaluation of the specimen? Select all that apply.*

** Rationale: An ABG requisition usually contains information about the date and time the specimen was drawn, the client's temperature, whether the specimen was drawn with the client using room air or using supplemental oxygen, and the ventilator settings if the client is on a mechanical ventilator. A list of the client's allergies is not a necessary piece of information required for analysis of the specimen.

*Question: A client with cancer is receiving cisplatin. Which findings indicate that the client is experiencing an adverse effect of the medication? Select all that apply.*

** Rationale: An adverse effect related to the administration of cisplatin, an antineoplastic medication, is ototoxicity with hearing loss. Tinnitus or ringing in the ears is associated with this ototoxicity. The nurse should monitor for this adverse effect when administering this medication. Increased appetite, frequent urination, and seeing yellow halos around objects are not adverse effects of this medication.

*Question: A client with sickle cell anemia is being treated for sickle cell crisis. The primary health care provider prescribes morphine sulfate 2 mg. The concentration of the vial is 10 mg/mL of solution. How many milliliters of solution would the nurse administer? Fill in the blank. Record the answer to one decimal place.*

** Rationale: Rationale not found

*Question: Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply.*

** Rationale: An eye patch or shield is applied to protect the eye and prevent any further detachment. Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment. Positioning, activity restrictions, and eye patches hinder the client in the performance of activities of daily living, and the client needs the nurse's assistance with these activities. Eye medications are prescribed postoperatively, and hemorrhage is also a postsurgery risk. Coughing is not encouraged because this can increase intraocular pressure and harm the client.

*Question: A client with a peripheral intravenous (IV) site calls the nurse to the room and tells the nurse, "The IV is not running right." Which findings would indicate an infiltrated IV? Select all that apply.*

** Rationale: An infiltrated IV is one that has dislodged from the vein, and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result 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. The other options indicate phlebitis.

*Question: A client is admitted to a psychiatric unit for observation following severe anxiety attacks. On admission, the client states, "There's nothing wrong with me. I shouldn't even be here. I am taking up a room, and there is probably someone else who really needs it." Although the nurse interprets this response as denial, which findings support a severe level of anxiety? Select all that apply.*

** Rationale: As anxiety progresses to severe levels, an individual's ability to think clearly and to solve problems becomes progressively impaired. Common physical signs/symptoms of anxiety are increased heart rate, elevated blood pressure (BP), sweaty palms, trembling, urinary frequency, diarrhea, a tight sensation in the chest, and difficulty breathing. A person in a panic state may misperceive surrounding events altogether and may react.

*Question: A client asks the nurse to describe how her baby is developing at 12 weeks gestation. Which milestones would the nurse identify as present at this time? Select all that apply.*

** Rationale: At the end of the 12th week, the fetus' sex is recognizable, blood is forming in the bone marrow, and the kidneys are able to secrete urine. The fetus cannot hear until approximately 24 weeks, and the testes do not descend into the scrotum until approximately 30 weeks.

*Question: The nurse is caring for a client who is receiving an intermittent feeding via a nasogastric (NG) tube. Before feeding the client via the NG tube, the nurse would take which actions? Select all that apply.*

** Rationale: Before administering the feeding, the nurse checks the placement of the tube by aspirating gastric contents and measuring the pH. In order to prevent aspiration while administering a tube feeding, the nurse should place the client in an upright sitting position or elevate the head of the bed at least 30 degrees. Formulas are administered at room temperature. Checking the client's temperature and administering medications is not related to the tube feeding procedure.

*Question: A client experiences an episode of Bell's palsy and complains about increasing clumsiness. The nurse would prepare the client for which diagnostic study (studies) to determine the cause of the complaints? Select all that apply.*

** Rationale: Bell's palsy can be caused by inflammation or a lesion of the facial nerve, and when the client presents with both Bell's palsy and increasing clumsiness, the health care team suspects more diffuse central nervous system lesions. The client should be referred to a neurologist or otolaryngologist as soon as possible to exclude other neurologic conditions. The most sensitive and specific tests that provide relevant diagnostic information for these types of pathology are cerebral angiography, LP, and computed tomography (options 2, 3, 6). The imaging studies illustrate central nervous system lesions, and the LP enables the care provider to analyze cerebrospinal fluid for immunoglobulins (antibodies) and other components. Because the client's neurological problem is unlikely to be metabolic, the sodium level is unlikely to be helpful (option 1). Usually electroencephalogram and oculovestibular reflex are tests reserved to evaluate electrical activity of the brain in seizure

*Question: The nurse is caring for a postoperative client who is wearing an abdominal binder following abdominal surgery. Which interventions would the nurse include in relationship to prescribed dressing change? Select all that apply.*

** Rationale: Binders are large bandages often made of elastic materials that attach together with Velcro and are applied over the abdominal dressing. After abdominal surgery, a binder is used to relieve tension from the suture line and provide support. This maintains the integrity of the incision, helps prevent dehiscence and wound evisceration, and thereby helps prevent infection. Using a binder, however, can hinder chest expansion, promote shallow breathing, and aggravate residual atelectasis and risk of pneumonia from surgery. The client is instructed to sit up to facilitate diaphragmatic excursion and to splint the incision for client comfort and suture line protection while coughing, deep breathing, and using the incentive spirometer. The binder is removed while the client is supine to have the dressing changed and then reapplied. The binder should be worn while the client ambulates. The binder can be removed when the primary health care provider is not present. The binder is ap

*Question: The nurse is caring for a client following an abdominal surgery performed 1 day ago. An intravenous (IV) line is infusing, and a nasogastric (NG) tube is in place and attached to low intermittent suction. The nurse monitors the client and notes that the bowel sounds are absent. The nurse would perform which actions? Select all that apply.*

** Rationale: Bowel sounds may be absent for 3 to 4 postoperative days owing to bowel manipulation during surgery. Passing flatus is another way to determine whether peristalsis is occurring postoperatively. The nurse should document the finding and continue to monitor the client. The suction is not increased on the NG tube, and the client should receive nothing by mouth (NPO) until after the onset of bowel sounds. There is no need to immediately notify the registered nurse.

*Question: The nurse is reviewing the health care record of a pregnant client at 16 weeks of gestation. Which assessment findings are most likely present at this time? Select all that apply.*

** Rationale: By 16 weeks gestation, fetal heart tones can be heard by Doppler and Braxton Hicks contractions may be felt by the mother. At this time, the fundus reaches midway between the symphysis pubis and the umbilicus. Blood pressure during pregnancy should not reach 140/90 at any point in the pregnancy. At 20 weeks, the fundus is located at the umbilicus.

*Question: The nurse is attending an in-service education session on the therapeutic use of calcium-channel blockers. The instructor of the session determines that teaching has been effective when the nurse correctly identifies that these medications are used for which disorders? Select all that apply.*

** Rationale: Calcium-channel blockers are medications that prevent calcium ions from entering cells. These agents have their greatest effects on the heart and blood vessels. They are used widely to treat hypertension, angina pectoris, and cardiac dysrhythmias. They are not used to treat glaucoma, acute kidney injury, or glomerulonephritis.

*Question: A client is admitted to the emergency department with carbon monoxide poisoning. Which signs and symptoms indicate carbon monoxide poisoning? Select all that apply.*

** Rationale: Carbon monoxide poisoning results from a buildup of carboxyhemoglobin. Evaluate for early signs and symptoms of carbon monoxide poisoning, which include headache and shortness of breath with mild exertion. Dizziness, nausea, vomiting, and mental changes appear next. As the amount of carbon monoxide in the bloodstream rises, the victim loses consciousness and develops cardiac and respiratory irregularities. A victim usually dies when the carbon monoxide bound with hemoglobin exceeds 70%. Although a cherry-red skin color is a clear indicator of carbon monoxide poisoning, skin color is often found to be pale or bluish with reddish mucous membranes. In carbon monoxide poisoning, the readings of pulse oximetry and the values of arterial blood gases can appear normal despite significant toxic exposure.

*Question: The nurse is admitting a client to the hospital who has been scheduled for gastrointestinal (GI) surgery later in the day. When asking the client whether the client has taken any scheduled or over-the-counter medications in the past 24 hours, which statements would concern the nurse? Select all that apply.*

** Rationale: Clients who are scheduled for GI surgery will be instructed by their primary health care provider or surgeon at least 2 weeks before surgery to stop any medications that can cause bleeding tendencies. Abnormal bleeding during surgery can place the client at risk for adverse surgical complications and increase the need for blood transfusions. Medications that are prescribed to lower the blood pressure may cause problems with anesthesia. The nurse should make sure the surgeon is aware that the client has taken an aspirin and the blood pressure medication. Adjustments may be made in the medications administered during surgery. A multiple vitamin taken the day before, stopping medications as prescribed, and taking the prescribed bowel preparation medications are not concerns that the nurse needs to report.

*Question: The nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply.*

** Rationale: Clients who produce excessive acid, under produce bicarbonate, or overly eliminate bicarbonate develop metabolic acidosis. Clients with malnourishment, diabetes mellitus, and status epilepticus produce excessive acids leading to metabolic acidosis. Clients with pancreatitis under produce bicarbonate and develop metabolic acidosis. Clients with severe prolonged diarrhea develop metabolic acidosis due to the over elimination of bicarbonate. The client with asthma could develop an acid-base imbalance from a respiratory problem.

*Question: The nurse is caring for an infant with a diagnosis of Hirschsprung's disease. The nurse would check for which clinical findings that are consistent with Hirschsprung's disease? Select all that apply.*

** Rationale: Clinical symptoms of Hirschsprung's disease during infancy include failure to thrive, constipation, abdominal distention, episodes of diarrhea and vomiting, signs of enterocolitis, explosive and watery diarrhea, and fever. The infant appears significantly ill. Intolerance to wheat occurs in celiac disease.

*Question: The nurse is assisting in preparing a client for discharge to home. Daily cold therapy has been prescribed for the client, and the nurse reinforces instructions about this treatment. Which client statements indicate adequate understanding of cold therapy treatment? Select all that apply.*

** Rationale: Cold therapy is useful to relieve pain and edema. The cold compress should be removed if numbness occurs and should never be directly applied to the area. The cold should be wrapped in a towel. Cold therapy should be used for only 15 to 20 minutes, 2 or 3 times a day. The client needs to be instructed not to place ice directly between the skin and a firm surface. The weight of the body and the low temperature of the ice may produce ischemia. The skin should be checked for signs of injury. The frozen ice pack is taken from the freezer and should be wrapped in a towel to help the client adjust to the cold.

*Question: The nurse is reviewing the medical record of a client diagnosed with conjunctivitis. Which signs and symptoms would the nurse expect to be noted? Select all that apply.*

** Rationale: Conjunctivitis is an infection of the conjunctiva of the eye. Signs and symptoms include pain or discomfort, increased tearing, itching, redness, and sometimes a sensation of a foreign object in the eye.

*Question: The nurse is caring for a client who was recently admitted to the inpatient unit of a psychiatric hospital with a diagnosis of delusions. Which are some therapeutic communication interventions the nurse needs to use when communicating with this client? Select all that apply.*

** Rationale: Delusions are false fixed beliefs that cannot be corrected by reasoning. Most commonly, delusional thinking involves themes or ideas of reference, persecution, grandiosity, jealousy, and control. The most common types of hallucinations are auditory, visual, olfactory, and tactile. The nurse needs to refer to the hallucinations as if they are real. The nurse would also ask the client directly about the hallucinations. For example: "What are you hearing?" The nurse also needs to watch the client for cues that he or she is hallucinating, such as eyes tracking an unheard speaker, and address any underlying emotion, need, or theme indicated by the hallucination. The nurse would focus on reality-based, "here-and-now" activities such as conversations or simple projects, and would encourage, not discourage, the use of competing auditory stimuli such as listening to music through headphones.

*Question: The nurse is collecting data about how well a client diagnosed with a gastrointestinal (GI) disorder is able to digest food. The nurse determines that which processes are involved in the complete digestive process? Select all that apply.*

** Rationale: Digestion is the mechanical and chemical process involving the breakdown of foods. Absorption is the transfer of digested food elements into the bloodstream. The blood then carries nutrients to the cells. Active transport is the process used to transfer nutrients into the cells. Options 1 and 3 are incorrect.

*Question: The nurse is reviewing laboratory results of a digoxin level for the client taking digoxin. The digoxin level is 2.5 ng/mL, which indicates digoxin toxicity. Which signs and symptoms would the nurse note? Select all that apply.*

** Rationale: Digoxin has a narrow therapeutic range. The therapeutic range is 0.8 to 2 ng/mL. Drug levels higher than the therapeutic level greatly increase the risk of toxicity. Classic symptoms of digitalis toxicity are yellow-green halos around lights, nausea, diarrhea, and confusion

*Question: Which information would the nurse provide to the client who will be receiving chemotherapy with doxorubicin? Select all that apply.*

** Rationale: Doxorubicin causes cardiotoxicity, and the client should be monitored for this adverse effect. It also causes alopecia and causes the urine and sweat to turn red. It is administered by the intravenous route. Because of its vesicant properties, doxorubicin can cause severe local injury if extravasation occurs. Bone marrow suppression can occur, and the client should report signs of this adverse effect to the primary health care provider or caregiver. Stool turns white in disorders that block bile secretion, such as cholelithiasis; this does not occur with chemotherapeutic agents.

*Question: The nurse is monitoring a client who sustained a head injury and suspects that the client has a skull fracture. This conclusion is based on which findings? Select all that apply.*

** Rationale: Drainage from the ear or nose (clear or pink-tinged) is an indicator of the presence of cerebrospinal fluid (CSF), which could be leaking as a result of the skull fracture. Bruising around the eyes (raccoon sign) is also an indicator of basilar skull fractures. Tachycardia, coughing, and lower back pain are not associated specifically with skull fractures.

*Question: The nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions would the nurse anticipate to be prescribed? Select all that apply.*

** Rationale: During the preoperative period, enemas or laxatives should not be administered. In addition, heat should not be applied to the abdomen. Any of these interventions can cause the rupture of the appendix and resultant peritonitis. Intravenous fluids would be started, and the child should receive nothing by mouth while awaiting surgery. Antibiotics are usually administered because of the risk of perforation. Preoperative medications are administered as prescribed.

*Question: A 4-year-old child sustains a fall at home injuring the right arm and is brought to the emergency department by the mother. The nurse would perform which emergency actions in the care of the child? Select all that apply.*

** Rationale: Emergency nursing actions to take for a child sustaining an extremity fracture include elevating the injured extremity, checking the extent of the injury including pain level, immobilizing the affected extremity, applying cold packs to the injured area, and monitoring the neurovascular status of the extremity.

*Question: The nurse is teaching a prenatal class on the anatomy and physiology of the female reproductive system including hormones. Estrogen produces which effects, either directly or indirectly, during pregnancy? Select all that apply.*

** Rationale: Estrogen increases the blood flow to the uterine blood vessels. It stimulates the development of the breast ducts in preparation for lactation. It also increases vascular changes in the skin and the mucous membranes of the nose and mouth. It also increases, rather than decreases, salivation. Estrogen also increases skin pigmentation, which accounts for the "mask of pregnancy."

*Question: The nurse is preparing to teach a pregnant client about the warning signs in pregnancy and prepares a list of the warning signs that indicate the need to notify the primary health care provider. Which warning signs would the nurse place on the list? Select all that apply.*

** Rationale: Facial or generalized edema, rapid weight gain, and visual disturbances are warning signs in pregnancy. Nausea upon arising is a common discomfort of pregnancy. Braxton Hicks contractions are the normal, regular, painless contractions of the uterus that may occur throughout the 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.

*Question: A client is in the first stage of labor. Which nursing actions are implemented in the first stage of labor? Select all that apply.*

** Rationale: Failure to empty the urinary bladder can lead to rupture of the urinary bladder, or it can prevent effective contractions, thereby restricting the progress of labor. Maternal and fetal assessments are critical to determine the progress of labor and the safety of the mother and fetus. Breathing and relaxation techniques are reviewed during the latent phase and encouraged during the active phase. The client should be allowed lollipops to hold and suck on between contractions for carbohydrate and fluid intake. The client may take showers.

*Question: A client presents at her primary health care provider's office 10 weeks pregnant with her first pregnancy. Which are presumptive signs of pregnancy that the client might be expected to have? Select all that apply.*

** Rationale: Fatigue, breast changes, nausea and vomiting, and amenorrhea are presumptive signs of pregnancy. Chadwick's sign, a bluish discoloration of the vagina and cervix, is a probable sign. Pigmentation changes of the face are not a sign of pregnancy, although they may occur with pregnancy.

*Question: The nurse in the emergency department is preparing to instill fluorescein into the eye of a client with the complaint of eye pain. Fluorescein dye is used to detect which conditions? Select all that apply.*

** Rationale: Fluorescein is a water-soluble dye that produces an intense green color. This agent is applied to the surface of the eye to detect lesions of the corneal epithelium; intact areas of the cornea remain uncolored but abrasions and other defects turn bright green. The dye will also collect around a foreign object

*Question: The nurse is told in a report that a client has a positive Chvostek's sign. Which other data would the nurse expect to find on data collection? Select all that apply.*

** Rationale: Focus on the subject, a positive Chvostek's sign, which is indicative of hypocalcemia. Other signs and symptoms include tachycardia, hypotension, paresthesias, twitching, cramps, tetany, seizures, positive Trousseau's sign, diarrhea, hyperactive bowel sounds, and a prolonged QT interval.

*Question: The nurse develops a plan of care for a client following a lumbar puncture. Which interventions would be included in the plan? Select all that apply.*

** Rationale: Following a lumbar puncture, the client remains flat in bed for 6 to 24 hours, depending on the primary health care provider's prescriptions. A liberal fluid intake (not NPO status) is encouraged to replace cerebrospinal fluid removed during the procedure, unless contraindicated by the client's condition. The nurse checks the puncture site for redness and drainage and monitors the client's ability to void and move the extremities.

*Question: The nurse is assigned to care for a client who has just returned to the nursing unit following a renal biopsy. The nurse plans to do which actions to properly care for this client for the remainder of the shift? Select all that apply.*

** Rationale: Following renal biopsy, serial urine samples are tested for occult blood. The urine should be observed for frank hematuria and the biopsy site for edema and bleeding. Fluids are encouraged to flush the kidney. Opioid analgesics are often used to manage the renal colic pain that some clients feel after this procedure. The nurse ensures that the client remains in bed for at least 24 hours or as prescribed. The nurse also frequently checks the client's vital signs and puncture site.

*Question: The nurse is assisting in preparing a list of instructions for a client who is being discharged following a tonsillectomy. Which instructions would the nurse include in the list? Select all that apply.*

** Rationale: Following 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 can hurt the surgical site. Rough foods and snacks such as raw fruits or vegetables should be avoided for 10 days to protect the scab that forms over 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.

*Question: The nurse is assigned to care for a pregnant client being admitted to the nursing unit. Laboratory and diagnostic studies have confirmed a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse collects data on the client and reviews the results of the laboratory and diagnostic studies, knowing that which findings are associated with this diagnosis? Select all that apply.*

** Rationale: Gestational trophoblastic disease is a group of rare tumors that involve abnormal growth of cells inside a woman's uterus. The most common signs and symptoms of gestational trophoblastic disease include elevated levels of hCG, vaginal bleeding, larger than normal uterus, failure to detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting, and early development of gestational hypertension. An elevated blood pressure also should be noted.

*Question: A client is suspected of having a diagnosis of Guillain-Barré syndrome (GBS). Which findings would support a diagnosis of Guillain-Barré syndrome? Select all that apply.*

** Rationale: Guillain-Barré syndrome may affect cranial nerves resulting in visual and hearing disturbances. It is characterized by symmetrical muscle weakness that typically begins in the lower extremities and ascends to the trunk and upper extremities. Approximately 95% of patients with GBS have a nearly complete recovery. Despite all the motor and sensory changes, level of consciousness and intellectual functioning remain unchanged.

*Question: The nurse is planning care for a child with hemolytic-uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse would plan to include which interventions in the care of the child? Select all that apply.*

** Rationale: HUS is thought to be associated with bacterial toxins, chemicals, and viruses that cause acute kidney injury in children. A child with HUS who is undergoing peritoneal dialysis for the treatment of anuria will be prescribed fluid restrictions. The treatment also involves providing adequate nutrition, preventing infection, and anticipating CNS involvement, which may include seizure, stupor, and coma. Peritoneal dialysis does not require an AV fistula (only hemodialysis does).

*Question: The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. Which probable signs of pregnancy refer to the softening of the uterus and related structures? Select all that apply.*

** Rationale: Hegar's sign is a softening of the lower uterine segment. Because of the softening, it is easy to flex the body of the uterus against the cervix which is known as McDonald's sign. Goodell's sign is the softening of the cervix and the vagina caused by increased vascular congestion. Braxton Hicks contractions are irregular, painless uterine contractions that begin in the second trimester. Chadwick's sign is the purplish or bluish discoloration of the cervix, vagina, and vulva caused by increased vascular congestion.

*Question: A nursing student enrolled in a physical assessment course is asked to describe the probable signs of pregnancy. The student displays correct understanding if the student lists which signs? Select all that apply.*

** Rationale: Hegar's sign is softening of the lower uterine segment. This allows the body of the uterus to flex against the cervix, which is termed McDonald's sign. Chadwick's sign is a purple or blue discoloration of the cervix, vagina, and vulva caused by increased vascular congestion. Moro's sign is also called the startle reflex seen in normal newborns. McBurney's sign is pain in the lower right abdominal quadrant and is frequently seen in appendicitis.

*Question: The nurse assessing a client diagnosed with laryngeal cancer would note which signs and symptoms? Select all that apply.*

** Rationale: Hemoptysis, a sensation of a lump in the throat, and hoarseness lasting more than 3 weeks are common signs and symptoms of laryngeal cancer.

*Question: A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 150 mEq/L (150 mmol/L). Which interventions would the primary health care provider likely prescribe? Select all that apply.*

** Rationale: Hypernatremia is described as having a serum sodium level that exceeds 145 mEq/L (145 mmol/L). The normal serum sodium level for an adult is 135 to 145 mEq/L (135 to 145 mmol/L). Signs and symptoms would include dry mucous membranes, loss of skin turgor, thirst, flushed skin, elevated temperature, oliguria, muscle twitching, fatigue, confusion, and seizures. Interventions include monitoring fluid balance, monitoring vital signs, reducing dietary intake of sodium, monitoring electrolyte levels, and increasing oral intake of water. Sodium replacement therapy would not be prescribed for a client with hypernatremia. Hypertonic saline is prescribed for severe hyponatremia.

*Question: The nurse working on an endocrine nursing unit understands that which correct concepts are used in planning care? Select all that apply.*

** Rationale: Hyperparathyroidism is a disease that involves excess secretion of parathyroid hormone (PTH). Elevation of PTH causes excess calcium to be removed from the bones. There is a decline in bone mass, which may cause a fracture if a fall occurs. Cushing's syndrome is likely to cause hypertension. Clients with hypothyroidism must be monitored for weight gain and clients with hyperthyroidism must be monitored for weight loss. Clients who have diabetes insipidus should be assessed for fluid deficit. Before surgery, the client with pheochromocytoma may be in hypertensive crisis and require close monitoring of vital signs and administration of IV antihypertensive medications. The client should be monitored for signs of orthostatic hypotension related to medication therapy.

*Question: The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? Select all that apply.*

** Rationale: Hypoglycemia is defined as a blood glucose level less than 70 mg/dL (4 mmol/L). Hypoglycemia occurs as a result of too much insulin, not enough food, or excessive activity. If possible, the nurse should confirm hypoglycemia with a blood glucose reading. Glucose is administered orally immediately; rapid-releasing glucose is followed by a complex carbohydrate and protein, such as a slice of bread or a peanut butter cracker. An extra snack is given if the next meal is not planned for more than 30 minutes or if activity is planned. If the child becomes unconscious, cake frosting or glucose paste is squeezed onto the gums, and the blood glucose level is retested in 15 minutes; if the reading remains low, additional glucose is administered. If the child remains unconscious, administration of glucagon may be necessary, and the nurse should be prepared for this intervention. Encouraging the child to ambulate and administering regular insulin would result in a lowered blood gluco

*Question: A client has a serum sodium level of 129 mEq/L (129 mmol/L) because of hypervolemia. The nurse anticipates the primary health care provider to prescribe which measures? Select all that apply.*

** Rationale: Hyponatremia is defined as a serum sodium level of less than 135 mEq/L (135 mmol/L). Normal serum sodium levels are 135 to 145 mEq/L (135 to 145 mmol/L). When it is caused by hypervolemia, it may be treated with fluid restriction. The low serum sodium value is a result of hemodilution. The serum electrolytes will be monitored daily to determine effectiveness of treatment. There is no indication that the oral intake should be withheld from the client. Salt tablets would not be indicated because the sodium will likely increase to a normal level with the fluid restriction. A 4-g sodium diet is a no-added-salt diet. Intravenous hypertonic saline (3%) is reserved for hyponatremia when the serum sodium level is lower than 125 mEq/L (125 mmol/L).

*Question: The nurse is monitoring the respiratory status of a client following insertion of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problems? Select all that apply.*

** 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.

*Question: The nurse is assessing the skin on a client who is immobile and notes the presence of a stage 2 pressure injury in the sacral area. Which nursing actions will encourage healing of a stage 2 pressure injury? Select all that apply.*

** Rationale: In general, stages I and II pressure injuries should be cleaned with mild soap and water or normal saline. Adequate nutrients are essential to maintain or restore skin integrity. All wound covers should allow oxygen to pass through. Any kind of massage around or on a reddened area of skin can damage fragile capillaries. In addition, rubber rings should not be used to elevate heels or sacral areas. Rings cause a concentrated area of pressure that places the client at a higher risk for developing pressure ulcers.

*Question: The nurse in a prenatal clinic is teaching a group of pregnant clients about physiological adaptations during pregnancy. Which are increased during the first trimester of pregnancy? Select all that apply.*

** Rationale: In the first trimester of pregnancy the pulse increases 10 to 15 beats per minute, the blood volume increases 40% to 50%, the cardiac output increases 30% to 50%, and red blood cell mass increases 17%. Blood pressure decreases in the first half of pregnancy, returning to baseline in the second half. The white blood cell count increases in the second and third trimesters.

*Question: A client with left-sided heart failure has been admitted to the hospital. The nurse is reviewing the medical record and notes which signs and symptoms? Select all that apply.*

** Rationale: Left-sided signs and symptoms include fatigue, dyspnea, wheezing, orthopnea, sleep apnea, pulmonary edema (pink, frothy sputum), pallor, and clammy skin. Right-sided heart failure signs and symptoms include fatigue, edema in sacrum, legs, feet, ankles, hepatomegaly, abdominal distention as a result of ascites, weight gain, and dyspnea.

*Question: A client has just delivered an 8-pound 8-ounce infant boy after a prolonged labor. The pediatrician prescribes ampicillin 50 mg to be given by the intramuscular route to the newborn every 8 hours. The nurse is initiating the first dose. Ampicillin is available in powder form for injection. The directions on the bottle indicate reconstitution with 0.9 mL of sterile diluent for a concentration of 125 mg/mL. How many milliliters (mL) would the nurse prepare to administer for the first do

** Rationale: Rationale not found

*Question: The nurse is reinforcing instructions regarding the prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which points would the nurse include in the session? Select all that apply.*

** Rationale: Measures to prevent tick bites focus on covering the body as completely as possible and spraying insect repellent containing DEET on the skin and clothing. Long sleeves and pants tucked into the socks along with closed shoes will offer some protection. Light-colored clothing should be worn so that ticks would be easily visible. Hikers should not sit directly on the ground and should cover the ground with an item such as a blanket. Ticks should be removed with tweezers.

*Question: The nurse would anticipate the use of which medications in the treatment of the client with heart failure? Select all that apply.*

** Rationale: Medications recommended for treatment of heart failure include diuretics, cardiac glycosides such as digoxin, PDE inhibitors, and ACE inhibitors. Clients in heart failure do not need anticoagulants or anticholinergics.

*Question: A 16-year-old child is brought to the emergency department by his mother with a complaint that the child just experienced a tonic-clonic seizure. On arrival in the emergency department no apparent seizures were occurring. The mother states that her son is taking medication for the seizure disorder. The nurse plans care, knowing that which medications are used for long-term control of tonic-clonic seizures? Select all that apply.*

** Rationale: Medications that are prescribed for long-term control of tonic-clonic seizures are gabapentin, ethosuximide, and carbamazepine. Diazepam is a medication that is prescribed to halt tonic-clonic episodes, and methylphenidate is a medication used to treat attention deficit hyperactivity disorder. Both of these medications are not suitable for long-term control of a seizure condition. Alprazolam is a medication used to treat anxiety.

*Question: The nurse notes that meloxicam is prescribed for a client. The nurse knows that what are the specific actions of this medication? Select all that apply.*

** Rationale: Meloxicam is used for the treatment of osteoarthritis. It is a medication with some cyclooxygenase (COX-2) selectivity and has analgesic, anti-inflammatory, and antipyretic actions. The other actions are not properties of meloxicam.

*Question: A nursing student is collecting data on a client recently diagnosed with meningitis. The student expects to note which signs and symptoms? Select all that apply.*

** Rationale: Meningitis is an infection or inflammation of the membranes covering the brain and spinal cord. Signs and symptoms can include a positive Kernig's sign, tachycardia (heart rate greater than 100 beats per minute), a red macular-type rash, and photophobia. Other signs and symptoms include severe headache, stiffness of the neck, irritability, malaise, and restlessness. Diarrhea and tinnitus are not usually associated with meningitis.

*Question: Which nursing actions would contribute to monitoring and maintaining a patent airway for the postoperative client? Select all that apply.*

** Rationale: Monitoring and maintaining a patent airway is a nursing responsibility. The nurse should monitor oxygen saturation closely and administer oxygen as prescribed. The use of an incentive spirometer is especially helpful to prevent atelectasis and hypoventilation. Unless contraindicated, the client should be positioned on the side or with the head turned to the side to prevent aspiration until fully recovered, alert, and with the gag reflex intact. The client is encouraged to deep breathe and cough every 2 hours to prevent atelectasis. The client should be repositioned every 2 hours, which changes the distribution of gas and blood flow in the lungs and helps move secretions.

*Question: A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings would the nurse expect to observe? Select all that apply.*

** Rationale: Nephrotic syndrome is a kidney disorder that is characterized by massive proteinuria, hypoalbuminemia, periorbital and facial edema, ascites, elevated serum lipids, and anorexia. The urine volume is decreased, and the urine is dark and frothy in appearance. The child with this condition gains weight.

*Question: Which safety measures would be implemented at delivery and when working in the newborn nursery? Select all that apply.*

** Rationale: Newborn safety and abduction prevention are a major responsibility for nurses working in the newborn nursery. Standard precaution guidelines are always followed to prevent transmission of bacteria and other illnesses to infants. Safety precautions to prevent infant abduction include footprinting the infant along with fingerprinting the mother on the identification card, as well as placing bracelet identification on the mother and infant immediately following delivery. Educating parents to only release their infant to those wearing proper identification is key in preventing infant abductions in the inpatient situation. Bassinets are to be 3 feet apart, not 1 foot apart.

*Question: The nurse is reinforcing discharge teaching to a client who was given a prescription for nifedipine for blood pressure management. Which instructions would the nurse reinforce? Select all that apply.*

** Rationale: Nifedipine is a calcium-channel blocker. Its therapeutic outcome is to decrease blood pressure. Its method of action is blockade of the calcium channels in vascular smooth muscle, promoting vasodilation. Side effects that can occur early in therapy include reflex tachycardia (palpitations) and first-dose hypotension, leading to orthostatic hypotension. Weight should be checked regularly to monitor for early signs of heart failure. Also the client is taught to take his or her own pulse. Nifedipine does not affect serum calcium levels. Increased water intake is not indicated in the client with cardiovascular disease.

*Question: A client is prescribed oral lorazepam 4 mg daily. The medication label reads 2 mg/mL. To ensure the correct dose, the nurse administers how many milliliters per dose? Fill in the blank.*

** Rationale: Rationale not found

*Question: A client is at risk for developing hypocalcemia. The nurse determines which signs are associated with this electrolyte disturbance? Select all that apply.*

** Rationale: Normal calcium levels are 9 to 10.5 mg/dL (2.25-2.75 mmol/L). Signs of hypocalcemia, calcium less than 9.0 mg/dL (2.25 mmol/L), include a positive Trousseau's sign (applying a blood pressure cuff and pumping it up above the systolic BP for 3 to 5 minutes results in a carpal spasm or palmar flexion) and increased neuromuscular excitability causing fine tremors when holding the hands out. Additional signs of hypocalcemia include paresthesias, hyperactive reflexes, Chvostek's sign (striking the side of the face and noting twitching), a decreased heart rate, hypotension, hyperactive bowel sounds, muscle cramps, tetany, seizures, insomnia, irritability, memory impairment, and anxiety. Increased blood pressure, increased heart rate, and hypoactive bowel sounds are all signs of hypercalcemia.

*Question: The nurse in a prenatal clinic is teaching a group of pregnant clients about anemia and foods high in iron. Which foods are high in iron content? Select all that apply.*

** Rationale: Nuts such as peanuts are high in iron content. Whole grains and eggs are also high in iron content. Although dried fruits may be high in iron, fresh fruits are not. Milk has little, if any, iron content.

*Question: The nurse is caring for a homebound older postoperative cardiovascular client. The caregiver's daughter says to the nurse, "My mother has fallen out of bed three times." Which actions would the nurse reinforce to prevent falls? Select all that apply.*

** Rationale: One action is to provide adequate lighting. Ensure that frequently used items, such as the telephone, eyeglasses, or other personal belongings, are easily accessible. Place bedside table and overbed table within reach. Restraints should not be used because they can cause the client to become more agitated. Leaving both side rails down on the bed of an older client increases the risk of falling, especially if the client will be reaching down to obtain a needed item.

*Question: Which laboratory results indicate a therapeutic drug level? Refer to chart. Select all that apply.View Chart*

** Rationale: Options 1, 3, and 5 are the only therapeutic drug levels; all the rest are abnormal (too high). Therapeutic drug levels are as follows: carbamazepine is 5 to 12 mcg/mL; digoxin is 0.5 to 2 ng/mL; gentamicin is 5 to 10 mcg/mL; phenytoin is 10 to 20 mcg/mL; theophylline is 10 to 20 mcg/mL; and tobramycin is 5 to 10 mcg/mL.

*Question: The nurse is instructing a client with osteomalacia about appropriate food items to include in the diet. Which food items would be included in the client's diet? Select all that apply.*

** Rationale: Osteomalacia is the softening of bone tissue characterized by inadequate mineralization of osteoid. It is the adult equivalent of rickets and vitamin D deficiency in children. Of the food items presented, milk, which has vitamin D added, provides the best source of vitamin D. Oily fish, especially wild caught such as salmon and mackerel, are also rich in vitamin D. Citrus fruits are high in vitamin C. Bread products are high in niacin. Green, leafy vegetables are high in folic acid.

*Question: The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula at 2L. To provide a safe delivery of the oxygen the nurse would avoid which actions? Select all that apply.*

** Rationale: Oxygen is most commonly administered with a nasal cannula to clients in the hospital or at home. If the tubing is attached to the client's bed linen, it will become dislodged from the nares whenever the client moves. The cannula should be applied by placing the nasal prongs in the nose and then adjusting the plastic slide on the cannula so that it is snug and comfortable but not tight. The tubing should have sufficient slack and be secured to the client's clothes. The tops of the ears should be examined for signs of redness and irritation. The nares should be checked frequently because oxygen will dry the nasal mucosa. Oxygen is a medication and its prescription should be verified every shift to ensure the correct rate.

*Question: The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply.*

** Rationale: Pediatric considerations in the care of a burn victim include the following: Scarring is more severe in a child than in an adult. A delay in growth may occur after a burn injury. An immature immune system presents an increased risk of infection for infants and young children. The higher proportion of body fluid to body mass in a child increases the risk of cardiovascular problems. Burns involving more than 10% of total body surface area require some form of fluid resuscitation. Infants and young children are at increased risk for protein and calorie deficiencies because they have smaller muscle mass and less body fat than adults.

*Question: Which statements indicate an understanding of the necessary dietary modifications of a client diagnosed with chronic kidney disease? Select all that apply.*

** Rationale: Protein restriction is necessary in clients with chronic kidney disease because urea nitrogen and creatinine are the end products of protein metabolism, and clients with chronic kidney disease cannot excrete these waste products. Generally, clients with chronic kidney disease are placed on 40 g of daily protein restriction. Therefore, a bagel would be preferable to eggs in a protein-restricted diet. The client should avoid salt; however, a salt substitute is not an appropriate alternative because salt substitutes contain large amounts of potassium, and clients with chronic kidney disease commonly are on sodium and potassium restrictions. Tea and coffee both contain caffeine; therefore, one is not a good substitute for the other. Milk contains protein, and its consumption should be curtailed in a protein-restricted diet. The client should avoid salt, and soy sauce contains large amounts of salt.

*Question: The nurse is caring for a postoperative client who had a pelvic exenteration. The primary health care provider has changed the client's diet from nothing by mouth (NPO) to clear liquids. The nurse checks for which information before administering the clear liquids? Select all that apply.*

** Rationale: Pelvic exenteration is a radical surgery for treatment of gynecological cancer involving removal of the uterus, ovaries, fallopian tubes, vagina, bladder, and urethra. Sometimes the descending colon and rectum may also be removed. The client would have a colostomy and ileal conduit created if part of the colon and rectum and bladder are removed. This surgery is done when no metastases have been found outside the pelvis, and the client is agreeable. It is done less often today. The client is kept NPO until peristalsis returns, usually in 4 to 6 days postoperatively. When signs of bowel function return, clear fluids are given. If no distention occurs, the diet is advanced as tolerated. It is most important to monitor for return of peristalsis by the presence of bowel sounds and passing flatus before feeding the client. Before giving the client liquids, the nurse does not need to inspect the incision, assess pain, or monitor the urinary output. These interventions would be

*Question: A client is receiving phenytoin. Which findings would indicate that the client is experiencing side/adverse effects related to this medication? Select all that apply.*

** Rationale: Phenytoin causes blood dyscrasias, such as decreased platelet counts and decreased white blood cell counts; it contributes to constipation as well. Gingival hyperplasia can occur, causing gums to bleed easily. Ataxia is a side effect of benzodiazepines.

*Question: A client with a closed head injury is receiving phenytoin, an anticonvulsant medication. Which would indicate that the client is experiencing side effects related to this medication? Select all that apply.*

** Rationale: Phenytoin causes blood dyscrasias, such as decreased platelet counts and decreased white blood cells counts; it contributes to constipation as well. Gingival hyperplasia can occur, causing gums to bleed easily, and blood glucose levels can be elevated when taking phenytoin. Sedation is a side effect of barbiturates, not phenytoin. Ataxia is a side effect of benzodiazepines.

*Question: When caring for a client diagnosed with pheochromocytoma, which signs and symptoms would the nurse note? Select all that apply.*

** Rationale: Pheochromocytoma is a catecholamine-producing tumor of the adrenal gland and causes secretion of excessive amounts of epinephrine and norepinephrine. Signs and symptoms of pheochromocytoma are related to excess catecholamine release. These include tachycardia and severe hypertension (as high as 250/150 mm Hg) that can be intermittent or persistent. Profuse diaphoresis, severe headache, palpitations, nausea, weakness, and pallor may also be present.

*Question: The nurse is asked to assist in preparing a heparin sodium infusion for a client with a diagnosis of thrombophlebitis. Which items would the nurse have available for this procedure? Select all that apply.*

** Rationale: Phytonadione is the antidote for warfarin sodium, so this is an unnecessary item. Protamine sulfate is the antidote for heparin and should be available if heparin overdose occurs. Heparin is administered by the intravenous (IV) route, so IV insertion equipment is needed. IV tubing will be necessary for connection of the IV solution with the prescribed heparin dosage to the client's IV catheter. Heparin is always infused via an IV pump or controller.

*Question: The nurse is reviewing the postoperative primary health care provider's (PHCP'S) prescriptions for a 3-week-old infant with Hirschsprung's disease admitted to the hospital for surgery. Which prescriptions documented in the child's record would the nurse question? Select all that apply.*

** Rationale: Postoperative management of Hirschsprung's disease includes taking vital signs but avoiding taking the temperature rectally. The client needs to remain NPO (nothing by mouth) status until bowel sounds return or flatus is passed, usually within 48 to 72 hours. The other options are correct postoperative management.

*Question: The nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Which instructions would the nurse place on the list? Select all that apply.*

** Rationale: Preprocedure 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. Any hair decorations should be removed. The client is informed that the test will take 45 minutes to 2 hours and that medications are usually not withheld before the test.

*Question: The nurse is collecting data from the client about the presence of presumptive, probable, and positive signs of pregnancy. Which are the positive signs of pregnancy? Select all that apply.*

** Rationale: Presumptive signs of pregnancy include urinary frequency and quickening. Probable signs of pregnancy include Goodell's sign, Chadwick's sign, Hegar's sign, McDonald's sign, abdominal enlargement, Braxton Hicks contractions, striae, and a positive pregnancy test. Fetal movement felt by the examiner, visualization of the fetus (ultrasound) and the presence of fetal heart tones are positive signs of pregnancy.

*Question: A client has a nasogastric tube in place that is attached to suction. The client is at risk for developing which electrolyte imbalances with prolonged suction? Select all that apply.*

** Rationale: Prolonged gastric suction can result in electrolyte imbalances. There can be deficits of potassium, sodium, or magnesium blood levels.

*Question: The nurse is administering a medication intramuscularly to an assigned client. The nurse would include which actions in administering the medication? Select all that apply.*

** Rationale: Proper technique for administering an injection by the intramuscular route includes using a Z-track technique and changing the needle after drawing it up, but before the medication is given. The ventral gluteus is an acceptable and preferred site for safe intramuscular injection. The syringe is held as a dart when the needle is inserted. The site should not be massaged after injection, but gentle pressure can be applied with an alcohol or dry gauze. Clean gloves, not sterile gloves, should be worn as part of standard precautions. The site should be cleansed with a circular motion using an antiseptic pad before the injection is given.

*Question: A client diagnosed with schizophrenia who is being prepared for discharge has been prescribed oral risperidone 6 mg daily. The medication label reads 2 mg/tablet. To ensure the correct dose, the nurse instructs the client to take how many tablets once daily? Fill in the blank.*

** Rationale: Rationale not found

*Question: A nursing student is preparing to assist with an ear irrigation on an assigned client who has a buildup of cerumen in the left ear. The nursing instructor asks the student about the procedure for the irrigation. The student nurse would perform the procedure in which correct order? Arrange the actions in the order that they should be used. All options must be used.*

** Rationale: Rationale not found

*Question: A primary health care provider has prescribed prochlorperazine 4 mg intramuscularly for a client who is vomiting. The label on the medication vial indicates prochlorperazine 5 mg per 1 mL. The nurse administers how many milliliters (mL) to the client? Fill in the blank. Record the answer to one decimal place.*

** Rationale: Rationale not found

*Question: A primary health care provider prescribes 1000 mL of 0.9% NaCl to be infused over a period of 12 hours. The drop (gtt) factor is 15 drops (gtts)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.*

** Rationale: Rationale not found

*Question: A primary health care provider prescribes atenolol 0.05 g orally daily. The label on the medication bottle states, atenolol 50-mg tablets. How many tablet(s) will the nurse administer to the client? Fill in the blank.*

** Rationale: Rationale not found

*Question: A primary health care provider prescribes digoxin 0.5 mg orally daily for a client with heart failure. The medication label states "0.25 mg per tablet." How many tablet(s) will the nurse administer to the client? Fill in the blank.*

** Rationale: Rationale not found

*Question: A primary health care provider prescribes morphine 6 mg intramuscularly for a client in pain. The medication label states "morphine 10 mg per mL." How many milliliters will the nurse administer to the client? Fill in the blank. Record the answer to one decimal place.*

** Rationale: Rationale not found

*Question: A primary health care provider prescribes phenobarbital, 10 mg by mouth daily. The medication bottle is labeled 15 mg/5 mL. How many milliliters (mL) will the nurse administer? Fill in the blank. Record your answer using 1 decimal place.*

** Rationale: Rationale not found

*Question: A primary health care provider prescribes phenytoin 0.1 g orally twice daily. The medication label states, 100-mg capsules. How many capsule(s) will the nurse prepare to administer the dose? Fill in the blank.*

** Rationale: Rationale not found

*Question: A primary health care provider's prescription reads potassium chloride 20 mEq in 1000 mL 0.9% NaCl and infuse at 100 mL/hr. The nurse assisting in caring for the client determines that the client will receive how many milliequivalents (mEq) of potassium every hour? Fill in the blank.*

** Rationale: Rationale not found

*Question: The insulin drip (continuous insulin infusion) is infusing at 1.5 mL per hour. There are 100 units of regular insulin in 100 mL of 0.9% NaCl. How many units of insulin will the client receive per hour? Fill in the blank. Record the answer to one decimal place.*

** Rationale: Rationale not found

*Question: The prescription reads to give ondansetron hydrochloride 0.15 mg/kg of body weight 30 minutes before receiving chemotherapy. The client weighs 132 pounds. How many milligrams (mg) of ondansetron hydrochloride will the nurse administer? Fill in the blank.*

** Rationale: Rationale not found

*Question: The primary health care provider prescribes ibuprofen 5 mg per kg for a child who weighs 13 pounds. How many milligrams (mg) would the nurse administer to the child? Fill in the blank. Record your answer using one decimal place.*

** Rationale: Rationale not found

*Question: The primary health care provider's prescription reads "levothyroxine, 100 mcg orally daily." The medication label reads "levothyroxine, 0.1 mg/tablet." The nurse prepares to administer how many tablet(s) to the client? Fill in the blank.*

** Rationale: Rationale not found

*Question: The clinic nurse is preparing to discuss cardiovascular changes of pregnancy in a prenatal class. Which information is appropriate for the nurse to present to this group? Select all that apply.*

** Rationale: Red blood cell production is increased during pregnancy and supine hypotension is a risk for the pregnant woman. The heart rate increases by 15 to 20 beats per minute. The hemoglobin count needs to decrease to below 11 g/dL to indicate anemia. Coagulation factors increase during pregnancy and place the pregnant woman at an increased risk for deep vein thrombosis. The white blood cell count increases slightly over the course of the pregnancy.

*Question: While discharge planning for a female teenager with anorexia nervosa, the nurse suggests that the teenager attends a meeting of the local chapter of the National Association of Anorexia Nervosa and Associated Disorders. Which responses by the teenager indicate that she will likely be compliant with this suggestion? Select all that apply.*

** Rationale: Responses related to going to do whatever it takes to get better and going and participating as much as I can in the group discussions indicate that the teenager will be compliant with the nurse's suggestion. Self-help groups serve to reduce the possibilities of further emotional distress, leading to pathology and necessary treatment. Option 1 indicates that the client's thinking is limited to short-term goals. Option 2 indicates that the client already has doubts about participation and has given herself permission to terminate participation in a self-help group. Option 4 identifies an ambivalent attitude that promises nothing. Options 3 and 5 indicate that the client is a proactive participant in her plan of care.

*Question: The nurse is collecting data on a client with severe preeclampsia. Which signs and symptoms are noted in severe preeclampsia? Select all that apply.*

** Rationale: Severe preeclampsia is characterized by blood pressure higher than 160/110 mm Hg, proteinuria 3+ or higher, and oliguria. Seizures (convulsions) are present in eclampsia and are not a characteristic of severe preeclampsia, although treatment is aimed at preventing eclampsia, which is characterized by seizures. Muscle cramps and contractions are not findings noted in severe preeclampsia, although the client is monitored for these occurrences.

*Question: A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions would the nurse reinforce to prevent another crisis from occurring? Select all that apply.*

** Rationale: Sickle cell crisis can be precipitated by cold, dehydration, stress, or infection. Increasing the amount of fluids will reduce the viscosity of blood, thus preventing vascular occlusion. A conscious effort to wash hands can improve the child's health by preventing infection. A sore throat is a sign of an infection and must be reported. It is important to avoid cold temperatures of any kind because this can cause vaso-occlusion. Folic acid avoidance is not necessary. Children need to be encouraged to set their own limits in play.

*Question: A client with acute kidney injury secondary to heart failure develops fluid volume excess. Which signs and symptoms would the nurse expect to see? Select all that apply.*

** Rationale: Signs and symptoms of fluid volume excess include: weight gain, slow bounding pulse, elevated blood pressure, firm subcutaneous tissues, crackles in lungs on auscultation, visible neck veins when lying down, decreased serum sodium, decreased hematocrit from hemodilution, and low urine specific gravity with high volume.

*Question: The nurse is reviewing the health care record of a client suspected of having mastoiditis. Which documented findings would the nurse expect to note if this disorder is present? Select all that apply.*

** Rationale: Signs and symptoms of mastoiditis include mastoid swelling (directly behind the ear) and soreness, headache, malaise, and an elevated white blood cell (WBC) count.

*Question: The nurse is assessing a client diagnosed with sinusitis. Which are signs and symptoms of sinusitis? Select all that apply.*

** Rationale: Signs and symptoms of sinusitis include a feeling of heaviness over the affected areas. This can feel like a toothache if maxillary sinusitis or a headache, especially in the morning, for frontal sinusitis. Nasal drainage can become purulent. The white blood count is elevated. A high fever and nuchal rigidity are signs and symptoms of meningitis, which is a possible complication of sinusitis.

*Question: The nurse is caring for a client newly diagnosed with type 1 diabetes mellitus. In reviewing the medical record the nurse would note which signs and symptoms? Select all that apply.*

** Rationale: Signs and symptoms of type 1 diabetes mellitus include extreme thirst (polydipsia), extreme hunger (polyphagia), frequent urination (polyuria), and rapid weight loss. Signs and symptoms of type 2 diabetes mellitus include weight gain, poor healing, blurred vision, and itching.

*Question: The nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record and notes that which findings are associated with the diagnosis of glomerulonephritis? Select all that apply.*

** Rationale: Signs of glomerulonephritis include headache, abdominal or flank pain, gross hematuria resulting in dark, smoky, cola-colored or red-brown urine and periorbital edema or facial edema. Clients are hypertensive and have decreased urine output. BUN levels may be elevated.

*Question: The nurse is monitoring a client at risk for placental abruption. Which findings are indicative of this complication? Select all that apply.*

** Rationale: Signs of placental abruption include a tender, rigid abdomen; pain; severe, dark red vaginal bleeding; maternal shock (hypotension); and fetal distress. The other options are incorrect.

*Question: The nurse is collecting data on a client with the diagnosis of anorexia nervosa. Which findings are indicative of anorexia nervosa? Select all that apply.*

** Rationale: Signs/symptoms of anorexia nervosa include being a high achiever, hypotension, dry skin, cold intolerance, and lanugo over the back and extremities. The client also experiences personality changes.

*Question: The nurse is caring for a client with laryngitis. Which interventions would the nurse implement? Select all that apply.*

** Rationale: Smoking irritates the throat, so the client is discouraged from smoking. A humidifier will prevent a dry nose and throat. Lozenges with a topical anesthetic agent will decrease throat discomfort. Voice rest means not talking at all, even whispering. There should be a sign on the intercom indicating voice rest and going to the client's room.

*Question: A client has a prescription to take sodium polystyrene sulfonate for several days. The client also needs to make some dietary changes. Which foods would the client avoid? Select all that apply.*

** Rationale: Sodium polystyrene sulfonate is a cationic exchange resin used as treatment for hyperkalemia (potassium level greater than 5.0 mEq/L [5.0 mmol/L]) Besides taking the medication, the client should avoid foods that are high in potassium content, including cabbage, mushrooms, and strawberries. Foods low in potassium are peaches and soybeans.

*Question: Which are age-related changes to the eyes? Select all that apply.*

** Rationale: Some age-related changes include arcus senilis, an opaque ring outlining the cornea that sometimes results from the deposition of fatty globules. The cornea flattens and develops an irregular curvature after age 65 years, causing astigmatism or making an existing astigmatism worse; vision becomes blurred. The sclera develops a yellowish tinge from fatty deposits; thinning of the sclera may cause a bluish tinge. The ciliary muscle has less ability to allow the eye to accommodate, a process responsible for the gradual extension of distance from the eyes at which an item to be read is held (presbyopia). This change usually begins around age 40 years. Pupil size becomes smaller, reducing the ability to see in dim light. Color discrimination decreases and may cause problems.

*Question: The nurse in the prenatal clinic is collecting data regarding the client's nutritional knowledge. The nurse determines that the client understands the food items that are high in folic acid when the client states that she will be sure to eat which food items? Select all that apply.*

** Rationale: Sources of folic acid include green, leafy vegetables; whole grains; fruits; liver; dried peas; and beans. Cheese is high in calcium, and rice and chicken are good sources of iron.

*Question: A prenatal client with vaginal bleeding is admitted to the labor unit. Which signs or symptoms indicate placenta previa? Select all that apply.*

** Rationale: The classic sign of placenta previa is the sudden onset of painless bright red vaginal bleeding. The uterus is soft with no abnormal contractions or irritability. Dark red bleeding accompanied by abdominal or low back pain is the typical characteristic of abruptio placentae. The woman's uterus is tender and unusually firm (boardlike) because blood leaks into its muscle fibers. Frequent, cramplike uterine contractions often occur (uterine irritability).

*Question: The nurse is helping prepare instructions for a client who has developed stomatitis following the administration of a course of antineoplastic medications. Which instructions would the nurse suggest to include in the plan of care? Select all that apply.*

** Rationale: Stomatitis (ulceration in the mouth) can occur as a result of the administration of antineoplastic medications. The client should be instructed to examine the mouth daily and report any signs of ulceration. If stomatitis occurs, the client should be instructed to rinse the mouth with diluted baking soda or saline. If the client appear to have thrush, a fungal infection with Candida albicans, then nystatin, an antifungal medication, should be prescribed. Foods and fluids are important and should not be restricted. Neutral foods that are neither hot nor cold are often better tolerated. The client should avoid toothbrushing and flossing when stomatitis is severe.

*Question: Two weeks following delivery, a client experiences subinvolution of the uterus. Which findings indicate subinvolution? Select all that apply.*

** Rationale: Subinvolution is a condition in which the uterus does not return to its normal size after childbirth. Manifestations include fever, pelvic pain or heaviness, red lochia (or return of bleeding after it has changed), or foul-smelling vaginal discharge. The uterine fundus is no longer palpable by 12 days postpartum; this is a normal finding and not indicative of subinvolution. Lochia alba is normal vaginal drainage at this time following delivery.

*Question: The nurse is conducting a presentation at a health fair about eye cancer. Which would the nurse include in the presentation as symptoms of eye cancer? Select all that apply.*

** Rationale: Symptoms of eye cancer can vary, but include shadows or flashes of light in the vision, blurred vision, patches of darkened pigmentation in the eye, partial or total loss of vision and pain in or around the eye. Option 2 is incorrect as the client would experience decreased visual acuity. Option 3 is incorrect because bulging of only one eye, not both eyes, would be noted.

*Question: The nurse would determine that which are risk factors for systemic lupus erythematous (SLE)? Select all that apply.*

** Rationale: Systemic lupus erythematous affects females more commonly than males. It is more common in African American females than in white females. The females are generally in the childbearing years.

*Question: Warfarin sodium is prescribed for a client. The nurse expects that the primary health care provider will prescribe which laboratory tests to monitor for a therapeutic effect of the medication? Select all that apply.*

** Rationale: The INR will assess for the therapeutic effect of warfarin sodium, and the aPTT will assess the therapeutic effect of heparin sodium. The platelet count will assess the client's potential for bleeding. Warfarin sodium doses are determined based on the results of the INR. The PT also is used to determine warfarin dosage. The D-dimer is used to detect pulmonary embolism and disseminated intravascular coagulation (DIC). The APTT is used to determine heparin dosage.

*Question: A client has been admitted to the hospital with a diagnosis of severe nausea and vomiting. The client has an indwelling intravenous (IV) catheter. The client's morning laboratory results show a serum blood sodium level of 130 mEq/L (130 mmol/L) and a serum blood chloride level of 92 mEq/L (92 mmol/L). Which IV fluids would provide free water, sodium, and chloride to the client? Select all that apply.*

** Rationale: The IV fluid 0.45% sodium chloride in water solution provides free water in addition to sodium and chloride, Dextrose 5% in 0.225% sodium chloride solution provides sodium, chloride, and free water. Lactated Ringer's solution is similar in composition to plasma except that it has excess chloride, no magnesium, and no bicarbonate. It does not provide free water or calories. The IV fluid 0.9% sodium chloride in water solution does not provide free water, calories, or other electrolytes. Dextrose 5% in lactated Ringer's solution is similar in composition to normal plasma except it does not contain magnesium. It does not provide free water.

*Question: A client is being given a transcutaneous electrical nerve stimulation (TENS) unit to use for relief of chronic pain. Which instructions would the nurse reinforce to the client about the TENS unit? Select all that apply.*

** Rationale: The TENS unit is a portable system that relieves pain and reduces the need for analgesics. It is attached to the skin of the body around the area of pain by electrodes. It is not necessary that the client remain in the hospital for this treatment. However, this pain relief method needs to be prescribed by a primary health care provider.

*Question: A client is admitted to the hospital and is in the first stage of labor. She tells you that her "bag of waters" broke. Which assessments of the amniotic fluid are considered to be normal? Select all that apply.*

** Rationale: The amniotic fluid is clear with a mild odor. White flecks in the amniotic fluid are from lanugo or vernix caseosa. A positive fern test indicates it is amniotic fluid. Amniotic fluid also contains glucose, proteins, and urea. A foul odor indicates the presence of infection.

*Question: The nurse is reading the primary health care provider's documentation regarding a pregnant client and notes that the primary health care provider has documented that the client has an android pelvic shape. Which descriptions apply to an android pelvis? Select all that apply.*

** Rationale: The android pelvis is wedge-shaped and narrow and is unfavorable for a vaginal birth. A gynecoid pelvic shape is rounded with a wide pubic arch and is the most favorable shape for a vaginal birth. An anthropoid pelvis is long, narrow, and oval. It is not as favorable of a shape for a vaginal birth as the gynecoid pelvis; however, it is a more favorable pelvic shape than the platypelloid or android. The platypelloid pelvis is flattened with a wide, short, oval shape and is also an unfavorable shape for a vaginal birth.

*Question: A mother of a child with a diagnosis of intussusception calls the nurse into the hospital room because the child is screaming in pain. Which manifestations of perforation would the nurse report immediately? Select all that apply.*

** Rationale: The child with intussusception classically presents with severe abdominal pain that is crampy and intermittent and that causes the child to draw in the knees to the chest. The signs of perforation and shock are evidenced by fever, an increased heart rate, a change in the level of consciousness or blood pressure, and respiratory distress; these signs need to be reported immediately. The options for hypoactive bowel sounds, profuse projectile vomiting, and ribbon-like stools are a part of the presentation picture of a child with intussusception but are not signs of shock.

*Question: The nurse is admitting a client who has a history of bipolar disorder to the hospital, and the primary health care provider has indicated that the client is currently in the manic phase. Which actions would the nurse include in the plan of care? Select all that apply.*

** Rationale: The client in the manic phase of the bipolar disorder needs to have limits set on behavior. During this phase, the client cannot understand reasoning. This also indicates a need for redirection or distraction when the client engages in inappropriate behavior. Decreasing stimulation will allow the client to rest. Because the client is constantly in motion, small frequent meals and finger foods are needed.

*Question: The nurse is doing discharge teaching with a client who has sickle cell disease. The nurse reinforces instructions to the client to avoid which factors that could precipitate a sickle cell crisis? Select all that apply.*

** Rationale: The client should avoid infections and emotional stress, which can increase metabolic demand and cause dehydration, precipitating a sickle cell crisis. The client should also avoid dehydration from other causes. Warm weather and mild exercise do not need to be avoided, but the client should take measures to avoid dehydration during these conditions. Fluids are important to prevent dehydration. Finally, the client should avoid being in areas of high altitude, or flying in a nonpressurized aircraft because of lesser oxygen tension in these areas.

*Question: Potassium iodide is prescribed for a client. The nurse reinforces instructions to the client that the primary health care provider would be notified if the client experiences which symptom? Select all that apply.*

** Rationale: The client should be informed 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 gums and teeth. The client should be instructed to withhold the medication and notify the primary health care provider if these signs occur. Gastric upset and a bitter taste may occur, but do not indicate iodism. The solution can be taken with milk or juice to minimize these effects.

*Question: The nurse is reinforcing discharge instructions to a client with a hiatal hernia. Which considerations would the nurse include in the teaching session? Select all that apply.*

** Rationale: The client should elevate the head of the bed during sleep and wait at least 1 hour after meals to perform chores. Smoking cigarettes increases acid secretion, so the client should be advised to stop smoking. The consumption of low-fat or nonfat foods is recommended, not moderate fat. The client should remain upright for an hour after eating.

*Question: The nurse instructs a client at risk for hypokalemia from thiazide diuretic therapy about foods that are high in potassium. The nurse determines that there is a need for further teaching if the client states that which foods are high in potassium and should be included in the diet plan? Select all that apply.*

** Rationale: The client was incorrect to state that eggs and bread and butter are good sources of potassium. One large egg provides 66 mg of potassium. White bread and butter is approximately 120 mg. One-half cup of raisins contains 700 mg of potassium. Four ounces of beef contains 420 mg, and 4 ounces of pork contains 525 mg of potassium.

*Question: Which clients are at risk for developing skin breakdown? Select all that apply.*

** Rationale: The client who is underweight does not have any cushioning to protect bony prominences. A client with a spinal cord injury has decreased mobility, which can cause skin breakdown to develop. Many clients with heart failure have edema, which can also lead to the development of skin breakdown. Sinusitis and benign prostatic hypertrophy do put the client at risk for skin breakdown.

*Question: The nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Which instructions would the nurse provide to the client? Select all that apply.*

** Rationale: The client with a stoma should be instructed to wash the stoma daily with a washcloth. 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 alcohol to a stoma because it is both drying and irritating. A thin layer of petroleum jelly applied to the skin around the stoma helps prevent cracking. The client is instructed to protect the stoma from water.

*Question: The nurse is caring for a group of clients on a clinical nursing unit. The nurse checks for signs of deficient fluid volume. Which clients are at risk for this fluid imbalance? Select all that apply.*

** Rationale: The client with an ileostomy is at risk for deficient fluid volume because of increased gastrointestinal tract losses. The client with pneumonia is at risk due to fever and coughing up respiratory secretions. The client with a high fever will lose fluid through the skin, which responds by vasodilation to cool off the body. Other causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output, insufficient IV fluid replacement, draining fistulas, or the presence of an ileostomy. Clients who have heart failure or renal failure often retain fluids and are at risk for excess fluid volume.

*Question: The nurse is caring for a client following a total hip replacement. The client has been diagnosed with iron deficiency anemia. The nurse instructs the client to increase intake of which foods? Select all that apply.*

** Rationale: The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat, liver and other organ meats, blackstrap molasses, clams, mussels, and oysters. Milk products are lowest in iron of all of the food sources listed. Potatoes, carrots, apples, and mangos are not rich sources of iron.

*Question: The nurse is collecting data from a client with hypertension being treated with diuretic therapy. The nurse would monitor the client for hypokalemia if the client is receiving which diuretic?*

*Answer: Bumetanide* Rationale: Bumetanide is a loop diuretic, which places this client at risk for hypokalemia. The nurse assesses this client carefully for signs of hypokalemia, monitors serum potassium levels, and encourages intake of potassium sources in the diet. Spironolactone, triamterene, and amiloride HCl are potassium-retaining diuretics.

*Question: The nurse has conducted dietary teaching with the client diagnosed with iron deficiency anemia. The nurse determines that the client understands the information if the client states the intention to increase intake of which foods? Select all that apply.*

** Rationale: The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat, liver, other organ meats, blackstrap molasses, and oysters. Other good sources of iron are kidney beans, whole wheat bread, egg yolk, spinach, kale, turnip tops, beet greens, carrots, raisins, and apricots. Pineapple, egg whites, and refined white bread are not rich sources of iron.

*Question: The nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which assigned clients are at risk for excess fluid volume? Select all that apply.*

** Rationale: The client with renal failure is most at risk for excess fluid volume because of the inability of the kidneys to excrete fluid. The client with chronic cirrhosis is at risk for fluid volume excess due to fluid retention secondary to portal hypertension and low levels of protein. Other causes of excess fluid volume include heart failure, liver disorders, excessive use of hypotonic intravenous (IV) fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion of table salt. The client with an ileostomy, a draining abdominal wound, or a nasogastric tube attached to suction is at risk for deficient fluid volume.

*Question: A client has a serum sodium level of 151 mEq/L (151 mmol/L), and the nurse reinforces dietary teaching about the types of foods to avoid. The nurse determines that there is a need for further teaching if the client states that which food choices are good? Select all that apply.*

** Rationale: The client's laboratory value reflects hypernatremia because the normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Based on this finding, the nurse should instruct the client to avoid foods high in sodium. Sauerkraut and American cheese are high in sodium content. These should include foods from animal sources, which contain physiological saline, and highly processed meats and other foods that often have sodium added as a preservative. Spinach and rhubarb are good food sources of calcium. Cabbage is low calorie and a good source of vitamin C. Fish is high in phosphorus.

*Question: The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse would observe for which early signs of HF? Select all that apply.*

** Rationale: The early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue, irritability, sudden weight gain, and respiratory distress. A cough may occur with HF as a result of mucosal swelling and irritation, but it is not an early sign. Slow and shallow breathing is not associated with heart failure.

*Question: A client asks the nurse to describe how her developing baby will get enough blood and oxygen. The nurse responds that the fetal circulatory system accomplishes this task by which means? Select all that apply.*

** Rationale: The fetal lungs do not function for respiratory gas exchange, so a special circulatory pathway, the ductus arteriosus, bypasses the lungs. A small amount of blood circulates through the resistant lung tissue, but the majority follows the path with less resistance through the ductus arteriosus into the aorta. The following three special characteristics enable the fetus to obtain sufficient oxygen from maternal blood: (1) fetal hemoglobin carries 20% to 30% more oxygen than maternal hemoglobin, (2) the hemoglobin concentration of the fetus is about 50% greater than that of the mother, and (3) the fetal heart rate is 110 to 160 beats per minute, making the cardiac output per unit of body weight higher than that of an adult.

*Question: The nurse is preparing to assist a primary health care provider with the insertion of a chest tube. The nurse anticipates that which supplies will be required for the chest tube insertion site? Select all that apply.*

** Rationale: The first layer of the chest tube dressing is petrolatum gauze, which allows for an occlusive seal at the chest tube insertion site. Additional layers of sterile 4 × 4 gauze cover this layer, and the dressing is secured with a strong adhesive tape or Elastoplast tape. Povidone-iodine solution may be used to clean the insertion site before the insertion of the chest tube. Kerlix dressing, which is a wrap-type dressing used to wrap and hold dressings in place is not used on the chest; these dressing types are used commonly to wrap dressings placed on the arms or legs.

*Question: The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Which interventions would be included in the plan of care? Select all that apply.*

** Rationale: The infant with RSV should be isolated in a private room or in a room with another child with RSV. The infant should be placed in a room near the nurses' station for close observation. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and to decrease pressure on the diaphragm. Cool, humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea. Contact precautions (wearing gloves and a gown) reduce the nosocomial transmission of RSV.

*Question: The nurse is caring for a 3-year-old child with suspected bacterial meningitis. Which signs and symptoms would the nurse expect to find during the initial data collection? Select all that apply.*

** Rationale: The initial signs and symptoms of bacterial meningitis include fever, nuchal rigidity, and irritability. The anterior fontanel closes by 12 to 18 months of age. Cough usually is not associated with bacterial meningitis.

*Question: The nurse is caring for a client diagnosed with Paget's disease. What abnormal laboratory values would the nurse specifically monitor in a client with Paget's disease? Select all that apply.*

** Rationale: The laboratory values the nurse would expect to note in the client with Paget's disease of the bone include an elevated serum calcium, an elevated 24-hour urinary hydroxyproline level, and an elevated serum alkaline phosphatase (ALP). Increases in ALP and urinary hydroxyproline levels along with calcium are the primary laboratory findings indicating possible Paget's disease. Disorders of bone and the parathyroid gland are often reflected in an alteration of the serum calcium or phosphorus level. Therefore these electrolytes, especially calcium, are monitored. ALP can be further evaluated by alkaline phosphatase isoenzymes. Serum isoenzyme levels of bone ALP are used to monitor effectiveness of treatment. A 24-hour urinary hydroxyproline level reflects bone collagen turnover and indicates the degree of disease severity. The higher the hydroxyproline, the more severe is the disease. Decreased serum potassium, increased CK-MM level, and elevated amylase level are not relate

*Question: Which instruction would the nurse reinforce to the client with diabetes mellitus receiving acarbose? Select all that apply.*

** Rationale: The mechanism of action of acarbose is a delay in absorption of dietary carbohydrates, thereby reducing the rise in blood glucose after a meal. To accomplish this, the medication must be taken with each meal. Because of its bacterial fermentation of unabsorbed carbohydrates in the colon, side effects such as borborygmus, cramps, abdominal distention, and flatulence can occur. The medication also can affect absorption of iron, leading to symptoms (shortness of breath, tiredness) of anemia.

*Question: A client has a terminal illness, and her spouse is distraught about the unrelenting pain she experiences. Which would the nurse implement as the most effective measures to alleviate the spouse's distress? Select all that apply.*

** Rationale: The most effective method of alleviating the spouse's distress is to provide comfort for both individuals. By helping the spouse comfort the client, the spouse helps alleviate the client's discomfort and thus helps attenuate his own distress. This is because providing comfort to the client gives the spouse a sense of purpose, control, and value. The nurse should encourage the couple to maintain intimacy. The remaining options are reasonable nursing interventions in palliative care; conveying respect helps maintain dignity and self-esteem, promoting therapeutic communication is important in establishing a caring relationship, and maintaining a presence helps prevent feelings of abandonment and isolation. Discouraging the spouse and client from talking about the illness discourages communication and will not alleviate distress.

*Question: The nurse is caring for a client whose magnesium level is 3 mEq/L (1.5 mmol/L) and the client is being treated for the magnesium imbalance. The nurse interprets that the electrolyte imbalance is resolving if which signs or symptoms are no longer present? Select all that apply.*

** Rationale: The normal magnesium level is 1.3 to 2.1 mEq/L (0.65-1.05 mmol/L). A client with a magnesium level of 3 mEq/L (1.5 mmol/L) is experiencing hypermagnesemia. Improvement is noted if the hypotension and loss of deep tendon reflexes have resolved. Signs of hypermagnesemia include neurological depression, drowsiness, and lethargy; loss of deep tendon reflexes; respiratory insufficiency; tachycardia and hypotension; and loss of consciousness. Tetany, muscular excitability, and twitches are seen in a client with hypomagnesemia. Chest pain is not associated with alterations in magnesium.

*Question: The nurse reviews an assigned client's laboratory report and notes a serum potassium level of 5.5 mEq/L (5.5 mmol/L). The nurse would determine that this is an expected finding if the client had which health problems? Select all that apply.*

** Rationale: The normal serum potassium level for an adult is 3.5 to 5.0 mEq/L (3.5 to 5 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. This electrolyte imbalance is likely to occur in clients who experience cellular shifting of potassium from early massive cell destruction as in trauma or burns. Potassium is mostly intracellular, so the cell destruction releases potassium into the blood. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis. The body physiologically responds to acidosis by moving hydrogen ions intracellularly and potassium ions extracellularly to compensate and maintain a normal pH (7.35 to 7.45). The client with Cushing's syndrome, ulcerative colitis, or diarrhea is at risk for hypokalemia.

*Question: The nurse is caring for a client that received a new diet prescription from the primary health care provider (PHCP) for nothing-by-mouth (NPO) except ice chips. Which actions would the nurse take to alleviate the effects of dehydration? Select all that apply.*

** Rationale: The nurse needs to be aware of the various kinds of diet prescriptions and which items are permitted in each. An NPO except ice chips prescription means that the only substance the client is permitted to consume orally is ice chips. Therefore, option 1 would be an incorrect nursing action. Option 2 would provide the nurse with client data to determine if the client is experiencing dehydration, as the mucous membranes are normally wet and not dry. Option 3 is incorrect because the nurse cannot increase the rate of IV fluids without a PHCP's prescription. Option 4 is a correct nursing action as providing frequent oral care with moist swabs will help to maintain moisture in the mouth. Option 5 is a correct nursing action because applying lubricant to the lips and oral mucous membranes will prevent drying out and cracking of the lips and mucosa.

*Question: A 1-month old child is hospitalized following a motor vehicle accident in which the parents are seriously injured. The nurse would select which toys for this child? Select all that apply.*

** Rationale: The nursery mobile is recommended for a 1-month-old child because it provides visual stimulation. If it is a musical nursery mobile, it also serves the purpose of providing auditory stimulation. Strings of big beads, stuffed animals, large puzzles, and a Jack-in-the-box are all age-appropriate toys for a child who is 6 to 12 months of age.

*Question: The nurse prepares the plan of care for a client with late-stage Alzheimer's disease who resides in a long-term care facility. Which would be priority concerns to include? Select all that apply.*

** Rationale: The priority concerns the nurse would include in the plan of care for this client are risk for injury, risk for infection, risk for aspiration, and impaired verbal communication. Risk for injury is an important diagnosis because clients with Alzheimer's eventually lose the ability of purposeful movement and to walk (falls, apraxia). Clients are at risk as a result of wandering, potential for burns, poisoning by ingesting bottles of noxious fluids/prescriptions taken incorrectly (amnesia, anomia). Late-stage Alzheimer's death frequently is secondary to infection or choking. Aspiration as a result of choking may be a source of infection resulting from aspiration pneumonia. Impaired verbal communication is also important to consider when planning care for these clients. Clients with late-stage Alzheimer's develop amnesia or memory impairment. Eventually loss of the ability to speak and to process communication correctly and a decreased ability to recognize and name objects

*Question: The nurse would recognize which are risk factors for pancreatic cancer? Select all that apply.*

** Rationale: The risk factors for pancreatic cancer include diabetes, cigarette smoking and chronic pancreatitis. A high-fat diet, rather than a low-fat diet, is a risk factor for pancreatic cancer. Older clients are at higher risk for the development of pancreatic cancer as 71 years of age is the median age of diagnosis.

*Question: The nurse monitors a 5-year-old child admitted to the hospital for a neuroblastoma for signs and symptoms related to the location of the tumor in the adrenal gland. Which descriptions would the nurse expect to be documented in the child's record specific to this tumor? Select all that apply.*

** Rationale: The signs and symptoms of a neuroblastoma depend on the location of the tumor. When the tumor is found on the adrenal gland, the findings will be consistent with a firm, nontender, irregular mass in the abdomen. This will likely cause some degree of urinary frequency or retention from compression on the ureter, or kidney.

*Question: A client with right-sided heart failure has been admitted to the hospital. The nurse is reviewing the medical record and notes which signs and symptoms? Select all that apply.*

** Rationale: The signs and symptoms of right-sided heart failure include fatigue; edema in the sacrum, legs, feet, and ankles; hepatomegaly; abdominal distention as a result of ascites; weight gain; and dyspnea. Left-sided signs and symptoms include fatigue, dyspnea, wheezing, orthopnea, sleep apnea, pulmonary edema (pink, frothy sputum), pallor, and clammy skin.

*Question: A prenatal client with severe abdominal pain is admitted to the labor and birthing department. Which data indicate to the nurse the presence of concealed bleeding? Select all that apply.*

** Rationale: The signs of concealed bleeding include increase in fundal height, a hard boardlike abdomen, persistent abdominal pain, late decelerations in the fetal heart rate, or decreasing baseline variability. Nausea, heavy vaginal mucus and early decelerations are not signs of concealed bleeding.

*Question: The nurse considers the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery. Which are correct about this protocol? Select all that apply.*

** Rationale: The surgeon is responsible for verifying the operative site and must mark the operative site before the client is brought into the operating room suite. The client will be asked to verify the site requiring surgery. The client may refuse to have the site marked and is asked about marking the site. Although the nurse may also verify the site, this procedure is a primary health care provider's responsibility. Verification of site should be done before the time-out period in addition to during the time-out period. Verification of the surgical site is not done at the completion of the procedure.

*Question: A client taking phenytoin has a serum phenytoin level of 30 mcg/mL. The nurse would expect to note which signs and symptoms on data collection of the client? Select all that apply.*

** Rationale: The therapeutic serum range of phenytoin should be 10 to 20 mcg/mL. A level of 30 mcg/mL indicates toxicity. Central nervous system (CNS) depression, lethargy, ataxia, and nausea are all signs of phenytoin toxicity. Nystagmus and diplopia also occur. Phenytoin toxicity depresses the CNS, thus hyperactive reflexes would not be present. Tinnitus is not associated with phenytoin toxicity; rather, it is associated with acetylsalicylic acid toxicity.

*Question: A client taking phenytoin has a serum phenytoin level of 30 mcg/mL. The nurse would expect to note which signs and symptoms on data collection? Select all that apply.*

** Rationale: The therapeutic serum range of phenytoin should be 10 to 20 mcg/mL. Central nervous system (CNS) depression, restlessness, ataxia, and nausea are all signs of phenytoin toxicity. Phenytoin toxicity depresses the CNS; thus hyperactive reflexes should not be present. Tinnitus is not associated with phenytoin toxicity; rather it is associated with acetylsalicylic acid (aspirin toxicity).

*Question: When examining the umbilical cord immediately after birth, which blood vessels are present in a normal umbilical cord? Select all that apply.*

** Rationale: The umbilical cord is made up of two arteries to carry blood from the embryo to the chorionic villi and one vein that returns blood to the embryo. There are no capillaries.

*Question: A client in the first trimester of pregnancy arrives at the health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse reinforces a list of instructions for the client regarding management of care. Which instructions would the nurse place on the list? Select all that apply.*

** Rationale: The woman is instructed to count the number of perineal pads used on a daily basis and to note the quantity and color of blood on the pad. The woman should also watch for the evidence of the passage of tissue. The woman is advised to curtail sexual activities until bleeding has ceased, and for 2 weeks following the last evidence of bleeding or as recommended by the primary health care provider or nurse-midwife.

*Question: A client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses the client 15 minutes after administering the medication and reminds the client to save all urine in the bathroom. Sixty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Which issues support the client's malpractice claim? Select all that apply.*

** Rationale: To prove malpractice against the nurse, the plaintiff must prove that the nurse owed a duty to the client; that the nurse breached the duty; and that as a result, harm was caused to person or property. The client has an increased risk of hypotension (option 2) because hypotension is a common adverse effect of bumetanide. This is the second dose within 4 hours, and the client has heart failure. The client can prove that the nurse did not protect him by failing to provide adequate teaching and perform correct and timely nursing interventions after administering the bumetanide. After the first 15-minute check, the nurse should continue increased client monitoring to ensure client compliance with safety measures. Replacing fluid volume is not the issue; furthermore, the goal of therapy is to reduce total body fluid. No data indicate that the dose of bumetanide, a loop diuretic, was excessive. However, because this medication can cause hypotension, especially after a repeat d

*Question: The nurse is reviewing the results of an eye examination on a client. Which tests can detect glaucoma? Select all that apply.*

** Rationale: Tonometry is an effective screening test for early detection of glaucoma. Glaucoma can cause a loss of the visual field so that also must be checked. The Snellen chart is used to check visual acuity. Electroretinography determines the electrical potential of the retina. Fluorescein angiography determines abnormal blood vessels or blood flow of the retina.

*Question: A client is seen in the health care clinic, and acute pyelonephritis is suspected. The nurse reviews the client's record and would expect to note which associated signs and symptoms documented? Select all that apply.*

** Rationale: Typical signs and symptoms of acute pyelonephritis include high fever, chills, nausea, vomiting, flank pain on the affected side with costovertebral angle tenderness, general weakness, and headache. The client often exhibits the typical signs and symptoms of cystitis with production of urine that is foul smelling and cloudy or bloody and that has an increased white blood cell (WBC) count.

*Question: The primary health care provider is performing a vaginal examination on a pregnant woman. Which assessments are considered to be normal physiological changes in the vagina? Select all that apply.*

** Rationale: Vaginal secretions increase and have a higher level of glycogen. Chadwick's sign is a bluish discoloration of the vagina caused by increased vascular congestion. The vaginal mucosa thickens. The vaginal secretions become acidic to prevent infections.

*Question: The nurse provides information to a client following a gastrectomy who is now diagnosed with pernicious anemia. Which instructions about pernicious anemia would the nurse reinforce to the client? Select all that apply.*

** Rationale: Vitamin B12 deficiency occurs from lack of intrinsic factor normally secreted by specialized cells in the gastric mucosa. Meticulous frequent oral hygiene will promote an improved appetite and prevent infection. The client has a sensitivity to cold, so additional blankets may be needed. Serum blood vitamin B12 levels need to be checked every 1 to 2 years to make sure replacement therapy is adequate. A diet high in iron content is appropriate for iron deficiency anemia rather than vitamin B12 deficiency. Replacement therapy is given for a lifetime, not just 5 years.

*Question: The nurse in the delivery room is caring for a newborn delivered 10 minutes ago. The nurse assists in preparing which medications that will be prescribed to be given within the first hour of life? Select all that apply.*

** Rationale: Vitamin K is administered within the first hour of birth to prevent hemorrhagic disease of the newborn. Antibiotic ophthalmic solutions are required prophylaxis to prevent ophthalmic neonatorum due to Neisseria gonorrhoeae or Chlamydia and are given within the first hour after birth. Hepatitis B vaccine is administered before baby discharge. Hepatitis A vaccine may or may not be required. Naloxone is used to treat respiratory depression. Lung surfactant, administered by direct intratracheal instillation, is indicated for prevention and treatment (rescue therapy) of respiratory distress syndrome (RDS).

*Question: The nurse is observing an assistive personnel (AP) talk to a client who is hearing impaired. The nurse would intervene if which actions are performed by the AP during communication with the client? Select all that apply.*

** Rationale: When communicating with a hearing-impaired client, the nurse should speak in a normal tone to the client and should not shout. The nurse should talk directly to the client while facing the client and speak clearly. Speak slowly and distinctly. Use short sentences or phrases. Ensure that the client can see your face clearly. Do not turn away while speaking.

*Question: A client suffered smoke inhalation and burns to the anterior trunk during a house fire. The nurse reviews the plan of care and notes that the client has an airway problem. Which findings support an airway problem? Select all that apply.*

** Rationale: While assessing a client who has sustained any burn to the upper chest, the neck, and the face, consider the client at high risk for respiratory distress. Signs of respiratory difficulty include a hoarse voice and a productive cough. Other physical findings suggesting an inhalation injury include singed nasal hairs; agitation; tachypnea; flaring nostrils or intercostal retractions; brassy cough, grunting, or guttural respiratory sounds; erythema or edema of the oropharynx or nasopharynx; and sooty sputum. Flushing occurs with carbon monoxide poisoning.

*Question: The primary health care provider writes a prescription for the nurse to obtain a consent for a colonoscopy. Which are the nurse's responsibilities to obtain an informed consent? Select all that apply.*

** Rationale: Witnesses are required to meet the state's legal requirements. A witness only verifies that this is the person who signed the consent and that it was a voluntary consent. The witness (often the nurse) does not verify that the client understands the procedure; this is the surgeon's responsibility. Informed consent should not be obtained if the client is disoriented; a family member legally can only sign a consent under certain situations, such as in an emergency. If family members object to surgery that the surgeon believes is essential, a court order may be obtained for the procedure. This practice is used only in extreme circumstances.

*Question: The nurse has reinforced instructions to the family of an older client who seems anxious about being discharged after cardiac surgery. The nurse understands further teaching is needed if a family member makes which statement?*

*Answer: "A daily, half-mile-long, brisk walk generally helps people bounce back more quickly and provides more of a sense of control."* Rationale: Clients generally increase activity by beginning a simple walking program starting with distances of 400 feet twice daily and gradually increasing the distance until able to walk 1¼ miles (usually at the end of the second week). Exercise has physiological and psychological benefits. The statements made in options 1, 2, and 3 are correct.

*Question: The nurse is preparing a client scheduled for a bone marrow aspiration, and the client asks the nurse whether the procedure will be painful. The nurse would make which response to the client?*

*Answer: "A local anesthetic will be given and will decrease the discomfort."* Rationale: A local anesthetic is used to anesthetize the skin and subcutaneous tissue to minimize tissue discomfort with needle insertion. The client will feel some pain and pressure briefly when the sample is aspirated out of the marrow. Most persons do experience some level of pain with a bone marrow aspiration. Clients will not receive general anesthesia or heavy sedation during the procedure.

*Question: The nurse has completed counseling about smoking cessation with a client with coronary artery disease (CAD). The nurse determines that the client has understood the material best if the client makes which statement?*

*Answer: "A smoker has twice the risk of having a heart attack as a nonsmoker."* Rationale: Cigarette smokers have twice the risk of having a myocardial infarction as a nonsmoker and have two to four times the risk of having sudden cardiac death. Smoking cessation will reduce its damaging effects on the cardiovascular system; however, its cessation will not cut the risk to zero in 1 year.

*Question: The nurse is assisting in preparing a teaching plan of care for a client being discharged from the hospital following surgery for testicular cancer. Which instruction would the nurse suggest to include in the plan?*

*Answer: "An elevation in temperature should be reported to the primary health care provider."* Rationale: For the client who has had testicular surgery, the nurse should emphasize the importance of notifying the primary health care provider if chills, fever, drainage, redness, or discharge occurs. These symptoms may indicate the presence of an infection. Often a prosthesis is inserted during surgery, so the client does not have to wait 6 months. The nurse instructs the client that he will be able to resume most of his usual activities within 1 week after discharge, except for lifting heavy objects (those weighing 20 pounds or more) and stair-climbing.

*Question: The nurse employed in a primary health care provider's office is collecting data on a client who is taking ergotamine tartrate. The nurse evaluates the effectiveness of therapy by asking which question?*

*Answer: "Are the headaches relieved?"* Rationale: Ergotamine tartrate is used to treat migraine or cluster headaches. Options 1, 3, and 4 are unrelated to the use of this medication.

*Question: The nurse is collecting data on a client with hyperparathyroidism. Which question would elicit accurate information about this condition from the client?*

*Answer: "Are you experiencing pain in your joints?"* Rationale: Hyperparathyroidism causes an oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood causing hypercalcemia. The bones suffer demineralization as a result of calcium loss leading to bone and joint pain and pathological fractures.

*Question: The nurse is teaching a client who is newly diagnosed with a hiatal hernia about measures to prevent recurrence of symptoms. Which statement would the nurse make to the client for consideration?*

*Answer: "Be sure to sleep with your head elevated in bed."* Rationale: Most clients with hiatal hernia can be managed by conservative measures that include a low-fat diet, avoiding lying down for an hour after eating, and keeping the head of the bed elevated.

*Question: A pregnant client tests positive for the hepatitis B virus (HBV), and the client asks the nurse whether she will be able to breastfeed the baby as planned after delivery. The nurse makes which response to the client?*

*Answer: "Breastfeeding is allowed once the baby has been vaccinated."* Rationale: Although HBV is transmitted in breast milk, once the first dose of hepatitis B vaccine and the serum immune globulin have been administered to the newborn, the woman may breastfeed without risk to the newborn. Options 2, 3, and 4 are incorrect responses.

*Question: The nurse is reinforcing diet teaching for a client on a low-sodium diet for hypertension. The nurse determines that there is a need for further teaching when the client makes which statement?*

*Answer: "Canned foods are inexpensive and are good to use on a low-sodium diet."* Rationale: A low-sodium diet is used as an adjunct to antihypertensive medications for the treatment of hypertension. Any commercial food that contains preservative is a significant source of sodium. Sodium retains fluid, which leads to hypertension secondary to increased fluid volume. Canned foods use salt as a preservative and should not be encouraged as part of a low-sodium diet. Lifelong medication is necessary in the treatment of hypertension.

*Question: The nurse is performing an assessment on a pregnant client who has had a severe asthma attack. The nurse asks the client about prescription and herbal medications she is taking, and the client tells the nurse that she has been taking the herb chamomile. Which statement made by the client demonstrates correct information about this herbal intervention?*

*Answer: "Chamomile should not be used while I am pregnant and because I have asthma."* Rationale: Chamomile is a known abortifacient and relaxant and should not be used during pregnancy. Persons with asthma should not use this herb because cross-hypersensitivity may result in persons who are allergic to sunflowers, ragweed, or members of the aster family. Options 1, 2, and 3 are incorrect statements regarding chamomile.

*Question: A client being seen in a primary health care provider's office has just been scheduled for a barium swallow the next day. The nurse writes down which instructions for the client to follow before the test?*

*Answer: "Do not eat or drink after midnight tonight."* Rationale: A barium swallow is an x-ray that uses a substance called barium for contrast to highlight abnormalities in the gastrointestinal (GI) tract. The client should not eat or drink after midnight. The client swallows the barium to outline the esophagus and stomach. No scope is involved in this procedure. Most oral medications are also withheld before the test, depending on the primary health care provider's instructions. It is important to monitor for constipation following the procedure, which can occur as a result of the presence of barium in the GI tract.

*Question: A generally healthy 63-year-old man is seen in the primary health care provider's office for a routine examination. Which statement made by the client is most important for the nurse to follow up on?*

*Answer: "Everyone in my immediate family has died from gastrointestinal cancer."* Rationale: The nurse should follow up on the statement about familial cancer. The client may have some anxiety that this will ultimately occur to him and the nurse should gather further data to understand the client's situation and to identify additional risk factors. Options 1, 2, and 4 identify appropriate client behaviors regarding the prevention and detection of gastrointestinal cancer.

*Question: A child is being sent home on digoxin after being diagnosed with a congenital heart defect. The medication needs to be given once a day. Which would the nurse reinforce in the teaching plan for the family?*

*Answer: "Give the medication in the morning 20 to 30 minutes before a feeding."* Rationale: Digoxin should be given in the morning before a feeding so that a parent can get in the routine of administering the medication. The medication must be accurately measured and drawn up in a syringe, never measured in a dropper. If the dose is vomited, it is skipped that day and the dose is resumed the next day. If the medication is forgotten in the morning, it is given as soon as remembered that day.

*Question: A client with carcinoma of the breast is admitted to the hospital for treatment with intravenous vincristine. The client tells the nurse that she has been told by her friends that she is going to lose all her hair. After offering an open-ended question in reply, the client expresses how she feels. The nurse then gives the client information. The nurse makes which appropriate response to the client?*

*Answer: "Hair loss may occur, and it will grow back, but it may have a different color or texture."* Rationale: Alopecia (hair loss) can occur following the administration of many antineoplastic medications. Alopecia is reversible, but new hair growth may have a different color and texture.

*Question: The nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question would the nurse ask the family to elicit information specific to the development of RF?*

*Answer: "Has the child had a sore throat or a fever within the past 2 months?"* Rationale: Rheumatic fever (RF) characteristically presents 2 to 6 weeks after an untreated or partially treated group A ß-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child has had a sore throat or an unexplained fever within the past 2 months. Options 1, 2, and 3 are unrelated to RF.

*Question: The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing a painful exacerbation of the disease. The mother asks the nurse if the child should perform range-of-motion (ROM) exercises at this time. The nurse would make which response to the mother?*

*Answer: "Have the child perform simple isometric exercises during this time."* Rationale: During painful episodes, hot or cold packs, splinting, and positioning the affected joint in a neutral position help to reduce the pain. Although resting the extremity is appropriate, it is important to begin simple isometric or tensing exercises as soon as the child is able. These exercises do not involve joint movement.

*Question: A client has been prescribed valproic acid for the treatment of generalized seizures, and the nurse reinforces instructions to the child about the potential side effects of the medication. Which statement by the client would indicate a need for further teaching?*

*Answer: "I am so glad that I won't lose any of my hair. I was worried what my friends would think."* Rationale: Side effects of valproic acid include nausea and vomiting, tremors, weight gain, and hair loss. It is important to take the medication whole and not crush or cut the medication.

*Question: The nurse has reinforced homecare instructions to the parent of a child who is being discharged after cardiac surgery. Which statement by the parent indicates the need for further teaching?*

*Answer: "I can apply lotion or powder to the incision if it is itchy."* Rationale: The mother should be instructed that lotions and powders should not be applied to the incision site because these items can affect the skin integrity and the healing process. Options 1, 3, and 4 are accurate instructions regarding home care after cardiac surgery.

*Question: A sexually active 20-year-old client has been diagnosed with viral hepatitis. Which statement made by the client would indicate a need for further teaching?*

*Answer: "I can never drink alcohol again."* Rationale: To prevent transmission of hepatitis, a condom is advised during sexual intercourse, as well as vaccination of the partner or close friends. 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 the liver function has returned to normal. The client's activity is increased gradually.

*Question: A psychiatric client diagnosed with schizophrenia approaches the nurses' station and shouts, "Shut up. I told you to be quiet." Looking at the nurse, the client says, "Can't you hear them shouting at me?" Which would be the nurse's best response?*

*Answer: "I don't hear the voices, but I can see how upsetting it must be for you."* Rationale: The best response by the nurse is "I don't hear the voices, but I can see how upsetting it must be for you." The nurse would not negate the client's experience but offer his or her own perception and try to understand what the voices are saying or telling the individual to do. Hallucinations are real to the client who is experiencing them. The brain is not processing stimuli accurately. The client who is hallucinating also may be experiencing anxiety, fear, loneliness, and low self-esteem. Option 1 is an attempt at assessments. Option 2 is a judgmental, disapproving, and nontherapeutic response. Option 3 rejects the client's feelings and negates the client's experience. The content of the hallucination is more important than the frequency of occurrence.

*Question: The nurse provides information to a client regarding breast self-examination (BSE). Which client statement indicates a need for further teaching regarding BSE?*

*Answer: "I don't need to do that; I'm too old for that."* Rationale: BSE should be done even after menopause. No one is too old to get breast cancer. The other options reflect an accurate understanding of BSE.

*Question: A client is being treated for moderate hypertension and has been taking diltiazem for several months. The client is seen by the primary health care provider, and Prinzmetal's angina is diagnosed. The nurse is instructing the client about diltiazem. Which client statement indicates a need for further teaching?*

*Answer: "I have to limit my coffee, but I can drink all the fruit juice I want."* Rationale: Diltiazem is a calcium-channel blocker that inhibits calcium influx through the slow channels of the membrane of smooth muscle cells. Calcium-channel blockers decrease myocardial oxygen demands and block calcium channels, thereby decreasing the force of contraction of the ventricular tissue. Client teaching about diltiazem includes taking pulse and blood pressure and keeping a record, changing position slowly, avoiding hazardous activities until stabilized, limiting caffeine consumption, and avoiding grapefruit juice.

*Question: The nurse provides homecare instructions to the parent of a child with attention deficit hyperactivity disorder regarding behavioral therapy interventions. Which statement by the parent indicates a need for further teaching?*

*Answer: "I hear that the side effects of the medication that my child will be on can cause overeating."* Rationale: The treatment plan for children with attention deficit hyperactivity disorder includes stimulant medications that may have the adverse effect of appetite suppression and weight loss, not overeating. Treatment for these children includes behavioral therapy, maintaining a consistent environment, and appropriate classroom placement. Regular medication administration and regular follow-up visits are also important instructions for the parents.

*Question: The nurse has reinforced instructions to a client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that there is a need for further teaching if the client makes which statement?*

*Answer: "I hope the incision from the test will heal quickly."* Rationale: An endoscopic retrograde cholangiopancreatography (ERCP) procedure is a test done to detect pathology involving the common bile, the hepatic, and pancreatic ducts and the pancreas. The client does not have an incision made during the procedure. The client needs to lie still for ERCP, which takes about an hour to perform. The client also must sign a consent form. IV 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.

*Question: A client is being discharged home, and the health care provider has prescribed spironolactone for the client. The nurse reinforces instructions to the client about the medication. Which statement by the client indicates a need for further teaching by the nurse?*

*Answer: "I know I need to eat foods that are high in potassium because of the diuretic effect of the medication."* Rationale: This medication is a potassium-retaining diuretic that is used to treat edema, hypertension, fluid retention and overload, and to increase urine output. Because the medication is a potassium-retaining diuretic and an adverse effect of the medication is hyperkalemia, the client should be cautioned about consuming foods that are high in potassium. The other options are correct client statements.

*Question: The mother of an infant newly diagnosed with cystic fibrosis is being taught proper nutritional needs for the infant. The nurse determines that the mother understands nutritional needs when the mother gives which response?*

*Answer: "I know I need to monitor my infant's stools, and if there are more than four stools a day, I will increase the pancreatic enzyme."* Rationale: Cystic fibrosis is an inherited condition involving exocrine (mucus producing) gland dysfunction and causing multisystem problems, especially involvement of the respiratory and gastrointestinal systems. Cystic fibrosis requires a high-calorie, high-protein diet with pancreatic enzyme replacement therapy. The infant needs to remain on the predigested formula until 1 year of age when formula can be discontinued, and then fat-free milk is consumed. The pancreatic enzyme should not be mixed with warmed foods because this inactivates the enzyme. Stools must be monitored, and pancreatic enzymes are administered based on the stool pattern.

*Question: The nurse is providing instructions to a parent of a child with patent ductus arteriosus (PDA). Which statement by the parent would indicate a need for further teaching?*

*Answer: "I know that my child will outgrow this problem; just give him time."* Rationale: A patent ductus arteriosus (PDA) is caused by a failure of the ductus to close within the first weeks of life. The infant may be asymptomatic or show signs of heart failure. The defect may be closed during cardiac catheterization or may require surgery. A characteristic machine-like murmur is present with PDA.

*Question: The nurse determines a 5-year-old child is in the expected Erikson's psychosocial stage if the child makes which comment?*

*Answer: "I like drawing my mommy pictures with my finger paints."* Rationale: A 5-year-old child would be expected to be experiencing Erikson's psychosocial stage of initiative versus guilt (late childhood, 3 to 6 years). A child in this stage enjoys exploring and making art. During Erikson's stage of industry vs. inferiority, which occurs during school age (6 to 12 years), a child spends a great deal of time in school and with friends. Hanging around at the mall describes behaviors that correspond with the stage that occurs during adolescence, identity vs. role confusion. Episodes of negativism best describes Erikson's stage of shame vs. doubt, which occurs during toddlerhood (early childhood, 18 months to 3 years).

*Question: The nurse is reinforcing discharge instructions to a client who has undergone transsphenoidal surgery for a pituitary adenoma. Which statement by the client indicates understanding of the discharge instructions?*

*Answer: "I need to call the doctor if I develop frequent swallowing or postnasal drip."* Rationale: The client should report frequent swallowing or postnasal drip after transsphenoidal surgery because it could indicate cerebrospinal fluid (CSF) leakage. The surgeon removes the nasal packing, usually after 24 hours. The client should deep breathe, but coughing is contraindicated because it could cause increased intracranial pressure (ICP). The client should also report a severe headache because it could indicate increased ICP.

*Question: The nurse is reinforcing instructions to a client with glaucoma receiving acetazolamide daily. Which statement by the client indicates an understanding of the adverse effects related to the medication?*

*Answer: "I need to call the doctor if I notice dark urine and stools."* Rationale: Acetazolamide is a carbonic anhydrase inhibitor. Nephrotoxicity and hepatotoxicity occur and are manifested by dark urine and stools, pain in the lower back, jaundice, dysuria, crystalluria, renal colic, and calculi. Bone marrow depression also may occur. Options 1, 3, and 4 are incorrect client statements.

*Question: The nurse is reinforcing instructions to a female client regarding the procedure for collecting a midstream urine sample. Which statement by the client indicates an understanding of the procedure?*

*Answer: "I need to collect the urine in the cup after I start to urinate."* Rationale: A midstream urine sample is one obtained by a technique that decreases the likelihood of contamination. The specimen is often used to determine if the client has a urinary tract infection. As part of the correct procedure, the client should cleanse the perineum from front to back with the antiseptic swabs that are packaged with the specimen kit. The client should begin the flow of urine, collecting the sample after starting the flow of urine. The specimen should be sent to the laboratory as soon as possible and not allowed to stand. Improper specimen handling can yield inaccurate test results. It is not normal procedure to douche before collecting any urine specimen.

*Question: The nurse in the prenatal clinic is taking a nutritional history from a pregnant adolescent. Which statement by the client would alert the nurse to a potential concern regarding adequate nutritional intake during the pregnancy?*

*Answer: "I need to gain only 10 pounds so that my baby will be small like I am."* Rationale: Pregnant adolescents are at higher risk for complications than are other pregnant clients. Adolescents are often concerned about their body image. If weight is a major focus, the adolescent is more likely to restrict calories to avoid weight gain. Only gaining 10 pounds, which is much too restrictive regarding weight gain, is the only response that suggests a possible concern. Option 1 expresses an attempt to consume required vegetables. Options 3 and 4 indicate that the client will consume items that will help increase calcium intake.

*Question: The nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child and the prevention of the transmission of the virus. Which statement by a parent indicates a need for further teaching?*

*Answer: "I need to provide a well-balanced, high-fat diet to my child."* Rationale: The child with hepatitis should consume a well-balanced, low-fat diet to allow the liver to rest. Options 1, 3, and 4 are components of the homecare instructions to the family of a child with hepatitis.

*Question: A client with chronic dermatitis has decided to receive testing to determine the cause of the condition. A patch test will be performed at the scheduled clinic visit in 2 weeks. The nurse reinforces instructions to the client regarding preparation for the test. Which statement by the client indicates an understanding regarding the preparation for this procedure?*

*Answer: "I need to stop taking my antihistamine 2 days before I come to the clinic for the test."* Rationale: Client preparation for a patch test includes informing the client to discontinue the administration of systemic corticosteroids or antihistamines for at least 48 hours before the test. Topical corticosteroid therapy may be continued as long as the agent is not applied on the area to be tested. To prevent suppression of the inflammatory response to an allergen, these medications must be discontinued. There are no dietary restrictions, and the client is not instructed to shower on the morning of the test using povidone-iodine, which is very irritating to already irritated skin.

*Question: The nurse reinforces instructions to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further teaching?*

*Answer: "I need to take my child's rectal temperature daily."* Rationale: The risk of injury to the fragile mucous membranes is so great in the child with leukemia that only oral, axillary, or temporal or tympanic temperatures should be taken. Rectal abscesses can easily occur in damaged rectal tissue, so no rectal temperatures should be taken. In addition, oral temperatures should be avoided if the child has oral ulcers. Options 1, 3, and 4 are appropriate teaching measures.

*Question: A clinic nurse is reinforcing home care instructions to a client with a diagnosis of glaucoma. Which statement by the client indicates an understanding of the treatment plan for glaucoma?*

*Answer: "I need to take my eye drops for the rest of my life."* Rationale: The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. Clients need to be instructed that medications will need to be taken for the rest of their lives. Limiting fluids and reducing salt will not decrease intraocular pressure. Restricting the amount of time reading is not a component of the plan.

*Question: The nurse caring for a client following a radical neck dissection and creation of a tracheostomy performed for laryngeal cancer is reinforcing discharge instructions to the client. Which statement by the client indicates the need for further teaching regarding care of the stoma?*

*Answer: "I need to use an air conditioner to provide cool air to assist in breathing."* Rationale: Air conditioners must be avoided to protect from excessive coldness and dryness in the air. A humidifier in the home should be used if excessive dryness is a problem. Protecting the stoma from water, powders and sprays are correct measures. Preventing the skin around the stomach from cracking is also correct.

*Question: The nurse has provided instructions to the mother of a child who has been diagnosed with bacterial conjunctivitis. Which statement by the mother would indicate the need for further teaching?*

*Answer: "I need to use hot compresses to relieve the eye irritation."* Rationale: Parents are to be instructed to use cool compresses to lessen eye irritation and wear dark glasses for photophobia. Options 1, 2, and 3 are correct measures.

*Question: The nurse is reinforcing instructions to a mother who is bottle-feeding a baby and who is complaining of breast engorgement. Which statement by the client indicates a need for further teaching?*

*Answer: "I should avoid wearing a bra at this time."* Rationale: Wearing a bra or applying a breast binder applies pressure, which reduces congestion and discomfort. Ice packs reduce circulation and thus congestion and also provide an anesthetic effect. Analgesics help relieve the pain.

*Question: A client has been diagnosed with a hearing loss caused by age-related changes in the ear. The nurse reinforces information about obtaining and learning to use a hearing aid. Which statement by the client indicates understating of the information?*

*Answer: "I should obtain a hearing aid as soon as possible."* Rationale: The sooner a client with a hearing loss obtains and learns to use a hearing aid, the greater the hearing improvement. The brain is better able to integrate the hearing aid transmissions when hearing has not been impaired for a very long time. The client should be told that there is an adjustment curve with new hearing aid use, and it often takes several trips back to the hearing aid center for minor adjustments to the instrument to be made. It also takes practice in using the aid to achieve better hearing.

*Question: The nurse is reinforcing discharge instructions to a client following surgical treatment for carpal tunnel syndrome. Which statement by the client would indicate a need for further teaching?*

*Answer: "I should perform pronation and supination exercises of my wrist starting 24 hours after surgery."* Rationale: There is a need for further teaching when the client says, "I should perform pronation and supination exercises of my wrist starting 24 hours after surgery." Postoperatively, depending on the type of surgical procedure, the client will have a bulky dressing in place for 4 to 7 days. The affected arm is elevated to reduce swelling. A sling is useful to limit movements and to keep the arm elevated. The sutures are removed in about 10 days after surgery. Within 2 to 3 weeks postoperatively, the client will begin physical therapy, with exercises to promote full range of motion of the wrist and prevent adhesion formation in the carpal tunnel.

*Question: The nurse reinforces home care instructions to a client diagnosed with systemic lupus erythematosus and instructs the client about methods to manage fatigue. Which statement by the client indicates a need for further teaching?*

*Answer: "I should take hot baths because they are relaxing."* 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.

*Question: A client with Parkinson's disease is beginning treatment with carbidopa/levodopa. Which statement made by the client indicates the need for further teaching?*

*Answer: "I should take my medication after a full meal."* Rationale: Carbidopa/levodopa should be taken on an empty stomach with a full glass of water to enhance absorption. Because the medication can cause orthostatic hypotension, clients should be taught to change positions slowly. To ease the side effect of dry mouth, sugarless chewing gum, hard candy, and frequent mouth rinses are indicated. The side effect of sleep difficulty should be reported. In addition, the client is taught to avoid high-protein meals because it affects the effectiveness of the medication.

*Question: The nurse is reinforcing instructions to a client who had an episiotomy during the birthing process. Which statement by the client indicates a need for further teaching?*

*Answer: "I should take sitz baths 3 or 4 times a day and test the water temperature to be sure that it is at 115° F."* Rationale: Following episiotomy, the client should be instructed in measures to decrease discomfort and perineal swelling. Ice decreases circulation, promotes vasoconstriction, reduces edema, and promotes a local anesthetic effect. Local anesthetic sprays reduce discomfort. Gluteal muscle tightening reduces direct pressure on the perineum, so discomfort is minimized. Heat from sitz baths increases circulation to the perineum, thereby promoting oxygenation and healing, which reduces discomfort. However, the water temperature should not be any greater than 100° F to 105° F.

*Question: The nurse has instructed a client diagnosed with tuberculosis (TB) about how to prevent the spread of infection after discharge. The nurse determines that the client needs further teaching if the client makes which statement?*

*Answer: "I should use disposable plates, forks, and knives."* Rationale: Because TB is transmitted by droplets, it cannot be carried on clothing, eating utensils, or other possessions. 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 the tissues carefully.

*Question: A maternity nurse is caring for a client who is admitted to the hospital with a diagnosis of gestational diabetes. This is the client's first pregnancy. Which statement by the client indicates a knowledge deficit regarding gestational diabetes?*

*Answer: "I shouldn't have eaten so many sweets before I became pregnant."* Rationale: Gestational diabetes is not necessarily caused by eating too many sweets before pregnancy. Options 1 and 2 indicate a common normal response. Option 4 is an accurate statement. Option 3 is the only option that indicates a knowledge deficit.

*Question: The nurse is talking with a client who has an arteriovenous fistula in the left arm. What statement by the client indicates a need for further teaching?*

*Answer: "I sleep on my left side with my arm tucked under my pillow."* Rationale: When a client has an arteriovenous graft or an AVF, it is important to check the site and protect it from injury. The site should be observed for signs indicating clotting or infection, and the peripheral circulation distal to the graft should also be checked (capillary refill and color of nail beds). Palpate for a thrill (vibration in the vessel) by gently laying your fingers on the enlarged vessel. You should be able to feel a buzz or vibration. A bruit (soft swishing sound) should be clearly heard on auscultation, and the rhythm of the sound should coincide with the client's pulse. The client should sleep with that extremity free (i.e., not on the side with the arm tucked underneath the body). Care is taken never to compress the extremity containing the vascular access.

*Question: A parent with a 6-year-old child diagnosed with enuresis discusses with the nurse the measures that are being taken to help her child. Which statement by the parent indicates a need for further teaching?*

*Answer: "I take away privileges such as TV time when the bed is wet in the morning."* Rationale: Providing a reward system appropriate for the child is more effective than a punitive system to treat enuresis. Interventions for treatment of enuresis include involving the child in caring for the wet sheets and changing the bed, to assist with the child taking ownership of the problem. Limiting fluid intake at night and encouraging the child to void just before going to bed is another effective intervention.

*Question: The nurse has provided instructions to the mother of an infant with viral pneumonia. Which statement by the mother would indicate the need for further teaching?*

*Answer: "I understand I will need to have my baby on antibiotics for this pneumonia."* Rationale: The child with viral pneumonia will not be prescribed antibiotics, it is bacterial pneumonia that requires antibiotics for treatment. It is important to monitor the infant for fever spikes because of the risk for febrile seizures. Use of a cough suppressant may be prescribed before rest times and meals if the cough is disturbing and unproductive. Promoting bed rest to conserve energy, encouraging fluid intake and the administration of antipyretics for fever, and bronchodilators are typical interventions for pneumonia.

*Question: When reinforcing instructions to the caregiver of a child about cast care, the nurse anticipates the need for further teaching when the caregiver makes which statement?*

*Answer: "I will allow my child to put cotton balls inside the cast to relieve pressure."* Rationale: Cast care includes keeping the casted extremity elevated on pillows or similar support for the first day, or as directed by the health care professional; elevating a lower limb when sitting and avoiding standing for too long; encouraging frequent rest for a few days; keeping the injured extremity elevated while resting; and not allowing the child to put anything inside the cast.

*Question: The nurse is reinforcing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by a parent indicates the need for further teaching?*

*Answer: "I will apply lotion under the brace to prevent skin breakdown."* Rationale: The use of either lotions or powders should be avoided because they can become sticky or cake under the brace, thus causing irritation. Options 1, 3, and 4 are appropriate statements regarding the care of a child with a brace.

*Question: The nurse reinforces home care instructions to the parents of a 3-year-old child who has been hospitalized with hemophilia. Which statement by a parent indicates the need for further teaching?*

*Answer: "I will avoid immunizations and dental hygiene treatments for my child."* Rationale: The nurse needs to stress the importance of immunizations, dental hygiene, and routine well-child care. Options 1, 2, and 3 are appropriate statements. The parents are also provided instructions regarding measures to take in the event of blunt trauma (especially trauma that involves the joints), and they are instructed to apply prolonged pressure to superficial wounds until the bleeding has stopped.

*Question: The nurse is instructing a client with Addison's disease about a newly prescribed medication, fludrocortisone acetate. Which statement by the client indicates a need for further teaching?*

*Answer: "I will be glad to gain weight."* Rationale: The client should notify the primary health care provider of weight gain. The client should take oral drugs with food or milk. The client should wear a Medic-Alert bracelet. Fludrocortisone acetate should not be stopped abruptly but should be tapered down.

*Question: A halo vest is applied to a client following a cervical spine fracture. The nurse reinforces instructions to the client regarding safety measures related to the vest. Which statement by the client indicates a need for further teaching?*

*Answer: "I will bend at the waist, keeping the halo vest straight to pick up items."* Rationale: The client with a halo vest should avoid bending at the waist because the halo vest is heavy and the client's trunk is limited in flexibility. It is helpful for the client to scan the environment visually because the client's peripheral vision is diminished from keeping the neck in a stationary position. Use of a walker and rubber-soled shoes may help prevent falls and injury, so these items are also helpful.

*Question: The school nurse is visiting a kindergarten classroom to teach the students the importance of hand washing. During the teaching session the nurse notes that one girl is scratching her head. On inspection, the nurse determines that the child has pediculosis capitis. When reinforcing instructions to the mother about care of this condition, which statement by the mother indicates that she needs further teaching regarding this condition?*

*Answer: "I will call a carpet cleaning service to clean all my carpets in the house."* Rationale: Teaching about measures to prevent the spread of pediculosis capitis includes washing items in hot water, vacuuming carpets, discouraging sharing of personal items, and sealing items in plastic bags that cannot be vacuumed. Option 2 is too costly for many families and is unnecessary. Option 2 indicates the mother does not understand the measures that will prevent the spread of the parasite.

*Question: 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. Which response to the client is appropriate?*

*Answer: "I will call the nursing supervisor to seek assistance regarding your request."* Rationale: Living wills are required to be in writing and signed by the client. The client's signature must be either witnessed by specified individuals or notarized. Many states prohibit any employee, including the nurse of a facility where the declaring is receiving care, from being a witness. Option 2 is not therapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor.

*Question: A client has just undergone computed tomography (CT) scanning with a contrast medium. The nurse determines that the client understands postprocedure when the client makes which statement?*

*Answer: "I will drink extra fluids for the day."* Rationale: After CT scanning, the client may resume all usual activities. The client should be encouraged to take in extra fluids to replace those lost with diuresis from the contrast dye. Options 2, 3, and 4 are unnecessary.

*Question: A client with a suspected throat infection with Streptococcus needs to have a throat culture obtained. The nurse would take which action after obtaining the culture if the specimen cannot be delivered to the laboratory for at least an hour?*

*Answer: Refrigerate the specimen.* Rationale: Refrigeration will stabilize the culture and prevent the growth of additional bacteria. Options 2, 3, and 4 are unnecessary.

*Question: The nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which statement made by the mother would indicate the need for further teaching?*

*Answer: "I will give my child cough syrup if a cough develops."* Rationale: Cough syrups and cold medicines are not to be given because they may dry and thicken secretions. During a croup attack, the child can be taken to a cool basement or garage. Acetaminophen is used if a fever develops. Adequate hydration of 500 mL to 1000 mL of fluids daily is important for thinning secretions.

*Question: The nurse is reinforcing instructions to the client about insulin glargine. The nurse determines that the client understands the action of the medication if the client makes which statement?*

*Answer: "I will give myself this medication subcutaneously once each night before bed."* Rationale: Insulin glargine is a modified human insulin with a prolonged duration of action (at least 24 hours). The medication is indicated for once-daily subcutaneous administration to treat adults and children with type 1 diabetes mellitus and adults with type 2 diabetes mellitus. The daily injection should be administered at bedtime. Regular insulin is the only insulin that can be added to an insulin pump. Regardless of the type of insulin the client uses, the blood glucose should be monitored at least daily if not more often.

*Question: The nurse determines that the client diagnosed with neutropenia needs further teaching if which statement is made by the client?*

*Answer: "I will include plenty of fresh fruits in my diet."* Rationale: Fresh fruits and vegetables are eliminated from the diet to avoid the introduction of pathogens. Fever of 100.4° F or greater should be reported immediately. Feeding and petting cats and dogs are fine as long as hand washing follows. Handling pet excrement must be avoided to avoid exposure to pathogens.

*Question: The nurse is reinforcing discharge instructions to a client following right eye corneal transplantation surgery. The nurse determines that the client understands the instructions if the client makes which statement?*

*Answer: "I will lie on my back or left side."* Rationale: Following corneal transplant surgery the client is instructed to lie only on his or her back and nonoperative side. A pressure dressing and eye shield are applied in the surgical suite after the procedure and should be removed only by the provider the next day. The shield is then worn at night and when around small children or pets for at least a month. It does not need to be worn all the time. Graft rejection is a possibility and is heralded by inflammation beginning near the graft edges. This finding must be reported promptly.

*Question: The nurse reinforces instructions to the parent of a child with meningococcal meningitis. Which statement by the parent indicates a need for further teaching?*

*Answer: "I will need to get my other children the pneumococcal vaccine, but not the baby yet, he is only 3 months."* Rationale: Pneumococcal conjugate vaccine is recommended for all children beginning at age 2 months to protect against meningitis, streptococcal pneumococci can cause many bacterial infections, including meningitis. Options 1, 2, and 3 are correct.

*Question: The nurse instructs a mother of a child who has seizures regarding seizure precautions. Which statement by the mother indicates a need for further teaching?*

*Answer: "I will need to give antiseizure medications when my child has a seizure."* Rationale: Antiseizure medications are given on a routine basis to prevent a seizure, they are not rescue medications given at the time of a seizure. Padding the side rails, having a child wear a medical alert bracelet, swimming with a companion, and wearing a protective helmet while riding a bike or skateboarding are just a few of the precautions that are discussed with families.

*Question: The nurse is providing discharge instructions to the parents of a 14-year-old child who is undergoing radiation for Hodgkin's disease. Which statement by a parent indicates the need for further teaching?*

*Answer: "I will need to keep my child's skin from flaking, so we will be allowing showers every 2 or 3 days."* Rationale: The side effects of radiation therapy include dry or moist desquamation (peeling of the skin) and the intervention includes washing the skin daily, using mild soap, applying a lubricant as prescribed. Options 1, 2, and 3 are appropriate statements.

*Question: The nurse is reinforcing instructions to the mother of an infant about postcircumcision care. The nurse determines that teaching has been effective when the mother states which?*

*Answer: "I will observe for signs of bleeding with each diaper change."* Rationale: The glans penis is dark red after circumcision then becomes covered with yellow exudate in 24 hours. This is normal and will persist for 2 to 3 days. The mother should not attempt to remove it. Soap should be used only after the circumcision is healed (5 to 6 days). The circumcision should be checked for bleeding with each diaper change. The penis should be washed gently with warm water to remove urine and feces.

*Question: The nurse is giving the client discharge instructions concerning glaucoma. Which client statement indicates a need for further teaching?*

*Answer: "I will only take the eye drops until my vision improves."* Rationale: Measures to prevent an increase in intraocular pressure (IOP) include a low-sodium (Furstenberg) diet, little caffeine intake, preventing constipation and Valsalva maneuver, and decreasing stress. Glaucoma medication must be taken regularly for life. The client should avoid night driving if possible.

*Question: The nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further teaching?*

*Answer: "I will place a steam vaporizer in my child's bedroom."* Rationale: Steam from warm running water in a closed bathroom and cool mist from a bedside humidifier are effective for reducing mucosal edema. Cool-mist humidifiers are recommended compared with steam vaporizers, which present a danger of scalding burns. Taking the child out into the humid night air may also relieve mucosal swelling. Remember, however, that a cold mist may precipitate bronchospasm.

*Question: The nurse determines an adolescent is showing progress toward completing Erikson's psychosocial developmental stages if the adolescent makes which statement?*

*Answer: "I've met people who like that kind of music and we're going to a concert next week."* Rationale: An adolescent (12 to 20 years) would be expected to be experiencing Erikson's psychosocial stage of identity vs. role confusion. In this stage an adolescent has strong social relationships and makes decisions about likes and dislikes. Not having an idea about the role in the future does not indicate successful progress through the stages. Life review and selecting a life partner are later into the development of the individual and do not occur generally during adolescence.

*Question: During a well-child checkup for a 4-month-old, the nurse reinforces instructing the mother how to introduce solid foods into her child's diet. Which statement indicates the mother needs further teaching?*

*Answer: "I will start giving home-prepared orange juice when my child is 3 months old."* Rationale: Solids should be introduced over a period of time between the ages of 4 and 6 months. Failure to introduce solids by 6 months of age might prevent the child from accepting solids later. The pattern in which solids are introduced is not important as long as meats are introduced after cereals, fruits, and vegetables. A single food should be consumed several times over a course of several days to determine if the child has an allergy. Home-prepared orange juice should not be given to the infant before 4 to 6 months of age because of the high nitrite level and high risk of allergic reaction.

*Question: Lispro insulin is prescribed three times a day, with the amount based on blood glucose levels. The nurse determines that the client understands teaching regarding lispro insulin if which statement is made?*

*Answer: "I will take the lispro 10 to 15 minutes before I eat breakfast, lunch, and dinner."* Rationale: Lispro is a rapid-acting insulin analog with an onset of action of 15 minutes. The client should administer the dose 0 to 15 minutes before eating a meal. Because the insulin peaks in ¾ to 1½ hours, it would not be beneficial to wait for 1 hour after the meal to administer it. In addition, if the lispro is given 1 hour before the meal, the medication will begin to peak before the client's meal is eaten, possibly resulting in hypoglycemia. Lispro administration should not be spread out evenly throughout the 24-hour day.

*Question: The nurse is giving home care instructions to a client with conjunctivitis. Which client statement indicates a need for further teaching?*

*Answer: "I will use a sterile gauze to rub any matter from my eyes."* Rationale: Home care for conjunctivitis is directed to prevent spread of infection. Antibiotic eye drops or ointment will be prescribed. Good hand washing and avoiding sharing washcloths help prevent spread of infection. The client can use warm or cool compresses to the eyes for discomfort. The client should avoid rubbing the eyes.

*Question: A client has received instructions on self-management of peritoneal dialysis. The nurse determines that the client needs further teaching if the client makes which statement?*

*Answer: "I will use a strong adhesive tape to anchor the catheter dressing."* Rationale: The client is at risk for impairment of skin integrity resulting from the presence of the catheter, exposure to moisture, and irritation from tape and cleansing solutions. The client should be instructed to use paper or nonallergenic tape to prevent skin irritation and breakdown. It is proper procedure for the client to use aseptic technique and to self-monitor vital signs and weight on a daily basis.

*Question: The nurse determines that a client with coronary artery disease (CAD) understands disease management if the client makes which statement?*

*Answer: "I will walk for one-half hour daily."* Rationale: Lack of physical exercise contributes to the development of CAD, and engaging in a regular program of exercise helps retard progression of atherosclerosis by lowering cholesterol levels and developing collateral circulation to heart tissue. Options 2 and 3 are incorrect because obesity and a diet high in fat can contribute to CAD. Option 4 is incorrect because genetic factors also contribute to CAD.

*Question: The nurse is reinforcing discharge instructions to the parent of a 2-year-old child who has had an orchiopexy to correct cryptorchidism. Which statement by the parent indicates a need for further teaching?*

*Answer: "I'll let him decide when to return to his play activities."* Rationale: All vigorous activities should be restricted for 2 weeks after surgery to promote healing and prevent injury. This will prevent dislodging of the suture, which is internal. Normally, 2-year-old children will want to be very active. Therefore, allowing the child to decide when to return to his play activities may prevent healing and cause injury. The parents should be taught to monitor the child's temperature; provide analgesics, as needed; and monitor the urine output.

*Question: A client has experienced pulmonary embolism. The nurse would assess for which symptom that is most commonly reported?*

*Answer: Chest pain that occurs suddenly* 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 apprehension and restlessness,

*Question: The nurse is caring for a client with a diagnosis of metastatic breast carcinoma. Tamoxifen citrate 10 mg orally twice daily is prescribed for the client, and the nurse is reinforcing instructions to the client regarding the medication. Which statement by the client would indicate an understanding of the medication?*

*Answer: "If I have difficulty seeing, I need to call the primary health care provider."* Rationale: Tamoxifen citrate is an antineoplastic medication that competes with estradiol for binding to estrogen in tissues containing a high concentration of receptors, such as the breasts, the uterus, and the vagina. Frequent side effects include hot flashes, nausea, vomiting, vaginal bleeding or discharge, pruritus vulvae, and skin rash. Adverse or toxic reactions include retinopathy, corneal opacity, and decreased visual acuity. The client needs to report menstrual irregularities, pelvic pain or pressure, and visual disturbances.

*Question: The client has been prescribed nifedipine. The nurse is instructing the client about nifedipine. Which client statement indicates a need for further teaching?*

*Answer: "If I see empty tab shells in my stool, I need to report it to my doctor."* Rationale: Client teaching about nifedipine includes changing position slowly to avoid orthostatic hypotension and avoiding grapefruit juice and alcohol. The client is not to discontinue nifedipine abruptly but gradually taper dosage. If empty tab shells appear in stools, it is not significant.

*Question: The nurse provides homecare instructions to the parents of a child with heart failure regarding the procedure for the administration of digoxin. Which statement by a parent indicates the need for further teaching?*

*Answer: "If my child vomits after medication administration, I will repeat the dose."* Rationale: The parents need to be instructed that if the child vomits after the digoxin is administered, they are not to repeat the dose. Options 1, 2, and 3 are accurate instructions regarding the administration of this medication. Additionally, the parents should be instructed that if a dose is missed and it is not noticed until 4 hours or more later, the dose should not be administered.

*Question: The nurse is reinforcing instructions to the family of a client with Alzheimer's disease regarding tacrine. Which statement by the family would indicate an understanding of the side/adverse effects related to this medication?*

*Answer: "Increased urination may be an indication of an adverse effect."* Rationale: Tacrine is a cholinergic agent. Frequent side effects of this medication include nausea, vomiting, diarrhea, dizziness, and headache. Overdose (adverse effects) will cause cholinergic crisis, including increased salivation, lacrimation, urination, defecation, bradycardia, hypotension, and increased muscle weakness. Fever is not an adverse effect, although if a fever occurs and persists this may be an indication of an unassociated infection and the primary health care provider should be notified. Constipation is not associated with this medication, and if constipation occurs, measures can be taken to relieve it. Difficulty voiding is not associated with the use of this medication. Although this symptom may warrant primary health care provider notification, it does not indicate the need to discontinue the medication.

*Question: The parents of a newborn have been told that their child was born with bladder exstrophy and the parents ask the nurse about this condition. Which response would the nurse give to the parents about bladder exstrophy?*

*Answer: "It is an extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall."* Rationale: Bladder exstrophy is a congenital anomaly that is characterized by the extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall. The cause is unknown, and there is a higher incidence among males. Options 1, 2, and 3 are not characteristics of this disorder.

*Question: The nurse is teaching first aid measures to a group of adolescents about appropriate treatment for burns. The nurse would anticipate the need for further teaching when one of the adolescents makes which statement?*

*Answer: "It is appropriate to place butter on the burn."* Rationale: It is appropriate to remove burned clothing and any jewelry from a burned victim. Burned clothing is removed to prevent further damage from smoldering fabric and hot beads of melted synthetic materials. Jewelry is removed to eliminate the transfer of heat from the metal and to prevent constriction resulting from edema formation. This also provides access to the wound and prevents painful removal later. The victim should be placed in a horizontal position and kept warm. Remaining in the vertical position may cause the hair to ignite or the inhalation of flames, heat, or smoke. Application of topical ointments, oils, butter, or other home remedies is contraindicated and can cause increased burn injury.

*Question: A client with myxedema has changes in intellectual function such as impaired memory, decreased attention span, and lethargy. The client's husband is upset and shares his concerns with the nurse. Which statement by the nurse is helpful to the client's husband?*

*Answer: "It seems that you are concerned about your wife's condition, but the symptoms may improve with continued therapy."* Rationale: Using therapeutic communication techniques, the nurse acknowledges the husband's concerns and conveys that the client's symptoms are common with myxedema. With thyroid hormone therapy, these symptoms should decrease, and cognitive function often returns to normal. Option 1 is not appropriate and offers false reassurance. Option 2 is pessimistic and untrue. Option 3 is not helpful, and it blocks further communication.

*Question: A client is having trouble remembering his prescribed medication regimen. Which statement by the nurse is therapeutic?*

*Answer: "Let me go over your prescribed medications with you again."* Rationale: Reinforcement of knowledge and behaviors is vital to the success of the client's self-care. Option 2 may devalue a client's family. Option 3 places the issue on hold, and option 1 requests an explanation from the client. Option 4 clarifies previous information.

*Question: The nurse awakens a client on the inpatient psychiatric unit for breakfast. The client replies, "Do you realize it's Sunday? I've worked hard here all week and this is my day of rest. I'll get up at 11:30." Which would be the nurse's best response?*

*Answer: "Let me know if you change your mind, and I'll get you something to eat."* Rationale: The nurse's best response would be "Let me know if you change your mind, and I'll get you something to eat." Delusions are false fixed beliefs, and it is never useful to argue with the client regarding the content of the delusion. This can intensify the client's retention of the irrational beliefs. Once a client describes a delusion, it is important not to dwell on it. Rather, focus the conversation on more reality-based topics. Option 2 reinforces caring. Option 1 is rigid and is directly challenging to this client's delusion. Option 3 is using the nontherapeutic technique of interpreting and may be perceived as challenging to the client. Option 4 is plausible, but the expectation to "participate in all activities" is not realistic.

*Question: The nurse is instructing a mother of a 1-year-old child with strabismus about the treatment options. Which statement by the mother would indicate the need for further teaching?*

*Answer: "My child will outgrow this by the time he is 2 years old and be able to see just fine."* Rationale: Although strabismus is considered a normal finding in young infants, it should not be present after 4 months of age, so the 1 year old will likely not outgrow the condition. The use of an eye patch helps to strengthen the weak eye and surgery may be required for the condition. A muscle imbalance or the paralysis of the extraocular muscles may be the cause or strabismus could be congenital.

*Question: The nurse reinforces home care instructions with a client diagnosed with impetigo. Which statement indicates the need for further teaching about the measures that will prevent the spread of infection?*

*Answer: "My clothes can be laundered with other household members' clothes."* Rationale: It is necessary to separate the client's laundry from other household members' clothing. Thorough handwashing, separating laundry, and separate washing of the client's dishes are required because the infection is contagious as long as skin lesions are present. Antibiotics are administered and should be continued as prescribed.

*Question: The nursing instructor asks a nursing student about phenylketonuria (PKU). Which statement made by the student indicates a need for further teaching?*

*Answer: "PKU primarily affects the gastrointestinal system."* Rationale: PKU is a genetic disorder that results in central nervous system (CNS) damage from toxic levels of phenylalanine in the blood, not the gastrointestinal system. PKU is an autosomal-recessive disorder, and treatment includes the dietary restriction of phenylalanine intake. All 50 states require screening newborns for PKU.

*Question: The nurse is assisting in conducting a prenatal session with a group of expectant parents. Which comment related to female hormones made by a parent indicates the need for further teaching?*

*Answer: "Prolactin is the hormone responsible for the initiation of labor."* Rationale: Prolactin stimulates the secretion of milk, called lactogenesis. Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding. Progesterone stimulates the secretions of the endometrial glands, causing endometrial vessels to become highly dilated and tortuous in preparation for possible embryo implantation.

*Question: The nurse is conducting a prenatal session with a group of expectant parents. The nurse recognizes that teaching regarding hormones has been successful if a parent makes which statement?*

*Answer: "Prolactin is the hormone responsible for the secretion of milk."* Rationale: Prolactin stimulates the secretion of milk. Oxytocin may assist in the onset of labor and stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding. Oxytocin is also responsible for the "let-down" reflex associated with lactation, but it is not responsible for maintenance of the pregnancy. Progesterone stimulates the secretions of the endometrial glands, causing endometrial vessels to become highly dilated and tortuous in preparation for possible embryo implantation. Testosterone is produced by the adrenal glands in the female and induces the growth of pubic and axillary hair at puberty.

*Question: A client with myasthenia gravis is being discharged on pyridostigmine bromide. The nurse reinforces medication instructions with the client and makes which statement to the client?*

*Answer: "Take the medication before activities such as eating."* Rationale: Pyridostigmine bromide is an anticholinesterase that is used to improve muscle strength in the client with myasthenia gravis. Taking the medication before activities such as eating helps lessen fatigue and dysphagia and improves muscle strength. The medication should be taken with food. Clients should avoid quinine, antacids, magnesium, and morphine sulfate and its derivatives because these medications can reverse the action of the pyridostigmine bromide and increase weakness. The medication should be taken regularly and on time to prevent fluctuating blood levels, which can cause weakness.

*Question: A client is scheduled for an amniocentesis and tells the nurse, "I'm not sure I should have this test done." Which response by the nurse is appropriate?*

*Answer: "Tell me what concerns you have."* Rationale: The nurse needs to gather more data and assist the client in exploring her feelings about the test. Options 2, 3, and 4 are blocks to communication and are nontherapeutic nursing responses.

*Question: A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which statement by the client indicates understanding of this stress reduction measure?*

*Answer: "The best thing about this is that I can use it anywhere, anytime."* Rationale: Guided imagery involves the client's creation of an image in the mind, concentrating on the image, and gradually becoming less aware of the offending stimulus. It does not require any adjuncts and does not need to be done in a quiet area only, although some clients may use other relaxation techniques or play music with it.

*Question: The nursing instructor asks a student nurse to describe osteogenic sarcoma. Which statement by the student indicates the need for further teaching?*

*Answer: "The child does not experience pain at the primary tumor site."* Rationale: Osteogenic sarcoma is the most common bone tumor in children. A clinical manifestation of osteogenic sarcoma is progressive, insidious, intermittent pain at the tumor site. By the time these children receive medical attention, they may be in considerable pain from the tumor. Options 1, 3, and 4 are accurate regarding osteogenic sarcoma.

*Question: The nursing instructor asks a nursing student about sudden infant death syndrome (SIDS). Which statement by the student indicates further teaching is needed?*

*Answer: "The incidence of SIDS has been found to be higher in breast-fed infants and infants that use a pacifier."* Rationale: The incidence of SIDS has been found to be lower in breastfed infants and infants who sleep with a pacifier. Options 2, 3 and 4 are correct.

*Question: A client taking an angiotensin-converting enzyme (ACE) inhibitor reviewed the medication information sheet and notes that the medication is used to treat hypertension. He states, "I have heart failure. Why am I taking this medicine?" The nurse responds by making which statement?*

*Answer: "The medication causes relaxation in your arteries and veins and decreases the heart's work."* Rationale: ACE inhibitors produce multiple benefits in heart failure. By lowering arteriolar tone, these medications improve regional blood flow, and by reducing cardiac afterload, they increase cardiac output. By causing venous dilation, they reduce pulmonary congestion and peripheral edema. By dilating blood vessels in the kidney, they increase renal blood flow and thereby promote excretion of sodium and water. This loss of fluid has two beneficial effects: (1) it helps reduce edema and (2) by lowering blood volume, it decreases venous return to the heart thereby reducing right-heart size. Also by suppressing aldosterone and by reducing local production of angiotensin II in the heart, ACE inhibitors may prevent or reverse pathological changes in cardiac structure. Therefore, options 1, 3, and 4 are incorrect.

*Question: The nurse is reinforcing instructions to a client with essential hypertension about medication therapy with irbesartan. Which client statement would indicate a need for further teaching?*

*Answer: "The medication reduces my need for exercise."* Rationale: The medication irbesartan is an antihypertensive, and as with any antihypertensive, the client must maintain a healthy lifestyle that includes dietary modifications and exercise. Antihypertensives should be taken in the morning. Smoking and consuming caffeine must be avoided. The client should be taught how to monitor his own blood pressure.

*Question: The nurse is collecting data from a client with type 2 diabetes mellitus. Which statement by the client indicates an understanding of the medication regimen?*

*Answer: "The medication that I am taking helps release the insulin I already make."* Rationale: Clients with type 2 diabetes mellitus have decreased or impaired insulin secretion. Oral hypoglycemic agents are given to these clients to facilitate glucose use and need to be taken on a regular schedule as prescribed. To maintain normal blood glucose levels throughout the day, oral hypoglycemic agents such as metformin are not taken on an as-needed basis depending on the blood glucose levels. Insulin injections may be given during times of stress-induced hyperglycemia. Oral insulin is not available or effective because of the breakdown of the insulin by digestion.

*Question: Thyroid replacement therapy is prescribed for a client diagnosed with hypothyroidism. The client asks the nurse when the medication will no longer be needed. Which response by the nurse would be accurate?*

*Answer: "The medication will need to be continued for life."* 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 improve symptoms, these improvements do not constitute a reason to interrupt or discontinue the medication.

*Question: The nurse is teaching a client with a urinary stoma about how to change the collection bag and appliance at home. Which of the following client statements indicate an understanding of the procedure?*

*Answer: "The pouch needs to be changed every 5 to 7 days."* Rationale: Clients with urinary diversions need to be educated on the proper care of the urinary stoma. An appliance with an attached collection bag is placed over the stoma to collect urine. The most ideal time to change the appliance is in the morning, not at night. The stoma needs to be cleaned with both non-residual soap and water, not just water. The skin barrier is cut no more than 3 millimeters larger than the stoma to prevent urine leakage and irritation of the exposed skin. The pouch needs to be changed every 5 to 7 days. Therefore, option 3 indicates client understanding of the procedure.

*Question: The nursing student is asked to describe the size of the uterus in a pregnant client at the end of pregnancy. Which response by the student indicates an understanding of the anatomy of this structure?*

*Answer: "The uterus is round and weighs approximately 1000 grams."* Rationale: Before conception, the uterus is a small pear-shaped organ entirely contained in the pelvic cavity. Before pregnancy, the uterus weighs approximately 60 g (2 ounces). At the end of pregnancy, the uterus weighs approximately 1000 g (2.2 pounds) and has a sufficient capacity for the fetus, placenta, and amniotic fluid.

*Question: The nurse prepares to administer erythromycin ophthalmic ointment to a newborn infant immediately after delivery. Which statement made by the mother indicates that the mother understands the purpose of her newborn receiving this medication?*

*Answer: "This medication will provide protection from Neisseria gonorrhoeae and Chlamydia."* Rationale: Erythromycin is effective in protecting the newborn against N. gonorrhoeae and Chlamydia. It is less irritating to the newborn's eyes than silver nitrate, does not stain, and may be administered at any safe temperature. This medication does not protect the infant from hepatitis B, speed up drying the umbilical cord, or prevent the newborn from having bleeding episodes.

*Question: A client with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which response by the nurse is appropriate?*

*Answer: "Usually, these physical changes slowly improve following treatment."* Rationale: The client with Cushing's syndrome should be reassured that most physical changes resolve with treatment. Options 1, 2, and 4 are not therapeutic responses.

*Question: A client arrives at the ambulatory care center complaining of flulike symptoms. On data collection, the client tells the nurse that he was bitten by a tick and is concerned that the bite is causing the sick feelings. The client requests a blood test to determine the presence of Lyme disease. Which question would the nurse ask next?*

*Answer: "When were you bitten by the tick?"* Rationale: There is a blood test available to detect Lyme disease; however, it is not a reliable test if performed before 4 to 6 weeks following the tick bite. The appropriate question by the nurse should elicit information related to when the tick bite occurred.

*Question: The nurse is caring for an infant with a diagnosis of hyperbilirubinemia. When explaining to the infant's mother the use of phototherapy, the nurse would make which statement?*

*Answer: "While undergoing phototherapy, your infant should wear an eye shield that is removed during feedings."* Rationale: Lotions and ointments should not be used during phototherapy because they absorb heat and can cause burns. The infant's eyes must be protected by an opaque mask to prevent overexposure to the light. The eye shield should cover the eyes completely but not occlude the nares. Before the mask is applied, the infant's eyes should be closed gently to prevent excoriation of the corneas. The mask should be removed periodically and during infant feedings so that the eyes can be checked and cleansed with water and the parents can have visual contact with the infant. Hydration maintenance in the healthy newborn is carried out with human milk or infant formula; there is no benefit to administering oral glucose or plain water because these do not promote excretion of bilirubin in stools and may in fact perpetuate enterohepatic circulation, thus delaying bilirubin excretion.

*Question: The nurse is assisting with data collection for a parent and son during a well-child visit. The nurse determines the child is in the phallic stage of Sigmund Freud's theory of personality development if the parent makes which comment?*

*Answer: "Yesterday my son asked me why he looked different from his sister."* Rationale: Freud's phallic stage of development includes the recognition of differences between the sexes. Accomplishing toilet training occurs during the Freud's anal stage. Development of pubic hair is characteristic of the genital stage. Freud's latency stage is characterized by same sex friendships and making comments about the other sex.

*Question: A client who has undergone femoropopliteal bypass grafting says to the nurse, "I hope I don't have any more problems that could make me lose my leg. I'm so afraid that I'll have gone through this for nothing." Which is an appropriate nursing response?*

*Answer: "You are concerned about losing your leg?"* Rationale: The appropriate response is the one that uses the therapeutic technique of restatement. Option 2 restates the client's concern and provides an opportunity for the client to further discuss the concern. Options 1, 3, and 4 are inappropriate because they provide false reassurance and do not address the client's concern.

*Question: A client is experiencing impotence after taking an antihypertensive medication. The client states, "I would sooner have a stroke than keep living with the side effects of this medication." The nurse would make which appropriate response to the client?*

*Answer: "You are concerned about the side effects of your medication?"* Rationale: Reflection of the client's comment lets the client know that you are hearing his concerns without judging. The nurse cannot understand what the client is experiencing (option 1). Option 3 devalues the health care provider's judgment. Option 2 is confrontational and unsupportive.

*Question: A client who is scheduled for surgery and who is to be placed in skeletal traction says to the nurse, "I'm not sure if I want to have this skeletal traction or if the skin traction would be best to stabilize my fracture." Based on the client's statement, the nurse would make which response to the client?*

*Answer: "You have concerns about skeletal versus skin traction for your type of fracture?"* Rationale: Asking the client if there are concerns about skeletal versus skin traction identifies the therapeutic communication technique of paraphrasing. Paraphrasing is restating the client's message in the nurse's own words. Telling the client the fracture is unstable and the client will die without the surgery identifies a communication block that reflects a lack of the client's right to an opinion. It also will cause fear in the client. Also, saying that skeletal traction is more effective than skin traction is offering a false reassurance, and this type of response will block communication. In addition, saying that there is no reason to be concerned is also a communication block and reflects a lack of the client's right to an opinion.

*Question: A client with pheochromocytoma is scheduled for surgery and says to the nurse, "I'm not sure that surgery is the best thing to do." Which response by the nurse is appropriate?*

*Answer: "You have concerns about the surgical treatment for your condition?"* Rationale: Paraphrasing is restating the client's message in the nurse's own words. Option 2 addresses the therapeutic communication technique of paraphrasing. The client is reaching out for understanding. In option 4, the nurse is offering a false reassurance, and this type of response will block communication. Option 3 also represents a communication block because it reflects a lack of the client's right to an opinion. In option 1, the nurse is expressing approval, which can be harmful to the nurse-client relationship.

*Question: The nurse is caring for a client who has just had rotator cuff repair. The client asks the nurse how soon he can resume his tai chi classes. The nurse would make which statement to the client?*

*Answer: "You shouldn't be doing any exercises that require the use of your upper arms until you have been cleared to do so by the primary health care provider."* Rationale: Tai chi is a slow, relaxed, and graceful series of movements. In tai chi, each movement flows into the next one and the entire body is always in motion, with the movements performed gently and at uniform speed. The upper arms often are held in a horizontal fashion. Clients who have had shoulder repair (rotator cuff repair) will not be able to lift the affected arm to perform the movements. Doing so can undo the surgical repair and cause the client severe pain. The client may be able to resume tai chi at some point in the future when permitted by the primary health care provider.

*Question: Abdominal ultrasonography is prescribed for a client who is pregnant. The nurse provides information to the client regarding the procedure and makes which statement?*

*Answer: "You will be positioned on your back and turned slightly to one side with your head elevated."* Rationale: The client is positioned on the back with the head and the knees supported by pillows. The client's head will be elevated, and the client will be turned slightly to one side to prevent supine hypotension. The procedure takes 10 to 30 minutes. A full bladder makes it easier for sound waves to reach the pelvic area, so the client should be instructed to drink 1 to 2 quarts of clear fluid 1 hour before the test. The client should not void until the ultrasound is obtained. The ultrasound will not take an hour, the client should not urinate before the procedure, and the side position is not used.

*Question: A client with acute pyelonephritis is scheduled for a voiding cystourethrogram. After the nurse provides information about this procedure, the client states, "I can't urinate in front of other people. I have a 'bashful' kidney." What is the nurse's best response?*

*Answer: "You will be screened and given as much privacy as possible."* Rationale: Having to void in the presence of others can be very embarrassing for clients and actually may interfere with the client's ability to void. The nurse teaches the client about the procedure to try to minimize stress from lack of preparation and gives the client encouragement and emotional support. Screens may be used in the radiology department to try to provide an element of privacy during this procedure. Since a catheter was inserted to instill the dye, it could be left in place if the client is unable to urinate.

*Question: A postoperative client received a spinal anesthetic. The client has not experienced pain because the anesthetic has not yet worn off. The nurse would monitor the client closely for pain and provide the client with which instruction?*

*Answer: "You will need to let me know when you start to get feeling back in your legs."* Rationale: The nurse should tell the client to "let me know when you start to get feeling back in your legs". Analgesics need to be encouraged in the postoperative client as needed. The nurse explains that the client will start to feel sensation as the spinal anesthetic wears off. Along with the increased sensation, the client will also experience pain. Although saying pain might not be felt because of the spinal anesthesia may be correct information, it does not address the issue of pain assessment. Telling the client that you will bring the pain medication at 10:00 p.m. is not appropriate, because the nurse does not schedule the pain medication administration. Also, telling the client that the client will not be able to take pain medication until the client has been up to the bathroom is incorrect because the client should be medicated before any activity is attempted, especially in the postope

*Question: A client with type 1 diabetes mellitus in the first trimester of pregnancy is scheduled for a primary health care provider's visit. The client asks the nurse whether a change in the medication to treat the diabetes will occur at this time. Which statement is true?*

*Answer: "Your normal insulin dosage will have to be decreased."* Rationale: Typically, insulin dosage may have to be reduced to avoid hypoglycemia in the first trimester when nausea decreases appetite and physical activity may be reduced. A prescribed amount of insulin may be administered with additional Insulin being given on a sliding scale in which the woman varies her dose of insulin based on blood glucose levels. NPH insulin is not given at dinnertime because hypoglycemia during the night can occur.

*Question: During a well-child visit a mother states she is frustrated with her 2-year-old child. Whenever she asks him if he wants something to eat, he says "no," but then he starts to cry when she does not give him the food. The nurse would provide which instruction to explain the psychosocial concepts related to growth and development of the toddler?*

*Answer: "Your toddler is asserting his independence as he is progressing through the stage of autonomy versus shame and doubt."* Rationale: According to Erikson, toddlers are acquiring a sense of autonomy while overcoming a sense of shame and doubt. They are attempting to relinquish their dependence and assert independence, which will be present as negativism in their quest for independence. The word no is a very strong part of their vocabulary. Therefore, the other options are inaccurate. Toddlers can be given very simple choices to achieve autonomy. There is nothing in the question that mentions mistrust. Magical thinking refers to cognitive development.

*Question: The nurse is reinforcing postprocedure teaching after a client underwent an upper gastrointestinal (GI) series. The nurse reminds the client that the stools will remain white for approximately how long?*

*Answer: 1 to 2 days* Rationale: It takes at least 12 to 24 hours and possibly up to 3 days for a substance to pass through the colon. The other time frames listed are excessive. Barium should be eliminated to prevent the risk of impaction from this substance.

*Question: The nurse is reading a primary health care provider's prescription and notes that a client is to receive a medication at 1:00 p.m. Using the military time clock, the nurse administers the medication at which time? Refer to figure.View Figure*

*Answer: 1* Rationale: According to the National Patient Safety goals, health care agencies are mandated to use military time, which is a 24-hour system that avoids misinterpretation of a.m. and p.m. times. Instead of two 12-hour cycles in standard time, the military clock is one 24-hour time cycle. 1:00 p.m is 1300 hours.

*Question: When performing cardiopulmonary resuscitation (CPR), the nurse would deliver how many breaths per minute to an adult client?*

*Answer: 10* Rationale: During CPR, the nurse would deliver 10 breaths per minute to an adult client. Therefore, 8, 16, and 20 are incorrect.

*Question: A registered nurse has just hung a 250-mL bag of packed red blood cells (PRBCs) on a client. The licensed practical nurse assisting in caring for the client plans to remain with the client for at least how many minutes following the start of the infusion?*

*Answer: 15 minutes* Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, which is the most frequent period during which a transfusion reaction may occur. This enables the nurse to quickly detect a reaction and intervene quickly. Option 1 is not enough time to remain with the client. The time frames in options 3 and 4 are unnecessary.

*Question: The nurse is caring for a woman in labor. The nurse monitors the baseline fetal heart rate (FHR) and would document which findings as a normal FHR pattern?*

*Answer: 150 beats per minute, moderate variability* Rationale: The normal baseline fetal heart rate has a lower limit of 110 to 120 beats per minute and an upper limit of 150 to 160 beats per minute. Variability desired is moderate indicating a periodic change of 6 to 25 beats per minute. Options 1, 3, and 4 are incorrect based on FHR range.

*Question: A client sustains a burn injury to the anterior right and left legs and perineal area. According to the rule of nines, the nurse would determine that this injury constitutes which body percentage?*

*Answer: 19%* 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 1%. If the anterior right leg (9%), the anterior left leg (9%), and the perineum (1%) were burned, the area of injury would equal 19%, according to the rule of nines.

*Question: Using the rule of nines, calculate the burn percentage for the client. Which matches your calculations? Refer to the figure; the burned area is the darkly shaded area. Refer to figure.View Figure*

*Answer: 19* Rationale: The rule of nines is a quick method for early assessment of burn surface area. The head and neck are equal to 9%; each arm is equal to 9%; each leg is equal to 18%; the entire trunk is equal to 36%; and the genitalia are equal to 1%.

*Question: Bethanechol chloride is prescribed for a client. When would the nurse tell the client to take the medication?*

*Answer: 2 hours after meals* Rationale: Administration of bethanechol with meals 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.

*Question: The nurse is reviewing the laboratory studies of a client receiving epoetin alfa. When would the nurse expect to note a therapeutic effect of this medication on the hemoglobin and hematocrit?*

*Answer: 2 months after therapy* Rationale: Epoetin alfa stimulates erythropoiesis. Initial effects are noted within 1 to 2 weeks, and hematocrit levels reach normal levels in 2 to 3 months. Therefore, this medication is not intended for clients who require immediate correction of severe anemia, and it is not a substitute for emergency transfusions.

*Question: The nurse hangs a 1000-mL intravenous (IV) bag of 5% dextrose in water (D5W) at 0700. The IV is to infuse at 100 mL/hr, and the nurse places a time tape on the IV bag. At noon the nurse would expect that the infusion line on the IV bag would be at which point? Refer to figure.View Figure*

*Answer: 2* Rationale: If an IV is to infuse at 100 mL/hr, in a 5-hour period (0700 to 1200) a total of 500 mL would have infused. The infusion line is connected to the IV bag and catheter hub; the fluid line will be at the 500 mL position of the time tape strip.

*Question: The nurse is collecting physical assessment data for a patient with possible splenomegaly. The nurse should palpate which abdominal quadrant? Refer to figure.View Figure*

*Answer: 2* Rationale: The spleen is located in the left upper quadrant of the abdomen and can be palpated in the area. Therefore, the other options are incorrect.

*Question: A client with Crohn's disease has a prescription to begin taking antispasmodic medication. The nurse would schedule the medication so that each dose is taken at which time?*

*Answer: 30 minutes before meals* Rationale: To be effective in decreasing bowel motility, antispasmodic medications should be administered 30 minutes before mealtime. The other options are incorrect.

*Question: The nurse is providing cardiopulmonary resuscitation (CPR) to an adult cardiac arrest victim. Which is the proper compression-to-ventilation ratio for one-person CPR?*

*Answer: 30:2* Rationale: Current cardiopulmonary resuscitation guidelines based on evidence-based practice for one-person cardiopulmonary resuscitation recommend a 30 compression:2 respiration ratio. All other options are incorrect and will be less effective in the resuscitation of this victim.

*Question: During a routine well-child checkup for a 2½ year old, the nurse plans to teach the mother proper nutrition and weight gain expectations for her child. The nurse reviews the chart and finds that the toddler's birth weight was 7 pounds 15 ounces. The nurse expects that the child should weigh approximately how much at this time?*

*Answer: 31 pounds 12 ounces* Rationale: By the age of 2½ years, the toddler should have quadrupled his or her birth weight. The child doubles the birth weight by age 5 to 6 months and triples the birth weight by 1 year of age. The correct choice, 31 pounds 11 ounces, is quadruple the birth weight.

*Question: A client has just been treated with cardioversion. The nurse should check which measure first?*

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

*Question: The nurse is checking the apical heart rate of a client with a complaint of angina. The nurse places the stethoscope in which anatomical area? Refer to figure.View Figure*

*Answer: 4* Rationale: The apical heart rate is assessed best by placing the stethoscope in the mitral area, which is located in the fifth intercostal space on the left side of the chest at the apex of the heart. The aortic area is located in the second intercostal space just right of the sternum. Erb's point is located in the third intercostal space just left of the sternum. The pulmonic area is located in the second intercostal space just left of the sternum.

*Question: 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 intravenous (IV) solution will most likely be prescribed for this client?*

*Answer: 5% dextrose in lactated Ringer's solution* Rationale: For this client, the goal of therapy is to expand intravascular volume as quickly as possible. In this situation, the client will likely experience a decrease in intravascular volume from blood loss, resulting in decreased blood pressure. Therefore, a solution that increases intravascular volume, replaces immediate blood loss volume, and increases blood pressure is needed. The 5% dextrose in 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 the remaining options 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.

*Question: Isoniazid is prescribed for a 2-year-old child with a positive tuberculin skin test. The mother of the child asks the nurse how long the child will need to take the medication. Which time frame is the appropriate response to the mother?*

*Answer: 9 months* Rationale: Isoniazid is given to prevent TB infection from progressing to active disease. A chest x-ray film is obtained before the initiation of preventive therapy. In infants and children, the recommended duration of isoniazid therapy is 9 months. For children with human immunodeficiency virus infection, a minimum of 12 months is recommended.

*Question: The nurse is caring for a group of clients who are taking herbal medications at home. Which client would be given instructions with regard to avoiding the use of herbal medications?*

*Answer: A 10-year-old female client with a urinary tract infection* Rationale: Children should not be given herbal therapies, especially in the home and without professional supervision. There are no general contraindications for the clients described in options 1, 2, and 4.

*Question: A blood glucose screening measurement is performed on a pregnant client, and the results indicate that the blood glucose is elevated. Which prescription would the nurse anticipate for the client?*

*Answer: A 3-hour glucose tolerance test* Rationale: A maternal glucose is prescribed to screen for gestational diabetes. If it is elevated, a 3-hour glucose tolerance test is recommended to determine the presence of gestational diabetes. A sliding-scale regular insulin dose, an oral hypoglycemic agent, or NPH insulin should not be prescribed based solely on the maternal glucose levels. Further follow-up should be implemented.

*Question: A pregnant client has been diagnosed with placental abruption. The client should be prepared for which intervention or procedure?*

*Answer: A cesarean birth* Rationale: Early diagnosis of placental abruption is critical in managing it effectively. Plans should be instituted for continuous fetal monitoring, blood analysis, and either an immediate cesarean birth or vaginal delivery. Options 1, 3, and 4 are not helpful in managing this problem.

*Question: The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition?*

*Answer: A chronic disability characterized by impaired muscle movement and posture* Rationale: Cerebral palsy is a chronic disability characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infection. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.

*Question: The nurse is assigned to care for four clients. When planning client rounds, which client would the nurse collect data from first?*

*Answer: A client receiving oxygen who is having difficulty breathing* Rationale: The airway is always a 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 would have intermediate priority.

*Question: Which client is the safest one for a licensed practical nurse (LPN) to care for?*

*Answer: A client recovering from a scheduled cesarean delivery* Rationale: The LPN should care for the most stable, least high-risk client. In this case, a client who had a scheduled cesarean delivery would be the most stable client. A client who is receiving a blood transfusion will need ongoing assessment and is at higher risk than a client recovering from a scheduled cesarean delivery. Von Willebrand disease is a type of inherited blood-clotting disorder that puts the client at high risk for hemorrhage. A client with a previous postpartum hemorrhage is also at higher risk for postpartum complications.

*Question: The nurse is preparing to discharge a client who has had a parathyroidectomy. When reinforcing instructions to the client about the prescribed oral calcium supplement, which information would the nurse include?*

*Answer: Take the calcium 30 to 60 minutes following a meal.* Rationale: Oral calcium supplements can be taken 30 to 60 minutes after meals to enhance their absorption and decrease gastrointestinal irritation. All the other options are unrelated to oral calcium therapy.

*Question: The nurse is monitoring several older adults for adverse drug effects. Which client requires closest monitoring for drug toxicity?*

*Answer: A client who consumes a high-carbohydrate, low-protein diet* Rationale: A client who consumes a high-carbohydrate, low-protein diet is at highest risk of drug toxicity because an unbound active drug still circulates in the bloodstream. A client with a decreased, not an increased, hemoglobin and plasma protein level, is at higher risk of drug toxicity. A client who refuses to take antihypertensive medication would have a low drug level and would be less likely to experience drug toxicity.

*Question: A nurse working in a long-term care facility is assigned to care for four clients on the hospice unit. In planning client rounds, which client would the nurse collect data on first?*

*Answer: A client who was complaining of severe back pain on the previous shift* Rationale: The nurse is working on a hospice unit, which means that the nurse is caring for terminally ill clients. The client who is terminally ill needs to be comforted, and the nurse must maintain a satisfactory lifestyle through the phase of dying. Although all of these clients need the nurse's attention, the client who needs to be seen first would be the client who was in severe pain on the previous shift. The nurse should evaluate this client to see if further pain medication is needed. Alleviating suffering is a priority nursing responsibility. Because pain is often an element of suffering, promoting optimal pain relief is a primary goal.

*Question: The nurse determines that which client is at greatest risk for development of acute respiratory distress syndrome (ARDS)?*

*Answer: A client with pancreatitis and gram-negative sepsis* Rationale: The client with pancreatitis and gram-negative sepsis is at greatest risk of developing ARDS because of the presence of two risk factors for its development. Although the client with blunt chest trauma is also at risk, those who have multiple risk factors have a three to four times greater incidence for development of ARDS. Massive blood transfusion is a risk factor for ARDS; however, this client has received only 1 unit. Pulmonary edema after myocardial infarction occurs when increased pulmonary capillary hydrostatic pressure causes flooding of the pulmonary interstitial spaces and then the alveoli. The pulmonary edema that occurs in ARDS is due to damage to pulmonary vasculature resulting in increased pulmonary capillary permeability.

*Question: A client is being evaluated as a potential kidney donor for a family member. The donor asks the nurse why a different team of people other than the team working with the potential recipient is doing the evaluation. Which response would the nurse give to the client?*

*Answer: A conflict of interest by the team evaluating the recipient and the team evaluating the donor is avoided.* Rationale: Both the kidney donor and recipient need thorough medical and psychological evaluation before transplant surgery. To avoid conflict of interest, evaluation of the donor is done by a team different from that caring for the recipient. The psychosocial issues in living-related organ donation may be very complex, and conversations with the donor are held in strict confidence to preserve family relations.

*Question: The nurse is caring for a client with a cerebral aneurysm who is on aneurysm precautions and is monitoring the client for signs of aneurysm rupture. The nurse understands that which is an early sign of rupture?*

*Answer: A decline in the level of consciousness* Rationale: Rupture of a cerebral aneurysm usually results in increased intracranial pressure (ICP). The first sign of pressure is a change in the level of consciousness because of compression of the reticular formation in the brain. This change in level of consciousness can be as subtle as drowsiness or restlessness. Because centers that control blood pressure are located lower in the brainstem than those that control consciousness, changes in pulse pressure are a later sign. Options 1 and 2 are not early signs of ICP. These signs may occur later if the ICP has led to neurological damage.

*Question: While collecting data on a client being prepared for an adrenalectomy, the nurse obtains a temperature reading of 100.8° F. The nurse analyzes this temperature reading as which?*

*Answer: A finding that needs to be reported immediately* Rationale: An adrenalectomy is performed because of excess adrenal gland function. Excess cortisol production impairs the immune response, which puts the client at risk for infection. Because of this, the client needs to be protected from infection, and minor variations in normal vital sign values must be reported so that infections are detected early before they become overwhelming. In addition, the surgeon may elect to postpone surgery in the event of a fever because it can be indicative of infection. Options 1, 3, and 4 are not correct interpretations.

*Question: A client diagnosed with peptic ulcer disease and scheduled for a pyloroplasty asks the nurse about the procedure. The nurse would base the response on which information?*

*Answer: A pyloroplasty involves an incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum.* Rationale: Option 4 describes the procedure for a pyloroplasty. 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 cells that produce hydrochloric acid.

*Question: Nalidixic acid is prescribed for a client diagnosed with a urinary tract infection. Reviewing the client's record, the nurse notes that the client is prescribed warfarin on a daily basis. Which prescription would the nurse anticipate because the client is taking this oral anticoagulant?*

*Answer: A reduction in the anticoagulation dosage* Rationale: Nalidixic acid can intensify the effects of oral anticoagulants. When an oral anticoagulant is combined with nalidixic acid, a reduction in the anticoagulant dosage may be needed.

*Question: The nurse is monitoring a client with a diagnosis of gastric ulcer. Which finding would indicate perforation of the ulcer?*

*Answer: A rigid, boardlike abdomen* Rationale: Perforation is a surgical emergency. It is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which becomes rigid and boardlike. Nausea and vomiting may occur with peptic ulcer disease but does not indicate perforation. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding.

*Question: The nurse is caring for an 18-month-old child who has been vomiting. Which is the appropriate position to place the child during naps and sleep time?*

*Answer: A side-lying position* Rationale: The vomiting child should be placed in an upright or side-lying position to prevent aspiration. Options 1, 3, and 4 will place the child at risk for aspiration if vomiting occurs.

*Question: The surgeon asks the nurse to obtain a urinary catheter that will be used for continuous bladder irrigation. Which urinary catheter would be the nurse obtain?*

*Answer: A triple-lumen catheter* Rationale: Straight catheters are used for intermittent catheterization. Double-lumen catheters are used for indwelling urinary catheterization in which one lumen drains urine in the bladder and the other lumen is used to inflate and deflate the balloon. Triple-lumen catheters are used for continuous bladder irrigation or bladder medication instillation. One lumen is to inflate and deflate the balloon, another lumen is to drain urine and the irrigation solution, and the other lumen instills the irrigation solution into the bladder. A Coudé tip catheter is a catheter with a curved tip at the end used to advance the catheter past a hypertrophied prostate, in which using a standard catheter would be difficult. Therefore, option 3 is correct.

*Question: An explosion occurred at an industrial plant involving injury to 50 victims. The nurse at the scene determines that which victim would be transported to the hospital first?*

*Answer: A victim with singed nasal and facial hair and difficulty breathing* Rationale: Singed nasal and facial hairs suggest the victim has inhaled a heated substance. In addition, the victim is experiencing respiratory difficulty and should receive treatment at the scene and then immediately be transported to the emergency department. Although closed fractures are serious, victims can wait for transportation after initial emergency management, such as immobilization. Minor soft tissue injuries are considered nonurgent and can wait for treatment. Fixed, dilated pupils in a pulseless victim indicate the victim is already deceased.

*Question: The nurse is monitoring the daily weight of an infant with heart failure (HF). Which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the registered nurse?*

*Answer: A weight gain of 1 lb in 1 day* Rationale: A weight gain of 0.5 kg (1 lb) in 1 day is a result of the accumulation of fluid. The nurse should monitor the urine output, monitor for evidence of facial or peripheral edema, check the lung sounds, and report the weight gain. Tachypnea and an increased BP would occur with fluid accumulation. Diaphoresis is a sign of HF, but it is not specific to fluid accumulation and it usually occurs with exertional activities.

*Question: A client has undergone fluoroscopy-assisted aspiration biopsy of a lung lesion. The nurse determines that the client is experiencing complications from the procedure if the nurse makes which observation?*

*Answer: Absence of breath sounds in the right upper lobe* Rationale: Pneumothorax and bleeding are possible complications of this procedure. The client is observed for signs of respiratory difficulty such as dyspnea, change in breath sounds, vital signs, pallor, and diaphoresis. Observation of the sputum for traces of blood or hemoptysis also is indicated. The absence of breath sounds in the right upper lobe indicates a potential pneumothorax.

*Question: A client's arterial blood gases reveal a pH of 7.51 and a bicarbonate level of 31 mEq/L. The nurse prepares for the administration of which medication that would be prescribed to treat this acid-base disorder?*

*Answer: Acetazolamide* Rationale: Acetazolamide is a diuretic used in the treatment of metabolic alkalosis. This medication causes excretion of sodium, potassium, bicarbonate, and water by inhibiting the action of carbonic anhydrase. Administration of sodium bicarbonate would aggravate the already existing condition and is contraindicated. Furosemide is a loop diuretic, and spironolactone is a potassium-retaining diuretic. These are of no value when there is a need to excrete bicarbonate.

*Question: The nurse is caring for a client who is suspected of having lung cancer. The nurse monitors the client for which most frequent early sign of lung cancer?*

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

*Question: When discussing the rationale for levothyroxine with a client with hypothyroidism, the nurse would emphasize that the client can anticipate which primary expected outcome?*

*Answer: Achieving normal thyroid hormone levels* Rationale: Laboratory determination of the serum thyroid-stimulating hormone level (TSH) is an important means of evaluation of therapy with levothyroxine. Effective therapy will cause the elevated TSH levels to decrease. 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 established, TSH levels will remain suppressed for the duration of the therapy. Although energy levels are expected to increase, the primary expected outcome is measured by thyroid hormone levels. Alleviating depression and increasing blood glucose levels are unrelated to this medication.

*Question: Allopurinol has been prescribed for a client with chronic tophaceous gout. The nurse explains to the client that what condition can occur during the first few months of treatment?*

*Answer: Acute gouty arthritis* Rationale: Allopurinol is an antigout medication. It decreases uric acid production by inhibiting the enzyme xanthine oxidase and reduces uric acid concentrations in serum and urine. During the initial months of treatment, allopurinol may increase the incidence of acute gouty arthritis. The risk of an attack can be reduced by concurrent treatment with colchicine or a nonsteroidal anti-inflammatory drug (NSAID).

*Question: A pregnant woman in the second trimester of pregnancy complains of constipation and describes the home care measures she is taking to relieve the problem. Which would the nurse determine is a harmful measure in preventing constipation?*

*Answer: Adding 1 tablespoon of mineral oil to a bowl of cereal daily* Rationale: Mineral oil should not be used as a stool softener because it inhibits the absorption of fat-soluble vitamins in the body. Constipation should be treated with increased fluids (six to eight glasses per day) and a diet high in fiber. Increasing exercise is also an excellent way to improve gastric motility.

*Question: The parents of a neonate who is not circumcised asks the nurse why the foreskin should not be retracted. The nurse explains that retracting the foreskin would be avoided because which complication may occur?*

*Answer: Adhesions* Rationale: In newborn males, the prepuce is continuous with the epidermis of the glans and is nonretractable. Forced retraction may cause adhesions to develop. Separation should be allowed to occur naturally, which will take place between 3 years and 5 years of age. Most foreskins are retractable by 3 years of age and should be pushed back gently for cleaning once a week.

*Question: A hospitalized client is newly diagnosed with diabetes mellitus. The client must take both NPH and regular insulin for glucose control. The nurse develops a teaching plan to help the client meet which outcome as a first step in managing the disease?*

*Answer: Adjust insulin according to capillary blood glucose levels.* Rationale: There are many learning goals for the client who is newly diagnosed with diabetes mellitus. The client must learn dietary control, medication management, and proper exercise in order to control the disease. As a first step, the client learns to adjust medication (insulin) according to blood glucose results as prescribed by the primary health care provider. The client should then focus on long-term dietary control and weight loss, which will often lead to a decreased need for insulin. At the same time that diet is being controlled, the client should begin a regular exercise program to aid in weight loss.

*Question: A client is to have an upper gastrointestinal (GI) series. Which nursing action would be done concerning the procedure?*

*Answer: Administer a laxative after the procedure because barium was administered.* Rationale: Barium sulfate, which is used as contrast material during an upper GI series, is a constipating material. If it is not eliminated from the GI tract, it can cause obstruction. Therefore, laxatives or cathartics are administered as part of routine postprocedure care. Checking for return of a gag reflex, being on clear liquids for 2 days, and a signed consent for an iodine based dye are not related to the procedure.

*Question: The nurse notes that a client is due in hydrotherapy for a burn dressing change in 30 minutes. The nurse plans to take which action next in the care of this client?*

*Answer: Administer an opioid analgesic last taken 6 hours ago.* Rationale: The client should receive pain medication approximately 30 minutes before a burn dressing change. This will help the client tolerate a painful procedure. The client does not need to be NPO for this procedure. Dressing supplies are not sent with the client because they are available in the hydrotherapy area. A robe and slippers are given to the client for transport but are not indicated 30 minutes ahead of time.

*Question: A hospitalized client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, the nurse administers nitroglycerin, 0.4 mg sublingually. After 5 minutes, the client states, "My chest still hurts." If the vital signs have remained stable, which action would the nurse perform?*

*Answer: Administer another nitroglycerin tablet.* Rationale: Nitroglycerin tablets usually are prescribed 1 every 5 minutes as needed (PRN) for chest pain, for a total dose of 3 tablets. Waiting 10 minutes is inappropriate if the client is having chest pain. Oxygen at 10 L is an unsafe dose. There is no need to call the resuscitation team at this time.

*Question: A client is in respiratory alkalosis induced by gram-negative sepsis. The nurse assists in implementing which measure as the effective means to treat the problem?*

*Answer: Administer prescribed antibiotics.* Rationale: The most effective way to treat an acid-base disorder is to treat the underlying disorder. In this case, the problem is sepsis, which is most effectively treated with antibiotic therapy. Antipyretics will control fever secondary to sepsis but do nothing to treat the acid-base disorder. The paper bag and partial rebreather mask will help the client rebreathe exhaled carbon dioxide, but again, these do not treat the primary cause of the imbalance.

*Question: A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin sodium. The nurse is told that the client's prothrombin time is 18 seconds with a control of 11 seconds. Which action would the nurse plan?*

*Answer: Administer the next dose of warfarin sodium.* Rationale: The therapeutic range for prothrombin time (PT) 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 is 16.5 to 22 seconds. The nurse should administer the next dose as usual.

*Question: The client arrives at an emergency department complaining of severe abdominal pain. The initial diagnosis is acute abdomen, and an x-ray and an abdominal ultrasonogram are prescribed to be obtained immediately. The nurse prepares the client for these diagnostic tests and reviews the primary health care provider's prescriptions. Which prescription would the nurse most likely question if written on the primary health care provider's prescription form?*

*Answer: Administration of an opioid analgesic* Rationale: Until a differential diagnosis is determined and a decision about the need for surgery is made, the nurse should question a prescription to give an opioid analgesic because it could mask the client's symptoms. The nurse can expect the client to be placed on NPO status and to have an IV line inserted. Insertion of an NG tube may be helpful to provide decompression of the stomach.

*Question: A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. Which does the nurse anticipate to be prescribed?*

*Answer: Administration of immune globulin and vaccine in the infant soon after birth* Rationale: A hepatitis B screen is performed to detect the presence of antigens in maternal blood. If antigens are present, the infant should receive immune globulin and a vaccine soon after birth. Options 1, 2, and 3 are incorrect actions or treatment measures.

*Question: A client is scheduled for endoscopic retrograde cholangiopancreatography (ERCP). The nurse includes which intervention in the plan of care for the client?*

*Answer: After the procedure, keep the client nothing by mouth (NPO) until the gag reflex returns.* Rationale: ERCP is often done to explore the common bile duct or pancreatic duct. ERCP requires that a client is NPO for 12 hours before the procedure. Because an endoscope is inserted through the oral cavity, the throat is sprayed with an anesthetic and the client will be kept NPO until the gag reflex returns. The client often is given sedation during the procedure and may not recall the testing. Enemas are not needed. Radioactive isotopes are not used for this test. Contrast dye is injected via a catheter into the pancreatic or bile ductal systems.

*Question: During a fire drill, the nurse enters a laundry room and a waste basket is marked as on "fire." The nurse activates the alarm, closes the laundry room door, and obtains a fire extinguisher and returns to the laundry room. Which action by the nurse shows that additional training is needed?*

*Answer: Aiming at the top flames of the fire* Rationale: A fire can be extinguished by the use of a fire extinguisher. To use the extinguisher, remember the mnemonic PASS (P = Pull the pin; A = Aim at the base of the fire; S = Squeeze the handle; S = Sweep from side to side to coat the area evenly). The nurse needs additional training if the nurse aims the extinguisher stream at the top flames of the fire. The nurse should aim at the base of the fire. The other options: pulling the pin, squeezing the handle and sweeping back and forth are correct.

*Question: A client with a diagnosis of cystitis has an indwelling urinary catheter and is being cared for by an assistive personnel (AP). The nurse observes the AP care for the client and intervenes if the AP performs which action?*

*Answer: Allows the drainage tubing to rest under the leg* Rationale: Proper care of an indwelling catheter is especially important to prevent prolonged infection or reinfection in the client with cystitis. 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. 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.

*Question: A nursing student is caring for a client in the health care clinic who has been diagnosed with glaucoma. The client has a history of heart disease. The nursing instructor asks the student about which group of medications used to treat glaucoma that would be contraindicated?*

*Answer: Alpha2-adrenergic agonists* Rationale: All of these medication groups can be prescribed to treat glaucoma; however, alpha2-adrenergic agonist medications are contraindicated in heart disease.

*Question: A client is admitted to the hospital with a diagnosis of acute pancreatitis. The nurse would plan care knowing that most likely, which problem will occur with this disorder?*

*Answer: Alteration in comfort related to abdominal pain* Rationale: Abdominal pain is the predominant symptom of acute pancreatitis. Shock and hypovolemia may occur from hemorrhage, toxemia, or loss of fluid into the peritoneal space. Potassium and sodium may be lost due to gastric suction and frequent vomiting. Hyperglycemia may result from impaired carbohydrate metabolism.

*Question: A lethargic yet easily aroused 6-year-old child is brought to the emergency department with a diagnosis of an overdose with diazepam. During the initial data collection, the nurse determines that the child's blood pressure and respirations are below normal for his age. The Glasgow Coma Scale is performed and reveals a score of 10. Based on this information the nurse determines that which problem would have the highest priority?*

*Answer: Altered respiratory status* Rationale: Although all of the problems may be appropriate, airway is always the highest priority. The other problems can be addressed once a patent airway is ensured and maintained.

*Question: The nurse is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The nurse places which item on the seat of the chair as the best device for pressure relief?*

*Answer: Alternating air pad* Rationale: The client who cannot independently shift weight, which includes a client with tetraplegia, should have a pressure relief pad in place under the buttocks to prevent skin breakdown. The best products for use in providing pressure relief are those that equalize the client's weight on the device. These include foam, water, gel, or alternating air pads. A plastic-lined pad absorbs moisture but provides no pressure relief. A pillow provides cushion but does not redistribute weight equally. An air ring relieves pressure in some spots but causes pressure in others by its design.

*Question: A client has been admitted to the telemetry unit with a diagnosis of bradycardia. The nurse is reviewing the client's prescriptions with the registered nurse. The client has a history of open-angle glaucoma. Which prescription would the nurse question?*

*Answer: Atropine intravenously* Rationale: Measures to prevent an increase in intraocular pressure (IOP) include a low-sodium diet, little caffeine intake, and preventing constipation and Valsalva maneuver. Glaucoma medication must be taken regularly for life. Atropine is contraindicated for a client with open-angle glaucoma. Docusate sodium is a stool softener.

*Question: A client diagnosed with chronic kidney disease is being treated at home with continuous ambulatory peritoneal dialysis. The client notes that there is a decrease in the catheter outflow following the prescribed 6-hour dwell time and calls the nurse to report this occurrence. The nurse would reinforce instructing the client to take which action?*

*Answer: Ambulate in the home.* Rationale: The most common causes of decreased outflow of dialysate in peritoneal dialysis are displacement and obstruction of the catheter. Obstruction may be a result of malposition, adherence of the catheter tip to internal organs, constipation, or infection. The client with decreased catheter outflow should first attempt to displace the catheter tip from internal organs by changing positions or walking. This may be a simple solution to the problem. If the client has been constipated, treatment of the constipation would be necessary. The primary health care provider need not be notified immediately unless the client is exhibiting signs of infection or if attempts to noninvasively clear the obstruction are not effective. Straight catheterization of the bladder will not alleviate this problem, and the client should never instill any type of medication into the catheter besides the medications contained in the dialysate solution.

*Question: After 7 days of wound care, a client who has a well-granulated pressure injury reports to the nurse, "I'm feeling better overall." Which nursing intervention most likely contributed to the client's feelings?*

*Answer: Ambulation three times daily* Rationale: The effects of exercise include client reports of feeling better generally because the benefits of exercise are wide ranging. Ambulation can enhance tissue oxygenation and other cardiovascular, pulmonary, metabolic, integumentary, neuromuscular, and conditioning benefits. Thus, the wide-ranging benefits of exercise are more likely to promote an overall sense of feeling better versus benefiting from pain control, less discomfort, or a well-granulated wound. The benefits of pain management, comfort measures, and dressing changes are more limited (options 1, 2, and 3).

*Question: A client is scheduled to have electroconvulsive therapy (ECT). Which information would the nurse tell the client?*

*Answer: Amnesia of events occurring near the period of the therapy is common.* Rationale: The most common side effects of ECT include amnesia of events occurring near the period of the therapy and the potential for transient confusion as a result of the seizure and barbiturate anesthetic. Stating that many patients experience long-term memory loss is incorrect because in most cases clients experience little long-term memory loss. Stating that there are no expected side effects associated with ECT is also incorrect. Stating that the client will receive no medications during the procedure is incorrect because general anesthesia and a muscle relaxant usually are administered.

*Question: A client in her 24th week of pregnancy is admitted to the hospital in preterm labor. She asks the nurse if her baby will live if the labor cannot be stopped. Which diagnostic test would the nurse expect the primary health care provider to prescribe?*

*Answer: Amniocentesis for fetal surfactant level* Rationale: An amniocentesis is performed to obtain a specimen of fluid to detect the surfactant level. By 20 weeks of gestation the lungs have matured functionally enough for the fetus to survive outside the uterus (age of viability), but special care in the neonatal intensive care unit (NICU) would be required. A biophysical profile consists of a group of five fetal assessments: fetal heart rate and reactivity (the NST), fetal breathing movements, fetal body movements, fetal tone (closure of the hand), and the volume of amniotic fluid (AFI). Chorionic villus sampling consists of obtaining a small part of the developing placenta to analyze fetal cells at 10 to 12 weeks of gestation. The ultrasound scan measures the amniotic fluid pockets in all four quadrants surrounding the mother's umbilicus and produces an amniotic fluid index (AFI). From 5 to 19 cm is considered normal.

*Question: A preliminary diagnosis is made for a child with acute lymphoblastic leukemia (ALL). In reviewing the complete blood cell count (CBC) of the child, the nurse would expect to find which?*

*Answer: An erythrocyte (red blood cell) count of 2 cells in 1 mL of peripheral blood* Rationale: ALL is diagnosed based on the history and the signs and symptoms a child presents during a primary health care provider's visit. The diagnosis also can be made during a routine physical exam or unrelated injury in which the child is brought to a medical clinic. A CBC is done initially to assist with a diagnosis. The CBC would indicate leukopenia (lower than normal WBCs), anemia, and thrombocytopenia. The values in options 1 and 2 are normal results for this age group and do not indicate anemia. Option 3 does not indicate leukopenia. Option 4 is the only laboratory value that is a lower result than a normal RBC count for this age group and is an indicator of anemia or possible leukemia.

*Question: The nurse who is caring for a client with kidney failure notes that the client is dyspneic, and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom would the nurse expect to note in this client?*

*Answer: An increase in blood pressure* Rationale: Impaired cardiac or kidney function can result in fluid volume excess. Findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure, a bounding pulse, an elevated central venous pressure, weight gain, edema, neck and hand vein distention, an altered level of consciousness, and a decreased hematocrit level.

*Question: The nurse reviews the phenytoin level of a client with a seizure disorder. The nurse notes that the plasma drug level is 9 mcg/mL. Which would the nurse anticipate to be prescribed for the client?*

*Answer: An increase in the present dosage* Rationale: The dosing objective is to produce phenytoin levels between 10 and 20 mcg/mL. Levels below 10 mcg/mL are too low to control seizures. At levels greater than 20 mcg/mL, signs of toxicity begin to appear.

*Question: A client undergoing a computed tomography (CT) scan develops chest pain, wheezing, and stridor after injection of contrast media. Which type of shock is this client most likely exhibiting?*

*Answer: Anaphylactic* Rationale: Injection of contrast media may result in anaphylaxis and most likely occurs as a result of mast cell degranulation. If not recognized and treated immediately, the client will progress to anaphylactic shock. Septic shock is a systemic inflammatory response to a documented or suspected infection. Neurogenic shock occurs when there is loss of sympathetic tone. Cardiogenic shock occurs when the heart fails as a pump.

*Question: The nurse is caring for a client receiving digoxin. The nurse monitors the client for which early manifestation of digoxin toxicity?*

*Answer: Anorexia* Rationale: Digoxin is a cardiac glycoside used to manage and treat heart failure and to control ventricular rates in clients with atrial fibrillation. The most common early symptoms of toxicity include gastrointestinal disturbances such as anorexia, nausea, and vomiting. Neurological abnormalities also can occur early and include fatigue, headache, depression, weakness, drowsiness, confusion, and nightmares. Facial pain, personality changes, and ocular disturbances (photophobia, light flashes, halos around bright objects, yellow or green color perception) are also signs of toxicity but are not early signs.

*Question: A lethargic, pale child is brought to the primary health care provider's office with symptoms of periorbital edema and reduced quantity of urine output. The urine is cloudy and smoky in color. The nurse asks the mother if the child has had any recent infections, to which the mother responds that the child had a very sore throat a few weeks ago. The primary health care provider suspects that the child might have acute poststreptococcal glomerulonephritis. Which laboratory test would ru

*Answer: Antistreptolysin titer* Rationale: Option 3 is the only laboratory test that will determine if a streptococcal infection was present. The other options do not relate to a past streptococcal infection. A urinalysis will determine if protein is present in the urine, which is present in glomerulonephritis. A throat culture will determine if a current throat infection is present. A blood creatinine clearance laboratory test will determine glomerular filtration rate.

*Question: A client with a burn injury begins to cry and states to the nurse, "I don't want anyone seeing me. I look awful." The nurse determines that the client is experiencing which associated problem?*

*Answer: Appearance* Rationale: The client with a burn injury experiences structural and functional changes of the integumentary system as a result of this injury. The client's statement indicates a problem with appearance. Options 1, 3, and 4 do not relate to the client's statement.

*Question: The nurse is reinforcing dietary instructions to a client who is taking triamterene. The nurse instructs the client that it is acceptable to consume which food item daily?*

*Answer: Apple* Rationale: Triamterene is a potassium-retaining diuretic, which means that the client must avoid the intake of foods high in potassium. Options 2, 3, and 4 are high-potassium food items.

*Question: A topical corticosteroid is prescribed by the primary health care provider for a child with atopic dermatitis (eczema). Which instruction would the nurse give the parent about applying the cream?*

*Answer: Apply a thin layer of cream and rub it into the area thoroughly.* Rationale: Atopic dermatitis is a superficial inflammatory process involving primarily the epidermis. A topical corticosteroid may be prescribed and should be applied sparingly (thin layer) and rubbed into the area thoroughly. The affected area should be cleaned gently before application. A topical corticosteroid should not be applied over extensive areas. Systemic absorption is more likely to occur with extensive application.

*Question: The nurse is reviewing the health care provider's prescriptions written for a client admitted with a diagnosis of acute cellulitis of the lower leg. The nurse would question which prescription?*

*Answer: Apply cold compresses to the affected area.* Rationale: Warm compresses such as moist heat may be used to decrease discomfort, erythema, and edema. After tissue and blood cultures are obtained, antibiotics are initiated. The nurse should provide supportive care as prescribed to manage symptoms such as fatigue, fever, chills, headache, and myalgia. Cold compresses are not a component of the treatment measures.

*Question: The nurse is monitoring a client with a spinal cord injury for signs of spinal shock. Which sign is indicative of this complication of a spinal cord injury?*

*Answer: Areflexia below the level of injury* Rationale: Spinal shock represents a temporary but profound disruption of spinal cord function, which occurs immediately after injury and is clinically evident within 30 to 60 minutes. It is a state of areflexia characterized by the loss of all neurological function below the level of injury. Flaccid paralysis, bradycardia, and hypotension occur. The body is unable to use either shivering or perspiring as a means of controlling body temperature.

*Question: A toddler ingested drain cleaner found under the sink. The frantic mother calls poison control and asks what she should do because the child has started vomiting blood. What is the nurse's immediate response?*

*Answer: Ask the mother if the child is breathing on his own.* Rationale: Initial emergency procedures following poisoning relate to ensuring that the child's airway, breathing, and circulation (ABCs) are stabilized. Water is used as a diluent if a strong corrosive is ingested but not if the child is vomiting because this would increase the risk of aspiration. Options 2 and 4 are inappropriate.

*Question: A newborn is transferred to the neonatal intensive care unit with an admitting diagnosis of esophageal atresia accompanied by a distal tracheoesophageal fistula (TEF). When assisting with care for the newborn, which would be the priority concern?*

*Answer: Aspiration* Rationale: Because TEF manifests itself with regurgitation and coughing, the concern that has the highest priority is aspiration. Although the other problems are an important part of care, the one with the highest concern relates to airway.

*Question: The nurse gathers data from a client admitted to the hospital with a diagnosis of gastroesophageal reflux disease (GERD) scheduled for a Nissen fundoplication. Based on an understanding of this disease, the nurse would determine that the client may be most at risk for which complication?*

*Answer: Aspiration* Rationale: The primary symptom of GERD is heartburn, which is also called pyrosis. Another symptom is regurgitation. The client reports the feeling of warm fluid traveling up the throat. If the fluid reaches the level of the pharynx the client notes a sour or bitter taste in the mouth. This effortless regurgitation frequently occurs when the client is in the upright position. If regurgitation occurs when the client is recumbent, the client is at risk for aspiration. Belching may be a symptom of the disease. Diarrhea and abdominal pain are not specifically associated with the disease.

*Question: A 5-year-old child has been transferred to the pediatric unit after a cardiac catheterization. Which intervention has the highest priority in the care of this child immediately following the procedure?*

*Answer: Assess for any bleeding on the dressing.* Rationale: Bleeding is a primary concern following this procedure. Although options 2, 3, and 4 are correct interventions, they are not the priority.

*Question: A toddler is rushed to the emergency department by her father, who states that he found the child sitting on the floor with an empty bottle of vitamins. He is not sure how many vitamins were in the bottle. The child is responsive but crying. What is the nurse's immediate action?*

*Answer: Assess the child and take the vital signs.* Rationale: Initial emergency procedures relate to ensuring that the child's airway, breathing, and circulation (ABCs) are stabilized. Because the child is responsive and crying, vital signs should be taken initially as the immediate action. Cardiorespiratory support is not indicated because the child is responsive by crying. In this situation, further data collection and instituting primary health care provider's prescriptions would be done after ensuring that the child is stable and vital signs are assessed.

*Question: The nurse is assessing a 36-month-old male child during a wellness visit to the pediatrician. The child weighs 43 pounds and is 41 inches tall. After plotting the measurements on the standardized growth charts for a 36-month-old, which should the nurse do next?*

*Answer: Assess the parents' body shape and stature.* Rationale: The most prominent feature of childhood and adolescents is physical growth. Birth weight for infants doubles in 4 to 7 months and triples by the end of the first year of life. Weight quadruples by the end of the second year, and then slows to a steady annual rate of 4.4 to 6 pounds (2.09 to 2.73 kg) of weight gain per year until the adolescent growth spurt. The average weight for a 3-year-old is 32 pounds (14.6 kg). Growth in height remains steady at a yearly increase of 2½ to 3 inches (6.75 to 7.5 cm). The average height for a 3-year-old is 37 ¼ inches (95 cm). This child is above the 100th percentile for height and weight when plotted on the growth charts for males. A strong correlation exists between parent and child with regard to traits such as height, weight, and rate of growth. Most physical characteristics, including shape and form of features, body build, and physical peculiarities are inherited and influence

*Question: A client with viral hepatitis states to the nurse, "I am so yellow." The nurse would best respond by taking which action?*

*Answer: Assist the client in expressing feelings.* Rationale: The client's feelings should be explored to discover how the client feels about the disease process and appearance so appropriate interventions can be planned. Restricting visitors, keeping the client isolated, and instructing the client that skin turning yellow is the consequence of alcoholism are inappropriate.

*Question: The nurse prepares to discharge a fifty-year-old client who is experiencing family-related stress. Which goal does the nurse include to help the client achieve the primary developmental task?*

*Answer: Assist the client resume her familial role.* Rationale: The primary developmental task of middle adulthood is to realize generativity and to help guide children or the next generation through social situations in a productive manner. Thus, the nurse helps the client reclaim her role in the family as mentor and facilitator to avert stagnation in society. Helping the client with acceptance of aging is a developmental task of older adults and developing critical thinking skills are developmental tasks of young adults. Alleviating the stress response includes blocking the action of epinephrine and norepinephrine; the potential benefits from doing so are less directly related to the client's developmental task than helping her resume her role in the family.

*Question: A client in active labor with intact membranes is complaining of back discomfort. An analgesic was administered 1 hour ago but has not relieved the discomfort. The nurse would avoid which measure at this time to assist in relieving the back discomfort?*

*Answer: Assist the client to ambulate in the room.* Rationale: Ambulation should be avoided because the client is in active labor and received an analgesic 1 hour ago. Each of the other options identifies measures that are both safe and effective to reduce back discomfort for the client.

*Question: A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the client stands and begins to walk, the client begins to complain of chest pain. The nurse would take which action?*

*Answer: Assist the client to get back into bed.* Rationale: The client is assisted back to bed to put the client at rest. The nurse can then measure vital signs and administer nitroglycerin that is prescribed for as-needed (PRN) use. The nurse should then report the chest pain episode to the health care provider. The nurse should not continue to assist the client into the bathroom because it places the client in danger because of continued myocardial oxygen demands.

*Question: A male client has a history of urinary tract infections due to urinary retention. Which intervention would the nurse implement to decrease the risk of infection?*

*Answer: Assist the client to stand for voiding.* Rationale: Most men are conditioned to urinate from a standing position, so a reasonable strategy is to assist the client to a standing position to increase the chance of emptying the bladder. This will decrease the risk of infection as the bladder empties more completely. Withholding fluids after 6:00 p.m. may improve client sleep but is harmful and is more likely to increase than decrease the risk of bladder infection. Thorough hand washing is always suitable for client teaching; however, bladder contamination from the client's hands is not the problem. Monitoring the temperature will not prevent infection but aids in the early detection of infection.

*Question: The nurse is performing a postpartum fundal assessment on a client 6 hours after delivery. The nurse finds the fundus above the umbilicus and displaced to the right. Which intervention would the nurse do first?*

*Answer: Assist the client to the bathroom to void and then reassess the fundus.* Rationale: A full bladder causes the uterus to be displaced above the umbilicus and well to one side of the abdominal midline. After voiding, if the fundus is boggy, it can be massaged, but this is not the first action. The woman should be assisted to the bathroom to void and then the fundus should be reassessed. Turning the client to her left side will not bring the fundus to midline. This is not a normal finding; the fundus should be firm at the umbilicus or 1 fingerbreadth below the umbilicus 6 hours after delivery.

*Question: The nurse notes this rhythm on a client's cardiac monitor. The nurse next reports that the client is experiencing which heart rhythm? Refer to figure.View Figure*

*Answer: Atrial fibrillation* Rationale: Atrial fibrillation is characterized by no distinct P waves and an irregular ventricular response. In sinus bradycardia and normal sinus rhythm, there will be clear distinct P waves and a regular ventricular rhythm. In ventricular fibrillation. there are no clear P waves or QRS complexes.

*Question: A young adult college student begins to throw objects, shout insults, and stamp his feet after an instructor returned his work, noting it was substandard. Using Erikson's theory of personality development, which developmental stage has this individual unsuccessfully mastered?*

*Answer: Autonomy vs. shame and doubt* Rationale: Negative feelings of doubt and shame arise when individuals are made to feel self-conscious and shame. The positive outcomes of mastering this developmental stage are self-control and willpower. The lasting outcomes of initiative vs. guilt are direction and purpose. Not mastering this stage leads to guilt and lack of purpose. The ego quality developed from a sense of industry is competence. Feelings of inadequacy and inferiority may result from not mastering this task. The outcome of successful mastery of identity vs. role confusion is a sense of personal identity. Inability to solve this conflict results in role confusion.

*Question: An 18-month-old child is being discharged after surgical repair of hypospadias. Which postoperative nursing care measure would the nurse stress to the parents as they prepare to take this child home?*

*Answer: Avoid tub baths until the stent has been removed.* Rationale: After hypospadias repair, the parents are instructed to avoid giving the child a tub bath until the stent has been removed to prevent infection. Diapers are placed on the child to prevent the contamination of the surgical site. Toilet training should not be an issue during this stressful period. Fluids should be encouraged to maintain hydration.

*Question: The nurse is reinforcing instructions to a client with angina pectoris about measures to reduce recurrence of chest pain. The nurse would stress to the client the importance of taking which measure?*

*Answer: Avoiding exposure to either very hot or very cold weather* Rationale: The client should avoid extreme hot or cold temperatures to avoid placing undue stress on the cardiovascular system. The client should space activities throughout the day rather than save them for the end of the day when the client is more fatigued. The client should eat smaller meals so less blood flow is diverted for the work of digestion. Exercise is important, but the client should keep most items stored at heart level to prevent straining and increased intrathoracic pressure, which can decrease cardiac output.

*Question: The nurse would plan to fill which chamber of the chest drainage unit to prevent atmospheric air from reentering the pleural space? Refer to figure.View Figure*

*Answer: B* Rationale: To prevent atmospheric air from reentering the client's pleural space, the nurse needs to fill the water seal chamber to the level prescribed by the manufacturer, usually 2 cm. This is the minimum amount of fluid needed to prevent atmospheric air from reentering the pleural space. Therefore, options 1, 3, and 4 are incorrect. Option 1 identifies the suction control chamber. Options 3 and 4 identify the collection chamber.

*Question: The mother of a 5-year-old child brings the child to the emergency department and tells the nurse that the child fell. A fracture is suspected, and an x-ray is taken. The results indicate that the child has a comminuted fracture of the right humerus. The mother asks the nurse to describe this type of fracture, and the nurse draws a picture for the mother. Which picture identifies this type of fracture? Refer to figure.View Figure*

*Answer: B* Rationale: When small fragments of bone are broken from the fracture shaft and lie in the surrounding tissues, the fracture is called comminuted. An open or compound fracture (option 1) is a fracture with an open wound from which the bone is or has protruded. In an oblique fracture (option 3), a diagonal line across the bone is noted. In a greenstick fracture (option 4), the bone is partially bent and partially broken.

*Question: The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the urine test and would most likely expect to note which finding?*

*Answer: Bacteriuria* Rationale: Epispadias is a congenital defect that involves the abnormal placement of the urethral orifice of the penis. In clients with this condition, the urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic leads to the easy access of bacterial entry into the urine. Options 1, 3, and 4 are not characteristically noted with this condition.

*Question: The nurse is planning a dietary menu for a client with heart failure who is being treated with digoxin and furosemide. Which would be the best dinner choice from the daily menu?*

*Answer: Baked fish, mashed potatoes, and carrot-raisin salad* Rationale: Furosemide depletes potassium, and a client on digoxin and furosemide needs to maintain normal potassium levels and moderate salt intake. Hypokalemia may make the client more susceptible to digoxin toxicity. The recommended daily intake for potassium is 2000 mg. Option 4 is not the best choice because beef vegetable soup contains a high amount of sodium and a minimal amount of potassium. Macaroni and cheese is also high in sodium and contains no potassium. Option 1 is not the best choice because beef ravioli is high in sodium and contains no potassium. Spinach soufflé is a good source of potassium but also contains sodium. Option 3 is not the best choice because roasted chicken breast, brown rice, and stewed tomatoes contain a minimal amount of potassium. Option 2 is the best choice because all three foods are high in potassium and low in sodium.

*Question: A client is diagnosed as having a bowel tumor, and several diagnostic tests are prescribed. The nurse reinforces instructions to the client and includes information that which test will confirm the diagnosis of malignancy?*

*Answer: Biopsy of the tumor* Rationale: A biopsy, removing a piece of tissue for analysis, is done to determine whether a tumor is malignant or benign. An MRI, CT scan, and ultrasound will visualize the presence of a mass but will not confirm a diagnosis of malignancy.

*Question: The nurse is reviewing the record of a child scheduled for a primary health care provider's visit. Before data collection, the nurse notes documentation that the child has enuresis. Based on this diagnosis, the nurse plans to focus on which factor when collecting data?*

*Answer: Bladder function* Rationale: Enuresis refers to a condition in which the child is unable to control bladder function, although he or she has reached an age at which control of voiding is expected. Nocturnal enuresis, or bed-wetting, is common in children.

*Question: The nurse is beginning to ambulate a client with activity intolerance caused by bacterial endocarditis. The nurse determines that the client is best tolerating ambulation if which parameter is noted?*

*Answer: Blood pressure that increases from 114/82 to 118/86 mm Hg* Rationale: General indicators that a client is tolerating exercise include an absence of chest pain or dyspnea, a pulse rate increase of less than 20 beats per minute, and a blood pressure change of less than 10 mm Hg.

*Question: A client complaining of chest pain has an as-needed (PRN) prescription for sublingual nitroglycerin. Before administering the medication to the client, the nurse would first check which parameter?*

*Answer: Blood pressure* Rationale: Assessing the blood pressure is a priority before administering nitroglycerin to determine the vasodilative effect of the medication and to monitor for a drop in blood pressure. Cardiac rhythm and respiratory rate are also important to assess after checking the blood pressure. Peripheral pulses do not need to be checked before administering this medication.

*Question: A client is returned to the nursing unit following thoracic surgery with chest tubes in place. During the first few hours postoperatively, the nurse assisting in caring for the client checks for drainage. Which type of drainage is expected?*

*Answer: Bloody* 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 significant clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing.

*Question: A client arrives at the ambulatory care clinic with low abdominal pain. A routine urine specimen reveals hematuria. The client does not have a fever. The nurse would next ask the client about a history of which condition?*

*Answer: Blow or trauma to the bladder or abdomen* 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 because they are infections. Renal cancer would cause pain in the flank area, not the low abdomen.

*Question: The nurse is caring for a client with a suspected diagnosis of aplastic anemia. Which test would the nurse anticipate to be performed to confirm the diagnosis?*

*Answer: Bone marrow aspiration* Rationale: A bone marrow aspiration will identify aplastic anemia and will identify pancytopenia, a deficiency in erythrocytes, leukocytes, and thrombocytes, and confirm that the source of the problem is bone marrow dysfunction. A Schilling test is diagnostic for pernicious anemia. A sickle cell screen is diagnostic for sickle cell anemia. A complete blood cell count will identify anemia but may not identify the specific type and also the leukopenia and thrombocytopenia.

*Question: The nurse discovers an unresponsive, breathing newborn infant. To assess circulatory status, the nurse would palpate which arterial pulse area?*

*Answer: Brachial* Rationale: To assess circulation in an infant younger than 1 year, the nurse should check the brachial pulse. If the child is older than 1 year, the carotid pulse is palpated. The popliteal and femoral areas are not easily palpated in an infant because of the infant's body mass.

*Question: A client with Parkinson's disease is developing dementia. Which action would the nurse plan to assist the client in maintaining self-care abilities?*

*Answer: Break down activities into small steps.* Rationale: It is often necessary to break down activities of daily living (ADLs), such as dressing, into small steps and explain what is happening at each step in very specific and simple terms. Large groups and complex activities should be avoided when clients have Parkinson's disease and dementia, because they are likely to cause the individual to become agitated or have a catastrophic reaction (become angry and display aggressive behavior). Routine is very important, and it is necessary to introduce changes very slowly, so the day and time of bathing should remain constant. Music has a positive influence including improved capacity to communicate, reminisce, and recall memories.

*Question: The nurse has finished suctioning a client. The nurse would use which parameters to best determine the effectiveness of suctioning?*

*Answer: Breath sounds are clear* Rationale: The nurse evaluates the effectiveness of the suctioning procedure by auscultating breath sounds. This helps determine if the respiratory tract is clear of secretions. In addition, breath sounds must be auscultated before every suctioning procedure. Client skin color, client statement of comfort, and Sao2 at 98% do not determine the effectiveness of suctioning.

*Question: The nurse is performing tracheal suctioning on an assigned client. The nurse uses which parameter as the accurate indicator that suctioning has been effective?*

*Answer: Breath sounds are now clear.* Rationale: Clear breath sounds are the most accurate indicator of the effectiveness of a suctioning procedure. Options 3 and 4 are incorrect because they are less precise. Option 2 is incorrect because the need for suctioning may be influenced by factors other than the effectiveness of previous suctioning. These other factors could include improvement of underlying respiratory condition, fluid status, and effectiveness of cough.

*Question: A client who underwent a bronchoscopy was returned to the nursing unit 1 hour ago. The nurse determines that the client is experiencing complications of the procedure if the nurse notes which sign/symptom?*

*Answer: Breath sounds greater on the right than the left* Rationale: Asymmetrical breath sounds could indicate pneumothorax, and this should be reported to the primary health care provider. A weak cough and gag reflex 1 hour postprocedure is an expected finding because of residual effects of intravenous sedation and local anesthesia. A respiratory rate of 22 breaths per minute and an oxygen saturation of 95% are acceptable measurements.

*Question: The nurse is collecting data from a client with pneumonia. Chest auscultation over areas of consolidation reveals this breath sound. (Refer to audio.) The nurse should interpret this sound to be indicative of which breath sound?*

*Answer: Bronchial breath sounds* Rationale: The sound that the nurse hears is a bronchial breath sound. Bronchial breath sounds are loud, high-pitched sounds that resemble air blowing through a hollow pipe. The expiration phase is louder and longer than the inspiration phase, and there is a distinct pause between the inspiration and expiration phase. Bronchial breath sounds normally are heard only over the manubrium. When they are heard over the periphery of the lung, they indicate abnormal sound transmission because of consolidation of lung tissue as in pneumonia. A pleural friction rub is a superficial, low-pitched, coarse rubbing or grating sound that sounds like two surfaces rubbing together and is heard in the client with pleurisy. Vesicular breath sounds normally are heard over the lesser bronchi, bronchioles, and lobes (peripheral lung fields). These sounds are soft and low-pitched and resemble a sighing or gentle rustling. Bronchovesicular breath sounds normally are heard ove

*Question: The nurse in the emergency department is listening to the breath sounds of a client with respiratory distress and hears this sound. (Refer to audio.) The nurse determines that this finding is characteristic of which disorder?*

*Answer: Bronchitis* Rationale: The sound that the nurse hears is a low-pitched wheeze. A wheeze is a continuous musical or hissing noise that results from the passage of air through a narrowed airway. The two main types include a low-pitched wheeze, which is associated with bronchitis, and a high-pitched wheeze, which is associated commonly with obstructive lung disease, such as asthma or emphysema. A low-pitched wheeze is a musical snoring or moaning sound that is heard throughout the respiratory cycle, although it is more prominent on expiration. A high-pitched wheeze is a high-pitched musical squeaking sound that predominates in expiration but may occur in both expiration and inspiration. Lung crackles normally are heard in heart failure. A client with emphysema may also have lung crackles.

*Question: A client comes to a primary health care provider's office complaining of a bite on the arm. The client reports that he recently removed a tick from the same location. Which characteristic is a classic sign of Lyme disease that can result from an infected tick?*

*Answer: Bull's-eye rash* Rationale: The classic characteristic of Lyme disease is a small bite with a bull's-eye rash, although not all individuals who sustain a bite develop this rash. A painful rash around a necrotic lesion is indicative of a brown recluse spider bite. Papules, vesicles, and oval lesions are not characteristics of Lyme disease.

*Question: The nurse reinforces teaching a client on how to administer enoxaparin subcutaneously. The nurse determines that the client understands the correct procedure if the client does which on a return demonstration?*

*Answer: Bunches the skin before injection* Rationale: With subcutaneous injection of enoxaparin, the administration technique is the same as for heparin. The smallest-gauge needle available (25- to 27-gauge) is used to prevent injection site hematoma, a "bunching" technique is used, and the medication is injected deep into fatty abdominal tissue. The fat layer is gathered between the finger and thumb. This may not be possible on a very thin client. Aspiration before injecting is not done, and the injection site is not massaged. The needle is withdrawn gently to minimize bleeding, and injection sites are rotated systematically.

*Question: The nurse is reviewing the medical record of a client who is suspected of having systematic lupus erythematosus (SLE). Which sign would the nurse expect to be documented in the record that is most related to this diagnosis?*

*Answer: Butterfly rash on cheeks and bridge of the nose* Rationale: SLE primarily occurs in females 10 to 35 years of age and is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and the bridge of the nose is a characteristic sign of SLE. Two hemoglobin S genes are found in sickle cell anemia. Recurrent emboli and ascites in the abdomen are found in many conditions but are not usually noted in SLE.

*Question: The nurse is preparing to administer a soapsuds enema to a client. Into which position would the nurse place the client to administer the enema? Refer to figure.View Figure*

*Answer: C* Rationale: To administer an enema, the nurse assists the client into the left side-lying (Sims') position with the right knee flexed. This position allows the enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum, thus improving the retention of solution. Option 1 is a supine position. Option 2 is a prone position. Option 4 is a right side-lying (semiprone) position.

*Question: The nurse would instruct the client taking atomoxetine to avoid foods containing which substance?*

*Answer: Caffeine* Rationale: The action of atomoxetine is central nervous system (CNS) stimulation. Thus, the client should avoid other CNS stimulants, such as caffeine. Calcium, potassium, and saturated fat are not contraindicated for consumption in the client taking atomoxetine and do not need to be avoided.

*Question: The nurse is caring for a client with liver disease. Laboratory studies are performed, and the client's serum calcium level is 13 mg/dL. The nurse checks to see that which medication is available in the stock medication supply area on the clinical nursing unit that may be needed to treat this calcium imbalance?*

*Answer: Calcitonin* Rationale: The normal serum calcium level is 8.6 to 10 mg/dL. This client is experiencing hypercalcemia. Calcium gluconate and calcium chloride are used to treat tetany that results from acute hypocalcemia. In hypercalcemia, large doses of vitamin D should 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.

*Question: The nurse reinforces instructions to the mother about dietary measures for a 5-year-old child with lactose intolerance. The nurse would tell the mother that which supplement will be required as a result of the need to avoid lactose in the diet?*

*Answer: Calcium and vitamin D* Rationale: Lactose intolerance is the inability to tolerate lactose, the sugar that is found in dairy products. Removing milk from the diet can provide relief from symptoms. Additional dietary changes may be required to provide adequate sources of calcium and vitamin D.

*Question: The nurse reviews the client's laboratory data. Which data warrant notification of the registered nurse and an immediate call to the primary health care provider? Refer to chart.View Chart*

*Answer: Calcium level* Rationale: The normal range for calcium is 9 to 10.5 mg/dL. A calcium value of 7.2 mg/dL represents hypocalcemia and should be reported immediately to the primary health care provider because it may lead to a decrease in heart rate and contractility. The sodium, potassium, and magnesium laboratory results are within normal limits. Abnormal results must be reported to avoid adverse consequences of electrolyte disturbances.

*Question: The nurse is caring for a client who had a total knee replacement. Postoperatively, the nurse monitors for which highest priority assessment?*

*Answer: Calf pain* Rationale: The highest priority assessment that the nurse needs to monitor in this client is the presence of calf pain. Deep vein thrombosis is a potentially serious complication of lower extremity surgery. Calf pain is a sign of this complication. Although bladder distention may occur postoperatively, this assessment is incorrect because it is not specific to the information in the question. Extremity lengthening or shortening may occur as a result of knee replacement but is not the highest priority. Additionally, heel breakdown is not the highest priority.

*Question: The nurse is preparing to deliver a food tray to a client whose religion is Judaism and follows kosher preferences. The nurse checks the food on the tray and notes that the client has received a roast beef dinner with whole milk as a beverage. Which action would the nurse take?*

*Answer: Call the dietary department and ask for a new meal tray without the milk.* Rationale: In following kosher preferences, the dairy-meat combination is not acceptable. Pork and pork products are not allowed in the traditional Jewish religion. If the client wants milk, it can be obtained from the unit's kitchen and served according to the client's preferences. Obtain a new meal tray that does not have both meat and milk. Delivering the tray as is, changing the milk product, and serving pork will violate kosher practice.

*Question: The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle attached to a syringe containing a clear liquid into the antecubital area. Which action would be the appropriate initial action by the nurse?*

*Answer: Call the nursing supervisor.* 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. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities as required. Option 2 is not the appropriate action. Option 3 is not an initial action. Security may be called if a disturbance occurs, but no data in the question support this. Therefore, this is not the appropriate initial action.

*Question: The nurse participating in a free health screening at the local mall obtains a random blood glucose level of 200 mg/dL on an otherwise healthy client. The nurse tells the client to do which as a next step?*

*Answer: Call the primary health care provider to have the value rechecked as soon as possible.* Rationale: Adult diabetes mellitus can be diagnosed either by symptoms (polydipsia, polyuria, and polyphagia) or by laboratory values. Diabetes is also diagnosed by an abnormal glucose tolerance test when random plasma glucose levels are greater than 200 mg/dL, or fasting plasma glucose levels are greater than 140 mg/dL on two separate occasions. Further confirmation of this result is needed to ensure appropriate diagnosis and therapy.

*Question: A child has fluid volume deficit. The nurse collects data and determines that the child is improving and the deficit is resolving if which finding is noted?*

*Answer: Capillary refill is less than 2 seconds.* Rationale: Indicators that fluid volume deficit is resolving would be capillary refill less than 2 seconds, specific gravity of 1.002 to 1.025, urine output of at least 1 mL/kg/hour, and adequate tear production. A capillary refill time less than 2 seconds is the only indicator that the child is improving. Urine output of less than 1 mL/kg/hour, a specific gravity of 1.030, and no tears would indicate that the deficit is not resolving.

*Question: The nurse is assessing a pediatric client with a diagnosis of retinoblastoma. The nurse assesses for which most common clinical finding for a child with this diagnosis?*

*Answer: Cat's-eye reflex* Rationale: Clinical symptoms of retinoblastoma include cat's-eye reflex, which is sometimes called "white eye," (most common sign); strabismus (second most common sign); red, painful eye; and blindness (late signs). Cat's-eye reflex is commonly observed by the parent and is described as a whitish "glow" in the pupil. This represents visualization of the tumor as the light momentarily falls on the mass and is the most common sign.

*Question: The nurse is reinforcing dietary instructions to a client with heart failure (HF). The nurse determines that the client understands the instructions if the client states that which food item will be avoided?*

*Answer: Catsup* Rationale: Catsup is high in sodium. Leafy green vegetables, cooked cereal, and sherbet all are low in sodium. Clients with heart failure should monitor sodium intake.

*Question: A client with breast cancer is being treated with cyclophosphamide. The nurse plans care, knowing that this medication fits which classification?*

*Answer: Cell cycle phase nonspecific* Rationale: Cyclophosphamide is an antineoplastic medication of the alkylating classification. Medications in this classification are cell cycle phase-nonspecific and affect all phases of the reproductive cell cycle. Cell cycle phase-specific medications affect cells only during a certain phase of the reproductive cycle. An antimetabolite medication is one that blocks the metabolism or normal functioning of an organism. A hormonal medication is one that either supports or blocks the action of a hormone.

*Question: The nurse observes that a client's nasogastric tube has suddenly stopped draining. The tube is connected to suction, the machine is on and functioning, and all connections are snug. After checking placement, the nurse gently flushes the tube with 30 mL of normal saline, but the tube still is not draining. The nurse would conclude which is the problem, and what action would be taken?*

*Answer: Channels of gastric secretions may be bypassing the holes in the tube; turning the client will promote stomach emptying.* Rationale: The nurse must check nasogastric tubes regularly to maintain the tube's patency and ensure that it is draining properly. Nasogastric tubes are used to decompress the stomach. The gastric distention will be relieved only if the tube drains properly. One cause of improper tube drainage is that channels of gastric secretions form along the walls of the stomach and bypass the holes in the nasogastric tube. Turning the client regularly helps collapse the channels and promotes gastric emptying. The tube already has been flushed, so it is unlikely that it is still blocked by thick secretions. Although this is a problem that requires attention and intervention, it is not a serious complication.

*Question: The wife of a client with diabetes mellitus who takes insulin calls the nurse in a primary health care provider's office about her husband. She states that her husband is sleepy and that his skin is warm and flushed. She adds that his breathing is faster than normal and his pulse rate seems fast. Which action would the nurse tell the wife to do first?*

*Answer: Check his blood glucose level.* Rationale: The client's signs and symptoms are consistent with hyperglycemia. The wife should first obtain a blood glucose reading that the nurse should then report to the primary health care provider. Option 1 or 4 may be done at a later time if required. Option 2 is unrelated to the client's immediate problem.

*Question: The nurse is caring for a 3-hour-old infant and notes that the infant has not eaten since birth, is jittery, and has a weak cry. The mother states that she can't get the baby to eat. Which action would the nurse take first?*

*Answer: Check the blood glucose level.* Rationale: This infant has classic symptoms of hypoglycemia. The nurse should plan to check the infant's blood glucose to determine the extent of hypoglycemia, if any, and then to take action by calling the primary health care provider and feeding the infant as per agency policy. Allowing the infant to sleep may cause the hypoglycemia to remain untreated and result in neurological damage.

*Question: A child is brought to the emergency room, and the mother reports that the child accidentally swallowed paint thinner after mistaking it for water. The nurse would perform which action first?*

*Answer: Check the circulation, airway, and breathing status of the child.* Rationale: Actions to take in the case of a child swallowing poison include assessing the child and treating the child first, not the poison. Circulation, airway and breathing, and vital signs need to be assessed. Resuscitation measures would be initiated if the assessment indicates a need. The next step is to terminate exposure to the poison, such as emptying the mouth of pills or other materials or flushing the skin with water. Then identify the poison, if possible, and take measures to prevent absorption of the poison, such as administering the antidote if known. Transport the child to an emergency department for further treatment.

*Question: A client has just undergone endoscopy. Which is the essential postprocedure nursing intervention?*

*Answer: Check the gag reflex before giving oral foods or fluids.* Rationale: During the endoscopy procedure, a scope is introduced through the mouth to visualize the esophagus, stomach, and some of the duodenum. The client is given a local anesthetic in the back of the throat and sedation during the procedure. The client may not eat or drink after this procedure until protective airway reflexes return in order to prevent aspiration. The nurse must document that the gag and swallow reflexes have returned. The client can usually eat as desired after the gag reflex returns, not just clear liquids. A local anesthetic gargle is not used postprocedure. The client does not require activity or positioning restrictions such as 90-degree elevation following the procedure.

*Question: A client with a fractured femur is placed in skeletal traction. The nurse would do which to monitor for nerve injury?*

*Answer: Check the neurovascular status of the affected extremity.* Rationale: The nurse would check the neurovascular status and assess for pallor and coolness of the affected extremity, paresthesias, or complaints of increasing pain. Bone fragments and tissue edema associated with a fracture can cause nerve damage. Although the blood pressure measurement provides an overall indication of circulatory status, it is not directly related to the neurovascular status of the extremity and would not provide information about the presence of nerve injury. Checking pin sites for drainage provides information about infection. The client should not be encouraged to perform active range of motion to an extremity that is fractured and in traction.

*Question: The nurse enters a client's room and finds the client slumped down in the chair. Breathing is shallow and a pulse is present. Based on this data, the nurse determines that which action is the priority?*

*Answer: Check the vital signs and level of consciousness.* Rationale: The client is breathing and has a pulse; therefore, further data are needed before any other action is taken. The vital signs and level of consciousness should be checked. Once that assessment is made, the primary health care provider is notified, who will then contact the family. Activating the emergency response system is not indicated at present.

*Question: The nurse is assigned to care for a client being admitted to the mental health unit following a suicide attempt. The client attempted the suicide by lacerating both wrists. Which is the initial nursing action upon admission of the client?*

*Answer: Check the wound sites.* Rationale: The physiological integrity of the client is always assessed first. Although options 2, 3, and 4 may be appropriate at some point, the initial action should be to assess the wounds.

*Question: A client has been taking indomethacin for gout and experiencing side/adverse effects. Which assessment would the nurse expect the primary health care provider to prescribe?*

*Answer: Checking for occult blood* Rationale: One adverse effect of indomethacin is gastrointestinal bleeding. The stool guaiac test is noninvasive and is widely used as a gross screening for blood in the gastrointestinal tract. It is not used for any of the other assessments listed.

*Question: A primary health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription?*

*Answer: Checks the amount of urine output* Rationale: In hypotonic dehydration, electrolyte loss exceeds water loss. The priority assessment before administering potassium chloride intravenously would be to assess the status of the urine output. Potassium chloride should never be administered in the presence of oliguria or anuria. If the urine output is less than 1 mL/kg/hour to 2 mL/kg/hour, potassium chloride should not be administered. Although options 1, 2, and 3 are appropriate assessments for a child with dehydration, these assessments are not related specifically to the IV administration of potassium chloride.

*Question: The nurse is assisting a client with cystitis to select foods that are appropriate for an acid-ash diet. The nurse encourages the client to eat which food?*

*Answer: Cheese* 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 are not included are milk and milk products such as ice cream, all vegetables except corn and lentils, all fruits except cranberries, plums, and prunes, and foods containing high amounts of sodium, potassium, calcium, and magnesium.

*Question: A client has received instructions about an upcoming cardiac catheterization. The nurse determines that the client has the best understanding of the procedure if the client knows to report which symptoms?*

*Answer: Chest pain* Rationale: The client is taught before cardiac catheterization to immediately report chest pain or any unusual sensations. The client is taught that a warm, flushed feeling may accompany dye injection, occasional palpitations may occur, and the urge to cough may occur as the catheter tip touches the cardiac muscle. The client may be asked to cough or breathe deeply from time to time during the procedure. Because a local anesthetic is used, the client should feel pressure, but not pain, at the insertion site.

*Question: An older client is transferred to the nursing unit following a graft to a stage 4 pressure injury. Which combination of dietary items would the nurse encourage the client to eat to promote wound healing?*

*Answer: Chicken breast, broccoli, strawberries, milk* Rationale: Protein and vitamin C are necessary for wound healing. Poultry and milk are good sources of protein. Broccoli and strawberries are good sources of vitamin C. Options 1, 2, and 3 do not provide protein or vitamin C.

*Question: The nurse is instructing the mother of a child with cystic fibrosis (CF) about the appropriate dietary measures. Which meal best illustrates the most appropriate diet for a client with cystic fibrosis (CF)?*

*Answer: Chicken tenders and a baked potato with butter* Rationale: Children with CF are managed with a high-calorie, high-protein diet. Pancreatic enzyme replacement therapy is undertaken, and fat-soluble vitamin supplements are administered. Fats are not restricted unless steatorrhea cannot be controlled by increased levels of pancreatic enzymes. Chicken tenders and a baked potato with butter provide a high-calorie and high-protein meal that includes fat.

*Question: The nurse is caring for a hospitalized client with a suspected diagnosis of tuberculosis (TB). Which finding does the nurse expect to note during data collection?*

*Answer: Chills and night sweats* Rationale: The client with tuberculosis usually experiences cough (either 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.

*Question: A client's kidneys are retaining larger than normal amounts of sodium. The nurse is reviewing the most recent laboratory data. The nurse would expect which laboratory value to be abnormal since the client is retaining sodium?*

*Answer: Chloride 112 mEq/L* Rationale: Sodium is a cation. When sodium retention is increased, the kidney also has increased reabsorption of chloride and bicarbonate, which are anions. The chloride level is elevated, whereas the bicarbonate level is normal. Calcium 8.8 mg/dL and potassium 4.1 mEq/L are incorrect because calcium and potassium are cations.

*Question: An adult client just admitted to the hospital with heart failure also has a history of diabetes mellitus. The nurse consults with the registered nurse to verify a prescription for which medication that the client was taking before admission?*

*Answer: Chlorpropamide* Rationale: Chlorpropamide is an oral hypoglycemic agent that exerts an antidiuretic effect and should be administered cautiously or avoided in the client with cardiac impairment or fluid retention. It is a first-generation sulfonylurea. Insulin does not cause or aggravate fluid retention. Acarbose is a miscellaneous oral hypoglycemic agent.

*Question: The nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely manifestation of this condition in the medical record?*

*Answer: Choking with feedings* Rationale: Any child who exhibits the "3 Cs"—coughing and choking during feedings and unexplained cyanosis—should be suspected of having TEF. Options 1, 2, and 4 are not specifically associated with TEF.

*Question: Methenamine is prescribed for a client diagnosed with a gram-positive urinary tract infection. The nurse would question the prescription if which preexisting disorder is noted in the client's record?*

*Answer: Cirrhosis* Rationale: Methenamine is contraindicated in clients with renal or hepatic disease or those with severe dehydration. The nurse would question the primary health care provider's prescription for this medication in the client with cirrhosis.

*Question: The nurse is reinforcing dietary instructions to a client who is taking spironolactone. The nurse instructs the client to avoid which food in the daily diet?*

*Answer: Citrus fruits* Rationale: Spironolactone is a potassium-retaining diuretic. Hyperkalemia is the principal adverse effect. Clients are instructed to restrict their intake of potassium-rich foods such as citrus fruits and bananas. Options 1, 2, and 3 are appropriate food items to include in the daily diet.

*Question: The nurse is assisting in checking the reflexes on a neonate. In eliciting the Moro reflex, the nurse would perform which action?*

*Answer: Clap the hand or slap on the mattress.* Rationale: The Moro reflex is elicited by a loud noise, such as a hand clap or a slap on the mattress. The neonate should respond (in sequence) with extension and abduction of the limbs, followed by flexion and abduction of the limbs, followed by flexion and adduction of the limbs. This reflex disappears at 6 months of age. The rooting reflex is elicited by touching the cheek area with the finger. The plantar grasp reflex is elicited by stimulating the ball of the foot by firm pressure, and the palmar grasp reflex is elicited by stimulating the palm of the hand by firm pressure.

*Question: When a client progresses from preeclampsia to eclampsia, which is the nurse's first action?*

*Answer: Clear and maintain an open airway.* Rationale: It is important as a first action to clear and maintain an open airway and prevent injuries to the client. Options 1, 2, and 4 are all procedures that should be done, but none of them is the first action.

*Question: The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is adequately tolerating the procedure if which observation is made?*

*Answer: Coughing occurs with suctioning.* Rationale: The nurse monitors for adverse effects of suctioning, which include cyanosis, excessively rapid or slow heart rate, or the sudden development of bloody secretions. If they occur, the nurse stops suctioning and reports these signs to the primary health care provider immediately. 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.

*Question: The licensed practical nurse (LPN) is assisting in the care of a client who was experiencing vertigo and tinnitus due to an acoustic neuroma that was surgically removed via a craniotomy procedure. Which finding would the LPN immediately report to the registered nurse (RN)?*

*Answer: Clear, colorless drainage from the nose* Rationale: An acoustic neuroma is a unilateral benign tumor that occurs where the vestibulocochlear nerve (cranial nerve VIII) meets the internal auditory canal. Although benign, the tumor can compress and ultimately damage structures within the inner ear, which can result in unilateral sensorineural hearing loss. Acoustic neuromas may be removed through the ear, or via a craniotomy procedure in which it is removed through a surgically created bone flap in the skull. The nurse caring for a post-craniotomy client would be aware of the post-operative complications, which can include infection, bleeding, permanent facial nerve paralysis, hearing loss, increased intracranial pressure and cerebrospinal fluid leakage. Option 1 would be immediately reported to the RN who would contact the surgeon as this could indicate cerebrospinal fluid leakage which puts the client at risk for infection, such as meningitis. Option 2 indicates that the cl

*Question: The nurse is collecting neurological data on an unconscious client. On application of a central noxious stimulus, the nurse observes this response. How should the nurse document this response on the client's record? Refer to figure.View Figure*

*Answer: Client demonstrated decerebrate posturing.* Rationale: In decerebrate posturing, the arms are extended and the hands are hyperpronated while the legs are extended with plantar flexion of the feet. In decorticate posturing, the arms are internally rotated, adducted, and flexed at the elbows and wrists, while the legs are extended. In opisthotonic posturing, there is arching of the spine. Ataxic is not a type of posturing.

*Question: The nurse determines that which client is most likely to be a candidate for cardioversion?*

*Answer: Client with unstable rapid atrial fibrillation* Rationale: Cardioversion is a synchronized shock, delivered during ventricular depolarization. The machine must be able to seek out R waves and mark them so that the device delivers the shock at the appropriate time. Clients in atrial fibrillation are candidates for this treatment, and the goal is to try to restore normal sinus rhythm through cardioversion. Although the client with ventricular tachycardia can be cardioverted because of the presence of QRS complexes, this is done only when the client has a pulse. Pulseless ventricular tachycardia and ventricular fibrillation clients always are defibrillated. Junctional rhythm is neither cardioverted nor defibrillated.

*Question: A client has sustained full-thickness circumferential burns of the trunk. Which would be the priority concern of the nurse?*

*Answer: Client's ability to adequately ventilate* Rationale: When a full-thickness burn of the trunk is circumferential, the chest movement can be restricted and breathing will be affected. This is because full-thickness burns are hard, dry, leathery eschar (dead tissue) that does not expand to accommodate edema underlying the eschar. Urine output of 30 to 50 mL/hr is indicative of adequate response to fluid resuscitation measures. When layers of skin are destroyed, barriers to invasion by microorganisms are removed, increasing the risk for infection. In addition, burn injuries are extremely painful, and the nurse must institute measures to manage pain. Although these are important, urine output, infection risk, and burn pain are not priorities over the client's ventilatory status.

*Question: A client who was struck by a car while jogging is brought to the emergency department by emergency medical services. The client is unconscious, and a ruptured spleen is suspected. Emergency measures are instituted but are unsuccessful. The client's fiancé is with the client and tells the nurse that the client is an organ donor. In anticipation that the client's eyes will be donated, which would the nurse implement?*

*Answer: Close the deceased client's eyes and place gauze and a small ice pack on the eyes.* Rationale: When a corneal donation is anticipated, the client's eyes are closed and gauze pads with a small ice pack are placed on the client's eyes. The head of the bed should be elevated. Antibiotic eye drops also may be prescribed. These actions will assist in preventing infection and edema. Within 2 to 4 hours the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. It is unnecessary to obtain the client's will. Dry dressings should not be applied over the eyes. Calling the National Eye Bank to confirm that the client is a donor will delay necessary and immediate intervention.

*Question: Which laboratory result would verify the diagnosis of bacterial meningitis?*

*Answer: Cloudy cerebrospinal fluid with high protein and low glucose levels* Rationale: A diagnosis of meningitis is made by testing the cerebrospinal fluid (CSF) obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include increased pressure, cloudy cerebrospinal fluid, a high protein level, and a low glucose level.

*Question: The primary health care provider aspirates synovial fluid from a knee joint of a client diagnosed with rheumatoid arthritis. The nurse reviews the laboratory analysis of the specimen and would expect the results to best indicate which finding?*

*Answer: Cloudy synovial fluid* Rationale: Cloudy synovial fluid is diagnostic of rheumatoid arthritis. Organisms present in the synovial fluid are characteristic of a septic joint condition. Bloody synovial fluid is seen with trauma. Urate crystals are found in gout.

*Question: A client's preoperative vital signs are temperature 98.6°F (37°C) orally, apical pulse 80 beats per minute with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure 168/94 mm Hg in the right arm. Based on the interpretation of these findings, which action would the nurse take first?*

*Answer: Compare these values to those recorded previously.* Rationale: Preoperative assessment of vital signs provides important baseline data with which to compare following surgery. Anxiety and fear commonly cause elevations in the heart rate and blood pressure. The nurse should review and compare the vital signs to those recorded previously. The vital signs as stated in the question do not need to be reported to the registered nurse immediately. The apical pulse is not above the normal range, and an apical radial pulse for a full minute is not required. Rechecking the blood pressure in 5 minutes is likely to show an unchanged blood pressure measurement.

*Question: The nurse is caring for a pediatric client in skin traction. To prevent skin breakdown, which nursing intervention for this child is best?*

*Answer: Stimulate circulation with gentle massage over pressure areas.* Rationale: Nonadhesive straps and/or elastic bandage on skin traction are replaced when permitted and/or when absolutely necessary. Circulation should be stimulated with gentle, not vigorous, massage over pressure areas. The child's position should be changed at least every 2 hours to relieve pressure.

*Question: This morning a client sustained a right proximal fibula and tibia fracture that was casted in a long leg plaster cast. During evening rounds, the nurse notes that the right lower extremity capillary refill is greater than 3 seconds and the toes are edematous and dusky. The client states that the pain medication is not working anymore and that the right foot feels like it is asleep. The nurse analyzes the data and determines that the client's signs/symptoms are indicative of which comp

*Answer: Compartment syndrome* Rationale: The client's signs/symptoms are indicative of compartment syndrome. In this situation, the edema and the cast are compressing the structures within the leg. As pressure within the fascia compartment increases, nerves and blood vessels are occluded, resulting in ischemia and unrelieved pain, known as compartment syndrome. The primary health care provider needs to be notified as soon as possible. Fat embolism may result from a fracture, but the client is not experiencing any signs/symptoms of this complication. Venous thrombosis may occur after fractures but would not affect sensation. Volkmann's contracture is a result of compartment syndrome in an upper extremity following a fractured humerus.

*Question: Tamoxifen is prescribed for the client with metastatic breast carcinoma. The nurse assists in planning care, knowing that which is the primary action of this medication?*

*Answer: Compete with estradiol for binding to estrogen in tissues containing high concentrations of receptors.* Rationale: Tamoxifen is an antineoplastic medication that competes with estradiol for binding to estrogen in tissues containing high concentrations of receptors. It is used in the treatment of metastatic breast carcinoma in women and men. It is also effective in delaying the recurrence of cancer following mastectomy. It reduces DNA synthesis and estrogen response.

*Question: The father of a newly delivered full-term newborn is observing admission of the infant to the nursery. He asks the nursing student performing the admission why a cover is being placed on the baby scale to weigh and measure the newborn? The response that the nursing student should make is based on understanding the mechanism of heat loss in the newborn. This nursing intervention is designed to protect the newborn against which heat loss mechanism?*

*Answer: Conduction* Rationale: There are 4 modes of heat loss. Conduction is loss of body heat to cooler surfaces that are in direct contact with the skin. Radiation is loss of body heat to a cooler surface that is not in direct contact with the skin. Convection is loss of heat from the body surface to cooler ambient air. Evaporation is loss of heat when liquid is converted to a gas.

*Question: The nurse is collecting data on a client diagnosed with Parkinson's disease. Which finding indicates a serious complication of this disorder?*

*Answer: Congested cough and coarse rhonchi heard during auscultation* Rationale: Clients with Parkinson's disease are at risk for aspiration. A congested cough and coarse rhonchi may be present after a client aspirates. Although constipation is a problem for clients with Parkinson's disease, the concern is greater if the client has not had a bowel movement by the third day. Resting and pill-rolling tremors and a shuffling, propulsive gait are characteristic findings in Parkinson's disease.

*Question: The nurse assists with admitting a child with a diagnosis of acute stage Kawasaki disease. When obtaining the child's medical history, which manifestation is likely to be noted?*

*Answer: Conjunctival hyperemia* Rationale: During the acute stage of Kawasaki disease, the child presents with fever, conjunctival hyperemia, a red throat, swollen hands, a rash, and enlargement of the cervical lymph nodes. During the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. During the convalescent stage, the child appears normal, but signs of inflammation may be present.

*Question: A client with Parkinson's disease "freezes" while ambulating, increasing the risk for falls. Which suggestion would the nurse include in the client's plan of care to alleviate this problem?*

*Answer: Consciously think about walking over imaginary lines on the floor.* Rationale: Clients with Parkinson's disease can develop bradykinesia (slow movement) or akinesia (freezing or no movement). Having these individuals imagine lines on the floor to step over can keep them moving forward. Although standing erect and using a cane can help prevent falls, these measures will not help a person with akinesia move forward. Clients with Parkinson's disease should walk with a wide gait, not with the feet close together. A wheelchair should be used only when the client can no longer ambulate with assistive devices such as canes or walkers.

*Question: The nurse is caring for a client in labor. The fetal heart rate is 156 beats per minute and regular. The client's contractions are occurring every 4 minutes with a duration of 42 seconds and moderate intensity. The nurse would do which at this time?*

*Answer: Continue monitoring the client because the data reflect acceptable progress.* Rationale: The normal fetal heart rate ranges from 110 to 160 beats per minute. Signs of potential complications of labor are contractions consistently lasting 90 seconds or longer, contractions consistently occurring 2 minutes or less apart, fetal bradycardia, tachycardia, or persistently decreased variability, and an irregular fetal heart rate. Based on the data in the question, the nurse should continue to monitor the client.

*Question: The client is in the second stage of labor. As the baby begins to crown, the primary health care provider administers a pudendal nerve block in preparation for an episiotomy. Which action would the nurse take?*

*Answer: Continue to assess vital signs and fetal heart rate the same as before the nerve block.* Rationale: Pudendal nerve block may be used when an episiotomy is to be performed, if forceps or a vacuum extractor is to be used to facilitate birth, or when lacerations must be sutured after birth in a woman who does not have regional anesthesia. Pudendal block does not change maternal hemodynamic or respiratory functions, vital signs, or the fetal heart rate because it is considered a local anesthetic. Therefore, the nurse should continue to assess vital signs and fetal heart rate the same as before the nerve block.

*Question: A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. Which intervention would be appropriate to decrease the client's anxiety?*

*Answer: Convey empathy, trust, and respect toward the client.* Rationale: The appropriate intervention is to address the client's feelings related to the anxiety and to convey empathy, trust, and respect toward the client. Administering a sedative is not the most appropriate intervention. The nurse should not ignore the client's anxious feelings. A client will not relate to medical terms, particularly when anxiety exists.

*Question: A nursing instructor is observing a nursing student caring for a newborn with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by which action?*

*Answer: Covering the bladder with a sterile, nonadhering moist dressing* Rationale: The priority nursing intervention right after birth of a neonate with exstrophy of the bladder is to prevent infection of the sac. Infection of the sac can result if the sac leaks. This can be prevented by keeping the sac moist and covered. It is also imperative that the covering be of a nonadhering type.

*Question: Intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximately 24 hours to increase urine output and maintain the client's blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and coughing. For which additional signs of a complication would the nurse assess based on the previously known data?*

*Answer: Crackles in the lungs* Rationale: Circulatory (fluid) overload is a complication of therapy. Signs include rapid breathing, dyspnea, a moist cough, and crackles. Blood pressure and heart rate also increase if circulatory overload is present. Therefore, since the nurse previously noted rapid breathing and coughing, the nurse should then assess for a moist cough and crackles. Hematoma is another potential complication and is characterized by ecchymosis, swelling, and leakage at the IV insertion site, as well as hard and painful lumps at the site. Allergic reaction is a complication of administration of IV fluids or medication and is characterized by chills, fever, malaise, headache, nausea, vomiting, backache, and tachycardia; this type of reaction could also occur if the IV solutions infused are incompatible; however, there was no indication of multiple solutions being infused simultaneously in this question. Chest pain radiating to the left arm is a classic sign of cardiac co

*Question: The nurse is discussing signs of severe airway obstruction with a group of nursing students. Which sign would the nurse emphasize as one that indicates severe airway obstruction?*

*Answer: Cyanosis* Rationale: Signs of severe airway obstruction include cyanosis, poor air exchange, increased breathing difficulty, a silent cough, or inability to speak or breathe. A loud cough, pink color to the skin, and respiratory rate of 12 to 16 breaths per minute are incorrect and may be signs of mild respiratory distress that would not require immediate intervention.

*Question: A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia (BPH), the nurse questions the client about use of which medication?*

*Answer: Decongestants* Rationale: In the client with BPH, episodes of urinary retention can be triggered by certain medications such as decongestants, anticholinergics, and antidepressants. The client should be questioned about use of these medications if presenting with urinary retention. Retention also can be precipitated by other factors such as alcoholic beverages, infection, bed rest, and becoming chilled.

*Question: A client arrives at the health care clinic for follow-up care and evaluation of the effectiveness of prazosin. Which finding indicates a therapeutic effect related to the use of this medication?*

*Answer: Decrease in blood pressure* Rationale: Prazosin is an antihypertensive medication. The principal indication for its use is hypertension. A decrease in blood pressure indicates a therapeutic effect of the medication. Options 1, 3, and 4 are unrelated to the use of this medication.

*Question: A client with bladder cancer is receiving cisplatin and vincristine. The nurse plans care, knowing that which is the purpose of administering both of these medications?*

*Answer: Decrease medication resistance and reduce medication toxicity* Rationale: Cisplatin is an alkylating medication and vincristine is a vinca alkaloid. Alkylating medications are cell cycle phase nonspecific. Vinca alkaloids are cell cycle phase specific. Combinations of medications are used to enhance tumoricidal effects. Use of combination medications decreases medication resistance, increases destruction of cancer cells, and reduces medication toxicity. This combination does cause alopecia and gastrointestinal side effects.

*Question: The nurse is collecting data from a client receiving pioglitazone 30 mg orally daily. Which finding indicates that the client is experiencing the expected result of the action of this medication?*

*Answer: Decreased fasting blood glucose and reduced hemoglobin A1c (HbA1c)* Rationale: Pioglitazone is similar to other thiazolidinediones, also known as glitazones. Like rosiglitazone, pioglitazone activates peroxisome proliferator-activated receptor PPAR-gamma, and thereby reduces insulin resistance. In clients with type 2 diabetes, monotherapy with pioglitazone can decrease fasting blood glucose by 30 to 56 mg/dL, and can lower HbA1c by about 0.9%.

*Question: A child is admitted to the pediatric unit with a diagnosis of coarctation of the aorta (COA). The primary health care provider prescribes that the child's blood pressure be taken every 4 hours in the legs and arms. The nurse would expect which blood pressure readings in the child's legs and arms?*

*Answer: Decreased in the legs and increased in the arms* Rationale: Coarctation indicates a narrowing in the aorta. This would indicate an increased pressure proximal to the defect and a decreased pressure distal to the defect. This would result in a lower blood pressure in the legs and a higher blood pressure in the arms, which is indicated in option 3. Therefore, options 1, 2, and 4 are incorrect.

*Question: A client who has received sodium bicarbonate in large amounts is at risk for developing metabolic alkalosis. The nurse checks this client for which signs and symptoms characteristic of this disorder?*

*Answer: Decreased respiratory depth and rate and dysrhythmias* Rationale: The client with metabolic alkalosis is likely to exhibit a decrease in respiratory rate and depth, nausea, vomiting, diarrhea, restlessness, numbness and tingling in the extremities, twitching in the extremities, hypokalemia, hypocalcemia, and dysrhythmias. Disorientation and dyspnea could be associated with hypoxemia. Tachypnea, dizziness, and paresthesias are often associated with hyperventilation and respiratory alkalosis. Drowsiness, headache and tachypnea are not associated with metabolic alkalosis.

*Question: A client has a history of seizures. The primary health care provider has prescribed amitriptyline three times daily. The nurse seeks clarification of the prescription, knowing that the client is at risk for injury because of which adverse effect of the amitriptyline?*

*Answer: Decreased seizure threshold* Rationale: Amitriptyline, a tricyclic antidepressant, lowers the seizure threshold, increasing the risk of seizures. This may not be the medication of choice for a client who is already at risk for seizure activity. The other adverse effects are unrelated to the use of this medication.

*Question: The nurse is assisting in monitoring a preterm infant in the neonatal intensive care unit who received surfactant. The nurse monitors for which desired therapeutic outcome of this medication?*

*Answer: Decreased tachypnea and nasal flaring* Rationale: Lung surfactant, administered by direct intratracheal instillation, is indicated for prevention and treatment (rescue therapy) of respiratory distress syndrome (RDS). Surfactant therapy lowers the surface-tension forces that cause alveolar collapse and thereby rapidly improves oxygenation evidenced by decreased respiratory rate (tachypnea) and nasal flaring. Decreased acrocyanosis, improved cardiac output and increased body temperature are not therapeutic outcomes of this medication.

*Question: The nurse is caring for a client receiving magnesium sulfate for preeclampsia. During the administration of this medication, which would the nurse specifically monitor?*

*Answer: Deep tendon reflexes* Rationale: Loss of reflexes is often the first sign of developing toxicity. The nurse should assess knee jerk (patellar tendon reflex) for evidence of diminished or absent reflexes. Although apical heart rate, degree of edema, and presence of pitting peripheral edema may be components of the assessment, these are not specifically associated with this medication.

*Question: A client admitted to the hospital with a diagnosis of myocardial infarction (MI) tells the nurse that the pain likely resulted from the fried chicken sandwich that the client had for lunch. The nurse's response is based on which fact?*

*Answer: Denial is a common occurrence early after MI.* Rationale: An early initial coping response following MI is denial. The nurse uses this knowledge of this common response in planning care for the client. Option 1 is an opinion and not based on information in the question. There is no evidence in the question to support options 3 and 4.

*Question: The nurse is collecting data on a client with a diagnosis of hypothyroidism. Which of these behaviors, if present in the client's history, would the nurse determine as being likely related to the symptoms of this disorder?*

*Answer: Depression* Rationale: Hypothyroid clients experience a slow metabolic rate, and its manifestation includes apathy, fatigue, sleepiness, and depression. Anxiety, irritability, and nervousness are the clinical symptoms of hyperthyroidism.

*Question: The nurse is reinforcing a teaching session to a group of adolescent pregnant clients and is discussing the importance of nutrition. The nurse includes which information in the discussion?*

*Answer: Describing the appropriate amount of weight gain required during the pregnancy* Rationale: The developmental stage of the adolescent needs to be addressed when the nurse is providing instructions regarding nutrition during pregnancy. The adolescent should not be told to eliminate favorite foods and places to eat. This may cause the adolescent to rebel. Eating only when hungry could lead to a deficit in nutrients. The adolescent is more likely to follow suggestions when the nurse explains why the weight gain is important.

*Question: The nurse is caring for a child with a diagnosis of diabetes insipidus. The nurse anticipates that the primary health care provider will prescribe which medications?*

*Answer: Desmopressin acetate* Rationale: Desmopressin acetate is used to treat diabetes insipidus. Propylthiouracil is used to treat hyperthyroidism. One of the uses for furosemide is to treat syndrome of inappropriate antidiuretic hormone (SIADH). Methimazole is also used to treat hyperthyroidism.

*Question: After weeks of witnessing a hospice client's deterioration and subsequent death from liver failure, his family disagrees about performing an autopsy. Which criterion does the nurse use to determine if the autopsy can proceed?*

*Answer: Determination by the client's son* Rationale: The nurse works with the client's son to determine if an autopsy can be performed (option 4) because the only powers that supersede an offspring's decision are the client's written statement, a durable power of attorney, or a surviving spouse. In order, a parent, brother, or sister can make the decision if the client has no children. A client's will involves bequeathing property and does not contain information about medical care (option 1). The client's sibling is consulted after an offspring (option 2). The client's death is unlikely to be a medical examiner's case or a suspicious death, so a medical examiner's ruling is not indicated.

*Question: A female client complains of an "odd, left-sided, twinge-like pain" along the anterior axillary line and states she has had this feeling for the past 3 days. Which is the initial action?*

*Answer: Determine if the pain is cardiac in origin.* Rationale: The best initial action is to rule out chest pain of cardiac origin to eliminate a cardiovascular etiology related to the client's complaint. If the pain is left untreated and the pain is caused by myocardial ischemia or infarction (MI), the client could suffer a devastating cardiac injury. Furthermore, the nurse does this because a female presenting with an MI is more likely to display atypical clinical indicators including fatigue and dyspnea. After instituting measures to rule out a cardiac problem, the nurse completes the client assessment by auscultating the heart and lungs and by reviewing the medical record. After a cardiac problem is ruled out, the nurse can administer an analgesic if prescribed.

*Question: The nurse notes that a client's urinalysis report contains a notation of positive red blood cells (RBCs). The nurse interprets that this finding is unrelated to which information in the client's medical record?*

*Answer: Diabetes mellitus* Rationale: Hematuria can be caused by trauma to the kidney such as with blunt trauma to the lower posterior trunk or flank. Kidney stones can cause hematuria as they scrape the endothelial lining of the urinary system. Anticoagulant therapy can cause hematuria as a side effect. Diabetes mellitus does not cause hematuria, although it can lead to renal failure from prerenal causes.

*Question: A client has been diagnosed with pyelonephritis. The nurse interprets that which health problem has placed the client at risk for this disorder?*

*Answer: Diabetes mellitus* Rationale: Risk factors associated with pyelonephritis include diabetes mellitus, hypertension, chronic renal calculi, chronic cystitis, structural abnormalities of the urinary tract, presence of urinary stones, and indwelling or frequent urinary catheterization. Options 1, 3, and 4 are not risk factors for pyelonephritis.

*Question: A client with possible hiatal hernia complains of frequent heartburn and regurgitation. The nurse would gather further information about the presence of which sign or symptom?*

*Answer: Difficulty swallowing* Rationale: Although many clients with hiatal hernia are asymptomatic those with symptoms usually have difficulty swallowing, along with heartburn and reflux. Dizziness after meals, left lower quadrant pain 2 hours after eating, and moderate right upper quadrant pain unrelated to eating are unrelated to this disorder.

*Question: A 2-year-old child is admitted to the hospital with a diagnosis of nephrotic syndrome. In planning care for this child, which nursing intervention would be of highest priority?*

*Answer: Dipstick the urine for protein every 4 hours.* Rationale: Continuous monitoring of fluid retention and excretion is an important nursing intervention in the care of the child with nephrotic syndrome. Although it is important to maintain a strict intake and output in monitoring fluid retention and excretion, the goal of treatment with this child is to decrease the amount of protein lost in the urine. Because this is the goal, option 3 has the highest priority. Although weight is monitored, it is not necessary to check the weight morning and evening. Taking vital signs with blood pressure is important but is not the priority in this situation and does not have to be monitored every 2 hours.

*Question: A client scheduled for a pulmonary angiography is fearful about the procedure and asks the nurse if the procedure involves significant pain and radiation exposure. The nurse gives a response to the client that provides reassurance, based on which understanding?*

*Answer: Discomfort may occur with needle insertion, and there is minimal exposure to radiation.* Rationale: Pulmonary angiography involves minimal exposure to radiation. The procedure is painless, although the client may feel discomfort with insertion of the needle for the catheter that is used for dye injection. No and moderate pain and no exposure to radiation are incorrect.

*Question: A pediatric nurse arrives at work and is told to report (float) to the emergency department (ED) for the day because the ED is expecting numerous victims to arrive following a train crash. The nurse has never worked in the ED and is anxious about floating to this area. Which is the appropriate nursing action?*

*Answer: Discuss her anxieties and concerns with the nursing supervisor about floating.* Rationale: Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can only work in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountered with this situation, the nurse should discuss any anxieties and concerns with the nursing supervisor about floating. Options 1 and 3 may be interpreted as client abandonment. Option 2 isnot the appropriate action because it is not within the realm of the nurse's responsibilities to ask another nurse to float.

*Question: The nurse is collecting data on a pregnant client in her 22nd week. The nurse prepares to use a fetoscope to auscultate the fetal heart rate. The nurse hears a fetal heart rate of 115 beats per minute. Which action would the nurse take?*

*Answer: Document the assessment.* Rationale: Fetal heart sounds can be heard with a fetoscope by 18 to 20 weeks of gestation. The fetal heart rate ranges between a low of 110 to120 beats/minute and a high of 150 to 160 beats/minute. Since the fetal heart rate is normal, the nurse should document the findings. Notifying the primary health care provider, having another nurse recheck the assessment, and comparing maternal pulse rate to fetal pulse rate are unnecessary at this time.

*Question: The nurse is assigned to care for a child after a myringotomy with the insertion of tympanostomy tubes. The nurse notes a small amount of reddish drainage from the child's ear after the surgery. On the basis of this finding, which action would the nurse take?*

*Answer: Document the findings.* Rationale: After a myringotomy with the insertion of tympanostomy tubes, the child is monitored for ear drainage. A small amount of reddish drainage is normal during the first few days after surgery. However, any heavy bleeding or bleeding that occurs after 3 days should be reported. The nurse would document the findings. Options 2, 3, and 4 are not necessary.

*Question: The nurse is caring for a client following total hip replacement who has a wound suction drain in place. At the end of the 8-hour shift, the nurse empties 45 mL of drainage from the wound-suction device. Based on this amount of drainage, which action is appropriate?*

*Answer: Document the findings.* Rationale: Following total hip replacement, the hip incision may have a wound-suction drain in place, which is expected to drain usually less than 50 mL every 8 hours. The nurse should document the findings. The nurse may check the client's blood pressure, but this action is not directly related to the amount of drainage from the device. There is no need to notify the registered nurse immediately, although this information may need to be conveyed to the registered nurse at the end of the work shift. Placing the leg flat in bed should be done only if prescribed by the primary health care provider. Additionally, this action is unrelated to the subject of the question.

*Question: The nurse is changing the diaper of a 1-day-old, full-term female newborn and notes that the genitalia are red and swollen and that a thick, white mucoid vaginal discharge is present. Based on these findings, the nurse determines that which action is the best?*

*Answer: Document the findings.* Rationale: The genitalia of a newborn female are frequently red and swollen. This edema disappears in a few days. A vaginal discharge of thick, white mucus is seen in the first week of life. The mucus is occasionally blood tinged by about the third or fourth day and stains the diaper. The cause of the pseudomenstruation, like that of breast engorgement, is the withdrawal of maternal hormones.

*Question: The nurse is assessing a client during a prenatal visit. The nurse takes the client's temperature and notes that the temperature is 99.2° F. Which nursing action is appropriate?*

*Answer: Document the temperature.* Rationale: The normal temperature during pregnancy is 98° to 99.6° F (36.2° to 37.6° C). A temperature above this level suggests infection that might require medical management. Options 2, 3, and 4 are unnecessary.

*Question: The nurse is reinforcing dietary instructions to a pregnant client with a history of lactose intolerance. The nurse would instruct the client to consume which best food item to ensure an adequate source of calcium in the diet?*

*Answer: Dried fruits* Rationale: The best source of calcium is dairy products. Women with lactose intolerance need other sources of calcium because they are not able to consume dairy products. Calcium is present in dark green, leafy vegetables; broccoli; legumes; nuts; and dried fruits. Cheese is a dairy product and cannot be eaten by a client who has lactose intolerance. Spinach contains calcium, but it also contains oxalates that decrease calcium availability. Orange juice does not contain significant amounts of calcium unless fortified with calcium.

*Question: A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. Which would the nurse tell the child?*

*Answer: Drink a half a cup of orange juice before soccer practice.* Rationale: An extra snack of 10 g to 15 g of carbohydrates eaten before activities and for every 30 to 45 minutes of activity will prevent hypoglycemia. A half cup of orange juice will provide the needed carbohydrates. The child or parents should not be instructed to adjust the amount or time of insulin administration, and meal amounts should not be doubled.

*Question: The nurse is collecting data from a newly admitted client recently diagnosed with borderline personality disorder. Which data provided by the client best supports the nurse's concern that the client is not using effective coping skills?*

*Answer: Driving under the influence (DUI) conviction resulted in a 1-year suspended license* Rationale: The DUI conviction resulting in a 1-year suspended license best supports the nurse's concern that the client is not using effective coping skills. This best reflects the nurse's concern because reliance on alcohol, especially to the degree that it results in serious illegal behavior, represents ineffective coping. Individuals diagnosed with borderline personality disorder may display self-destructive behaviors as a result of inadequate psychological resources. Although a 1½-pack-a-day nicotine habit indicates the use of nicotine as an unhealthy coping mechanism, it does not have the same degree of potential danger to both the client and innocent victims. Option 2, a two-year alienation from parents and siblings, and option 3, a weight loss of 10 pounds in the last 2 months, may be a result of factors other than ineffective coping.

*Question: A client is diagnosed with Haemophilus influenzae pneumonia. In addition to standard precautions, which other precautions would be instituted immediately by the nurse?*

*Answer: Droplet precautions* Rationale: Droplet precautions are instituted when the disease is transmitted via large particle droplets, such as in the case of H. influenzae pneumonia. Contact precautions are initiated when the organism can be transmitted by direct client contact or by contact with items in the client's environment. Airborne precautions are instituted when the organism is transmitted by airborne droplet nuclei, such as in the case of tuberculosis. Neutropenic precautions are initiated when the client is at risk of contracting a life-threatening infection.

*Question: The nurse is instructing a client who had a herniorrhaphy about how to reduce postoperative swelling following the procedure. Which would the nurse suggest to the client to prevent swelling?*

*Answer: Elevate the scrotum.* Rationale: Following herniorrhaphy, the client should be instructed to elevate the scrotum and apply ice packs while in bed to decrease pain and swelling. The client also is instructed to apply a scrotal support when out of bed. Limiting fluids, applying heat to the abdomen, and maintaining a low-roughage diet are incorrect.

*Question: A client taking an aldosterone antagonist known as eplerenone for hypertension asks about side effects of this medication. The nurse tells the client that which sign/symptom is a side effect?*

*Answer: Elevated potassium level* Rationale: Eplerenone is a selective aldosterone receptor blocker. The medication is used for hypertension and heart failure and has one significant side effect, hyperkalemia. Therefore, options 1, 2, and 3 are incorrect.

*Question: The nurse monitors the laboratory data on a client at risk for coronary artery disease. A fasting blood glucose reading of 200 mg/dL is recorded on the chart. The nurse analyzes this result as indicative of which finding?*

*Answer: Elevated, signaling the presence of diabetes mellitus, a risk factor of coronary artery disease* Rationale: A fasting blood glucose of 200 mg/dL signals the presence of diabetes mellitus. Diabetes mellitus predisposes a client to coronary artery disease. Options 1, 2, and 4 are inaccurate interpretations.

*Question: A client admitted to the hospital with coronary artery (CAD) disease complains of dyspnea at rest. The nurse determines that which would be of most help to the client?*

*Answer: Elevating the head of the bed to at least 45 degrees* Rationale: The management of dyspnea generally is directed toward alleviation of the cause. Symptom relief may be achieved or at least aided by placing the client at rest with the head of the bed elevated. Supplemental oxygen may be used but placing equipment at the bedside is not directly helpful. Monitoring of oxygen saturation detects early complications but does not help the client. Likewise, placing an oxygen cannula at the bedside for use would not help the client.

*Question: A client's spouse becomes distraught when thinking about his wife's terminal prognosis. Which action would the nurse implement to best assist the spouse?*

*Answer: Encourage development of realistic goals.* Rationale: The nurse can best assist the spouse by encouraging the development of realistic goals. This promotes the contextual dimension of hope. Option 1 is a premature and incorrect action as it takes away any hope that the spouse may anticipate. It is inappropriate to encourage establishing new relationships; the spouse's focus is on his wife at this time. Option 4 is inappropriate. Although hope should not be taken away from a client or spouse, promoting the expression of positive outcomes is providing false hope.

*Question: The nurse is assigned to care for a client admitted to the postpartum unit following delivery of a full-term healthy infant. The nurse checks the mother's temperature and notes that it is 100.4° F (38° C). Which nursing action is appropriate?*

*Answer: Encourage oral fluids.* Rationale: Temperatures up to 100.4° F (38° C) in a mother during the first 24 hours after birth are often related to the dehydrating effects of labor. Increasing hydration by encouraging oral fluids will help bring the temperature to a normal reading. Administering acetaminophen, immediately notifying the RN or primary health care provider or removing blankets and reassessing the temperature are unnecessary actions at this time.

*Question: The nurse caring for a child with aplastic anemia is reviewing the laboratory results and notes a white blood cell (WBC) count of 6000 mm3 (6 × 109/L) and a platelet count of 20,000 mm3 (20 × 109/L). Which nursing intervention would be incorporated into the plan of care?*

*Answer: Encourage quiet play activities.* Rationale: Precautionary measures to prevent bleeding should be taken when a child has a low platelet count. These include no injections, no rectal temperatures, the use of a soft toothbrush, quiet activities, and abstinence from contact sports or activities that could cause an injury. Strict isolation would be required if the WBC count was low. Naps and a diet high in iron are unrelated to the risk of bleeding.

*Question: The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse would instruct the mother to take which action?*

*Answer: Encourage the child to drink liquids.* Rationale: When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to aid in clearing the ketones. The child should be encouraged to drink liquids. Bringing the child to the clinic immediately is unnecessary. Insulin doses should not be adjusted or changed.

*Question: The nurse is assisting in developing a plan of care for a client who will be returning to the nursing unit following a cardiac catheterization via the femoral approach. Which nursing intervention would be included in the postprocedure plan of care?*

*Answer: Encourage the client to increase fluid intake.* Rationale: Immediately following a cardiac catheterization using the femoral approach, the client should not flex or hyperextend the affected leg. Placing the client in the Fowler's position increases the risk of hemorrhage. Fluids are encouraged to assist in removing the contrast medium from the body. Asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or thrombus were developing. Flexion or hyperextension and range-of-motion exercises of the extremity are contraindicated. The regularly scheduled medications are needed to treat acute and chronic conditions.

*Question: A client has the following laboratory values: pH of 7.55, HCO3- of 22 mm Hg, and a Pco2 of 30 mm Hg. Which action would the nurse take?*

*Answer: Encourage the client to slow down his breathing.* Rationale: The client is in respiratory alkalosis based on the laboratory results of a high pH and low Pco2. Interventions for respiratory alkalosis are voluntary holding of the breath or slowed breathing and rebreathing exhaled CO2 by methods such as using a paper bag or rebreathing mask, as prescribed. Dialysis and administration of insulin are interventions for metabolic acidosis. Suctioning the client would improve respiration status and treat respiratory acidosis.

*Question: A client receiving a blood transfusion begins to exhibit flushing, stridor, and a drop in blood pressure. The nurse would obtain which medication from the emergency cart to have ready for use as prescribed?*

*Answer: Epinephrine* Rationale: The symptoms exhibited by the client are compatible with an allergic reaction to the transfusion. Other common symptoms of allergic reaction are nausea and vomiting, diarrhea, and loss of consciousness. The nurse prepares to administer epinephrine and corticosteroid medications as prescribed. Norepinephrine is a sympathetic agonist used to treat hypotension but is not indicated in an allergic reaction. Lidocaine is an antidysrhythmic medication. Theophylline is a bronchodilator, which could be prescribed if needed to treat bronchospasm.

*Question: The nurse is teaching a pregnant client about the physiological effects and hormone changes that occur in pregnancy. The client asks the nurse about the purpose of estrogen. Which description explains the purpose of estrogen?*

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

*Question: The nurse observes the following rhythm on the cardiac monitor. Which action would the nurse take first? Refer to the figure.View Figure*

*Answer: Evaluate the client for hypotension and assess mental status.* Rationale: After determining that the client is in sinus bradycardia with a heart rate of 40 beats per minute, the nurse should evaluate the client first for signs and symptoms of decreased cardiac output. Signs and symptoms of decreased cardiac output include hypotension, altered mental status, weak peripheral pulses, and decreased urinary output. If the bradycardia is new or the client has evidence of decreased cardiac output, the primary health care provider would then be notified. Transcutaneous pacing or atropine administration may be instituted if evidence of decreased cardiac output is present.

*Question: A client is at risk for complications of heart failure. Which is the nurse's priority for early detection of the most likely cause of complications with this client?*

*Answer: Evaluating total body fluid* Rationale: Fluid overload can cause complications for the client with heart failure. Therefore, the nurse evaluates the client's fluid balance to forestall activation of harmful compensatory mechanisms and deterioration of other organ systems that increasing total body fluid can cause. This is the nurse's priority because balancing the client's fluid status has the broadest range of potential benefits for the client including improving oxygenation. The vital signs, serum electrolytes, and electrocardiogram are important assessments yet remain secondary in importance to fluid status because they are items that are affected by fluid balance.

*Question: The nurse is reinforcing instructions to the assistive personnel (AP) who will be caring for a client with security devices (hand restraints). How often would the nurse instruct the AP to check the client's skin and circulation under the security devices?*

*Answer: Every 30 minutes* Rationale: The nurse should instruct the AP to check the restraints, circulatory status, and skin integrity every 30 minutes. Additionally, restraints need to be released at least every 2 hours to permit muscle exercise and promote circulation. Agency guidelines regarding the use of restraints always should be followed.

*Question: The nurse reviews the record of a child who was just seen by the primary health care provider (PHCP). The PHCP has documented a diagnosis of suspected aortic stenosis. Which specific sign/symptom of aortic stenosis would the nurse anticipate?*

*Answer: Exercise intolerance* Rationale: The child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted, but it is not specific to this type of disorder alone. Options 2 and 4 are not related to this disorder.

*Question: A client who is experiencing severe respiratory acidosis has a potassium level of 6.2 mEq/L. The nurse determines this result is best characterized by which interpretation?*

*Answer: Expected and indicates that acidosis has driven hydrogen ions into the cell, forcing potassium out* Rationale: With severe respiratory acidosis, compensatory mechanisms fail. As hydrogen ion concentrations continue to rise, they are driven into the cell forcing intracellular potassium out. This is an expected finding in this situation. Options 1, 2, and 3 are incorrect interpretations.

*Question: A client diagnosed with tuberculosis (TB) is distressed over the loss of physical stamina and fatigue. The nurse would provide which explanation for these symptoms?*

*Answer: Expected, and the client should very gradually increase activity as tolerated* Rationale: The client with TB 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.

*Question: A client who experienced a myocardial infarction (MI) tells the nurse that he is fearful about not being able to return to a normal life. Which action by the nurse is therapeutic at this time?*

*Answer: Explore specific concerns with the client.* Rationale: The therapeutic action by the nurse is one that gathers more data. This then allows the nurse to formulate the appropriate response. Each of the incorrect options is nontherapeutic because they place the client's feelings on hold and do not address them.

*Question: The nurse is collecting data on a client who was just admitted to the hospital with a diagnosis of coronary artery disease (CAD). The client reveals having been under a great deal of stress recently. Which would the nurse do next?*

*Answer: Explore with the client the sources of stress in life.* Rationale: The nurse should encourage the client to explore and verbalize stressors. Later, the nurse can teach the client strategies for coping with stress such as the basic relaxation techniques of deep breathing, progressive muscle relaxation, and visualization. Asking whether the client wants to see a psychiatrist could be construed as excessive or insulting and puts the client's feelings on hold. Reassuring the client that everybody seems stressed these days ignores the client's concerns. Asking the client to write down a list of stressors places further data collection of this area on hold.

*Question: The nurse is developing goals for a school-age child with a knowledge deficit related to the use of inhalers and peak flow meters. The nurse identifies which goal as appropriate for this child?*

*Answer: Expresses feelings of mastery and competence with breathing devices* Rationale: School-age children strive for mastery and competence to achieve the developmental task of industry and accomplishment. Options 1 and 2 do not relate to the knowledge deficit. Option 4 is an intervention rather than a goal.

*Question: When planning care for a woman with gestational hypertension (GH), the nurse plans to encourage which maternal behavior?*

*Answer: Expression of hope for a positive outcome* Rationale: Hoping for a positive outcome is an appropriate coping mechanism. It is important to support an expression of hope by a client with a high-risk pregnancy as long as the hope is realistic (e.g., fetus is viable). Anticipatory grieving is not a positive adaptation for this client. Grieving should begin when a loss occurs. Walking 1 to 2 miles daily is contraindicated for a woman with gestational hypertension. Delaying nursery preparations at home reflects an "expecting the worst" situation.

*Question: After an eye examination, a client has been diagnosed with acute angle-closure glaucoma. The nurse collecting data from the client asks the client about an accompanying history of which sign/symptom?*

*Answer: Eye pain* Rationale: Common symptoms of acute angle-closure glaucoma are blurred vision, severe pain, and vision loss. Color blindness and difficulty seeing at night are unrelated findings. Yellow-green vision may sometimes accompany digoxin toxicity.

*Question: The nurse is assessing the pain in a 3-year-old child after an appendectomy. Which pain scale would the nurse use?*

*Answer: FACES pain rating scale* Rationale: There is a pain-rating tool identified with children as young as a neonate. Because the child in this question is 3 years old, the recommended pain scale is the FACES pain scale, which can be used with children as young as 3 years of age. The numeric scale is used with children who can count to 100 by ones. The poker child tool is used beginning with children who are 4 years old.

*Question: The nurse determines that motor function of which cranial nerve is intact if the client can perform this action? Refer to figure.View Figure*

*Answer: Facial* Rationale: The motor function of the facial nerve is tested by asking the client to smile, frown, close the eyes tightly, lift the eyebrows, and puff the cheeks. The acoustic nerve assesses hearing and is sensory. To determine if motor function of the trigeminal nerve is intact, the nurse should have the client clench the teeth tightly and attempt to separate the client's jaw while the teeth are tightly clenched. To test the motor function of the glossopharyngeal nerve, the nurse should depress the client's tongue with a tongue blade, have the client say "ahhh," and watch for the uvula and soft palate to rise in the midline.

*Question: The nurse working the 3:00 to 11:00 pm shift notes that a client with coronary artery disease (CAD) has a prescription for serum lipid levels to be drawn in the morning. The nurse places the client on which dietary preparation to ensure accurate test results?*

*Answer: Fasting for 12 hours* Rationale: To obtain an accurate cholesterol level, a client must fast 12 hours before the tests. Options 2 and 4 interfere with accurate test results, and option 3 represents an unnecessary time period.

*Question: A client is scheduled for an oral cholecystography. The nurse would plan to obtain what type of diet for the evening meal before the test?*

*Answer: Fat-free* Rationale: Normal dietary intake of fat should be maintained during the days preceding the test in order to empty bile from the gallbladder. A fat-free diet is prescribed on the evening before the test. The fat-free supper prevents contraction of the gallbladder and allows accumulation of the contrast substance needed for x-ray visualization. The client is not given a liquid, low-protein, or high-carbohydrate diet the evening meal before the test.

*Question: A client scheduled for a thyroidectomy says to the nurse, "I am so scared to get cut in my neck." Based on the client's statement, the nurse determines that the client is experiencing which problem?*

*Answer: Fear about impending surgery* Rationale: The client is having a difficult time coping with the scheduled surgery. The client is able to express fears but is scared. No data in the question support options 2, 3, and 4.

*Question: A client with cirrhosis admitted to the hospital diagnosed with severe jaundice is having diagnostic testing. Because the client has no complaints of fatigue, the client is encouraged to ambulate in the hall to maintain muscle strength. The client paces around the room but will not enter the hall. The nurse would determine which concern is most likely the reason for the client's reluctance to walk in the hall?*

*Answer: Feeling self-conscious about appearance* Rationale: Clients with jaundice frequently have a body image disturbance because of a change in appearance. This can be manifested in negative verbal or nonverbal behavior. Unfamiliarity with the hospital, fear of catching another disease, and not wanting to overexert are unrelated to the data in the question.

*Question: A client who has undergone a cardiac catheterization using the right femoral approach is returned to the nursing unit. Thirty minutes later the client complains of numbness and tingling of the right foot. The pedal pulse is weak, and the foot is pale. The nurse notifies the registered nurse because these symptoms are consistent with which problem?*

*Answer: Femoral artery thrombus or hematoma* Rationale: Adverse changes such as numbness and tingling, coolness, pallor, cyanosis, or sudden loss of peripheral pulses indicate serious circulatory impairment and are reported to the registered nurse immediately, who then contacts the primary health care provider. Allergic reaction to the dye is a systemic problem, not a local one. The data in the question are not consistent with sciatic pain. Infection does not become apparent this quickly.

*Question: A client is admitted to the hospital with possible rheumatic heart disease. The nurse collects data from the client and checks the client for which signs/symptoms?*

*Answer: Fever and sore throat* Rationale: Rheumatic heart disease can occur as a result of infection with group A beta-hemolytic streptococcal infections. It is frequently triggered by streptococcal pharyngitis, which is assessed by noting for the presence of sore throat and fever. The other options are unrelated to this problem and indicate possible yeast infection, skin lesions, and urinary tract infection, respectively.

*Question: The nurse is collecting data from a client with epididymitis. The nurse would expect to note which signs and symptoms of this problem?*

*Answer: Fever, nausea and vomiting, and painful scrotal edema* Rationale: Typical signs and symptoms of epididymitis include scrotal pain and edema, which often are accompanied by fever, nausea and vomiting, and chills. It most often is caused by infection, although sometimes it can be caused by trauma. Diarrhea and ecchymosis are not associated with this disorder.

*Question: A client who has had a radical neck dissection begins to hemorrhage at the incision site. Which action by the nurse would be contraindicated?*

*Answer: Lowering the head of the bed to a flat position* 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, contacts the registered nurse immediately who will then call the primary health care provider immediately.

*Question: A mother brings her 15-month-old child to the primary health care provider's office with complaints that the child has suddenly developed a bright red rash on her cheeks. She has no other symptoms and has been playing and eating as usual. Based on the appearance of the child, the nurse might suspect that the child has which communicable disease?*

*Answer: Fifth disease* Rationale: Fifth disease has the general appearance of "slapped cheeks." Many children do not have any symptoms before the appearance of the reddened cheeks. This characteristic is not associated with the communicable diseases identified in options 1, 2, or 4.

*Question: The nurse reinforces instructions to the parents of a child with sickle cell anemia regarding the precipitating factors related to pain crisis. Which, if identified by a parent as a precipitating factor, indicates the need for further teaching?*

*Answer: Fluid overload* Rationale: Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or general stress. The mother of a child with sickle cell disease should encourage a fluid intake of 1.5 to 2 times the daily requirement to prevent dehydration.

*Question: The nurse is caring for a client with a spinal cord injury. High-top sneakers on the client's feet will prevent the occurrence of which?*

*Answer: Foot drop* Rationale: The most effective way to prevent foot drop is to use posterior splints or high-top sneakers. A foot board prevents plantar flexion but also places the client at greater risk for developing pressure ulcers of the feet. Pneumatic boots prevent deep vein thrombosis but not foot drop.

*Question: The nurse is preparing to administer an enteral feeding through a nasogastric tube. The nurse would place the client in which position during and after the feedings?*

*Answer: Fowler's* Rationale: The client is placed with the head of the bed elevated 30 to 45 degrees both during and after feedings to prevent aspiration. The Sim's, supine, and Trendelenburg's positions place the client at risk for aspiration.

*Question: The nurse is assisting a hospitalized client who is newly diagnosed with coronary artery disease (CAD) to make appropriate selections from the dietary menu. The nurse encourages the client to select which meal?*

*Answer: Fresh strawberries, steamed vegetables, and baked fish* Rationale: Diets high in saturated fats raise the serum lipid level, which in turn raises the blood cholesterol. Over time, high blood cholesterol levels lead to the development of atherosclerosis and diseases such as coronary artery disease. A diet that is low in saturated fats is helpful in reducing the progression of atherosclerosis. Meats and dairy products tend to be higher in fat than other food groups.

*Question: An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings would the nurse expect to note?*

*Answer: Fruity breath odor and decreasing level of consciousness* Rationale: Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Signs of hyperglycemia include fruity breath odor and a decreasing level of consciousness. Hunger can be a sign of hypoglycemia or hyperglycemia, but hypertension is not a sign of diabetic ketoacidosis. Hypotension occurs because of a decrease in blood volume related to the dehydrated state that occurs during diabetic ketoacidosis. Cold, clammy skin, irritability, sweating, and tremors all are signs of hypoglycemia.

*Question: The nurse is assessing a client who is at 32 weeks of gestation. It has been 4 weeks since her last visit. Which assessment needs to be reported to the primary health care provider?*

*Answer: Fundal height, 38 cm* Rationale: From 22 weeks until term, the fundal height measured in centimeters is roughly plus or minus 2 cm of the gestational age of the fetus in weeks. If the fundal height exceeds weeks of gestation, additional assessment is necessary to investigate the cause for the unexpected uterine size. If an unexpected increase in uterine size is present, it may be that the estimated date of delivery is incorrect, and the pregnancy is more advanced than previously thought. If the estimated date of delivery is correct, it may be possible that more than one fetus is present or excessive amniotic fluid is present. Expected weight gain is a pound a week in the second and third trimesters. The blood pressure and fetal heart tones are in normal ranges.

*Question: The nurse is assisting with gathering admission assessment data on a 2-year-old child who has been diagnosed with nephrotic syndrome. The nurse collects data knowing that which is a common characteristic associated with nephrotic syndrome?*

*Answer: Generalized edema* Rationale: Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, and edema. The urine is dark, foamy, and frothy, but microscopic hematuria may be present. Frank, bright red blood in the urine does not occur. Urine output is decreased and the blood pressure is normal or slightly decreased.

*Question: A client with Guillain-Barré syndrome has been asking many questions about the condition, and the nursing staff feels that the client is very discouraged about her condition. It is important for the nurse to include which information in discussions with the client?*

*Answer: Generally, a vast number of people recover from this condition.* Rationale: The vast majority of clients with Guillain-Barré syndrome recover from the paralysis because it affects peripheral nerves that have the capacity to remyelinate. Maximum paralysis can take up to 4 weeks to develop. Paralysis progresses distally to proximally. Rehabilitation can take from 6 months to 2 years.

*Question: The nurse carries out a standard prescription for a stat electrocardiogram (ECG) on a client who has an episode of chest pain. The nurse would take which action next?*

*Answer: Give sublingual nitroglycerin per the primary health care provider's prescriptions.* Rationale: After completing the stat ECG, the nurse would administer a nitroglycerin tablet to dilate the coronary arteries and relieve ischemic pain. The nurse would not wait to see whether pain resolves on its own but would determine whether the pain is relieved with nitroglycerin. The nurse would do a repeat ECG if it is prescribed. The nurse would report the episode of pain to the primary health care provider but should administer the nitroglycerin before doing so.

*Question: The nurse is caring for a client who has been diagnosed as having a kidney mass. The client asks the nurse the reason for a renal biopsy when other tests such as computed tomography (CT) and ultrasound are available. In formulating a response, the nurse incorporates the knowledge that a renal biopsy serves which purpose?*

*Answer: Gives specific cytological information about the lesion* Rationale: Renal biopsy is a definitive test that gives specific information about whether the lesion is benign or malignant. An ultrasound discriminates between a fluid-filled cyst and a solid mass. Renal arteriography outlines the renal vascular system.

*Question: Cyclobenzaprine is prescribed for a client for muscle spasms, and the nurse is reviewing the client's record. Which disorder, if noted in the record, would indicate a need to contact the primary health care provider about the administration of this medication?*

*Answer: Glaucoma* Rationale: Because cyclobenzaprine 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 time (2 to 3 weeks). The conditions in options 2, 3, and 4 are not a concern with this medication.

*Question: Propantheline bromide is prescribed for a client with bladder spasms. Which disorder, noted in the client's record, alerts the nurse to question the prescription for this medication?*

*Answer: Glaucoma* Rationale: Propantheline bromide is contraindicated in clients with narrow-angle glaucoma, obstructive uropathy, gastrointestinal disease, or ulcerative colitis. Options 2, 3, and 4 are not contraindications to the use of this medication.

*Question: The nurse is assigned to care for a client on contact precautions. On review of the client's record, the nurse notes that the client has a hospital-acquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator and requires frequent suctioning. The nurse gathers supplies before entering the client's room and obtains which necessary protective items?*

*Answer: Gloves, mask, gown, and goggles* Rationale: The nurse needs to consider what personal protective equipment (PPE) is needed depending on the type of precautions required by the organism and the likelihood of splatter occurring during a treatment. Goggles are worn to protect the mucous membranes of the eye, and a mask is worn to protect the mouth and respiratory system during interventions that may produce splashes of blood, body fluids, secretions, and excretions. Suctioning and a wound irrigation are treatments in which splatter is likely. In addition, contact precautions require the use of gloves and a gown to be worn if direct client contact is anticipated. Shoe protectors are not necessary.

*Question: The nurse is reinforcing instructions to a pregnant client regarding the need to consume folic acid in the diet. The nurse determines that the client understands the instructions when the client states that it is necessary to include which food item in the diet?*

*Answer: Green, leafy vegetables* Rationale: Sources of folic acid include green, leafy vegetables; whole grains; fruits; liver; dried peas; and beans. Rice, cheese, and chicken are not sources of folic acid.

*Question: A visitor brings a suicidal client a brightly packaged gift. The nurse accompanies the visitor to the client's room and takes which action?*

*Answer: Has the client open the gift with the nurse present* Rationale: The nurse would have the client open the gift with the nurse present. It is important for the nurse to be concerned with the safety of the client. The visitor may or may not be aware of the client's suicidal thoughts or the hospital safety policies. The client would open the gift in the presence of the nurse so that sharp or unsafe objects could be locked in the client's safety box. Leaving the package unattended in the room with the client is hazardous. The other actions are incorrect and unsafe.

*Question: When checking a child's trochlear nerve function, the nurse would perform which data collection technique?*

*Answer: Have the child look down and in.* Rationale: Having the child look down and in will assess the function of the trochlear nerve. Having the child look toward the temporal side is the technique for checking the abducens nerve. Having the child bite down hard and open the jaw is the technique for checking the trigeminal nerve. Having the child show the teeth to note symmetry of expression is the data collection technique for checking the facial nerve.

*Question: A 4-year-old child is reluctant to take deep breaths following abdominal surgery. Which measure would be effective to encourage deep breathing?*

*Answer: Have the child pretend to be a big bad wolf blowing the little pig's house down.* Rationale: The preschooler has a vivid imagination and loves to pretend. Engaging the child in therapeutic play appropriate to age is considered the most effective way to intervene. Balloons are unsafe because of the potential aspiration of latex. The peak flowmeter is used to assess vital capacity rather than to encourage breathing. Chest percussion and postural drainage will not affect depth of respiration.

*Question: A child has epistaxis. The nurse understands that which treatment is appropriate for epistaxis?*

*Answer: Have the child sit up and lean forward.* Rationale: Correct treatment for epistaxis (a nosebleed) involves having a client sit up and lean forward. Therefore, having the child assume a supine position or sit up and tilt the head backward are incorrect. Continuous pressure would be applied to the nose for at least 10 minutes.

*Question: A client with a nasal tumor is being admitted to the hospital. The nurse collects data about which primary symptom that the client is expected to exhibit?*

*Answer: Nasal obstruction* Rationale: Nasal obstruction is the most common symptom associated with a nasal tumor because the tumor occupies space in the nasal area. Bleeding (epistaxis) may occur but is not a primary sign. Headache and a runny nose are not compatible with the clinical picture of a client with a nasal tumor.

*Question: The nurse notices that a client with trigeminal neuralgia has been withdrawn, is having frequent episodes of crying, and is sleeping excessively. Which method is the best way for the nurse to explore issues with the client regarding these behaviors?*

*Answer: Have the client express the feelings in writing.* Rationale: Speaking can exacerbate the pain that occurs with trigeminal neuralgia. Having the client record feelings in writing will help the nurse gain an understanding of the client's concerns without increasing the client's pain. Discussing the issue with the family will not provide insight into the client's feelings. It is not in the client's best interest to refer the matter to the primary health care provider or to ignore the behavior. The nurse should explore the client's concerns and offer support.

*Question: A client enters the urgent care center with epistaxis but no obvious facial injury. The nurse would take which action?*

*Answer: Have the client sit down, lean forward, and apply pressure to the nose.* Rationale: Sitting the client with the head forward and with pressure applied to the nose is the most effective way to initially control bleeding. Treatment is always directed at a conservative measure first. Placing the client in the semi-Fowler's position causes the client to swallow blood. Preparing a nasal balloon for insertion is invasive and used only when all other efforts have failed. Biting on a tongue blade does not cause cessation of nasal bleeding.

*Question: A client with known coronary artery disease (CAD) begins to experience chest pain while getting out of bed. The nurse would take which action?*

*Answer: Have the client stop and lie back down in bed.* Rationale: The pain associated with coronary artery disease is called angina pectoris, and it occurs because of myocardial tissue ischemia from insufficient blood flow to the heart. The nurse should first have the client stop the activity and lie back down to decrease the workload and oxygen demand on the heart. Getting a prescription for pain medicine and reporting the complaint to the health care provider can be done after ensuring that the client is resting. The pain medication that is likely to be prescribed is nitroglycerin, which is a coronary vasodilator. Having the client continue to get out of bed and into a chair is contraindicated and will worsen the pain and possibly lead to myocardial infarction.

*Question: The nurse is caring for a client with coronary artery disease, and a topical nitrate is prescribed for the client. Why is acetaminophen usually prescribed to be taken before the administration of the topical nitrate?*

*Answer: Headache is a common side effect of nitrates.* Rationale: Headache occurs as a side effect of nitrates. Acetaminophen may be given before nitrates to prevent headaches or to minimize the discomfort from the headaches. Option 2 is incorrect. Options 3 and 4 are unrelated to the data in the question.

*Question: The nurse notes that a client is being treated with nesiritide. The nurse would expect this client to be experiencing which disorder?*

*Answer: Heart failure* Rationale: Nesiritide is a synthetic form of human B-type natriuretic peptide (BNP) indicated only for short-term, intravenous therapy of hospitalized clients with acutely decompensated heart failure. It is not used for polycythemia, hepatic failure, or myocardial infarction.

*Question: The nurse is planning for the nursery room admission of a large-for-gestational-age (LGA) infant. In getting ready to care for this infant, the nurse prepares equipment for which diagnostic test?*

*Answer: Heel stick blood glucose* Rationale: After birth, the most common problem in the LGA infant is hypoglycemia, especially if the mother has diabetes mellitus. At delivery when the umbilical cord is clamped and cut, the maternal blood glucose supply is lost. The newborn continues to produce large amounts of insulin, which depletes the infant's blood glucose within the first hours after birth. If immediate identification and treatment of hypoglycemia are not performed, the newborn may suffer central nervous system damage because of inadequate circulation of glucose to the brain. Indirect and direct bilirubin levels are usually prescribed after the first 24 hours because jaundice is usually seen at 48 to 72 hours after birth. There is no rationale for prescribing an Rh and ABO blood type unless the maternal blood type is O or Rh negative. Serum insulin levels are not helpful because there is no intervention to decrease these levels in order to prevent hypoglycemia.

*Question: The nurse is assisting in admitting a client with schizophrenia to an acute-care inpatient psychiatric unit from the emergency department; however, the client refuses admission. Which intervention would the nurse implement?*

*Answer: Help the client with problem-solving.* Rationale: Unless the client is declared incompetent or dangerous, the nurse assists the client with problem-solving. This action will engage the client in the plan of care in the hope that the continued conversation will delay the client's departure and shift thought processes to a plan for health and well-being and a functional life. A schizophrenic client is likely to have altered thought processes and thus have irrational plans or be unable to plan without assistance as in option 1. In options 3 and 4 the nurse avoids blocking exits and promotes security devices, respectively, which can be interpreted as false imprisonment or assault because, as the client advocate, the nurse knows that a client has the right to self-determination.

*Question: A client diagnosed with pernicious anemia asks the nurse what caused the deficiency. The nurse replies that it is most likely a result of which condition that is part of the client's health history?*

*Answer: Hemigastrectomy* Rationale: The client who has had surgical resection of the stomach or small intestine may develop pernicious anemia as a complication. This results from decreased production of intrinsic factor (gastrectomy) or decreased surface area for vitamin B12 absorption (intestinal resection). The client then requires vitamin B12 injections for life. Decreased iron intake leads to iron deficiency anemia, which is often easily treated with iron supplements. Excessive vitamin C intake and hypothyroidism are unrelated to pernicious anemia.

*Question: The nurse is interpreting the laboratory results of a client who has a history of diagnosed chronic ulcerative colitis. The nurse would determine that which result indicates a complication of ulcerative colitis?*

*Answer: Hemoglobin 10.2 g/dL* Rationale: A normal hemoglobin level ranges from 12 to 16 g/dL. The client with ulcerative colitis is most likely anemic because of chronic blood loss in small amounts with exacerbations of the disease. These clients often have bloody stools and are at increased risk for anemia. The other laboratory results are within a normal range.

*Question: The nurse analyzes the results of laboratory studies performed on a client with diagnosed peptic ulcer disease (PUD). Which laboratory value would most indicate a complication associated with the disease?*

*Answer: Hemoglobin 10.2 g/dL* Rationale: The most common complications of peptic ulcer disease are hemorrhage, perforation, pyloric obstruction, and intractable disease. A low hemoglobin and hematocrit level indicate bleeding. The normal hemoglobin range in females is 12 to 16 g/dL and in males is 14 to 18 g/dL. A white blood cell count is performed to indicate the presence of infection or inflammation. The normal white blood cell count is 5000 to 10,000 mm3. The normal platelet range is 150,000 to 400,000 mm3. The creatinine measures renal function. The normal value is 0.6 to 1.3 mg/dL.

*Question: The nurse is caring for a client receiving chemotherapy and determines that the client has developed myelosuppression. Which laboratory value would support the client's diagnosis of myelosuppression?*

*Answer: Hemoglobin 9.4 g/dL, hematocrit 26%* Rationale: The client has been diagnosed with myelosuppression, which is bone marrow depression. The correct option is the hemoglobin and hematocrit, which is decreased. Hemoglobin is the main component of erythrocytes. Hematocrit represents red blood cell mass and is an important measurement in the identification of blood abnormalities. Red blood cells are produced in the bone marrow. BUN and creatinine address renal function. Protein levels address the amount of albumin in serum and low levels reflect decreased functioning by the liver and/or poor protein intake. These other laboratory values are within normal range.

*Question: In planning nutrition for the client with hypoparathyroidism, which diet would be appropriate?*

*Answer: High in calcium and low phosphorous* Rationale: Hypocalcemia is the end result of hypoparathyroidism resulting from either a lack of parathyroid hormone (PTH) secretion or ineffective PTH influence on tissue. Calcium is the major controlling factor of PTH secretion. Because of this, the diet needs to be high in calcium but low in phosphorus because these two electrolytes must exist in inverse proportions in the body. The other options are not dietary interventions with hypoparathyroidism.

*Question: The nurse is caring for the client diagnosed with tuberculosis (TB). Which finding made by the nurse would be inconsistent with the usual clinical presentation of tuberculosis?*

*Answer: High-grade fever* Rationale: The client with TB usually experiences cough (either productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweating (which may occur at night), and a low-grade fever.

*Question: A client with suspected Guillain-Barré syndrome has a lumbar puncture performed. The cerebrospinal fluid (CSF) protein is 750 mg/dL. The nurse analyzes these results as which?*

*Answer: Higher than normal, supporting the diagnosis of Guillain-Barré* Rationale: Seven to 10 days following the onset of symptoms of Guillain-Barré, the spinal fluid protein levels become extremely high. Normal CSF protein is 15 to 45 mg/dL. A value of 750 mg/dL is higher than normal, supporting the diagnosis of Guillain-Barré.

*Question: The client complains of stomach pain 30 minutes to 1 hour after eating. The pain is not relieved by further intake of food, although it is relieved by vomiting, and a gastric ulcer is suspected. The nurse would gather which additional data from the client to support this diagnosis?*

*Answer: History of alcohol use, smoking, and weight loss* Rationale: Alcohol use, smoking, and weight loss are most commonly associated with gastric ulcers. The other options do not identify risk factors commonly associated with this disorder. Frequent "heartburn" with a sour taste in the mouth may be seen in gastroesophageal reflux disease.

*Question: The nurse is assigned to care for a client who has returned to the nursing unit following a left nephrectomy. The nurse places the highest priority on monitoring which data?*

*Answer: Hourly urine output* Rationale: Following a nephrectomy, it is imperative to measure the urine output hourly. This is done to monitor the function of the remaining kidney and to detect renal failure early if it occurs. The client may also experience significant pain after this surgery, which could affect the client's ability to reposition, cough, and deep breathe. Therefore, the next most important measurements are vital signs (including oxygen saturation), pain level, and bed mobility. Clear liquids are not given until the client has bowel sounds, which are not referred to in this question.

*Question: A client newly diagnosed with diabetes mellitus takes NPH insulin every day at 7:00 am. The nurse has taught the client how to recognize the signs of hypoglycemia. The nurse determines that the client understands the information presented if the client watches for which signs and symptoms in the late afternoon?*

*Answer: Hunger; shakiness; and cool, clammy skin* Rationale: The client taking NPH insulin obtains peak medication effects approximately 6 to 12 hours after administration. At the time that the medication peaks, the client is at risk of hypoglycemia if food intake is insufficient. The nurse should teach the client to watch for signs and symptoms of hypoglycemia including anxiety, confusion, difficulty concentrating, blurred vision, cold sweating, headache, increased pulse, shakiness, and hunger. The other options list various signs and symptoms of hyperglycemia.

*Question: A client with chlamydial infection has received instructions on self-care and prevention of further infection. The nurse determines that the client needs further teaching if the client states which?*

*Answer: I will use an antibiotic prophylactically to prevent symptoms of Chlamydia.* Rationale: Antibiotics are not taken prophylactically to prevent acquisition of urethritis from Chlamydia. The risk of reinfection can be reduced by limiting the number of sexual partners and by the use of condoms. In some instances, follow-up culture is requested in 4 to 7 days to confirm a cure.

*Question: Which condition places the client at risk for developing acute postrenal failure?*

*Answer: Hydronephrosis* Rationale: Postrenal failure is caused by an obstruction in the urinary tract anywhere from the tubules to the urethral meatus. Some causes of obstruction include calculi, tumors, prostatic hypertrophy, or strictures that impede the normal flow of urine. This causes the renal pelvis and calices to become distended (hydronephrosis). Urine production continues, and the urine becomes trapped because of the obstruction. The accumulating urine exerts pressure on the renal pelvis, and this pressure can destroy the nephrons in the kidney. This type of renal failure is called "postrenal." Dehydration places the client at risk for acute prerenal failure because the kidneys are not being perfused. Other causes of prerenal failure include shock, decreased cardiac output, and hypotension. Rhabdomyolysis and glomerulonephritis place the client at risk for intrarenal failure.

*Question: The client with diabetes mellitus receiving peritoneal dialysis asks the nurse why it is important to leave the dialysate infused only for a specific amount of time. The nurse responds that not adhering to the dwell time can increase the risk of the client experiencing which complication?*

*Answer: Hyperglycemia* Rationale: Dialysate contains glucose, which helps remove fluids through an osmotic gradient. An extended dwell time increases the risk of hyperglycemia in diabetic clients as a result of the absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin during peritoneal dialysis. Options 1, 2, and 4 are not associated specifically with dwell time.

*Question: The nurse is assigned to care for a group of clients on the clinical nursing unit. Which client is least likely to develop third spacing of fluids?*

*Answer: Hypertension* Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as "third-space fluid." This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third spacing include body tissues, the pleural and peritoneal cavities and the pericardial sac. In clients with severe burns, fluid shifts out to the tissues in the area of the burn as sometimes evidenced by blistering. In clients with renal failure, there is a loss of protein due to failure of the kidney to retain protein, and fluid shifts from the blood out into the tissues causing the client to have edema in extremities and face. In Laënnec's cirrhosis the liver becomes fibrotic because of insufficient protein intake, alcoholism, and other conditions. The liver normally produces protein as albumin. With the loss of sufficient levels of albumin in clients with cirrhosis, the fluid shifts out into the abdomen (ascites) or tissu

*Question: The nurse is admitting a client with chronic kidney disease (CKD) to the nursing unit. The nurse monitors the client for which frequent cardiovascular sign that occurs in CKD?*

*Answer: Hypertension* Rationale: Hypertension is the most common cardiovascular finding in the client with CKD. It is a result of a number of mechanisms including volume overload, renin-angiotensin system stimulation, vasoconstriction from sympathetic stimulation, and absence of prostaglandins. Hypertension may also be the cause of the renal failure. It is an important item to assess because hypertension can lead to heart failure in the CKD client because of increased cardiac workload in conjunction with fluid overload.

*Question: The nurse is caring for an adult client with respiratory distress syndrome. A review of the arterial blood gas results indicates that the client is experiencing respiratory alkalosis. The nurse would then examine the results of serum electrolytes to see whether which electrolyte imbalance is present?*

*Answer: Hypokalemia* Rationale: Signs and symptoms of respiratory alkalosis include a decrease in the respiratory rate and depth, headache, lightheadedness, vertigo, mental status changes, paresthesias such as tingling of the fingers and toes, hypokalemia, hypocalcemia, tetany, and seizures. Signs and symptoms do not include hyponatremia, hypercalcemia, or hyperkalemia.

*Question: The nurse suspects neurogenic shock in a client with complete transection of the spinal cord at the T3 (thoracic 3) level if which clinical symptoms are observed?*

*Answer: Hypotension and bradycardia* Rationale: Spinal cord transection at the T5 level or above may lead to neurogenic shock. This injury results in massive vasodilation without compensation because of the loss of sympathetic nervous system vasoconstrictor tone. As a result, hypotension and bradycardia will be manifested. Hypertension with either bradycardia or tachycardia would not be exhibited.

*Question: A client has just completed an information session about measures to minimize the progression of coronary artery disease (CAD). Which statement indicates an initial understanding of lifestyle alterations?*

*Answer: I should eat a diet that is low in fat and cholesterol.* Rationale: A diet that is low in fat and cholesterol helps slow the progression of CAD. This must be accompanied by regular exercise and cessation of smoking. If these measures are effective, the client may not need daily medication.

*Question: The nurse is reinforcing dietary instructions for a client diagnosed with peptic ulcer disease. Which statement made by the client indicates a need for further teaching?*

*Answer: I will eat a bland diet only.* Rationale: A bland diet is unnecessary. The client should not skip meals, but tea and coffee should be avoided because they cause an increase in acid production. Spicy foods should be discontinued if they cause pain.

*Question: The nurse is reinforcing preprocedure instructions to a client scheduled for a barium swallow at 8.00 am. Which statement by the client indicates a need for further teaching?*

*Answer: I will limit myself to two cigarettes only on the morning of the test.* Rationale: Smoking increases mucous and acid production and can interfere with the test. The stomach should be empty at the time of a barium swallow because food and medications can interfere with test results. For this reason, all foods, liquids, medication, and smoking are avoided for 8 hours before the test.

*Question: The nurse is reviewing the medication record of a client with a diagnosis of acute gastritis. Which medication noted on the client's record would the nurse most likely question?*

*Answer: Ibuprofen* Rationale: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) and can cause ulceration of the esophagus, stomach, duodenum, or small intestine. It is contraindicated in a client with a gastrointestinal disorder. Furosemide is a loop diuretic. Digoxin is an antidysrhythmic. Propranolol hydrochloride is a beta-adrenergic blocker. Furosemide, digoxin, and propranolol hydrochloride are not contraindicated in clients with gastric disorders.

*Question: A client is diagnosed with hyperparathyroidism. The nurse teaching the client about dietary alterations to manage the disorder tells the client to limit which food in the diet?*

*Answer: Ice cream* Rationale: The client with hyperparathyroidism is likely to have elevated calcium levels. This client should reduce intake of dairy products such as milk, cheese, ice cream, or yogurt. Apples, bananas, chicken, oatmeal, and pasta are low-calcium foods.

*Question: The nurse is preparing a session regarding nutrition for a group of culturally diverse pregnant women. The nurse determines that the priority nursing intervention includes which action?*

*Answer: Identify the cultural food preferences of each client.* Rationale: The priority nursing intervention is to identify the cultural food preferences of each client. This information is needed in order to adequately provide information regarding appropriate nutrition. The socioeconomic status may be an important component, particularly when the nurse is determining whether a client's financial situation permits the purchase of appropriate food items. A baseline weight also may be important. Encouraging appropriate nutrition and the need to avoid fast-food restaurants is also important. However, an adequate nutritional plan can be formulated only if cultural food preferences are identified.

*Question: The nurse is working with a client diagnosed with anorexia nervosa. As the nurse plans care, which would be focused on as the primary problem?*

*Answer: Impaired nutritional status* Rationale: A client with anorexia nervosa has a decreased appetite, which can be a result of any number of causes. The plan of care primarily focuses on the risk of impaired nutritional status. The other options listed may or may not be associated with this client's diagnosis.

*Question: To assess for the presence of the posterior tibialis pulse, the nurse would palpate which areas?*

*Answer: In the groove behind the medial malleolus and the Achilles tendon* Rationale: The posterior tibialis pulse can be located in the groove behind the medial malleolus or the inside of the ankle behind the bone. The femoral pulse is palpated just below the inguinal ligament halfway between the pubis and anterior superior iliac spine. Popliteal pulses, although difficult to palpate, may be felt behind the knee in the popliteal fossa. The dorsalis pedis pulse is located on the top of the foot.

*Question: The nurse is reinforcing home care instructions to a client following a fenestration procedure for the treatment of otosclerosis. Which instruction would the nurse give the client?*

*Answer: Increase fluids and take a stool softener daily.* Rationale: Following ear surgery, clients need to avoid straining when having a bowel movement. Clients need to be instructed to avoid drinking with a straw for 2 to 3 weeks, avoid air travel, and avoid coughing excessively. Clients need to avoid getting their head wet, washing their hair, and showering for 1 week. Swimming is also avoided. Clients need to avoid rapidly moving the head, bouncing, and bending over for 3 weeks.

*Question: During the emergent phase after a major burn injury, which abnormalities would the nurse expect to note?*

*Answer: Increased hematocrit and increased potassium* Rationale: During the emergent phase of a burn injury, the client's hemoglobin and hematocrit will be elevated because of fluid loss. Sodium will be decreased because of trapping in edema fluid and loss through plasma leakage. Potassium will be increased because of disruption of the sodium-potassium pump, tissue destruction, and red blood cell hemolysis, and albumin will be low because of loss through the wound and increased capillary permeability.

*Question: The nurse is monitoring a client who is receiving a dose of an adrenergic bronchodilator. The nurse plans to monitor for which side effect of this medication?*

*Answer: Increased pulse and blood pressure* Rationale: Side effects of an adrenergic bronchodilator can include tachycardia, hypertension, chest pain, dysrhythmias, nervousness, restlessness, and headache, among others. The nurse monitors for these effects during therapy. Options 1, 2, and 3 are not side effects.

*Question: A client wishes to donate blood for a family member and asks the nurse about the procedure for identifying compatibility. The nurse tells the client that which test will be done to test compatibility?*

*Answer: Indirect Coombs* Rationale: The indirect Coombs test detects circulating antibodies against red blood cells (RBCs) and is the "screening" component of the prescription to "type and screen" a client's blood. This test is used in addition to the ABO typing, which is normally done to determine blood type. The direct Coombs test is used to detect idiopathic hemolytic anemia, by detecting the presence of autoantibodies against the client's RBCs. Eosinophil and monocyte counts are part of a complete blood count, a routine hematological screening test. A red blood cell count is also part of a complete blood count and determines the number of circulating red blood cells but does not determine compatibility.

*Question: A client is seen in the health care clinic for complaints of vaginal bleeding and mild abdominal cramping. On further data collection, the nurse notes that the client's last menstrual period was 10 weeks ago. The client reports that a home pregnancy test was performed and the results were positive. On physical examination, it is noted that the client has a dilated cervix. The nurse understands that the client is at risk for which type of abortion?*

*Answer: Inevitable* Rationale: An inevitable abortion is a termination of pregnancy that cannot be prevented. Moderate to severe bleeding with mild abdominal cramping and cervical dilation is present. An incomplete abortion presents with heavy bleeding, severe cramping, cervical dilation, and passage of large clots. A threatened abortion presents with slight to moderate bleeding and intermittent cramping, but no dilation. A septic abortion presents with bleeding with odor, cervical dilation, and fever. Cramping may be present.

*Question: A surgeon is performing an abdominal hysterectomy. Before the surgery is completed, the operating room nurse counts the sponges and notes that the sponge count is not correlating with the preoperative count. Which action by the nurse is important?*

*Answer: Informing the surgeon of the situation* Rationale: The surgeon has the ultimate responsibility for the safety of the client and can stop the surgery until the sponge is found. Although documenting is necessary, this is not the most important action. Although options 3 and 4 may be appropriate, the surgeon needs to be informed about the missing sponge.

*Question: A client seeks medical attention for intermittent episodes in which the fingers of both hands become cold, pale, and numb. The client states that they then become reddened and swollen with a throbbing, achy pain and Raynaud's disease is diagnosed. Which factor would precipitate these episodes?*

*Answer: Ingestion of coffee or chocolate* Rationale: Raynaud's disease is a bilateral form of intermittent arteriolar spasm, which can be classified as obstructive or vasospastic. Episodes are characterized by pallor, cold, numbness, and possible cyanosis followed by erythema, tingling, and aching pain in the fingers. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress.

*Question: The client with peptic ulcer disease has been prescribed to take cimetidine. The nurse determines that which is the primary action of this medication?*

*Answer: Inhibits histamine action* Rationale: Cimetidine is a histamine antagonist and works by inhibiting histamine action. Option 1 describes antibiotics, respectively. Option 2 describes antacids. Option 3 describes cytoprotective agents.

*Question: The nurse is reviewing the procedure for vitamin K injection in the newborn with a nursing student. Which information would the nurse provide to the student?*

*Answer: Inject into skin that has been cleansed with alcohol.* Rationale: Vitamin K is given in the middle third of the vastus lateralis muscle using a 25-gauge, ½-inch needle. It is injected into skin that has been cleansed with alcohol and allowed to dry for 1 minute; this removes organisms and prevents infection. It is administered at a 90-degree angle. The site is massaged after removing the needle to increase absorption of the medication.

*Question: The nurse is preparing to administer an acetaminophen suppository to a child. The nurse plans which action?*

*Answer: Insert the suppository 1 to 2 cm into the rectum.* Rationale: When administering a suppository to a child, the child should be positioned on the left side with the right leg flexed. The child should be asked to take a deep breath (not hold the breath) to further relax the sphincter. The suppository is gently inserted past the internal sphincter; the distance required to place the medication is approximately 1 to 2 cm. After insertion, the buttocks should be held together until the urge to expel the suppository has passed.

*Question: The nurse is planning care for a client with Bell's palsy. Which measure would be included in the plan?*

*Answer: Instill artificial tears and wear a patch over the affected eye at night.* Rationale: Instilling artificial tears and patching the affected eye at night protects the eye from corneal abrasions. Warm packs, not cold, will alleviate discomfort. Wearing dark glasses is recommended, as is gentle massage of the affected side.

*Question: The nurse is preparing to irrigate a client's sigmoid colostomy. The nurse would plan for which intervention to perform this procedure?*

*Answer: Instilling 500 to 1000 mL of lukewarm tap water through the stoma* Rationale: Clients with sigmoid colostomies may require irrigation of the stoma to promote regular colon emptying. Irrigation is performed by instilling 500 to 1000 mL of lukewarm tap water through the stoma and then allowing the irrigation solution and stool to drain into a collection bag. The nurse hangs the irrigation solution so that the bottom of the bag is level with the client's shoulder. The nurse inserts the irrigation tube without force into the stoma and unclamps the tubing to allow the solution to flow into the stoma. The nurse would clamp the tubing if cramping occurs and then resume the instillation as tolerated.

*Question: After attending the same social function 5 days ago, 50 individuals arrive at the hospital over a 4-day period with fever; an itchy, reddish brown papule; and complaints of nausea, vomiting, and severe abdominal pain. Cutaneous anthrax is suspected by the health care team. Which is the nurse's priority for client care?*

*Answer: Institute contact precautions.* Rationale: The clients present with clinical indicators consistent with cutaneous anthrax. This form of anthrax is highly contagious, and the nurse must institute contact precautions because Bacillus anthracis is transmitted by direct contact, flies, and fomites (option 2). Once contact precautions are in place, the remaining treatment should commence immediately because delayed treatment increases the risk of mortality. Anthrax vaccine may be administered to clients with cutaneous anthrax (option 4) because this form of anthrax does not confer acquired immunity and because the toxins potentially released from B. anthracis can be lethal. Ciprofloxacin is the medication of choice for anthrax infection and pharmacotherapy can last for 60 days (option 1). Frequent vital signs are needed for early detection of shock (option 3).

*Question: The nurse is planning care for a client whose oxygenation is being monitored by a pulse oximeter. Which intervention is important to ensure accurate monitoring of the client's oxygenation status?*

*Answer: Instruct the client not to move the sensor.* Rationale: The pulse oximeter passes a beam of light through the tissue, and a sensor attached to the fingertip, toe, or earlobe measures the amount of light absorbed by the oxygen-saturated hemoglobin. The oximeter then gives a reading of the percentage of hemoglobin that is saturated with oxygen (Sao2). Motion at the sensor site changes light absorption. The motion mimics the pulsatile motion of blood, and because the detector cannot distinguish between movement of blood and movement of the finger, results can be inaccurate. The sensor should not be placed distal to blood pressure cuffs, pressure dressings, arterial lines, or any invasive catheters. The sensor should not be taped to the client's finger. If values fall below preset norms (usually 90%), the client should be instructed to deep breathe if this is appropriate.

*Question: While assessing a client who is admitted to the hospital with a diagnosis of pleurisy, the nurse would note which characteristic symptom of this disorder?*

*Answer: Knifelike pain that worsens on inspiration* Rationale: A typical symptom with pleurisy is a knifelike pain that worsens on inspiration. This is a result of the friction caused by the rubbing together of inflamed pleural surfaces. This pain usually disappears when the breath is held because these surfaces stop moving. The client does not experience early morning fatigue or dyspnea relieved by lying flat.

*Question: A client with chronic obstructive pulmonary disease (COPD) on bed rest is weaned from the ventilator before transferring to a medical unit. To adequately restore client strength before getting the client out of bed, which is the priority client activity for the nurse to incorporate in the plan of care?*

*Answer: Instruct the client to reposition himself.* Rationale: Therapy for COPD usually includes glucocorticoids that carry a high risk of complications such as muscle and bone wasting, fragile skin, impaired immune functioning, and fluid retention, so the nurse must restore some client strength before attempting to get the client out of the bed. Because the client is likely to be weak from bed rest and lack of activity during mechanical ventilation and treatment, the nurse establishes outcomes for the client including restoration of pulmonary, cardiovascular, and musculoskeletal functioning to return to baseline functioning. To begin safely, the nurse instructs the client to reposition himself in bed to exert force on muscles and bones helping to reverse the tissue loss incurred during bed rest. The nurse initially positions a client with COPD at 45 degrees or higher until the client can tolerate a lower position and still maintain adequate oxygenation. Self-repositioning can be fol

*Question: A client in a long-term care facility who has a history of angina pectoris wants to go for a short walk outside with a family member. It is a sunny but chilly December day. The nurse would perform which intervention to care for this client in a holistic manner?*

*Answer: Instruct the family member to dress the client warmly before going outside.* Rationale: The nurse should meet both the physiological and psychosocial needs of the client in a holistic manner by asking the family member to be sure that the client is dressed warmly before going outside. Option 4 is correct because dressing the client warmly will decrease the chance of vasoconstriction, which may lead to an angina attack. Options 1 and 2 ignore the psychosocial needs. Option 3 is detrimental to physiological needs because, in addition to the cold weather, caffeine places an additional burden on the heart.

*Question: The nurse is reinforcing discharge instructions to a client who had a unilateral adrenalectomy. Which information would be a component of the instructions?*

*Answer: Instructions about early signs of a wound infection* Rationale: A client who is undergoing a unilateral adrenalectomy will be placed on corticosteroids temporarily to avoid a cortisol deficiency. These medications will be gradually weaned in the postoperative period until they are discontinued. Because of the anti-inflammatory properties of corticosteroids, clients who undergo an adrenalectomy are at increased risk for developing wound infections. Because of this increased risk for infection, it is important for the client to know measures to prevent infection, early signs of infection, and what to do if an infection is present. Maintaining a diabetic diet, application of an ostomy pouch, and lifelong replacement of all adrenal hormones are incorrect instructions.

*Question: The nurse is reinforcing instructions to a client regarding the administration of lypressin. The nurse instructs the client that the medication will be taken by which routes?*

*Answer: Intranasal* Rationale: Lypressin is administered by the intranasal route. It is used for diabetes insipidus. The usual adult dosage is 1 or 2 sprays into each nostril 4 times daily. Options 1, 3, and 4 are incorrect.

*Question: The nurse has given simple instructions on preventing some of the complications of bed rest to a client who experienced a myocardial infarction. The nurse would intervene if the client were performing which of these contraindicated activities?*

*Answer: Isometric exercises of the arms and legs* Rationale: The client with myocardial infarction should avoid activities that tense the muscles, such as isometric exercises. These increase intra-abdominal and intrathoracic pressures and can decrease the cardiac output. They also can trigger vagal stimulation causing bradycardia. Deep breathing and coughing, repositioning self from side to side, and ankle circles, plantar, and dorsiflexion exercises are acceptable.

*Question: A pregnant woman reports to the health care clinic complaining of loss of appetite, weight loss, and fatigue. Following an assessment, tuberculosis is suspected. A sputum culture is obtained and identifies the Mycobacterium tuberculosis in the sputum. The nurse reinforces instructions to the client regarding therapeutic management of tuberculosis. Which statement is included in therapeutic management?*

*Answer: Isoniazid plus rifampin will be required for a total of 9 months.* Rationale: More than one medication may be used to prevent growth of resistant organisms in the pregnant woman with tuberculosis. Treatment must continue for a prolonged time. The preferred treatment for the pregnant woman is daily isoniazid plus rifampin for a total of 9 months. Ethambutol is also added initially if drug resistance is suspected. Pyridoxine (vitamin B6) is often administered with isoniazid to prevent fetal neurotoxicity. The infant will be tested at birth and may be started on preventive isoniazid therapy. Skin testing should be repeated at 3 months on the infant, and isoniazid may be stopped if the skin test result remains negative. If the skin test result converts to positive, a full course of isoniazid should be given.

*Question: The nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately?*

*Answer: It helps to avoid medication errors.* Rationale: Medication reconciliation is an organized process to avoid medication errors; it compares the client's medication prescriptions to all of the medications that the client has been taking. Primary health care providers must review this list and prescribe appropriate medications. This process is neither used to educate clients and families of the adverse or side effects of current medications nor to determine if the client's insurance will pay the cost of the medications. Notifying the pharmacy of what medications the client is taking while in the hospital and screening for allergies are not specific purposes of the medication reconciliation process.

*Question: The nurse is reinforcing medication instructions to a client who has been prescribed simvastatin. Which is the action of simvastatin?*

*Answer: It inhibits hepatic synthesis of cholesterol.* Rationale: The process of cholesterol reduction begins with inhibition of hepatic HMG-CoA reductase, the rate-limiting enzyme in cholesterol biosynthesis. In response to decreased cholesterol production, hepatocytes synthesize more HMG-CoA reductase. As a result, cholesterol synthesis is restored. However, for reasons that are not fully understood, inhibition of cholesterol synthesis causes hepatocytes to synthesize more low-density lipoproteins (LDL) receptors. Therefore, options 2, 3, and 4 are incorrect.

*Question: The nurse has reinforced postprocedure instructions to a client who has undergone a colonoscopy. The nurse determines that there is a need for further teaching if the client makes which statement?*

*Answer: It is all right to drive an hour after the test is finished.* Rationale: The client should not drive for several hours after this test because the client would have received sedative medications during the procedure. The client should arrange in advance for someone to drive the client home. The client should resume intake slowly and progress as tolerated. The client may experience gas or abdominal tenderness for a short while after the procedure, which is normal.

*Question: A mother brings her 3-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 0 mg/dL (0 mcmol/L). The nurse reviews this result and makes which interpretation?*

*Answer: It is negative.* Rationale: Phenylketonuria is a genetic (autosomal recessive) disorder that results in central nervous system damage from toxic levels of phenylalanine (an essential amino acid) in the blood. It is characterized by blood phenylalanine levels greater than 20 mg/dL (1210 mcmol/L). The normal level is 0 mg/dL to 2 mg/dL (0-121 mcmol/L). A result of 0 mg/dL is a negative test result.

*Question: The client is receiving a full-thickness graft to a burn on the hand. The nurse understands that a full-thickness graft is being applied instead of a split-thickness graft because of which reason?*

*Answer: It provides better cosmetic results.* Rationale: For very deep burns and burns of the face, neck, or hands, a full-thickness graft may be preferred. A full-thickness graft includes skin and subcutaneous tissue and provides better cosmetic results. Split-thickness grafts can be stretched to cover more area and allows for wound exudate to be absorbed by a dressing. Both thick-thickness and split-thickness grafts have to be immobilized for 3 to 7 days.

*Question: A pregnant client in the prenatal clinic states that her last menstrual period (LMP) began April 5 and ended April 12. According to Nägele's rule, which is the estimated date of delivery (EDD)?*

*Answer: January 12* Rationale: Nägele's's rule is a noninvasive method of calculating the EDD as follows: subtract 3 months, add 7 days to the first day of the LMP, and add 1 year as appropriate. This is based on the assumption that the cycle is 28 days. April 5 plus 7 days minus 3 months is January 12.

*Question: A client recently diagnosed with diabetes mellitus requiring insulin tells the clinic nurse that he is traveling by air throughout the next week. The client asks the nurse for any suggestions about managing the disorder while traveling. Which action would the nurse tell the client to do?*

*Answer: Keep snacks in carry-on luggage to prevent hypoglycemia during the flight.* Rationale: A frequent concern of diabetics during air travel is the availability of food at times that correspond with the timing and peak action of the client's insulin. For this reason, the nurse may suggest that the client have carbohydrate snacks on hand. Insulin equipment and supplies should always be placed in carry-on luggage (not checked). This provides ready access to treat hyperglycemia, if needed, and prevents loss of equipment if luggage is lost. Checking blood glucose every 2 hours during the flight and obtaining referrals to primary health care providers in destination cities are unnecessary.

*Question: The nurse is teaching a hospitalized client who has had aortoiliac bypass grafting about measures to improve circulation. The nurse would tell the client to do which?*

*Answer: Keep the ankles uncrossed.* Rationale: A graft can become clotted from any form of pressure that results in impaired blood flow through the graft. Positions and movements to be avoided include bending at the hip or knee, crossing the knees or ankles, or the use of a knee gatch or pillows under the knees.

*Question: The nurse reviews the nursing care plan developed by a nursing student caring for a client who is receiving continuous tube feedings via a nasogastric (NG) tube. The nurse intervenes if the student documents which intervention in the plan?*

*Answer: Keep the feeding bag filled with at least 100 mL of feeding continuously so that it does not run dry.* Rationale: The placement of an NG feeding tube is checked at least every 4 hours for residual during administration of continuous tube feedings. Placement is also checked before each bolus with intermittent feedings and before the administration of medications through the tube. The bag and tubing are completely changed every 24 hours or per agency protocol. The hanging bag should be rinsed before new formula is added to it. An excess amount of formula should not be allowed to sit in the feeding bag because of the potential for the growth of bacteria.

*Question: The nurse is reviewing the postoperative prescriptions for an infant with hydrocephalus, who came back from surgery with a ventriculoperitoneal shunt. Which of the primary health care provider's prescriptions does the nurse question?*

*Answer: Keep the head of the bed elevated 45 degrees.* Rationale: Postoperative management for infants with hydrocephalus who have undergone ventriculoperitoneal shunt should be flat in bed to avoid the rapid reduction of intracranial fluid. Observe for increased ICP, if it occurs elevate the head of the bed to 15 to 30 degrees to enhance gravity flow through the shunt. Position the infant on the inoperative side to prevent pressure on the shunt valve. Monitor for signs of infection and check dressings for drainage. A high shrill cry in an infant can be a sign of increased ICP.

*Question: The nurse is reinforcing instructions to a client about safety measures while using oxygen in the home. The nurse determines that there is a need for further teaching if the client verbalized which statement?*

*Answer: Keep the oxygen concentrator as close to the room wall as possible.* Rationale: The oxygen concentrator is kept slightly away from the walls and corners to permit adequate airflow. The use of electric razors or other equipment that could emit sparks should be avoided while oxygen is in use. This could result in fire and injury to the client. Therefore, a straight razor is used for shaving. The client should follow the oxygen prescription exactly and should not allow smoking or any type of flame within 10 feet of the oxygen source. Other measures include keeping the source out of direct sunlight; having telephone numbers for the primary health care provider, nurse, and oxygen vendor available; and teaching the client signs and symptoms requiring emergency care.

*Question: A client with a tentative diagnosis of gastroesophageal reflux disease (GERD) is going to undergo ambulatory pH monitoring. The nurse assists in the procedure and would bring which item to the bedside?*

*Answer: Nasogastric (NG) tube* Rationale: Ambulatory pH monitoring requires insertion of a nasogastric tube, often a small tube that has a probe attached to determine the pH continuously. The test does not involve using an enema bag, an intravenous access, or subcutaneous injection.

*Question: The nurse is caring for a client who had a small bowel resection the previous day and has continuous gastric suction attached to the nasogastric tube. Which intravenous solution would the nurse anticipate to be prescribed for the client?*

*Answer: Lactated Ringer's solution* Rationale: Electrolyte solutions such as lactated Ringer's are used to replace fluid from gastrointestinal (GI) tract losses. Albumin is used for shock and protein replacement; 5% dextrose in water contains only glucose and no electrolytes to replace gastrointestinal losses. Normal saline contains no glucose, and glucose is essential for calories when a client takes nothing by mouth (NPO).

*Question: The nurse is assigned to care for a client with a diagnosis of hepatic encephalopathy. Which prescribed medication would the nurse most anticipate administering?*

*Answer: Lactulose syrup* Rationale: Lactulose syrup is a hyperosmotic laxative agent that has the adjunct benefit of lowering serum ammonia levels. This occurs because the medication lowers bowel pH, which aids the conversion of ammonia in the gut to the ammonium ion, which is poorly absorbed. Magnesium hydroxide is a saline laxative; however, phenolphthalein is a stimulant laxative. Psyllium hydrophilic mucilloid is a bulk laxative.

*Question: The nurse would include which instruction in a teaching plan for a client who has been diagnosed with peptic ulcer disease?*

*Answer: Learn to use stress reduction techniques.* Rationale: Identifying and reducing stress are essential to a comprehensive ulcer management plan. The client should also limit intake of foods that aggravate pain, quit smoking, and avoid irritants such as NSAIDs. Antibiotic therapy is often prescribed to treat this disease.

*Question: A primary health care provider has ordered digital removal of stool for a constipated client. How would the nurse position the client for this procedure?*

*Answer: Left lateral Sims' position* Rationale: For digital removal of stool, the client would be placed in the left lateral Sims' position, as this follows the anatomical curvature of the colon. Options 1, 2 and 4 are not appropriate positions for this procedure.

*Question: A client is receiving radiation therapy to the brain because of a diagnosis of a brain tumor. Which sign/symptom of the client is noted to be a positive outcome of the radiation therapy?*

*Answer: Less severe headache* Rationale: Radiation therapy for a brain tumor will decrease a headache, a common symptom, and this is a desired or positive outcome. Since the intracranial pressure will decrease with the shrinkage of the tumor, the headache should lessen. Radiation therapy often causes symptoms of fatigue and altered taste sensation. Clients may also experience nausea and vomiting because of the effects of the radiation on the brain's chemoreceptor trigger zone.

*Question: A client newly diagnosed with diabetes mellitus is having difficulty learning the technique of blood glucose measurement. The nurse would teach the client to do which action to perform the procedure properly?*

*Answer: Let the arm hang dependently and milk the digit.* Rationale: Before doing a finger stick for blood glucose measurement, the client should first wash the hands. Warm water should be used to stimulate the circulation to the area. The finger is punctured near the side, not the center, because there are fewer nerve endings along the side of the finger. The puncture is only deep enough to obtain an adequately sized drop of blood; excessively deep punctures may lead to pain and bruising. The arm should be allowed to hang dependently, and the finger may be milked to promote obtaining a good-sized blood drop.

*Question: The nurse is reinforcing dietary instructions to a client diagnosed with acute glomerulonephritis. The nurse determines that the client understands the information presented if the client states the intention to do which action?*

*Answer: Limit protein intake.* Rationale: The diet for the client with acute glomerulonephritis is generally high in calories and low in protein. This diet inhibits protein catabolism and allows the kidneys to rest. In acute glomerulonephritis, it is important to protect the kidneys while they are recovering their function. Sodium also may be limited depending on the amount of edema present. No specific recommendations are made for fiber, potassium, or magnesium food types.

*Question: A pregnant client asks the prenatal clinic nurse what the fetal period of development means. Which is correct information about the fetal period?*

*Answer: Longest period of fetal development* Rationale: The fetal period is the longest part of prenatal development. It begins 9 weeks after conception and ends with birth. All major systems are present in their basic form. The pre-embryonic period is the first 2 weeks after conception. Around the fourth day after conception, the fertilized ovum, now called a zygote, enters the uterus. The embryonic period of development extends from the beginning of the third week through the eighth week after conception. Basic structures of all major body organs are completed during the embryonic period.

*Question: A client with an oral endotracheal tube attached to a mechanical ventilator is about to begin the weaning process. The nurse asks the primary health care provider whether this process would be delayed temporarily based on administration of which medication to the client in the last hour?*

*Answer: Lorazepam* Rationale: Antianxiety medications (such as lorazepam) and opioid analgesics are used cautiously or withheld whenever possible in the client being weaned from a mechanical ventilator. These medications may interfere with the weaning process by suppressing the respiratory drive. The other medications do not interfere with the respiratory drive and will not affect the weaning process.

*Question: A client has been diagnosed with hypoparathyroidism. Which food groups should be included in the diet?*

*Answer: Low in phosphorus and high in calcium* Rationale: Hypoparathyroidism results in hypocalcemia. A therapeutic diet for this disorder is one that is high in calcium but low in phosphorus because these two electrolytes have inverse proportions in the body. All of the other options are unrelated to this disorder and are incorrect.

*Question: The nurse is preparing to provide a therapeutic environment for a client who recently had a myocardial infarction (MI). Which are characteristics of a therapeutic environment?*

*Answer: Low stimulus, low stress* Rationale: An environment that is low stimulus and low stress is needed to decrease anxiety and metabolic demands for the client after MI. Nursing care is directed at promoting rest and assisting with activities of daily living. Option 1 cannot be provided, and options 3 and 4 are too high in stimulus to be therapeutic.

*Question: A client with infective endocarditis is at risk for heart failure. The nurse monitors the client for which signs and symptoms of heart failure?*

*Answer: Lung crackles, peripheral edema, and weight gain* Rationale: The client with infective endocarditis may experience both left- and right-sided heart failure, and thus the nurse monitors the client for both pulmonary and peripheral symptoms such as lung crackles, peripheral edema, and weight gain. Options 2 and 4 relate to disorders of the brain and kidney, respectively. Option 3 contains symptoms that occur with pulmonary embolism, which is not related to the subject of the question.

*Question: A woman diagnosed with type 1 diabetes mellitus is in labor. Based on the knowledge of insulin and diabetes and pregnancy, the nurse will be prepared to care for a newborn infant who is likely to have which complication?*

*Answer: Macrosomia* Rationale: Typically, infants of diabetic mothers are large for gestational age. Maternal glucose crosses over the placenta to the fetus. The fetus is able to produce its own insulin; therefore, excessive body growth (macrosomia) results from high maternal glucose. After birth, hypoglycemia may be a problem because the infant's pancreas continues to produce large amounts of insulin (hyperinsulinemia), which quickly deplete the infant's glucose supply. Infants of diabetic mothers usually are delivered just before or at term because of an increased risk of ketoacidosis and intrauterine fetal death after 36 weeks. Polycythemia, not anemia, is commonly associated with infants of diabetic women.

*Question: The nurse is caring for a client within the first 24 hours following a total gastrectomy for gastric cancer. During this time frame, the nurse would focus on which priority intervention?*

*Answer: Maintaining a patent nasogastric (NG) tube* Rationale: An NG tube is inserted during surgery and is left in place for 24 to 48 hours to decompress the gastrointestinal tract, which enhances sealing of the suture line. It is essential that the NG tube does not become occluded because this could disrupt the suture lines if distention occurs. The other options are also appropriate, but not within the first 24 hours following surgery.

*Question: The nurse is told that a prenatal client is at risk for placental abruption. The nurse expects to note which risk factor documented in the client's record?*

*Answer: Maternal hypertension* Rationale: Maternal hypertension is a risk factor associated with placental abruption. This factor leads to degenerative changes in the small arteries that supply the intervillous spaces of the placenta. This results in thrombosis, causing retroplacental hematoma and leading to placental separation. Oliguria, gestational diabetes, and hyperemesis gravidarum are not associated risk factors.

*Question: The nurse reinforces the teaching plan for a client with a family history of breast cancer. Which teaching point would be included?*

*Answer: Measures to prevent and screen for cancer* Rationale: Teaching reinforcement should include interventions that prevent and detect breast cancer at an early stage through screening. Monthly breast self-examination and a yearly examination by a health care professional are recommended for all adult women. It is especially important for those with a familial history of breast cancer to have a healthy lifestyle that includes a diet low in saturated fat and to maintain a healthy weight.

*Question: A client is being discharged with a prescription for propranolol. When reinforcing instructions to the client about the medication, the nurse would include which information?*

*Answer: Medication should be withheld if the pulse rate drops below 60 beats per minute.* Rationale: Most beta 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 because of their vasodilative effect. The client needs to be instructed how to take the pulse rate and to notify the health care provider if the heart rate falls below 60 beats per minute.

*Question: A client presents to the emergency department with lethargy; deep, regular respirations; and a fruity odor to the breath. The client's arterial blood gas (ABG) results are pH of 7.25, Pco2 of 34 mm Hg, Po2 of 86 mm Hg, and HCO3- of 14 mEq/L. The nurse interprets that the client has which acid-base disturbance?*

*Answer: Metabolic acidosis* Rationale: Acidosis is defined as a pH of less than 7.35, and alkalosis is defined as a pH greater than 7.45. Respiratory acidosis is present when the Pco2 is greater than 45, and respiratory alkalosis is present when the Pco2 is less than 35. Metabolic acidosis is present when the pH is less than 7.35 and the HCO3- is less than 22 mEq/L, whereas metabolic alkalosis is present when the pH is greater than 7.45 and the HCO3- is greater than 27 mEq/L. This client's ABGs are consistent with metabolic acidosis. With a slightly alkalotic level of carbon dioxide there is evidence of some incomplete compensation.

*Question: A client underwent creation of an ileostomy 2 days ago. The nurse checks the client for signs of which acid-base disorder that a client with an ileostomy is at risk for developing?*

*Answer: Metabolic acidosis* Rationale: Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. These fluids may be lost from the body before they can be reabsorbed with conditions such as diarrhea or creation of an ileostomy. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis. The client with an ileostomy is not at risk for developing the acid-base disorders such as respiratory alkalosis or acidosis or metabolic alkalosis.

*Question: A client has had a set of arterial blood gases drawn. The results are pH, 7.34; Paco2, 37 mm Hg; Pao2, 79 mm Hg; and HCO3,- 19 mEq/L. The nurse interprets that the client is experiencing which acid-base imbalance?*

*Answer: Metabolic acidosis* Rationale: Metabolic acidosis occurs when the pH falls below 7.35, and the bicarbonate level falls below 22 mEq/L. With respiratory acidosis, the pH drops below 7.35 and the carbon dioxide level rises above 45 mm Hg. With respiratory alkalosis, the pH rises above 7.45 and the carbon dioxide level falls below 35 mm Hg. With metabolic alkalosis, the pH rises above 7.45 and the bicarbonate level rises above 26 mEq/L.

*Question: The nurse is caring for a client in the emergency department who has right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse would question which prescription?*

*Answer: Milk of magnesia* Rationale: A client with right lower quadrant pain may have appendicitis. This client should be NPO and given IV fluids for hydration. Cold packs may provide comfort. Laxatives are not prescribed; therefore, the nurse should question this prescription.

*Question: A client with hypoparathyroidism has hypocalcemia. The nurse avoids giving the client the prescribed vitamin and calcium supplement with which liquid?*

*Answer: Milk* Rationale: Milk products are high in phosphates, which should be avoided by a client with hypoparathyroidism. Otherwise, calcium products are best absorbed with milk because the vitamin D in the milk promotes calcium absorption.

*Question: The nurse is planning to instruct a client with diabetes mellitus who has hypertension about "sick day management." Which beverage does the nurse avoid putting on a list of easily consumed carbohydrate-containing beverages for use when the client cannot tolerate food orally?*

*Answer: Mineral water* Rationale: Diabetic clients should take in approximately 15 g of carbohydrate every 1 to 2 hours when unable to tolerate food because of illness. Each of the beverages listed in options 1, 2, and 3 provides approximately 13 to 15 g of carbohydrate in a half-cup serving. Mineral water is incorrect for two reasons. First, it contains sodium and should not be used by the client with hypertension. Second, it is not a source of carbohydrates.

*Question: The nurse is reviewing the record of a client in the labor room. Which documented notation refers to the relationship of the presenting part to the maternal ischial spines?*

*Answer: Minus (-) 1 station* Rationale: Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line. Lie describes how the fetus is oriented to the mother's spine. Presentation refers to the fetal part that enters the pelvis first. Position refers to how a reference point on the fetal presenting part is oriented within the mother's pelvis.

*Question: The nurse reinforces instructions to the client prescribed to take cyclosporine oral solution. Which instruction would the nurse primarily include?*

*Answer: Mix the concentration with chocolate milk.* 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 can raise cyclosporine levels. The client is instructed to dispense the oral liquid into a glass container using a specially calibrated pipette; mix it well and drink it immediately; fill the container with a diluent such as water and drink it to ensure ingestion of the complete dose; dry the outside of the pipette and return to its cover for storage.

*Question: A 3-year-old child is brought to the emergency department. The mother states that the child has had flulike symptoms with vomiting and diarrhea for the past 2 days. On data collection the nurse finds that the child's heart rate is slightly elevated and the blood pressure is normal. The child is irritable and crying only a few tears. The mother states that the child's weight before the illness was 33 pounds. The nurse finds the current weight to be 31 pounds. The nurse correctly interp

*Answer: Moderate dehydration* Rationale: Moderate dehydration demonstrates itself with a weight loss in children of 6% to 8% of weight. Mild dehydration would not present with these symptoms. In severe dehydration, additional findings would include lethargy and listlessness. The symptoms listed are all characteristics of moderate dehydration. Very mild dehydration is not a term used to describe dehydration.

*Question: A pregnant client at 36 weeks' gestation experiences painless bleeding and is admitted to the labor room. In addition to maintaining complete bed rest, which other actions would the nurse include in the plan of care?*

*Answer: Monitor IV fluid intake and monitor the fetal heart rate.* Rationale: Initial nursing actions for care of a pregnant client with bleeding include maintaining complete bed rest (to reduce the chance for further bleeding), initiating and monitoring an IV (anticipating the need for fluid replacement), and monitoring the fetal heart rate (assessing the status of fetus). Food and fluid may or may not be restricted. Reducing stimuli is not a priority consideration. A vaginal exam is not appropriate because it may stimulate uterine contractions and increase bleeding.

*Question: The nurse is assisting in preparing a plan of care for a client who will be receiving a calcium antagonist to prevent preterm delivery. Which action does the nurse include in the plan of care for the client to detect a side effect of the medication?*

*Answer: Monitor for increases in maternal and fetal heart rates.* Rationale: Calcium is essential for muscle contraction in smooth muscles, such as the uterus, so blocking calcium reduces the muscular contraction. Flushing of the skin, headache, and a transient increase in the maternal and fetal heart rates are common side effects. These medications can vasodilate so the woman is at risk for orthostatic hypotension.

*Question: The nurse is preparing a plan of care to monitor for complications in a client who will be returning from the operating room following transsphenoidal resection of a pituitary adenoma. Which nursing intervention does the nurse document in the plan as a priority for this client?*

*Answer: Monitor urine output.* Rationale: The most common complication of surgery on the pituitary gland is temporary diabetes insipidus. This results from deficiency in antidiuretic hormone (ADH) secretion as a result of surgical trauma. The nurse measures the client's urine output to determine whether this complication is occurring. Options 1, 3, and 4 are also components of the plan, but option 2 clearly identifies the priority intervention for this type of surgery.

*Question: The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which action would the nurse take?*

*Answer: Monitor vital signs and discontinue attempts at suctioning until the client is stabilized.* Rationale: If a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm while suctioning, the nurse must discontinue suctioning attempts until the client is stabilized. It is also important to monitor vital signs and pulse oximetry and preoxygenate the client for any repeated suctioning attempts. If the client's condition continues to deteriorate, then the respiratory department and primary health care provider may need to be notified.

*Question: Which nursing measure would be effective in preventing complications in a client with Addison's disease?*

*Answer: Monitoring the blood glucose* Rationale: The decrease in cortisol secretion that characterizes Addison's disease can result in hypoglycemia. Therefore, monitoring the blood glucose would detect the presence of hypoglycemia so that it can be treated early to prevent complications. Fluid intake should be encouraged to compensate for dehydration. Potassium intake should be restricted because of hyperkalemia. Option 4 would not prevent complications for this client.

*Question: The nurse is discharging a client from the hospital who was given a prescription for atorvastatin. The nurse would tell the client to report which adverse effect to the primary health care provider immediately?*

*Answer: Muscle pain and weakness* Rationale: Atorvastatin can injure muscle tissue. The muscle injury can progress to myositis, which is muscle inflammation associated with moderate elevation of creatine kinase (CK), an enzyme released from injured muscle. Myositis, in turn, may progress to potentially fatal rhabdomyolysis, defined as muscle disintegration or dissolution associated with a marked elevation of CK and possibly with renal failure. Tiredness and fatigue and flushing and redness are not related to atorvastatin therapy. Muscle pain and weakness is an expected side effect.

*Question: The nurse is caring for a client with acute otitis media. The nurse plans care knowing which treatment for this problem is likely to be included?*

*Answer: Myringotomy* Rationale: Myringotomy is a surgical procedure that allows fluid to drain from the middle ear. Bed rest is not required, but activity may be restricted. The mastoid bone is removed or partially removed for chronic otitis media. Diphenhydramine is an antiemetic used to treat nausea and vomiting.

*Question: The nurse is assisting in monitoring a pregnant client receiving nalbuphine for pain management. Which statement is true with regard to the use of nalbuphine?*

*Answer: Nalbuphine is not likely to cause significant respiratory depression.* Rationale: Nalbuphine is an opioid agonist-antagonist analgesic. It provides adequate analgesia without causing significant respiratory depression in the mother or neonate. It is not suitable for women with an opioid dependence because the antagonist activity could precipitate withdrawal symptoms (abstinence syndrome) in the mother and her newborn.

*Question: The nurse is assisting in caring for a client who is receiving morphine sulfate by continuous intravenous infusion. The nurse ensures that which medication is readily available if a morphine overdose occurs?*

*Answer: Nalmefene* Rationale: Nalmefene is a long-acting antagonist that is used to treat opioid overdose. Naloxone is also used to treat opioid overdose. Atropine sulfate is an anticholinergic used in the treatment of cholinergic crisis. Protamine sulfate is the antidote for heparin therapy, and promethazine is an antiemetic.

*Question: A client is admitted to the emergency department with a diagnosis of drug-induced anxiety related to overingestion of his prescribed antipsychotic medication. Which important piece of information would the nurse obtain initially?*

*Answer: Name of the ingested medication and the amount ingested* Rationale: The name and the amount of medication ingested are of utmost importance in treating this potentially life-threatening situation. The relatives and the reason for the suicide attempt are not the most important initial data. The length of time on the medication and symptom control are also not priorities in this situation. In an emergency, lifesaving facts are obtained first.

*Question: The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. What would the nurse look for on the cardiac monitor as a result of this laboratory value?*

*Answer: Narrow, peaked T waves* Rationale: A serum potassium level of 5.4 mEq/L is indicative of hyperkalemia. Cardiac changes include a wide, flat P wave; a prolonged PR interval; a widened QRS complex; and narrow, peaked T waves.

*Question: Atropine sulfate is prescribed for the client diagnosed with gastrointestinal hypermotility, and the nurse reviews the client's record before administering the medication. Which finding, if noted on the client's record, most indicates the need to contact the primary health care provider before administering the medication?*

*Answer: Narrow-angle glaucoma* Rationale: Atropine sulfate can cause mydriasis (dilation of the pupil) and cycloplegia (relaxation of the ciliary muscles). It is contraindicated in clients with narrow-angle glaucoma. Options 1, 2, and 4 are all therapeutic reasons for using the medication.

*Question: A client with cancer is receiving daunorubicin intravenously. The nurse assigned to assist in caring for the client monitors for which commonly expected side effect?*

*Answer: Nausea and vomiting* Rationale: Daunorubicin is an antineoplastic medication. The major gastrointestinal (GI) side effects include nausea, vomiting, stomatitis, and esophagitis. Cardiovascular side effects include heart failure and dysrhythmias. Other frequently occurring side effects are alopecia and bone marrow depression. Hypertension, polycythemia (increased red blood cells), and hypovolemia are not side effects of daunorubicin.

*Question: The nurse administers medications to the wrong client. During the investigation of the incident, it was determined that the nurse failed to check the client's identification bracelet before administering the medications. The nursing supervisor evaluates the situation and determines that the nurse can be guilty of negligence because negligence is correctly characterized by which statement?*

*Answer: Negligence is defined as the failure to meet established standards of care.* Rationale: The legal definition of negligence is the failure to meet accepted standards of care. Option 3 is an incorrect definition of negligence, although injury may have indeed come to the client as a result of negligence. Both the institution and nurse practice acts have provisions that identify and discourage acts of negligence.

*Question: The nurse is monitoring a client for Biot's respirations. Which condition causes Biot's respirations?*

*Answer: Neurological disorders* Rationale: Biot's respirations are irregular respirations of varying depth and periods of apnea seen in neurological disorders. Emphysema causes obstructive breathing, rising end-expiratory level with forced rapid breathing. Renal failure can cause Kussmaul respirations, which are rapid and deep. Severe anxiety causes hyperventilation.

*Question: Clients who are given a prescription for sildenafil should be taught that a potentially fatal medication interaction can occur with which medication?*

*Answer: Nitroglycerin* Rationale: Both sildenafil and nitrates promote vasodilation and hypotension. If these medications are combined, life-threatening hypotension could result. Therefore, sildenafil is contraindicated for clients taking nitrates. At least 24 hours should elapse after the last dose of sildenafil before a nitrate is given. The medications in options 1, 3, and 4 are not contraindicated.

*Question: Which action would the nurse include in the plan of care for a client following a renal scan?*

*Answer: No special precautions are needed except to wear gloves if coming into contact with the client's urine.* Rationale: No specific precautions follow a renal scan. The nurse wears gloves to maintain standard precautions. The nurse does not need to limit time of contact with the client because only a very small amount of radioactive material is used in the test. Clients are not placed on radiation precautions, and saving the urine after the test is not part of the test.

*Question: A client with Crohn's disease is seen by the primary health care provider, and a complete blood count (CBC) has been prescribed. The nurse reinforces instructions to the client who will be reporting to the laboratory in the morning to have the blood test drawn. The nurse gives the client which information about this test?*

*Answer: No special preparation is necessary.* Rationale: For most hematological laboratory studies, including a CBC, there is no special care needed either before or after the test. There is no reason to fast after midnight, drink extra liquids, or avoid red meat before the laboratory test being drawn.

*Question: A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion?*

*Answer: Normal saline infusion* Rationale: Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Rehydration is the initial step in resolving diabetic ketoacidosis. Normal saline is the initial IV rehydration fluid. NPH insulin is never administered by the IV route. Dextrose solutions are added to the treatment when the blood glucose level decreases to an acceptable level. Intravenously administered potassium may be required, depending on the potassium level, but would not be part of the initial treatment.

*Question: A primary health care provider (PHCP) has written a prescription for a preoperative client to have "enemas until clear." The nurse has administered three enemas, and the client is still passing brown liquid stool. Which action would the nurse take next?*

*Answer: Notify the primary health care provider.* Rationale: Up to three enemas may be given when there is a prescription for enemas until clear. If more than three are necessary, the nurse notifies the PHCP (or acts based on agency policy). Excessive enemas could cause fluid and electrolyte depletion. Options 2, 3, and 4 are incorrect because they all require administering further enemas.

*Question: The nurse is monitoring for bleeding in a child after surgery to remove a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which nursing action is appropriate?*

*Answer: Notify the registered nurse (RN).* Rationale: Colorless drainage on the dressing would indicate the presence of cerebrospinal fluid and should be reported to the RN immediately; the RN would then contact the primary health care provider. The colorless drainage should also be checked for evidence of cerebrospinal fluid; one method is to check for the presence of glucose using a dipstick. Options 1, 3, and 4 are incorrect and delay required immediate interventions.

*Question: A client prescribed infliximab via intravenous (IV) injection is complaining of difficulty swallowing. Which would be the initial nursing action?*

*Answer: Notify the registered nurse (RN).* Rationale: Infliximab is a monoclonal antibody and gastrointestinal anti-inflammatory. Allergic reactions and anaphylaxis can occur from this medication and can be fatal. This complaint could be the first sign of an anaphylactic reaction. The RN must be notified, and it is imperative that the infusion be shut off as soon as possible. Then the primary health care provider must be notified. An antihistamine such as diphenhydramine then may be prescribed. Instructing the client to take deep breaths and relax is not a helpful intervention in this situation.

*Question: The nurse notes that a client in labor has foul-smelling amniotic fluid, a maternal temperature of 101°F, and a urine output of 150 mL during the past 2 hours. The nurse would do which action at this time?*

*Answer: Notify the registered nurse of a possible maternal infection.* Rationale: Signs of maternal infection include foul-smelling amniotic fluid, a maternal temperature in the presence of adequate hydration (adequate urine output), and fetal tachycardia. The nurse should inform the registered nurse of these data (who will then notify the primary health care provider) so that treatment can be initiated. Options 1, 2, and 3 are unrelated to the data in the question.

*Question: The nurse is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. Based on this observation, the nurse would take which action?*

*Answer: Notify the registered nurse of the finding.* Rationale: In this instance, the tuft of hair may be indicative of a spinal anomaly, and the nurse would notify the registered nurse because the primary health care provider should be notified of the finding. It is inappropriate to discuss abnormal findings with the parents; this role is the responsibility of the primary health care provider if an anomaly is suspected or diagnosed. The nurse should take the priority intervention of notifying the primary health care provider before documenting in the chart.

*Question: A client recovering from a craniotomy complains of a "runny nose." Based on the interpretation of the client's complaint, which action would the nurse take?*

*Answer: Notify the registered nurse.* Rationale: If the client has sustained a craniocerebral injury or is recovering from a craniotomy, careful observation of any drainage from the eyes, ears, nose, or traumatic area is critical. Cerebrospinal fluid is colorless and generally nonpurulent, and its presence is indicative of a serious breach of cranial integrity. The nurse would check the drainage for the presence of glucose, which would be indicative of the presence of cerebrospinal fluid and would report the presence of any suspicious drainage to the registered nurse, who would then contact the primary health care provider.

*Question: The nurse is caring for a client who has bilateral vocal cord paralysis. The client begins to experience severe dyspnea; the nurse listens to the client's breath sounds and hears this sound. (Refer to audio.) Which intervention would the nurse take immediately?*

*Answer: Notify the registered nurse.* Rationale: The sound that the nurse hears is stridor. Vocal cord paralysis may be unilateral or bilateral and may result from injury, trauma, or disease that affects the larynx, laryngeal nerves, or vagus nerve. When only one vocal cord is involved, the airway remains patent, but the voice is affected. With abducted (open) bilateral vocal cord paralysis, the client experiences hoarseness; a breathy, weak voice; and aspiration of food. Bilateral adducted (closed) vocal cord paralysis causes airway obstruction and is a medical emergency if the symptoms are severe and the client is unable to compensate. Stridor, a harsh, high-pitched sound associated with breathing, is the major manifestation of airway obstruction. The nurse immediately notifies the registered nurse, who then notifies the primary health care provider. The nurse also places the client in a high-Fowler's position to aid in breathing and proper alignment of airway structures. The nurse

*Question: The nurse is caring for a client diagnosed with Buerger's disease. Which finding would the nurse determine is a potential complication associated with this disease?*

*Answer: Numbness and tingling in the legs* Rationale: Buerger's disease (thromboangiitis obliterans), which affects men between 20 and 40 years of age, has an unknown etiology. It is a recurring inflammation of the small and medium-sized arteries and veins of the upper and lower extremities that results in thrombus formation and occlusion of blood vessels. Pain with diaphoresis, discomfort in one digit, and cramping in the foot are not complications of this disorder. The finding that can be interpreted as a complication of the disorder is numbness and tingling in the legs.

*Question: The nurse has assisted with obtaining a blood specimen for arterial blood gas (ABG) analysis. The nurse avoids doing which to properly obtain and send the specimen?*

*Answer: Obtain a 3-mL syringe that is used for parenteral medication.* Rationale: The specimen is drawn into a heparinized syringe to prevent clotting of the blood. A 3-mL syringe used to administer parenteral medication is not used. The specimen should be placed on ice after it is obtained. The requisition is fully completed, identifying pertinent client information such as body temperature and amount of oxygen in use.

*Question: A mother brings her 5-month-old daughter into the pediatrician's office with complaints that the child has been vomiting during feedings. The mother also states that the child is sometimes very fussy. Which would be the nurse's initial action?*

*Answer: Obtain a complete history of the child's feeding habits.* Rationale: In most situations, a complete history and physical examination of the child is the initial step in diagnosing gastroesophageal reflux disease. The child's feeding habits will give the nurse an indicator of the growth status. The child is weighed and measured after the initial interview is completed with the parent. Hereditary factors are not the priority. Further diagnostic studies may be prescribed, but only after a complete history is obtained.

*Question: The nurse has a prescription to obtain a sample for urinalysis from a client with an indwelling urinary catheter. To prevent contamination of the specimen, the nurse would avoid which action?*

*Answer: Obtaining the specimen from the urinary drainage bag* Rationale: A urine specimen is not taken from the urinary drainage bag unless the specimen is taken immediately after catheter insertion. Urine undergoes chemical changes while sitting in the bag and does not necessarily reflect current client status. In addition, it may become contaminated with bacteria from opening the system. To obtain a urine specimen from a client that has not just had the catheter inserted, the tubing is clamped for several minutes, and a specimen is withdrawn from the upper port. The tubing must then be unclamped to prevent reflux of urine into the bladder. Options 1, 3, and 4 are correct actions.

*Question: A nursing instructor asks a nursing student about the characteristics of Hodgkin's disease. The instructor determines that the student needs additional study if the student states that which is an associated characteristic?*

*Answer: Occurs most often in older adults* Rationale: Hodgkin's disease is a disorder of young adults and primarily occurs between the ages of 20 and 40. It is considered one of the most treatable cancers. The presence of Reed-Sternberg cells on biopsy of the cervical lymph node is noted. Lymph node, spleen, and liver involvement occurs.

*Question: The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. Which time of the month would the nurse tell the client to perform breast self-examination?*

*Answer: On a specific day of the month and on that same day every month thereafter* Rationale: If the client has had a hysterectomy or is no longer menstruating, the BSE should be performed on the same day every month. Options 2 and 3 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.

*Question: An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. Which is the best position to place this infant at this time?*

*Answer: On his or her left side* Rationale: After the repair of a cleft lip, the infant should be positioned on the side opposite to the repair to prevent contact of the suture lines with the bed linens. In this case it is best to place the infant on the left side. Additionally, the flat or prone position can result in aspiration if the infant vomits.

*Question: The nurse is preparing a plan of care for a client who will be returning from surgery following a right lung wedge resection. Included in the plan of care is that in the postoperative period, the nurse would avoid which positioning?*

*Answer: On the right side* Rationale: Following a wedge resection, the client should not be placed on the operative side. Lying on the operative side hinders expansion of remaining lung tissue and may accentuate perfusion of poorly ventilated tissue. This further impedes normal gas exchange. In addition, complete lateral turning may be contraindicated. The surgeon's prescriptions for positioning after this surgical procedure are always followed.

*Question: Lispro insulin is prescribed for a child with type 1 diabetes mellitus. The nurse is reinforcing a teaching session with the child and mother about the onset, peak, and duration times of the insulin. The nurse provides which information about this type of insulin?*

*Answer: Onset of 15 to 30 minutes from injection time, peak of 2 to 4 hours later, and duration time of 4 to 8 hours* Rationale: Lispro insulin has an onset of action of 15 to 30 minutes from injection time, peak action of 2 to 4 hours later, and a duration time of 4 to 8 hours. Therefore, options 1, 3, and 4 are incorrect.

*Question: The nurse is caring for a client who is anxious and is experiencing dyspnea and restlessness from hypoxemia associated with pulmonary edema. Auscultation of the lungs reveals these breath sounds. (Refer to audio.) The nurse determines that these breath sounds usually result from which cause?*

*Answer: Opening of small airways that contain fluid* Rationale: The sounds that the nurse hears are high-pitched crackles. Crackles are audible when there is a sudden opening of small airways that contain fluid. Crackles are usually heard during inspiration and do not clear with a cough. They resemble the sound of a lock of hair being rubbed between the thumb and forefinger and are heard in conditions such as pulmonary edema. High-pitched crackles are characteristically fine and are high-pitched discontinuous popping noises (nonmusical sounds) heard during the end of inspiration. Medium-pitched crackles produce a moist sound about halfway through inspiration. Coarse crackles are low-pitched bubbling sounds that start early in inspiration and extend into the first part of expiration. Rhonchi (low-pitched, coarse, loud, low snoring or moaning sounds) are heard in conditions causing obstruction of the bronchus or trachea. A pleural friction rub (a superficial low-pitched coarse rubbing

*Question: In which area of the chest would the nurse expect to auscultate this breath sound? (Refer to audio.)*

*Answer: Over the peripheral lung fields* Rationale: Breath sounds are noises resulting from the transmission of vibrations produced by the movement of air in the respiratory passages. Normal breath sounds include bronchovesicular sounds, vesicular breath sounds, and bronchial breath sounds. The sounds that the nurse hears are vesicular breath sounds. Vesicular breath sounds normally are heard over the lesser bronchi, bronchioles, and lobes (peripheral lung fields). These sounds are soft and low pitched and resemble a sighing or gentle rustling, and the inspiration phase is longer than the expiration phase. Bronchovesicular breath sounds normally are heard over the first and second intercostal spaces at the sternal border anteriorly and at T4 medial to the scapula posteriorly (over major bronchi). These sounds are a mixture of bronchial and vesicular breath sounds and are moderately pitched with a medium intensity. The inspiration and expiration phases are equal. Bronchial breath soun

*Question: The nurse is caring for a client with a diagnosis of myasthenia gravis. The primary health care provider plans to perform an edrophonium test on the client to determine the presence of cholinergic crisis. In addition to planning care for the client during this testing, which equipment will the nurse ensure is at the bedside?*

*Answer: Oxygen equipment* Rationale: An edrophonium test is performed to distinguish between myasthenic and cholinergic crisis. Following administration of edrophonium, if symptoms intensify, the crisis is cholinergic. Because the symptoms of cholinergic crisis will worsen with the administration of edrophonium, atropine sulfate and oxygen should be immediately available whenever edrophonium is used.

*Question: The nurse is setting up the bedside unit for a client being admitted to the nursing unit from the emergency department with a diagnosis of coronary artery disease (CAD). The nurse would place highest priority on making sure that which is available at the bedside?*

*Answer: Oxygen tubing and flowmeter* Rationale: CAD causes obstruction to blood flow through one or more major coronary arteries, cutting off oxygen and nutrients to the cardiac cells, and resulting in chest pain. Providing oxygen to the client is important to help decrease pain and prevent its recurrence. A bedside commode and ECG machine may be helpful but are not the priority. A rolling shower chair has no value for this client because the client should be able to walk and shower if pain free and an activity prescription allows it.

*Question: The nurse is urging a client to cough and deep breathe after a 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 likely a result of which contributing factor?*

*Answer: Pain that is intensified because the location of the incision is near the diaphragm* 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 so uncomfortable. For this reason, opioids are used liberally and may be most effective when provided as patient-controlled analgesia or through epidural analgesia. Options 1, 2, and 3 are not specifically related to this client's situation.

*Question: In planning care for a child with contact dermatitis, which concern is the highest priority for the child?*

*Answer: Pain* Rationale: In any skin disorder, the goal with children is to offer comfort interventions so that the child can rest. Once pain has decreased, the skin can be assessed for integrity and infection. Although important, teaching is not the priority in this situation.

*Question: A child is admitted to the hospital with sickle cell crisis. The nurse checks this child for which frequent symptom of the disorder?*

*Answer: Pain* Rationale: Sickling crisis often causes pain in the bones and joints, accompanied by joint swelling. Pain is a classic symptom of the disease and may require large doses of opioid analgesics when it is severe. The symptoms listed in the other options are not part of the clinical picture.

*Question: A child with a diagnosis of a hernia has been scheduled for a surgical repair in 2 weeks. The nurse reinforces instructions to the parents about the signs of possible incarcerated hernia. The nurse tells the parents that which manifestation requires primary health care provider (PHCP) notification by the parents?*

*Answer: Pain* Rationale: The parents of a child with a hernia need to be instructed about the signs of an incarcerated hernia. These signs include irritability, tenderness at the site of the hernia, anorexia, abdominal distension, and difficulty defecating. The parents should be instructed to contact the PHCP immediately if an incarcerated hernia is suspected. These signs may lead to a complete intestinal obstruction and gangrene. Diarrhea, increased flatus and constipation are not associated with an incarcerated hernia.

*Question: A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse reviews the plan of care and would question which intervention that is written in the plan?*

*Answer: Palpate the abdomen for a mass.* Rationale: Wilms' tumor is an intraabdominal and kidney tumor. If Wilms' tumor is suspected, the mass should not be palpated. Excessive manipulation can cause seeding of the tumor and thus cause the spread of the cancerous cells. Hematuria, hypertension, and fever are signs and symptoms that are associated with Wilms' tumor.

*Question: The nurse is using a stethoscope to listen to a client's heart and hears this sound. (Refer to audio.) To assist in identifying the sound, the nurse would take which initial and best action?*

*Answer: Palpate the carotid pulse for a pulsation.* Rationale: The sound that the nurse hears is the first heart sound, S1. The first heart sound (S1) is created by the closure of the mitral and tricuspid valve (atrioventricular valves). It marks the onset of systole (ventricular contraction). When auscultated, the first heart sound (S1) is softer and longer than the second heart sound (S2). S1 is of a low pitch and is best heard at the left lower sternal border or the apex of the heart. It may be identified by palpating the carotid pulse while listening. S1 marks the beginning of ventricular systole and occurs right after the QRS complex on the electrocardiogram (ECG). Disease and stiffened A-V valves (as seen in rheumatic heart disease) may augment S1. Phonetically, if both heart sounds (S1 and S2) are auscultated as "lub-dup," S1 is the "lub." To assess S1, the nurse should assist the client to a supine position (head of the bed may be elevated slightly if necessary). Although the

*Question: A client with jaundice is complaining of pruritus. Which strategy would the nurse institute to help control the problem and prevent injury?*

*Answer: Pat the skin dry after bathing.* Rationale: The nurse should pat the client's skin dry after bathing or showering. Rubbing should be avoided because it may lead to further skin injury. The client should be bathed with tepid water rather than hot water. A cool environment should be maintained because a warm environment may promote further drying and increased sweating, which should be avoided. Emollient creams and lotions can be applied regularly to alleviate dryness.

*Question: The nurse is evaluating the effects of care for the client with deep vein thrombosis. Which limb observations should the nurse note as indicating the least success in meeting the outcome criteria for this problem?*

*Answer: Pedal edema that is 3+* Rationale: Symptoms of deep vein thrombosis include leg warmth, redness, edema, tenderness, and enlarged calf. If the problem is not resolved, or is minimally resolved, these symptoms will remain. Option 3 indicates full resolution of the problem, whereas options 2 and 4 indicate partial resolution. Option 1 is the correct option because it indicates the least degree of symptom reversal.

*Question: The nurse is assisting in checking for Tinel's sign in a client suspected of having carpal tunnel syndrome (CTS). Which technique would the nurse expect to be used to elicit this sign?*

*Answer: Percuss the medial nerve at the wrist as it enters the carpal tunnel, and monitor for tingling sensations.* Rationale: The presence of Tinel's sign is determined by percussing the medial nerve at the wrist as it enters the carpal tunnel. A tingling sensation over the distribution of the nerve occurs in CTS. The presence of Phalen's sign is determined by asking the client to flex the wrist at a 90-degree angle for 1 minute. Numbness and tingling over the distribution of the median nerve, the palmar surface of the thumb, and the index and middle fingers suggest CTS. Phalen's sign is also an indication of CTS. Dorsiflexing the client's hand and monitoring for pain in the forearm and placing pressure on the client's radial nerve and monitoring circulation status are incorrect.

*Question: After 5 days in the psychiatric unit, a manic client is able to tolerate short periods in the dayroom. The nurse overhears the client telling another client that he is a journalist posing as a client in order to write an article for a magazine. Which response is the nurse's best action?*

*Answer: Privately confront the client with reality.* Rationale: The nurse's best action is to privately confront the client with reality.

*Question: The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of tasks?*

*Answer: Perform follow-up with each staff member regarding the performance and outcome of the task.* Rationale: The ultimate responsibility for a task lies with the person who delegated it. Therefore, it is the nurse's primary responsibility to follow-up with each staff member regarding the performance of the task and the outcomes related to implementing the task. Not all staff members have the education, knowledge, and ability to make judgments about tasks being performed. The nurse documents that the task has been completed, but this would not be done until follow-up was implemented and outcomes were identified. It is not appropriate to assign the tasks that were not completed to the next nursing shift.

*Question: A 4-year-old child with acute lymphocytic leukemia has been admitted to the hospital in relapse. The priority concern is infection due to immunosuppression. Which interventions would the nurse include in the plan of care?*

*Answer: Perform oral hygiene 4 times a day.* Rationale: The child who is immunosuppressed is at risk for infection, and interventions must be performed frequently to prevent infection. The nursing interventions of monitoring vital signs once a shift and inspecting the child's mouth daily for mouth ulcers, as stated in options 1 and 3, are incorrect because of the time frames. Suppositories should not be administered when a child is immunocompromised because of the risk of perineal fissures.

*Question: A client who had a prostatectomy has learned perineal exercises to gain control of the urinary sphincter. The nurse determines that the client needs further teaching if the client states that he will perform which action as part of these exercises?*

*Answer: Perform the Valsalva maneuver.* Rationale: The Valsalva maneuver is avoided following 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.

*Question: A client is experiencing blockage of the eustachian tubes. The nurse teaches the client that which activities by the client may forcibly open the eustachian tube?*

*Answer: Performing the Valsalva maneuver* Rationale: Using the Valsalva maneuver increases pressure in the nasopharynx and may help open a blocked eustachian tube. The actions described in the other options will not accomplish this.

*Question: A client is admitted to the hospital with a diagnosis of pericarditis. The nurse reviews the client's record for which sign or symptom that differentiates pericarditis from other cardiopulmonary problems?*

*Answer: Pericardial friction rub* Rationale: A pericardial friction rub is heard when there is inflammation of the pericardial sac during the inflammatory phase of pericarditis. Chest pain that worsens on inspiration is characteristic of both pericarditis and pleurisy. Anterior chest pain may be experienced with angina pectoris and myocardial infarction. Weakness and irritability are nonspecific complaints that could accompany a wide variety of disorders.

*Question: The nurse is caring for a client who has a malignant lung neoplasm and has developed cardiopulmonary complications. On auscultation, the nurse hears these breath sounds over the left lower sternal border (over the apical area) and interprets the sounds as which? (Refer to audio.)*

*Answer: Pericardial friction rub* Rationale: The sound that the nurse hears is a pericardial friction rub. Pericardial friction rubs are caused by inflammation of the layers of the pericardial sac. (Acute pericarditis is associated with malignant neoplasms.) It may be heard with the diaphragm of the stethoscope positioned at the left lower sternal border (over the apical area). It is a scratchy, high-pitched rubbing sound produced when the inflamed, roughened pericardial layers create friction as their surfaces rub together. Stridor is a harsh, high-pitched sound associated with breathing and is the major manifestation of airway obstruction. Crackles are audible when there is a sudden opening of small airways that contain fluid. They are usually heard during inspiration, and they do not clear with a cough. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger and are heard in conditions such as pulmonary edema. Passage of air through a narrowed a

*Question: The nurse is collecting data on a client who sustained circumferential burns of both legs. The nurse would check which first?*

*Answer: Peripheral pulses* Rationale: The client who receives circumferential burns to the extremities is at risk for impaired peripheral circulation. The priority assessment should be to check for peripheral pulses to ensure that adequate circulation is present. Although the temperature, heart rate, and BP should also be assessed, the priority with a circumferential burn is the assessment for peripheral pulses.

*Question: The nurse is preparing a plan of care for a client being admitted to the hospital with a diagnosis of retinal detachment. Which measure would the nurse include in the plan of care?*

*Answer: Place an eye patch over the affected eye.* 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 primary health care provider. Visitors do not need to be restricted.

*Question: The nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data would the nurse expect to note as having been documented in the child's record?*

*Answer: Projectile vomiting* Rationale: Signs and symptoms of pyloric stenosis include projectile, nonbilious vomiting; irritability; hunger and crying; constipation; and signs of dehydration, including a decrease in urine output.

*Question: A cervical radiation implant is placed in the client for treatment of cervical cancer. Which intervention would the nurse most likely expect to note in the primary health care provider's prescriptions?*

*Answer: Place an indwelling urinary catheter* Rationale: The client with a cervical radiation implant should be maintained on bed rest in the dorsal position to prevent movement of the radiation source. An indwelling urinary catheter is placed before the insertion of the cervical radiation implant. The head of the bed is elevated to a maximum of 10 to 15 degrees for comfort. Turning the client onto her side is avoided. If the client needs to be turned, a pillow is placed between the knees and, with the body in straight alignment, the client is logrolled. All efforts are made to limit client movement to avoid displacement of the implant.

*Question: A hospitalized client states he has chest pain, and the nurse notes a prescription for "sublingual nitroglycerin 1 tablet every 5 minutes times 3 to relieve chest pain prn." How would the nurse administer the medication?*

*Answer: Place one pill under the tongue and reassess for relief in 5 minutes.* Rationale: Nitroglycerin relieves chest pain by decreasing the cardiac workload and improving myocardial oxygen supply. In the hospitalized client, nitroglycerin is administered for chest pain sublingually by placing 1 tablet under the tongue and letting it dissolve. The medication will enter the bloodstream quickly by being absorbed by the blood vessels under the tongue. The medication may be repeated for a total of 3 times at 5-minute intervals. This is spaced out this way to avoid a significant drop in blood pressure. The medication is not administered with water or swallowed. The route for nitroglycerin is not buccal, which is placing the medication against the mucous membranes of the cheek.

*Question: The nurse was caring for an infant who had come to the nursing unit for observation and treatment of tetralogy of Fallot. The child suddenly becomes cyanotic, and the oxygen saturation reading drops to 60%. The nurse would perform which action first?*

*Answer: Place the child in a knee-chest position.* Rationale: The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.

*Question: A client newly admitted to the labor unit reports to the nurse that she felt a large gush of fluid before arriving at the hospital. The nurse checks the client and notes that the umbilical cord is protruding from the vagina. Which action would the nurse take first?*

*Answer: Place the client in the Trendelenburg position.* Rationale: When an umbilical cord is protruding, nursing actions are directed at reducing cord compression and facilitating delivery of the fetus. The client should be placed in extreme Trendelenburg, Sims', or knee-chest position to reduce cord compression. The primary health care provider is notified, and an IV is started after initiating emergency care for the client.

*Question: An older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. The nurse reviews the plan of care and notices documentation of decreased cardiac output, dyspnea, and syncopal episodes. The nurse plans to take which important action?*

*Answer: Place the client on a cardiac monitor.* Rationale: The client with decreased cardiac output should be placed on continuous cardiac monitoring so myocardial perfusion and presence of dysrhythmias can be most accurately assessed. Other cardiovascular data should be collected at least every 2 hours initially.

*Question: A registered nurse (RN) asks a licensed practical nurse (LPN) to obtain a vial of mannitol for administration to a client. The LPN notes that the vial contains a few small crystals. Based on this observation, which would the LPN expect the RN to do?*

*Answer: Place the vial in warm water until the crystals dissolve.* Rationale: Crystals form in mannitol if the solution is cooled, but quickly dissolve if the container is placed in warm water, then cooled to body temperature before administration. Options 1 and 3 are unnecessary, and option 2 will not dissolve the crystals.

*Question: The nurse is caring for a client with a nasogastric (NG) tube and tests the pH of the aspirate to determine correct placement. The test results indicate a pH of 5. The nurse would determine this indicates which information?*

*Answer: Placement of the NG tube is accurate.* Rationale: After the nurse inserts an NG tube into a client, the correct location of the tube must be verified. Testing the pH of the gastric fluid and determining its acidity further verifies that the tube is in the stomach. The stomach contents are acidic, and a pH of 5 should indicate accurate placement. Reinserting the NG tube, rechecking the pH of the aspirate, and pulling the NG tube back are incorrect.

*Question: A licensed practical nurse (LPN) is providing instructions to an assistive personnel (AP) who is preparing to care for a deceased client whose eyes will be donated. The nurse intervenes if the AP performs which action?*

*Answer: Places a dry sterile dressing over the open eyes* Rationale: When a corneal donor dies, the eyes are closed and gauze pads wet with saline are placed over them with a small ice pack. Within 2 to 4 hours, the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. The head of the bed should also be elevated. Placing a dry sterile dressing over the open eyes would be an incorrect action by the AP.

*Question: The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate action?*

*Answer: Pull back on the tube and wait until the respiratory distress subsides.* Rationale: During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. It is not necessary to notify the primary health care provider immediately or remove the tube.

*Question: The parents of a teenager diagnosed with anorexia nervosa ask the nurse what part they can play during the long recovery period. The nurse accurately relates which actions the parents should take?*

*Answer: Planning a non-food-related activity* Rationale: Anorexia nervosa is characterized by the client's refusal to maintain minimal body weight or eat adequate quantities of food. There is a disturbance in the perception of body shape and size and an extreme fear of becoming fat. The client strives for perfection and control by controlling caloric intake. These clients may act immaturely and are socially insecure and exhibit fluctuating moods. The family should plan non-food-related and non-exercise-related activities that provide support to the adolescent (e.g., discussing a homework assignment). Power struggles and discussions of food should be avoided. A non-exercise activity should be planned, not a strenuous day on the beach.

*Question: The nurse is reviewing the health care record of a client with a new onset of pleurisy. The nurse notes documentation that the client does not have a pleural friction rub that was auscultated the previous day. How would this finding be interpreted?*

*Answer: Pleural fluid has accumulated in the inflamed area.* Rationale: Pleural friction rub is auscultated early in the course of pleurisy before pleural fluid accumulates. Once fluid accumulates in the inflamed area, there is less friction between the visceral and parietal lung surfaces, and the pleural friction rub disappears. That the medication therapy has been effective, that the deep breaths the client is taking are helping, and that there is a decreased inflammatory reaction at the site are incorrect interpretations.

*Question: A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD) and has an arterial blood gas test done. Which results would the nurse expect to note?*

*Answer: Po2 of 60 mm Hg and Pco2 of 50 mm Hg* Rationale: During an acute exacerbation of COPD, the arterial blood gases deteriorate with a decreasing Po2 and an increasing Pco2. In the early stages of COPD, arterial blood gases demonstrate a mild to moderate hypoxemia, with the Po2 in the high 60s to high 70s and normal arterial Pco2. As the condition advances, hypoxemia increases and hypercapnia may result.

*Question: The nurse is collecting data from a client who is being admitted to the hospital for a diagnostic workup for primary hyperparathyroidism. The nurse understands that which client complaint would be characteristic of this disorder?*

*Answer: Polyuria* Rationale: Hypercalcemia is the hallmark of hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis (polyuria). This diuresis leads to dehydration and the client would lose weight. Options 1, 3, and 4 are gastrointestinal (GI) symptoms but are not associated with the common GI symptoms typical of hyperparathyroidism (nausea, vomiting, anorexia, constipation).

*Question: When the nurse taps at the level of the client's facial nerve, the following response is noted. How would the nurse document this finding on the client's record? Refer to figure.View Figure*

*Answer: Positive Chvostek's sign* Rationale: Chvostek's sign and Trousseau's sign may be elicited in hypocalcemic clients. Tapping at the level of the facial nerve may result in ipsilateral twitching of the eye, cheek, and lip; this is called Chvostek's sign. Trousseau's sign refers to carpopedal spasm induced by inflating a blood pressure cuff on the hypocalcemic client's arm. Cullen's sign is ecchymosis around the umbilicus. Babinski's reflex may be elicited when the sole of the foot is stroked. Options 1, 2, and 4 are incorrect.

*Question: A client complains of pain in the lower back and pain and spasms in the hamstrings when the nurse attempts to extend the client's leg. How would the nurse record this finding on the client's medical record? Refer to figure.View Figure*

*Answer: Positive Kernig's sign* Rationale: Both Kernig's and Brudzinski's signs are suggestive of meningeal irritation, which occurs in meningitis. A positive Kernig's sign is the inability to extend the leg from a 90-degree flexion at the hip. Attempts to extend the leg cause pain and spasms in the hamstring muscles. With positive Brudzinski's sign, passive flexion of the head and neck causes flexion of the thighs and legs. Positive Trousseau's sign is a carpopedal spasm observed in the hypocalcemic client when a blood pressure cuff is inflated on the arm above the systolic pressure. A Babinski's reflex is elicited when the nurse strokes along the sole of the foot.

*Question: The nurse is collecting admission data on a client with Parkinson's disease. The nurse asks the client to stand with the feet together and the arms at the side and then to close the eyes. The nurse notes that the client begins to fall when the eyes are closed. Based on this finding, the nurse documents which in the client's record?*

*Answer: Positive Romberg's test* Rationale: Romberg's test checks for cerebellar functioning related to balance. The client stands with the feet together and the arms at the side and then closes the eyes. Slight swaying is normal, but loss of balance indicates a problem and a positive Romberg's test. Trousseau's sign indicates a calcium imbalance.

*Question: A client that is postgastrectomy is at high risk for hyperglycemia related to uncontrolled gastric emptying of fluid and food into the small intestine (dumping syndrome). Because of this risk, the nurse would plan to monitor which data?*

*Answer: Postprandial blood glucose readings* Rationale: Late symptoms of dumping syndrome following a gastrectomy occur 2 to 3 hours after eating and result from a rapid entry of increased carbohydrate food into the jejunum, a rise in blood glucose levels, and excessive insulin secretion. To monitor this, the nurse checks the blood glucose level 2 hours after meals. Options 1 and 4 are unrelated to the data in the question. A fasting blood glucose level would not accurately determine hyperglycemia.

*Question: The nurse is monitoring the results of periodic serum laboratory studies drawn on a client with diabetic ketoacidosis (DKA) receiving an insulin infusion. The nurse determines that which value needs to be reported?*

*Answer: Potassium 3.1 mEq/L* Rationale: The client with diabetic ketoacidosis initially becomes hyperkalemic as potassium leaves the cells in response to lowered pH. Once fluid replacement and insulin therapy are started, the potassium level drops quickly. This occurs because potassium is carried into the cells along with glucose and insulin and because potassium is excreted in the urine once rehydration has occurred. Thus, the nurse carefully monitors the results of serum potassium levels and reports hypokalemia (option 1) promptly. The other laboratory values are within the normal ranges.

*Question: A client with acute kidney injury (AKI) has been treated with sodium polystyrene sulfonate by mouth. The nurse evaluates this therapy as effective if which value is noted on follow-up laboratory testing?*

*Answer: Potassium, 4.9 mEq/L* Rationale: Of all the electrolyte imbalances that accompany renal failure, hyperkalemia is the most dangerous because it can lead to cardiac dysrhythmias and death. If the potassium level rises too high, sodium polystyrene sulfonate may be given to cause excretion of potassium through the gastrointestinal tract. Each of the electrolyte levels noted in the question falls within the normal reference range for that electrolyte. The potassium level is measured following administration of this medication to note the extent of its effectiveness.

*Question: The nurse is caring for a client experiencing thyroid storm. Which would be a priority concern for this client?*

*Answer: Potential for cardiac disturbances* Rationale: Clients in thyroid storm are experiencing a life-threatening event that is associated with uncontrolled hyperthyroidism. It is characterized by high fever, severe tachycardia, delirium, dehydration, and extreme irritability. Because the signs and symptoms of the disorder develop quickly, emergency measures must be taken to prevent death. These measures include maintaining hemodynamic status and patency of airway and providing adequate ventilation. Lack of sexual drive, inability to cope with the treatment plan, and self-consciousness about body appearance are not priorities in the care of the client in thyroid storm.

*Question: The nurse is assisting in developing a plan of care for a client receiving warfarin sodium. The nurse selects which problem as the priority in caring for this client?*

*Answer: Potential for injury* Rationale: Anticoagulant therapy predisposes the client to injury because of the inhibitory effects of the medication on the body's normal blood-clotting mechanism. Bruising, bleeding, and hemorrhage may occur in the course of activities of daily living and with other activities. Options 2, 3, and 4 are not specifically related to the care of a client receiving anticoagulants.

*Question: During data collection on a child for a well-child visit, a parent tells the nurse "We have a chore chart at our house. When our child does chores without prompting for 3 days in a row, the child gets an extra 30 minutes of screen time. So far, it seems to be working!" The nurse determines the child's behavior corresponds with which stage of Kohlberg's moral development?*

*Answer: Pre-conventional: Obtaining rewards* Rationale: The child is in the pre-conventional stage, and obtaining rewards is the focus of the child's behavior. There is nothing in the question that mentions avoiding punishment. In the later stages of Kohlberg's moral development, a person obeys rules and regulations, and makes and keeps promises.

*Question: A hypertensive client who has been taking metoprolol has been prescribed to decrease the dose of the medication. The client asks the nurse why this must be done over a period of 1 to 2 weeks. In formulating a response, the nurse incorporates the understanding that abrupt withdrawal could affect the client in which way?*

*Answer: Precipitate rebound hypertension* Rationale: Beta-adrenergic blocking agents should be tapered slowly. This will avoid abrupt withdrawal syndrome characterized by headache, malaise, palpitations, tremors, sweating, rebound hypertension, dysrhythmias, and possibly myocardial infarction (in clients with cardiac disorders including angina pectoris). Options 1, 2, and 4 are incorrect.

*Question: The nurse is caring for a client diagnosed with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed the nasogastric tube to be discontinued. To best determine the client's readiness for discontinuation of the nasogastric tube, which measure would the nurse check?*

*Answer: Presence of bowel sounds in all four quadrants* Rationale: Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction, and a nasogastric tube may be used to empty the stomach and relieve distention and vomiting. Bowel sounds return to normal as the obstruction is relieved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function returns may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, tube placement, and pH of gastric aspirate are important assessments for the client with a nasogastric tube in place, but these would not assist in determining the readiness for removing the nasogastric tube.

*Question: A client with lung cancer is receiving a high dose of methotrexate. Leucovorin is also prescribed. The nurse who is assisting in planning care for the client understands that administering the leucovorin with methotrexate is for which purpose?*

*Answer: Preserve normal cells* Rationale: High concentrations of methotrexate damage normal cells. To save normal cells, leucovorin is given, which is known as "leucovorin rescue." Folate alone (leucovorin is the form given with chemotherapy) is given to treat megablastic anemia and promote healthy fetal development during pregnancy. In this application, it does promote DNA and nucleic acid synthesis. The medication in either form does not promote excretion.

*Question: One unit of packed red blood cells has been prescribed for a client postoperatively because the client's hemoglobin level is low. The primary health care provider prescribes diphenhydramine to be administered before the administration of the transfusion. Why is this medication being given?*

*Answer: Prevent a rash and pruritus* Rationale: An urticarial reaction is characterized by a rash accompanied by pruritus. This type of transfusion reaction is prevented by pretreating the client with an antihistamine, such as diphenhydramine. All other options are incorrect. Acetaminophen, however, may be prescribed before the administration to assist in preventing an elevated temperature.

*Question: The child with cryptorchidism is being discharged after orchiopexy, which was performed on an outpatient basis. The nurse would reinforce instructions to the parents about which priority care measure?*

*Answer: Preventing infection at the surgical site* Rationale: The most common complications associated with orchiopexy are bleeding and infection. The parents are instructed in postoperative homecare measures, including the prevention of infection, pain control, and activity restrictions. The measurement of intake and output is not required. Anticholinergics are prescribed for the relief of bladder spasms; they are not necessary after orchiopexy. Cold, wet compresses are not prescribed. The moisture from a wet compress presents a potential for infection.

*Question: The nurse is reviewing the record of a child admitted to the hospital with nephrotic syndrome. Which finding would the nurse expect to note documented in the record?*

*Answer: Proteinuria* Rationale: The term nephrotic syndrome refers to a kidney disorder characterized by proteinuria, hypoalbuminemia, and edema. The child experiences fatigue, anorexia, increased weight, abdominal pain, and a normal blood pressure.

*Question: The nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. The nurse would do which intervention to effectively accomplish this goal?*

*Answer: Provide a quiet and low-stimulus environment.* Rationale: Chest pain can be minimized by a quiet, low-stimulus environment, which reduces factors that trigger chest pain such as emotional excitement. Each of the incorrect options increases the amount of client stimulation, which increases the risk of an anginal episode.

*Question: A child is diagnosed with Reye's syndrome. The nurse assists with developing a nursing care plan for the child and would include which intervention in the plan?*

*Answer: Provide a quiet atmosphere with dimmed lighting.* Rationale: Reye's syndrome is an acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver. A definitive diagnosis is made by liver biopsy. In Reye's syndrome, supportive care is directed toward monitoring and managing cerebral edema. Decreasing stimuli in the environment by providing a quiet environment with dimmed lighting would decrease the stress on the cerebral tissue and neuron responses. Hearing loss and urine output are not affected. Changing the body position every 2 hours would not affect the cerebral edema directly. The child should be positioned with the head elevated to decrease the progression of the cerebral edema and promote drainage of cerebrospinal fluid.

*Question: A hospitalized client with angina continues to have chest pain after the initial administration of a sublingual nitroglycerin tablet. The nurse would take which action?*

*Answer: Provide a second sublingual dose in 5 minutes.* Rationale: To terminate an acute anginal attack, sublingual nitroglycerin should be administered as soon as the pain begins. Administration should not be delayed until the pain has become severe. In the hospitalized client, if pain is not relieved in 5 minutes, the client should take another dose sublingually, and then a third tablet is taken 5 minutes later. Anginal pain that does not respond to nitroglycerin may indicate myocardial infarction. If the client is having a myocardial infarction, distraction techniques such as deep breathing and imagery will not relieve the pain.

*Question: A client diagnosed with paranoid schizophrenia has been exceedingly agitated, is threatening and shouting at everyone, and is refusing to participate in therapy. The nurse takes which initial action?*

*Answer: Provide for safety by recognizing the level of client anxiety and setting limits.* Rationale: The nurse's initial action is to recognize the level of client anxiety and setting limits. Providing for safety and setting firm limits on unacceptable and inappropriate behaviors in a nondefensive manner is the initial nursing action in this situation. Because the client's behavior is inappropriate, option 3 is incorrect. Options 1 and 2 may be appropriate at some point but not initially.

*Question: The nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse would incorporate which action as the best strategy to assist the client in coping with the disease?*

*Answer: Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.* Rationale: A primary role of the nurse in working with a 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 that will eradicate it. This gives the client a measure of power over the situation and outcome.

*Question: A client diagnosed with acquired immunodeficiency syndrome (AIDS) is experiencing shortness of breath related to Pneumocystis jiroveci pneumonia. Which measure would the nurse implement to assist the client in performing activities of daily living?*

*Answer: Provide supportive care with hygiene needs.* Rationale: Providing supportive care with hygiene needs as needed reduces the client's physical and emotional energy demands and conserves energy resources for other functions such as breathing. Low-microbial food; small, frequent meals; and meals and snacks with high protein, calories and nutritional value are important interventions for the client with AIDS but do not address the subject of activities of daily living. Low-microbial food will decrease the client's risk of infection. Small, frequent meals will assist the client in tolerating meals better. Meals and snacks with high protein, high calories, and high nutritional value will assist the client in maintaining appropriate weight and proper nutrition.

*Question: The client diagnosed with acquired immunodeficiency syndrome (AIDS) has difficulty swallowing. The nurse has given the client suggestions to minimize the problem. The nurse determines that the client has understood the instructions if the client verbalizes the intent to increase intake of which food(s)?*

*Answer: Puddings* Rationale: The client is instructed to avoid spicy, sticky, or excessively hot or cold foods. The client also is instructed to avoid foods that are rough, such as uncooked fruits or vegetables. The client is encouraged to take in foods that are mild, nonabrasive, and easy to swallow. Examples of these include baked fish, noodle dishes, well-cooked eggs, and desserts such as ice cream or pudding. Dry grain foods such as crackers, bread, or cookies may be softened in milk or another beverage before eating.

*Question: The nurse assists in preparing a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child with otitis media. Which would be included in the plan?*

*Answer: Pull the earlobe down and back before instilling the eardrops.* Rationale: When administering eardrops to a child who is younger than 3 years old, the ear should be pulled down and back. For children who are older than 3 years old, the ear is pulled up and back. Gloves do not need to be worn by the parents, but hand washing needs to be performed before and after the procedure. The child should be in a side-lying position with the affected ear facing upward to facilitate the flow of medication down the ear canal by gravity.

*Question: The nurse is performing an abdominal assessment on a client. The nurse interprets that which finding is abnormal and would be immediately reported?*

*Answer: Pulsation between the umbilicus and pubis* Rationale: The umbilicus should be in the midline with a concave appearance. The presence of pulsation between the umbilicus and the pubis could indicate an abdominal aortic aneurysm and should be reported. Bruits are not normally present. Bowel sounds vary according to the timing of the last meal and usually range in frequency from 5 to 35 per minute.

*Question: The nurse assisting in caring for a client hospitalized with acute pericarditis is monitoring the client for signs of cardiac tamponade. The nurse determines that which finding is unrelated to possible cardiac tamponade?*

*Answer: Pulse rate of 58 beats per minute* Rationale: Assessment findings 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 blood pressure by greater than 10 mm Hg). Bradycardia is the symptom that is unrelated.

*Question: The nurse is preparing to collect data on a client with a possible diagnosis of ectopic pregnancy. Which would the nurse check first?*

*Answer: Pulse* Rationale: The primary concern when ectopic pregnancy is suspected is the occurrence of bleeding and hypovolemic shock. Pulse is the only assessment that would provide information related to this occurrence. An elevated pulse is an indicator of shock. The nurse should also monitor for decreasing hematocrit levels and pain. Weight, temperature, and abdominal girth measurement do not provide data that indicate the occurrence of hypovolemic shock.

*Question: A client has a prescription to have radial arterial blood gases (ABGs) drawn. Before drawing the sample, an Allen's test will be performed. In performing the Allen's test, which blood vessel(s) would the nurse occlude?*

*Answer: Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the process with the other artery* Rationale: Before drawing an ABG, the nurse checks the collateral circulation to the hand with the Allen's test. This involves compressing both the radial and ulnar arteries and asking the client to close and open the fist. This should cause the hand to become pale. The nurse then releases pressure on one artery and observes if circulation is quickly restored. The process is then repeated releasing the other artery. The blood sample may be safely taken if there is adequate collateral circulation. Only the radial and ulnar arteries are occluded; the brachial artery would not be occluded when performing the Allen's test.

*Question: The nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement would be avoided?*

*Answer: Rectal* Rationale: Rectal temperature measurements should be avoided if diarrhea is present. The use of a rectal thermometer can stimulate peristalsis and cause more diarrhea. Axillary or tympanic measurements of temperature would be acceptable. Most measurements are performed via electronic devices.

*Question: The nurse is present at a disaster scene and is participating in the triage of victims. Which color tag would be assigned to a victim with evidence of open pneumothorax?*

*Answer: Red* Rationale: An open pneumothorax can be a life-threatening situation unless immediately managed. The victim has a reasonable chance of survival if immediate treatment is instituted, so a red tag should be attached to the victim. Yellow tags are placed on victims whose injuries can wait for treatment without threat to life (for example, closed fractures). Green tags are placed on victims with minimal injury (for example, minor lacerations) or those experiencing anxiety related to the disaster. Black tags are reserved for those who are dead or whose injuries are so extensive there is no chance of survival.

*Question: A client diagnosed with a peptic ulcer scheduled for a vagotomy asks the nurse about the purpose of this procedure. The nurse would explain to the client that a vagotomy primarily serves which purpose?*

*Answer: Reduces the stimulation of acid secretions* Rationale: A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion. Halting stress reactions, healing the gastric mucosa, and decreasing food absorption in the stomach are incorrect descriptions of a vagotomy.

*Question: A client that is postgastrectomy being discharged from the hospital tells the nurse, "I hope my stomach problems are over. I need to get back to work right away. I've missed a lot of work, and I may lose my job." Based on the client's statement, the nurse would determine that at this time, it is most appropriate to discuss which topic?*

*Answer: Reducing stressors in life* Rationale: Some clients need help reducing stressors in their lives. This may be extremely important for recovery. Clients may expect a rapid recovery and are disappointed when this does not occur. The client's statement provides an opportunity for the nurse to discuss stress and its relationship to gastrointestinal disorders. The data in the question are unrelated to wound care, exercise programs, or the postgastrectomy diet.

*Question: The nurse is monitoring a client with a spinal cord injury who is experiencing spinal shock. Which assessment will provide the nurse with the best information about recovery from the spinal shock?*

*Answer: Reflexes* Rationale: Areflexia characterizes spinal shock; therefore, reflexes should provide the best information. Vital sign changes are not consistently affected by spinal shock.

*Question: The nurse is reinforcing instructions to a client regarding epoetin alfa that will be administered subcutaneously by the client at home. The nurse tells the client to do which action?*

*Answer: Refrigerate the medication.* Rationale: The medication should be refrigerated but not frozen. The client should be instructed not to shake the medicine bottle. Syringes with a ½-inch needle are used to administer subcutaneous injections.

*Question: A client is in metabolic acidosis caused by diabetic ketoacidosis (DKA). The nurse prepares for the administration of which medication as a primary treatment for this problem?*

*Answer: Regular insulin* Rationale: The primary treatment for any acid-base imbalance is treatment of the underlying disorder that caused the problem. In this case, the underlying cause of the metabolic acidosis is anaerobic metabolism as a result of the lack of ability to use circulating glucose. Administration of regular insulin corrects this problem.

*Question: The nurse has just administered ibuprofen to a child with a temperature of 38.8°C (102°F). The nurse would also take which action?*

*Answer: Remove excess clothing and blankets from the child.* Rationale: After administering ibuprofen, excess clothing and blankets should be removed. The child can be sponged with tepid water but not cold water, because the cold water can cause shivering, which increases metabolic requirements above those already caused by the fever. Aspirin is not administered to a child with fever because of the risk of Reye's syndrome. Fluids should be encouraged to prevent dehydration, so oral fluids should not be withheld.

*Question: The nurse is preparing a client for a magnetic resonance imaging (MRI) examination. Which action by the nurse is important?*

*Answer: Remove metallic objects from the client.* Rationale: Metallic objects need to be removed before an MRI can be performed. The client usually does not need to be NPO. Ingestion of contrast material and dark glasses are not required for this test.

*Question: The staff nurse is observing a new graduate nurse provide indwelling urinary catheter care to an uncircumsized male client. Which action by the new graduate nurse would indicate a need for further teaching?*

*Answer: Removes a loose catheter anchor and places a new anchor on the shin* Rationale: Routine catheter care is imperative in the prevention of catheter-associated urinary tract infections (CAUTIs). Meticulous technique needs to be used to prevent the introduction of microorganisms to the urinary tract. For uncircumcised males, the nurse would retract the foreskin to inspect the urethral meatus for skin irritation and then cleanse the site with warm soapy water and return the foreskin to its normal position. The catheter tubing needs to be cleaned in a proximal to distal direction. The urinary drainage bag needs to be maintained below the level of the bladder to prevent reflux of urine into the urinary tract. Any loose anchors need to be removed and replaced to ensure the catheter tubing does not get pulled on, as this could cause trauma to the urethra. However, the anchor needs to be placed on the upper thigh, not the shin. Therefore, option 3 is the action that requires a need for

*Question: Tacrolimus is prescribed for a client. Which disorder in the client's record would the nurse note that indicates the medication needs to be administered with caution?*

*Answer: Renal insufficiency* Rationale: Tacrolimus is used with caution in immunosuppressed clients and those with renal or hepatic function impairment. It is contraindicated in clients with hypersensitivity to this medication or hypersensitivity to cyclosporine. Ulcerative colitis, diabetes insipidus, and coronary artery disease are not a concern with the use of this medication.

*Question: The nurse suspects that a coworker is substance impaired and is self-administering opioid medications rather than administering them to clients as prescribed. Which action would the nurse take?*

*Answer: Report the information to a supervisor.* Rationale: An impaired nurse is one who is unable to function effectively because of some type of substance abuse. Nurse practice acts require reporting the suspicion of impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This suspicion needs to be reported to the nursing supervisor, who will then report to the board of nursing. Reporting the information to the police, confronting the coworker, and calling the impaired nurse organization are incorrect. Confronting the nurse may cause a conflict. The supervisor will report the substance abuse situation as necessary.

*Question: The nurse is assessing a newly admitted client recently diagnosed with depression. Which data best supports that the client is at risk for self-harm?*

*Answer: Reported hopelessness* Rationale: The best data that supports that the client is at risk for self-harm is reported hopelessness by the client. Depression brings with it a feeling of hopelessness that may cause the client to believe the situation will never change. Depression often is associated with increased potential for self-harm with the most serious being suicide. Suicide may then be viewed as a way to end emotional pain. Although flat affect and observed tears are behaviors common in the depressed individual, they are not as strongly associated with the potential to self-harm as is reported hopelessness. Bruises on upper arms may indicate an attempt to self-harm, but a variety of other nonrelated explanations for the bruising exist.

*Question: The nurse is working in a tuberculosis (TB) screening clinic. The nurse understands that which population is at highest risk for TB?*

*Answer: Residents of a long-term care facility* Rationale: Residents of long-term care facilities are considered high-risk candidates for TB. Children younger than 4 years of age also are considered a high-risk group. Persons admitted for day surgery are not high-risk candidates. Foreign immigrants (especially from Mexico, the Philippines, and Vietnam) are considered high risk, but those from Australia are not.

*Question: The nurse is assisting in caring for a client with a newly inserted tracheostomy. The nurse notes documentation of an airway problem because of thick respiratory secretions. The nurse would monitor for which item as the best indicator of an adequate respiratory status?*

*Answer: Respiratory rate of 18 breaths per minute* Rationale: An airway problem could occur following tracheostomy from excessive secretions, bleeding into the trachea, restricted lung expansion caused by immobility, or concurrent respiratory conditions. The respiratory rate of 18 breaths per minute is well within the normal range of 14 to 20 breaths per minute. An oxygen saturation of 89% is less than optimal.

*Question: The nurse is assisting in caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. When collecting data on the client, the nurse checks which first?*

*Answer: Respiratory status* Rationale: Morphine sulfate depresses respirations. The nurse monitors the client's respiratory status closely. Although the incorrect options may be a component of the data collection process, option 4 identifies the priority nursing action.

*Question: An emergency department nurse is assigned to assist in caring for a client who has suffered a head injury following a motor vehicle crash. The nurse understands that the initial data collection would focus on which sign/symptom?*

*Answer: Respiratory status* Rationale: The initial data collection focuses on ensuring that the client has an adequate airway and respiratory status. In rapid sequence, the client's circulatory status is evaluated, followed by evaluation of the neurological status. Range of motion is not a priority. In fact, the extent of the injuries should be well established before assessing range of motion.

*Question: The nurse is caring for a woman in the labor room. The primary health care provider prescribes an oxytocic medication for the woman to augment her labor. Which finding indicates a need to discontinue the oxytocic medication?*

*Answer: Resting interval of 50 seconds* Rationale: Oxytocics are administered to augment labor because they stimulate the uterus to contract. Oxytocin is discontinued or its rate is reduced if signs of fetal compromise or excessive uterine contractions occur. Excessive uterine contractions are most often evidenced by contraction frequency greater than every 2 minutes, durations longer than 90 seconds, or resting intervals shorter than 60 seconds. Fetal heart tone rates are normally in a range of 110 to 160 beats/minute. Variable decelerations are abrupt decreases of 15 beats/minute below baseline, lasting 15 seconds to 2 minutes. These decreases begin and end abruptly; on the monitor they are V-, W-, or U-shaped.

*Question: The nurse is assisting in caring for a client who is receiving a dose of nalmefene intravenously to treat opioid overdose. The nurse plans to have which supplies available as supportive equipment in case it is needed?*

*Answer: Resuscitation equipment* Rationale: The nurse should have resuscitation equipment readily available to support nalmefene therapy if it is needed. Other adjuncts that may be needed include oxygen, a mechanical ventilator, and emergency medications.

*Question: The nurse reinforces home-care instructions to the parents of a child with celiac disease. Which food item would the nurse advise the parents to include in the child's diet?*

*Answer: Rice* Rationale: Dietary management is the mainstay of treatment for celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be required during the early period of treatment to correct deficiencies. These restrictions are likely to be lifelong, although small amounts of grains may be tolerated after the gastrointestinal ulcerations have healed.

*Question: The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. During data collection about the child, the nurse expects to note which characteristic of this type of posturing?*

*Answer: Rigid extension and pronation of the arms and legs* Rationale: Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing.

*Question: An older client with advanced Alzheimer's disease is placed in balanced suspension traction, and the primary health care provider expects to internally fixate the client's femur in 1 week. Based on this information, the nurse determines that the priority relates to addressing which client problem?*

*Answer: Risk for constipation* Rationale: Risk for constipation is the priority problem for this client. Although all of these problems may apply to this client, lying supine, being older, and having cognitive impairment places the client at extreme risk for constipation and possibly impaction. The client likely does have disturbed thought processes because of the Alzheimer's disease and impaired tissue integrity because of the fracture. Because activity is restricted, activity tolerance is unknown.

*Question: A client experiencing delusions of being poisoned is admitted to the hospital after not eating or drinking for several days. On data collection, the nurse notes no evidence of dehydration and malnutrition at this time. The nurse would immediately plan to address which client need?*

*Answer: Safety and security* Rationale: The nurse would immediately plan to address the client's need for safety and security. An important consideration when working with clients who have delusions is the maintenance of safety. Delusions may compel a client to take risks. Because the client shows no evidence of dehydration and malnutrition at this time, safety and security are the priority needs. Psychosocial needs, self-esteem, and love and belonging are not immediate client needs.

*Question: The nurse is assisting in preparing a teaching plan for a client with Ménière's disease. The nurse places highest priority on teaching the client information related to which information?*

*Answer: Safety* Rationale: Attacks of Ménière's disease come on suddenly and can be dangerous. The client is at risk for falls and requires information about how to prevent injury when symptoms begin. This information is highest in priority to maintain the client's well-being. The information listed in the other options is also needed but has lesser priority than preventing falls or injury.

*Question: The nurse is assisting in performing a prenatal examination on a client in the third trimester of pregnancy. The primary health care provider performs Leopold's maneuvers on the client. Which maneuver indicates the position of the fetus?*

*Answer: Second* Rationale: The first maneuver is to determine the presentation and lie of the fetus. The second maneuver indicates the position of the fetus. The third maneuver can determine whether the fetus is engaged in the pelvis. The fourth maneuver indicates the attitude of the fetus. Leopold's maneuvers should not be performed during a contraction.

*Question: A client's blood pressure is 100/78 mm Hg; the client has tachycardia and is cool and pale. The nurse assists the client to which position to promote tissue oxygenation and alleviate hypoxia?*

*Answer: Semi-Fowler's* Rationale: Coolness, pallor, and tachycardia are consistent with clinical indicators of hypoxia related to inadequate cardiac output. To reduce the myocardial workload, improve cardiac output, and promote tissue oxygenation, the nurse positions the client in the semi-Fowler's position to maintain perfusion to vital organs and promote chest expansion (option 3) so long as the client's neurological status is stable. The supine position removes the strain on the heart of pumping blood against gravity into the cerebral vasculature effectively; however, a flat position can lead to excessive preload and increase the cardiac workload (option 1). Left-lateral position could be satisfactory (option 2), but until the client is stable and unless the client is at risk for aspiration, semi-Fowler's position is a better choice. Trendelenburg's position is used when the client experiences profound hypotension or shock (option 4).

*Question: The nurse assigned to care for a client diagnosed with cirrhosis reviews the medical record and notes that the client has difficulty maintaining an effective breathing pattern due to pressure on the diaphragm. The nurse plans care knowing that which client position will best assist in facilitating breathing?*

*Answer: Semi-Fowler's* Rationale: The client experiencing difficulty maintaining an effective breathing pattern due to pressure on the diaphragm should be placed in a semi-Fowler's or Fowler's position. The nurse should support the client's arms and chest with pillows to facilitate breathing by relieving pressure on the diaphragm. The supine, Sims', and prone positions all are flat positions and would further affect the breathing pattern in the client.

*Question: The nurse is assisting in caring for a client in transfer from the postanesthesia care unit following nasal surgery. Nasal packing and a moustache dressing are in place. The nurse places the client in which position to best reduce swelling?*

*Answer: Semi-Fowler's* Rationale: The client who has nasal surgery may have packing in place postoperatively to decrease bleeding. The moustache dressing is a folded piece of gauze to catch any drainage that collects from the packing at the nasal cavity. The nurse should place the client in the semi-Fowler's position because elevating a body part will reduce swelling. The prone and supine positions do not decrease swelling because the client is lying flat. Sims' position, which is side-lying, also does not decrease the swelling.

*Question: The nurse is assisting with admitting a client to the hospital for the treatment of diagnosed dehydration. The client reports nausea, vomiting, diarrhea, and cramping for the past week. The nurse asks the client about medications being taken. The client denies taking prescription medications but states he has been taking some herbs given to him by a cousin. The nurse would alert the registered nurse when the client states he has been taking which herb?*

*Answer: Senna* Rationale: Senna is used to treat constipation and as a bowel preparation for surgery. Its side effects are nausea, vomiting, diarrhea, anorexia, and cramping. Side effects of kaolin are nausea, anorexia, and constipation. Common gastrointestinal (GI) side effects of green tea are nausea and heartburn; there are no known GI side effects from dill.

*Question: In the well-child clinic, the nurse observes an infant, age 10 months, playing with toys, bringing them to his mouth, and passing the toys from one hand to the next. The nurse determines the child is in which Jean Piaget's first developmental stage?*

*Answer: Sensorimotor* Rationale: Jean Piaget's first stage of cognitive development is the sensorimotor stage (birth to 2 years). The preoperational stage is the second stage (2 to 7 years of age). The concrete operational stage is the third stage (7 to 11 years of age). The formal operational stage is the fourth stage (11 years of age to adulthood).

*Question: The nurse is assisting in monitoring a client who may be started on parenteral nutrition (PN). The nurse reviews the client's laboratory results and determines that the client is at risk of severe malnutrition if the report indicates which critical level?*

*Answer: Serum albumin 2.8 g/dL* Rationale: Parenteral nutrition is used when a client has a nonfunctioning gastrointestinal system or is unable to eat enough to meet nutritional needs. The serum albumin level is a measurement of protein and a critical indicator of the need for PN. The client whose albumin level is 2.8 g/dL is at severe risk for malnutrition. The normal serum albumin level in the adult is 3.4 to 5 g/dL. The sodium, hemoglobin, and WBC count are within normal limits and are not directly related to malnutrition.

*Question: An adolescent is admitted to the hospital with complaints of lower right abdominal pain. The primary health care provider prescribes laboratory tests to rule out ectopic pregnancy rather than appendicitis. Which is most significant in ruling out an ectopic pregnancy?*

*Answer: Serum human chorionic gonadotropin* Rationale: The test to rule out an ectopic pregnancy is the serum human chorionic gonadotropin. The other tests may be prescribed to rule out appendicitis, but because the client is an adolescent it would be necessary to rule out an ectopic pregnancy as well. Urinalysis will rule out a urinary tract infection, and the white blood count and the C-reactive protein will rule out some other types of infection.

*Question: A client is admitted to the hospital with a venous stasis leg ulcer. The nurse is reviewing the physical examination in the medical record. Which symptom is least likely to be noted by the primary health care provider?*

*Answer: Sharp pain in the leg* Rationale: Characteristics of a venous stasis ulcer include lower leg edema, itchy scaly skin, brownish discoloration, and pain described as heaviness or dull ache in the calf or thigh.

*Question: The nurse is collecting data from a client on her first prenatal visit. Which factor indicates that the client is at risk for developing gestational diabetes during this pregnancy?*

*Answer: She has a history of chronic hypertension.* Rationale: Known risk factors that increase the risk of developing gestational diabetes include obesity (more than 198 lb), chronic hypertension, family history of type 2 diabetes mellitus, previous birth of a large infant (more than 4000 g), and gestational diabetes in a previous pregnancy. Options 2, 3, and 4 are not risk factors.

*Question: The nurse is monitoring a client following a motor vehicle crash. Which finding would indicate a need for chest tube placement?*

*Answer: Shortness of breath and tracheal deviation* Rationale: Shortness of breath and tracheal deviation result when lung tissue and alveoli have collapsed. Air entering the pleural cavity causes the lung to lose its normal negative pressure. The increasing pressure in the affected side displaces contents to the unaffected side. Shortness of breath results from decreased area available for diffusion of gases. Chest pain and shortness of breath are more commonly associated with myocardial ischemia or infarction. Clients requiring chest tubes exhibit decreasing oxygen saturation but will more likely experience tachypnea related to the hypoxia. Peripheral cyanosis is caused by circulatory disorders. Hypotension may be a result of tracheal deviation and impedance of venous return to the heart. It may also be the result of other problems such as a failing heart.

*Question: The nurse is reinforcing dietary instructions to a client diagnosed with systemic lupus erythematosus. Which dietary item would the nurse most instruct the client to avoid?*

*Answer: Steak* Rationale: The client with systemic lupus erythematosus 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.

*Question: The nurse is collecting data from a client recently diagnosed with paranoid schizophrenia. Which information best supports that the client is at risk for harming another individual?*

*Answer: Sibling stating, "I don't feel safe around my brother."* Rationale: The information that best supports that the client is at risk for harming another individual is a sibling stating, "I don't feel safe around my brother." This statement clearly identifies reluctance by the sibling to interact with the client based on fear for his or her safety. Paranoia is reflected in an individual's distrustful, suspicious attitude toward others that is unsupported by evidence. These characteristics result in an individual who is constantly looking for and reacting to imagined hostility from everyone encountered. This hypervigilance often results in aggressive, angry behavior directed toward others that may result in injury. Options 1 and 4 may be a result of aggressive behavior, but no clear connection exists to aggressive behavior toward others. The client statement, "I'll defend myself when I'm in danger," expresses a willingness to self-protect, but that in itself is not a clear connect

*Question: The nurse is caring for a postoperative adrenalectomy client. Which finding does the nurse specifically monitor for in this client?*

*Answer: Signs and symptoms of hypovolemia* Rationale: Following adrenalectomy, the client is at risk for hypovolemia. Aldosterone, secreted by the adrenal cortex, plays a major role in fluid volume balance by retaining sodium and water. A deficiency of adrenocortical hormones does not cause the signs/symptoms noted in options 1, 2, and 4.

*Question: The nurse is caring for a client with type 1 diabetes mellitus who is hyperglycemic. Which problem would the nurse consider first when planning care for this client?*

*Answer: Signs of dehydration* Rationale: Hyperglycemia can develop into ketoacidosis in the client with type 1 diabetes mellitus. Polyuria develops as the body attempts to get rid of the excess glucose, and the client will lose large amounts of fluid. Because glucose is hyperosmotic, fluid is pulled from the tissue. Nausea and vomiting can occur as a result of hyperglycemia and can lead to a loss of sodium and water. Water also is lost from the lungs in an attempt to get rid of excess carbon dioxide. The severe dehydration that occurs can lead to hypovolemic shock. Of the problems listed, dehydration is considered first.

*Question: The nurse is caring for a client with hypothyroidism who is overweight. Which food items would the nurse suggest to include in the plan?*

*Answer: Skim milk, apples, whole-grain bread, and cereal* Rationale: Clients with hypothyroidism may have a problem with being overweight because of their decreased metabolic need. They should consume foods from all food groups, which will provide them with the necessary nutrients; however, the foods should be low in calories. Skim milk, apples, whole-grain bread, and cereal is the only option containing food items that are low in calories.

*Question: The client with a diagnosis of acquired immunodeficiency syndrome has raised, dark purplish lesions on the trunk of the body. The nurse anticipates that which procedure will be done to confirm whether these lesions are due to Kaposi's sarcoma?*

*Answer: Skin biopsy* 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.

*Question: The client calls the health care clinic and tells the nurse that he was bitten by a tick. The client asks the nurse about the first signs of Lyme disease. The nurse would respond with which characteristic of stage 1 of Lyme disease?*

*Answer: Skin rash* Rationale: The hallmark of stage 1 of Lyme disease is the development of a skin rash within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a bull's-eye appearance (although some individuals do not develop a rash). The lesion enlarges up to 12 inches, and smaller lesions develop farther away from the original tick bite. It is important to note that in some individuals, a rash does not occur. In stage 1, most infected people develop flulike symptoms that last 7 to 10 days, and these symptoms may recur later. Options 2, 3, and 4 are not the first symptoms related to Lyme disease.

*Question: The nurse is caring for a client diagnosed as having a psychomotor retarded depression. Based on this condition, the nurse would expect to note which behavior in the client?*

*Answer: Slowed walking and talking* Rationale: Slowed walking and talking are characteristic behaviors of a retarded depression. The physical symptoms may be explained by the person's pessimistic view of the future, leading to the psychomotor inhibition/vegetative signs typically seen with depressed clients. Rapid pacing back and forth and verbalization of increasingly angry feelings may occur in any agitated state. Standing without moving for long periods is more likely seen in schizophrenia.

*Question: The nurse prepares to care for a client with inflamed joints and plans to use which item to maintain proper positioning for the inflamed joints?*

*Answer: Small pillows* Rationale: Small pillows, trochanter rolls, and splints will properly and safely maintain proper positions for rest of inflamed joints. Large pillows may cause positions of more flexion than indicated. A soft mattress and footboards will not be helpful to inflamed joints and should be avoided.

*Question: A client has undergone subtotal gastrectomy, and the nurse is preparing the client for discharge. Which item would be included when reinforcing instructions to the client about ongoing self-management?*

*Answer: Smaller, more frequent meals should be eaten.* Rationale: Following gastric surgery the client should eat smaller, more frequent meals to facilitate digestion. The client should resume activity gradually and should minimize stressors to prevent recurrence of symptoms. The client does require ongoing medical supervision and evaluation.

*Question: A physician tells the nurse that a potassium-retaining diuretic is being prescribed for the client with heart failure. The nurse reviews the health care physician's prescriptions expecting that which medication will be prescribed?*

*Answer: Spironolactone* Rationale: Spironolactone is a potassium-retaining diuretic that promotes sodium excretion while conserving potassium. Options 1, 2, and 4 identify diuretics that do not conserve potassium.

*Question: The nurse is inserting an indwelling urinary catheter in a client and begins to inflate the balloon when the client starts complaining of pain. Which action would the nurse take?*

*Answer: Stop inflating the balloon, allow the saline solution to drain into the syringe and advance the catheter further before reinflating the balloon* Rationale: The client's pain during inflation of the balloon may be related to the urinary catheter tip being located in the urethra and not the bladder. If the client begins to complain of pain with the inflation of an indwelling urinary catheter balloon, the nurse would allow the fluid injected into the balloon to drain back into the syringe attached to the balloon inflation port. Then, the nurse would advance the catheter further into the urethra to the bladder and then attempt to inflate the balloon. Therefore, option 4 is correct.

*Question: The nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. The nurse would take which appropriate action?*

*Answer: Stop the irrigation temporarily.* Rationale: If cramping occurs during colostomy irrigation, the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from infusion that is too rapid or is causing too much pressure. Increasing the height of the irrigation will cause further discomfort. The registered nurse does not need to be notified immediately. Medicating the client for pain is not the appropriate action.

*Question: A child has a basilar skull fracture. Which primary health care provider's prescription would the nurse question?*

*Answer: Suction via the nasotracheal route as needed.* Rationale: Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture. Because of the location of the injury, the suction catheter may be introduced into the brain. Fluids are restricted to prevent fluid overload. The child may require a urinary catheter for the accurate monitoring of I&O. An IV line is maintained to administer fluids or medications, if necessary.

*Question: A licensed practical nurse (LPN) is helping a registered nurse (RN) conduct an abdominal assessment. The LPN would assist the client into which most appropriate position?*

*Answer: Supine with the head raised slightly and the knees slightly flexed* Rationale: To perform an abdominal assessment, the client is placed in the supine position with the head raised slightly and the knees slightly flexed. This position will relax the abdominal muscles. If the head is raised to 45 degrees, the abdomen cannot be accurately assessed. The Sims' position is a side-lying position and does not adequately expose the abdomen for examination. Placing the head and feet flat results in the abdominal muscles becoming taut.

*Question: A client is scheduled for subtotal thyroidectomy. Potassium iodide is prescribed. The nurse understands that which outcome is the therapeutic effect of this medication?*

*Answer: Suppress thyroid hormone production.* Rationale: Potassium iodide solution is administered to hyperthyroid individuals in preparation for thyroidectomy to suppress thyroid function. Initial effects develop within 24 hours; peak effects develop in 10 to 15 days. Options 1, 2, and 3 are incorrect.

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

*Answer: Sweating and pallor* 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.

*Question: The nurse is reviewing the health history of a pregnant client. Which data noted in the client's health history would indicate a risk for spontaneous abortion?*

*Answer: Syphilis* Rationale: Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion. There is inconclusive evidence that genital herpes is a causative agent in abortion. Maternal age older than 40 years and diabetes mellitus are considered high risk factors in a pregnancy, increasing the risk for congenital malformations.

*Question: The nurse is caring for a new postoperative client and is monitoring the client for signs of shock. The nurse monitors for which signs of this postoperative complication?*

*Answer: Tachycardia, cold skin, and hypotension* Rationale: Postoperative hypotension or shock can have numerous causes such as inadequate ventilation, side effects of anesthetic agents or preoperative medications, and fluid or blood loss. The symptoms of shock include hypotension; tachycardia; cold, moist, pale, or cyanotic skin; and increased restlessness and apprehension.

*Question: The nurse is reinforcing home care instructions to a client following a gastric resection. The nurse would include which instruction to the client?*

*Answer: Take actions to prevent dumping syndrome.* Rationale: Dumping syndrome can occur in clients after gastric surgery and may occur as an early or late complication. Upper rather than lower gastrointestinal hemorrhage may also occur. A diet high in vitamin B12 will not prevent pernicious anemia because the client lacks intrinsic factor needed for absorption of the vitamin. Instead the client requires injections to supplement this vitamin. Iron supplements are necessary to help the absorption of parenteral vitamin B12.

*Question: The client's B-type natriuretic peptide (BNP) level is 691 pg/mL. Which intervention would the nurse institute when providing care for the client?*

*Answer: Take daily weights and monitor trends.* Rationale: BNP levels greater than 500 pg/mL indicate that heart failure is probable. Nursing measures are geared toward decreasing intravascular volume, decreasing preload, and decreasing afterload. Fluids increase intravascular volume, and elevating the legs above the level of the heart and positioning supine with the head of the bed at 30 degrees increase preload.

*Question: The nurse is planning adaptations needed for activities of daily living for a client with cardiac disease. The nurse would incorporate which instruction in discussion with the client?*

*Answer: Take in adequate daily fiber to prevent straining during a bowel movement.* Rationale: Standard instructions for a client with cardiac disease include, among others, lifestyle changes such as decreasing alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen program to prevent straining and constipation, and maintaining fluids and electrolytes. Increasing fluids to 3000 mL could lead to increased blood volume and an increased workload on the heart in the client with cardiac disease.

*Question: A primary health care provider has given a prescription for dietary iron supplements to the client with osteoporosis who has an iron deficiency anemia. The nurse suggests that the client do which to enhance compliance with therapy?*

*Answer: Take the medication following a meal.* Rationale: Iron preparations can be very irritating to the stomach and, to eliminate this problem from occurring, are best taken after a meal. They may also be taken 1 hour before a meal or between meals to enhance absorption. Primary health care provider preference will determine when the client would take the medication. The tablet is swallowed whole, not chewed. Because the client may experience constipation, the client should increase fluids and fiber in the diet to counteract this side effect of therapy.

*Question: A client with angina pectoris who was given a first dose of newly prescribed nitroglycerin sublingual tablets complains of slight dizziness and headache. The nurse takes which action first?*

*Answer: Takes the client's blood pressure.* Rationale: Clients receiving nitroglycerin for the first time are more likely to experience side effects of this coronary vasodilator, which includes a drop in blood pressure and headache. The nurse should take the blood pressure first. The nurse can then give acetaminophen for headache and document or report the side effects. The nurse should not ignore a client's concerns (option 2).

*Question: A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which important action in delivering holistic nursing care to this client?*

*Answer: Teaches about the effects of cocaine on the heart and offers referral for further help* Rationale: To provide the most holistic care, the nurse should meet the information needs of the client about the effects of cocaine on the heart and offer referral for further help with this possible addiction. Option 1 is not indicated and breaches the client's right to confidentiality. Option 2 is partially correct but does not meet the holistic needs of the client. Option 3 is incorrect because it "preaches" to the client.

*Question: The nurse having strong negative feelings toward a fellow employee tends to use the defense mechanism of projection. This nurse is likely to react to a disagreement with this fellow employee by which action?*

*Answer: Telling a friend that this employee hates her* Rationale: The nurse is likely to react to a disagreement with a fellow employee by telling a friend that this employee hates her. The defense mechanism of projection is an unconscious process that rejects emotionally unacceptable feelings to other people, objects, or situations and casts the blame onto another. Options 1 and 2 describe displacement in which the feeling is transferred to another person or object. Option 4 describes reaction formation in which a behavior that is directly opposite of a person's unacceptable trait is used.

*Question: The nursing student is developing information for use in a clinical conference about hearing disorders. In the presentation, the student plans to include the statement that the ear is housed in which bones of the skull?*

*Answer: Temporal* Rationale: The ear is housed in the temporal bone of the skull. It is not attached to the other bones listed in options 1, 2, or 4.

*Question: When checking a child's glossopharyngeal nerve function, the nurse would perform which data collection technique?*

*Answer: Test sense of sour or bitter taste on the posterior segment of the tongue.* Rationale: To test glossopharyngeal nerve function, the nurse would test the sense of sour or bitter taste on the posterior segment of the tongue. Having the child shrug the shoulders while applying mild pressure is the data collection technique for checking the accessory nerve. Having the child follow a light in the 6 cardinal positions of gaze is the technique for checking the oculomotor nerve. Testing the sense of sweet or salty taste on the anterior section of the tongue is the data collection technique for checking the facial nerve.

*Question: The nurse is assisting in preparing a plan of care for a client who is a Jehovah's Witness. The client has been told that surgery is necessary. Considering the client's religious preferences, the nurse would first verify with the client and then document which information?*

*Answer: The administration of blood and blood products is forbidden.* Rationale: In the Jehovah's Witness religion, surgery is not opposed, but the administration of blood and blood products is forbidden. Medication is an acceptable practice except if the medication is derived from blood products. Faith healing is forbidden in this religious group.

*Question: A client who has undergone a barium enema is being readied for discharge from the ambulatory care unit. Which instruction would the nurse include in instructions to the client?*

*Answer: The barium will cause the stools to be clay colored, but then the stool becomes normal colored.* Rationale: A barium enema is a diagnostic test used to determine if any pathology such as a tumor is in the lower colon. Discharge teaching following this procedure includes that the client should take a laxative to enhance passage of remaining barium from the bowel to prevent impaction. Stools change from clay color back to a normal color once all of the barium is eliminated. Any bleeding in the stools or diarrhea are not expected outcomes after a barium enema. There are no routine dietary restrictions after a barium enema.

*Question: The nurse is collecting data on a client admitted to the hospital with suspected carbon monoxide poisoning and notes that the client behaves as if intoxicated. The nurse uses this data to make which interpretation?*

*Answer: The behavior is likely the result of hypoxia.* Rationale: The client with carbon monoxide poisoning may appear intoxicated. This is the end result of hypoxia on the central nervous system (CNS). With carbon monoxide poisoning, oxygen cannot easily bind onto the hemoglobin, which is carrying strongly bound carbon monoxide. Because cerebral tissue has a critical need for oxygen, sustained hypoxia may yield this typical finding. For this reason, options 2, 3, and 4 are incorrect interpretations.

*Question: The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse would include which piece of information in discussions with the client?*

*Answer: The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.* Rationale: For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.

*Question: The nurse is caring for a hospitalized 5-year-old client. The nurse would recognize that which is normal for this child in this developmental stage?*

*Answer: The child believes the moon follows her.* Rationale: A 5-year-old child is in Jean Piaget's preoperational stage of egocentrism, such as believing the moon follows her. Being able to classify and sort facts describes Jean Piaget's concrete operational stage (7 to 11 years of age); thinking abstractly and considering others' points of view describe Jean Piaget's formal operational stage (11 years of age to adulthood).

*Question: An adolescent is admitted to the pediatric intensive care unit after suffering a seizure at school. She is alert on admission and tells the nurse that she has asthma and takes theophylline every day. She has a heart rate of 116 beats per minute with some shortness of breath. She also is complaining of nausea and vomiting. Which would the nurse suspect as the reason for the complaints that were gathered during the data collection process?*

*Answer: The child might have a toxic theophylline level.* Rationale: The early signs of theophylline toxicity are nausea, vomiting, tachycardia, headache, and irritability. Seizures indicate a toxicity level greater than 30 mcg/mL. A normal theophylline level is 10 to 20 mcg/mL. Severe dehydration, missed medication, and chronic seizure disorder are incorrect interpretations.

*Question: A client with a diagnosis of heart failure (HF) is preparing for discharge to home from the hospital. Which condition indicates the client is ready for discharge to home?*

*Answer: The client can verbally describe the daily medications, doses, and times to be administered.* Rationale: Medication therapy is an essential part of the therapeutic regimen for treating heart failure. The client must have a clear understanding of which medications to take and when. Options 1 and 3 can be carried out with the assistance of someone else. Option 2 may not be realistic for this client.

*Question: A client with a T4 spinal cord injury is to be monitored for autonomic dysreflexia (hyperreflexia). Which finding is indicative of this complication?*

*Answer: The client complains of a headache, and the blood pressure is elevated.* Rationale: Autonomic dysreflexia, also known as autonomic hyperreflexia, is a life-threatening syndrome. It is a cluster of clinical symptoms that results when multiple spinal cord autonomic responses discharge simultaneously. Exaggerated autonomic nervous system reactions to stimuli result in sudden hypertensive episodes with severe headache. The client may sweat profusely above the level of the cord lesion and complain of a stuffy nose. The knee-jerk response is not affected. Pupils may be dilated. Although a distended bladder is often the precipitating event, it is not indicative of dysreflexia, and not all clients with bladder distention exhibit dysreflexia.

*Question: The nurse is collecting data from a client with varicose veins. Which finding would the nurse identify as an indication of a potential complication associated with this disorder?*

*Answer: The client complains of leg edema, and skin breakdown has started.* Rationale: Complications of varicose veins include leg edema, skin breakdown, ulceration of the legs, trauma leading to rupture of a varicosity, deep vein thrombosis, or chronic insufficiency. The client with varicose veins may be distressed about the unsightly appearance of the varicosities. Complaints of heaviness and aching in the legs are common. Option 4 describes the Trendelenburg's test findings, which are indicative of varicose veins. In the test, the health care provider has the client lie down and elevate the legs to empty the veins. A tourniquet is then applied to occlude the superficial veins, after which the client stands and the tourniquet is released. If the veins are incompetent, they will quickly become distended due to backflow.

*Question: The nurse educator is describing the yin and yang theory of the ancient Chinese philosophy of Tao to a group of nursing students. The nurse educator explains that in this theory, foods are classified as hot and cold and are transformed into yin and yang energy when metabolized by the body. The nursing student understands this theory when the student makes which statement?*

*Answer: The client consumes cold foods when a "hot" illness is present.* Rationale: In the yin and yang theory, health is believed to exist when all aspects of the person are in perfect balance. Foods are classified as hot or cold and are transformed into yin and yang energy when metabolized by the body. 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.

*Question: The nurse notes that the client's physical examination record states the client's eyes moved normally through the six cardinal fields of gaze. The nurse makes which interpretation?*

*Answer: The client has normal ocular movements.* Rationale: The six cardinal fields of gaze track the client's ocular movements horizontally and diagonally to the left and right. These are the responsibility of the coordinated effort of cranial nerves III, IV, and VI. Peripheral and central vision are assessed during testing of visual acuity. The corneal reflex, or blink reflex, occurs with proper function of cranial nerve V (trigeminal nerve).

*Question: The nurse reinforces instructing a client how to use an incentive spirometer. Which observation would indicate the ineffective use of this equipment by the client?*

*Answer: The client is breathing through the nose.* Rationale: Incentive spirometry is not effective if the client breathes through the nose. The client should exhale, form a tight seal around the mouthpiece, inhale slowly, hold to the count of 3, and remove the mouthpiece to exhale. The client should repeat the exercise approximately 10 times every hour for best results.

*Question: The nurse is reinforcing instructions to a client about insertion of a Sengstaken-Blakemore tube. Which statement by the client indicates a need for further teaching?*

*Answer: The tube will be inserted through my mouth to my stomach.* Rationale: A Sengstaken-Blakemore tube may be used to control bleeding of esophageal varices when other interventions have been ineffective. It is inserted by the primary health care provider via the nose into the esophagus and stomach. The remaining option is incorrect.

*Question: A client with tetraplegia complains bitterly about the nurse's slow response to the call light and the rigidity of the therapy schedule. Which interpretation of this behavior would serve as a basis for planning nursing care?*

*Answer: The client is reacting to loss of control.* Rationale: Clients who feel a sense of control over their situation will adapt to their limitations more readily than those who think that they have lost control. Both of the client's complaints indicate a need for greater control. Clients should be offered an opportunity for input into scheduling and planning for staff response to their needs. For this reason, the client's complaints indicating depression, the need to adjust to institutional schedules, and the need to set limits on staff response time to call bells are incorrect interpretations of the client's behavior.

*Question: A client diagnosed with acquired immunodeficiency syndrome has a respiratory infection from Pneumocystis jiroveci and a client problem of impaired gas exchange written in the plan of care. Which indicates that the expected outcome of care has not yet been achieved?*

*Answer: The client limits fluid intake.* Rationale: The status of the client with a nursing diagnosis of impaired gas exchange would be evaluated against the standard outcome criteria for this nursing diagnosis. These would include that the client breathes easier, coughs 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.

*Question: A client with chronic obstructive pulmonary disease has anorexia secondary to fatigue and dyspnea while eating. The nurse determines that the client has followed the recommendations to improve intake if which action is taken?*

*Answer: The client plans to eat the largest meal of the day at a time when hungry.* Rationale: The client is taught to plan the largest meal of the day at a time when the client is most likely to be hungry. It is also beneficial to eat four to six small meals per day if needed. The client avoids dry foods, which are hard to chew and swallow. The client also avoids milk and chocolate, which have a tendency to thicken saliva and secretions. Finally, the client should avoid the use of caffeine, which contributes to dehydration by promoting diuresis.

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

*Answer: The client receiving nasogastric suction* Rationale: Potassium-rich gastrointestinal (GI) fluids are lost through GI suction, which places the client at risk for hypokalemia. The client with intestinal obstruction, Addison's disease, or metabolic acidosis is at risk for hyperkalemia.

*Question: The nurse is collecting data from a client who has recently been violently raped. Which data indicates that the client is experiencing rape-trauma syndrome?*

*Answer: The client reports nightmares involving being stalked when alone at night.* Rationale: When the client reports nightmares involving being stalked when alone at night indicates that the client is experiencing rape-trauma syndrome. This represents the presence of nightmares and a phobic reaction and thus reflects the most severe life-affecting symptom. Rape-trauma syndrome is a complex, stress-related reaction in which the victim develops symptoms that reflect abnormal and/or extended reactions to the event. Becoming tearful during the interview and stating, "I didn't deserve being hurt like this," represent healthy emotional responses to the event and are normal reactions to any acute traumatic event. Option 3 shows the client may be experiencing a misplaced sense of guilt regarding the rape, but this does not represent the most life-affecting symptom of rape-trauma syndrome.

*Question: A client is being prepared for electroconvulsive therapy (ECT). The nurse's plan of care for the night before ECT treatment would include which intervention?*

*Answer: The client shampoos and dries the hair, freeing it of all hair spray and creams.* 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. Although the client is NPO for 6 to 8 hours before treatment, the 18 to 24 hours identified in option 3 is not necessary. Some hospitals place inpatient clients on NPO status at midnight before ECT in the morning. Clients who are on antiseizure medications would continue to take the medication as prescribed. If NPO, they can take the medication with a sip of water. Option 2 is incorrect; visitors and activity are not limited. In addition, obtaining informed consent, minimization of client and family anxieties and fears concerning the procedure, and keeping the client free from injury are treatment goals for the client undergoing ECT.

*Question: A postoperative client is using an incentive spirometer. The nurse observes the client inhale slowly with the mouthpiece placed between the teeth with the lips closed. The client inhales to the preset inspiratory goal and holds the breath for about 3 seconds, then exhales slowly. The client takes one breath and returns the incentive spirometer to the bedside. Based on this observation, which interpretation would the nurse make?*

*Answer: The client should be repeating the sequence 10 to 20 times in each session.* Rationale: Incentive spirometer devices use a concept of sustained maximal inspiration. Each device has a means of setting an inspiratory goal. Correct use requires a spontaneous, slow, voluntary, deep breath. When full inhalation is reached, the breath is held for at least 3 seconds. This sequence is repeated 10 to 20 times an hour. Incentive spirometer exercises are most effective when used every hour while the client is awake.

*Question: The nurse is caring for a client with a head injury and is monitoring the client for signs of increased intracranial pressure (ICP). Which sign, if noted in the client, would the nurse report immediately?*

*Answer: The client vomits.* Rationale: The client with a closed head injury is at risk of developing increased ICP. This is evidenced by symptoms such as headache, dizziness, confusion, weakness, and vomiting. Tiredness, pain, and dizziness are expected occurrences. Vomiting may be an indication of increased ICP, requiring notification of the registered nurse and primary health care provider.

*Question: A client diagnosed with hepatic encephalopathy is receiving lactulose. The nurse determines that the medication is effective if which finding is observed?*

*Answer: The client who was previously oriented to person only can now state name, year, and present location.* Rationale: Hepatic encephalopathy produces alterations in level of consciousness because of the liver's inability to metabolize and cleanse the blood of ammonia and mercaptans. Lactulose is administered to decrease serum ammonia levels by facilitating movement of ammonia from the blood to the stool. Effectiveness is evident if the client has an improvement in level of consciousness.

*Question: The nurse is reading the primary health care provider's (PHCP's) progress notes in the client's record and sees that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss?*

*Answer: The client with a fast respiratory rate* Rationale: Sensible losses are those that the person is aware of, such as those that occur through wound drainage, gastrointestinal (GI) tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs.

*Question: The use of peritoneal dialysis for the treatment of chronic kidney disease would be contraindicated for which client?*

*Answer: The client with chronic obstructive pulmonary disease (COPD)* Rationale: Peritoneal dialysis requires instillation of approximately 2 L of a dialysate solution into the peritoneal space. This solution remains in the peritoneal space for a prescribed amount of time usually from 4 to 10 hours. This is known as the "dwell time." Although this fluid remains in the peritoneal space, it causes upward displacement of the diaphragm resulting in decreased lung expansion. A client with COPD would be at high risk for developing respiratory distress if the respiratory system were to be further compromised by the instillation of the dialysate solution and the resulting upward displacement of the diaphragm. Cataracts, varicose veins, and type 2 diabetes mellitus are not contraindications for peritoneal dialysis.

*Question: The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at the least likely risk for the development of third-spacing?*

*Answer: The client with diabetes mellitus* Rationale: Fluid that shifts into the interstitial space 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 include liver or kidney disease, major trauma, burns, sepsis, wound healing, major surgery, malignancy, malabsorption syndrome, malnutrition, alcoholism, and older age.

*Question: The use of peritoneal dialysis for the treatment of chronic kidney disease would be contraindicated for which client?*

*Answer: The client with severe emphysema* Rationale: Peritoneal dialysis requires the instillation of approximately 2 L of a dialysate solution into the peritoneal space. This solution remains in the peritoneal space for a prescribed amount of time, usually from 4 to 10 hours. This is known as the "dwell time." While this fluid remains in the peritoneal space, it causes upward displacement of the diaphragm resulting in decreased lung expansion. A client with severe emphysema would be at high risk for developing respiratory distress if the respiratory system were to be further compromised by the instillation of the dialysate solution and the resulting upward displacement of the diaphragm. Peritoneal dialysis is not contraindicated in the clients noted in options 1, 3, and 4.

*Question: The nurse is observing a client with chronic obstructive pulmonary disease (COPD) performing the pursed-lip breathing technique. Which observation by the nurse would indicate accurate performance of this breathing technique?*

*Answer: The client's exhalation is twice as long as inhalation.* Rationale: Prolonging the time for exhaling reduces air trapping because of airway narrowing or collapse in chronic obstructive pulmonary disease. Tightening the abdominal muscles aids in expelling air. Exhaling through pursed lips increases the intraluminal pressure and prevents the airway from collapsing.

*Question: The nurse assists in developing a plan of care for a client admitted to the hospital with an acute myocardial infarction (MI). Which is the priority problem during the acute phase?*

*Answer: The client's pain* Rationale: Pain is the prevailing symptom of acute MI. Relief of pain is a priority. Pain stimulates the autonomic nervous system, increasing myocardial oxygen demand. Although options 1, 3, and 4 are also appropriate problems, the presence of pain is the priority.

*Question: A client who had a lung resection for cancer has been told that bone metastasis has occurred. The client is considering megavitamin and diet therapy because the original surgery did not provide a cure. The client asks the nurse for an opinion of these therapies. In formulating a response, the nurse incorporates which concepts?*

*Answer: The client's right to autonomy and the nurse's obligation to behave ethically* Rationale: The client has the right to autonomy, or the exercise of personal choice. At the same time, the nurse has the obligation to behave ethically. Some unconventional cancer treatments have not been proven to be effective, may be toxic to the client, and may be extremely expensive. The nurse balances the client's right to self-determination with the obligation to share with the client knowledge about the ineffectiveness of these methods. Privacy is the right of a client to be free from intrusion by someone into their own personal affairs. Justice is the ethical principle of treating people fairly.

*Question: A 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 which?*

*Answer: The development of a vesicovaginal fistula* Rationale: A vesicovaginal fistula is a fistula connection that occurs between the bladder and the vagina. The fistula is an abnormal opening between these two body parts, and if this occurs, the client may experience drainage of urine through the vagina. Rupture of the bladder would cause pain. Stress is experienced in other ways. Altered perineal sensation would not be as specific as voiding through the vagina.

*Question: The nurse is providing emotional support to a client who experienced a spontaneous abortion. The nurse can best assist the client by planning care that focuses on which psychosocial issue?*

*Answer: The feelings of guilt that is often associated with grief* Rationale: Nurses must consider the psychological needs of the family experiencing spontaneous abortion. Grief often includes feelings of guilt. The grieving process is individual and may last a year or longer. The amount of pain and discomfort is important, but this is a physiological concern. It is not appropriate to focus on the client's ability to have other children.

*Question: A client is admitted to the nursing unit following a lobectomy. The nurse caring for the client notes that, in the first hour after admission, the chest tube drainage was 75 mL. During the second hour, the drainage dropped to 5 mL. Which finding does this indicate?*

*Answer: The tube may be occluded.* Rationale: Chest tube drainage in the first 24 hours following thoracic surgery may total 500 to 1000 mL. The sudden drop in drainage between the first and second hour indicates that the tube is possibly occluded and requires further evaluation. Options 1, 3, and 4 are incorrect interpretations.

*Question: The nurse is providing education to a client with gestational diabetes who was recently placed on insulin therapy. Which information would the nurse tell the client about insulin needs during the second and third trimesters of pregnancy?*

*Answer: The insulin needs will increase.* Rationale: Insulin needs in the second and third trimesters of pregnancy increase. Insulin dosages must be adjusted to balance changes in caloric intake and other factors that can increase insulin needs (e.g., illness, trauma, stress, adolescent growth spurt, pregnancy after the first trimester). Stating that the insulin needs will decrease or remain unchanged, or that the client will require both short- and long-term insulin therapy, is incorrect.

*Question: The parent of a client taking atomoxetine asks how the medication works to control attention deficit hyperactivity disorder (ADHD). The nurse's correct explanation is based on which fact?*

*Answer: The medication inhibits norepinephrine (NE) transport and reuptake.* Rationale: Atomoxetine is a selective inhibitor of NE reuptake and hence causes NE to accumulate at synapses. Options 1, 2, and 4 are not actions of atomoxetine. Antidepressants work by selective serotonin reuptake inhibition. Increasing dopamine and decreasing acetylcholine are important in the treatment of Parkinson's disease.

*Question: The mother of a premature baby asks the nurse why the baby is receiving a caffeine-type medication. Which answer would the nurse give to the mother?*

*Answer: The medication primarily decreases the number of apnea occurrences.* Rationale: Premature infants may experience prolonged apnea (lasting 15 seconds or more) along with bradycardia. Hypoxemia and neurological damage may result. Caffeine and other methylxanthines can reduce the number and duration of apnea episodes and promote a more regular pattern of breathing. Caffeine does not increase hunger; thus, option 1 is incorrect. Options 2 and 3 are incorrect because, although caffeine does increase urinary output and stimulate tachycardia, these are not the reasons that the medication is administered to the preterm infant; in addition, these would be considered side effects of the medication.

*Question: The nurse is assisting in planning a teaching session with a client diagnosed with urethritis caused by infection with Chlamydia. The nurse would plan to include which point in the teaching session?*

*Answer: The most serious complication of this infection is sterility.* Rationale: The most serious complication of chlamydial infection is sterility. The infection can be prevented by the use of latex condoms. It may be treated with doxycycline or with azithromycin. All sexual partners during the 30 days before diagnosis should be notified, examined, and treated as necessary.

*Question: The nurse observes a mother giving an oral iron supplement to her 6-year-old child with iron deficiency anemia. Which action by the mother indicates the need for further teaching?*

*Answer: The mother administered the iron with milk.* Rationale: Milk may affect absorption of the iron. Vitamin C increases the absorption of iron by the body. The mother should be instructed to administer the medication with a citrus fruit or a juice that is high in vitamin C. Water will not assist in absorption.

*Question: A 1-year-old child is seen in the primary health care provider's office with complaints of an elevated temperature that began the previous evening. When gathering subjective data from the mother, the nurse notices that which sign/symptom would most likely indicate the child has acute otitis media?*

*Answer: The mother states the child had purulent discharge from the ear last night.* Rationale: Subjective data are what the mother tells the nurse. Therefore, option 4 is correct because the mother is describing the child's ear drainage that occurred last night. The other options are considered objective data, which are observations that the nurse makes.

*Question: The nurse is assisting a client who underwent radical neck surgery to get out of bed. How does the nurse provide support to this client who is afraid to move the head?*

*Answer: The nurse places a hand behind the client's head.* Rationale: The nurse provides the most support to the surgical site by placing a hand behind the client's head. Options 3 and 4 involve little assistance or support by the nurse. Option 1 is unnecessary and could occlude a tracheostomy if one is in place.

*Question: The nurse reviews the nursing care plan of an older client with diabetic neuropathy of the lower extremities as a result of type 2 diabetes mellitus. The nurse plans care knowing that which problem has the highest priority for this client?*

*Answer: The possibility of injury as a result of decreased sensation in the legs and feet* Rationale: The client with diabetic neuropathy of the lower extremities has diminished ability to feel sensations in the legs and feet. This client is at risk for tissue injury and for falls as a result of this nervous system impairment. Thus the highest priority problem is option 4, which can be determined using Maslow's Hierarchy of Needs Theory. Options 2 and 3 represent problems that are more psychosocial in nature and as such are secondary needs using Maslow's theory. Option 1 is incorrect because intermittent claudication is not directly associated with diabetic neuropathy.

*Question: An older client with a history of hyperparathyroidism and severe osteoporosis is hospitalized. The nurse caring for the client plans to address which problem first?*

*Answer: The possibility of injury* Rationale: The client with severe osteoporosis as a result of hyperparathyroidism is at risk for injury as a result of pathological fractures that can occur from bone demineralization. The client may also have a risk for constipation from the disease process, but this is a lesser priority than client safety. The client may or may not have urinary elimination problems depending on other factors in the client's history. There is no information in the question to support whether the client needs teaching.

*Question: A client who is 36 hours post-myocardial infarction has ambulated for the first time. The nurse determines that the client best tolerated the activity if which observation is made?*

*Answer: The preactivity pulse rate is 86 beats per minute; the postactivity pulse rate is 94 beats per minute.* Rationale: The nurse checks vital signs and the level of fatigue with each activity. The client is not tolerating the activity if systolic BP drops more than 20 mm Hg, if the pulse rate increases more than 20 beats per minute, or if the client experiences dyspnea or chest pain. In addition, a significant drop in BP can indicate orthostatic hypotension, which is an abnormal condition. Cool, diaphoretic skin is a sign of some degree of cardiovascular compromise.

*Question: A client reports the chronic use of nasal sprays. The nurse reinforces instructions to this client about which piece of information related to chronic use of nasal sprays?*

*Answer: The protective mechanism of the nose may be damaged.* Rationale: The protective mechanisms of the nose may be altered with the chronic use of nasal sprays. Fungal infections occur with oral inhalers but not nasal sprays. Nosebleeds are uncommon. The client should not double-dose medications to increase their effect.

*Question: A bone marrow aspiration is scheduled for a client suspected of having leukemia. What intervention does the nurse anticipate will be done to protect the aspiration site and client from becoming infected?*

*Answer: The site will be cleansed thoroughly with an antiseptic and allowed to air dry before the procedure.* Rationale: A bone marrow aspiration is done on a client suspected of having leukemia to establish the diagnosis and the specific type. The bone marrow is taken from the sternum or iliac crest. Before bone marrow aspiration, the site is cleansed with an antiseptic solution and allowed to air dry. This helps reduce the number of bacteria on the skin and decreases the risk of infection from the procedure. The primary health care provider will use strict sterile technique, not clean technique, to perform the procedure. Antipyretic medication may be given for comfort to a febrile client but this will not affect the risk for infection. A local anesthetic will be administered, but this will decrease the pain involved with the procedure and not decrease the risk for infection.

*Question: The nurse checks a client's skin turgor and documents that the client exhibits normal fluid balance. Which statement correctly describes what the nurse has documented?*

*Answer: The skin when pinched immediately fell back to normal when released.* Rationale: Turgor (degree of elasticity) is checked by gently pinching up the skin over the abdomen, forearm, sternum, forehead, or thigh. In a person with normal fluid balance, the skin when pinched will immediately fall back to normal when released. If a fluid deficit is present, the skin may remain elevated or tented for several seconds after the pinch.

*Question: After pleading for information, a visitor learns from the nurse that his friend (the client) has died from human immunodeficiency virus (HIV). Inadvertently, the visitor informs the client's family about the client's HIV diagnosis. Which is the most serious potential consequence of possible damages caused by these events?*

*Answer: The state convicts the nurse for invasion of privacy.* Rationale: Nursing ethics include the nurse's promise to perform care with nonmaleficence and to maintain client privacy. The nurse's duty was to avoid releasing information about a client to others; however, the nurse released personal client information to a third party. This is an action that is a violation of nursing ethics, clients' rights, and civil law. As a result, the nurse could face civil action for invasion of privacy if the family can prove damages. The family can confront the friend about the veracity of the statement, the agency can issue an internal reprimand against the nurse, and the state board can issue an ethical reprimand; however, option 3 is the most serious consequence of the nurse's action because it most likely involves an award for the family.

*Question: The nurse is assisting to administer acetylcysteine to a client admitted with acetaminophen overdose. Before this medication is given, the nurse ensures which factor is in place?*

*Answer: The stomach is empty from emesis or lavage.* Rationale: Acetylcysteine can be given orally or by nasogastric tube to treat acetaminophen overdose, or it may be given by inhalation for use as a mucolytic. Before giving the medication as an antidote to acetaminophen overdose, the nurse ensures that the client's stomach is empty through emesis or gastric lavage. The solution is diluted in cola, water, or juice to make the solution more palatable. It then is administered orally or by nasogastric tube.

*Question: The nurse is caring for a client with a diagnosis of chronic kidney disease who is receiving dialysis. Epoetin alfa has been prescribed for the client. How would the nurse prepare to administer the medication?*

*Answer: The subcutaneous route* Rationale: Epoetin alfa is dispensed for subcutaneous or intravenous injections. Vials should not be shaken because epoetin alfa is a protein that can be denatured by agitation. Epoetin alfa is not to be mixed with other medications. The medication should be refrigerated but should not be frozen.

*Question: A primary health care provider has prescribed oxygen as needed for a 10-month-old infant with heart failure (HF). In which situation would the nurse administer the oxygen to the child?*

*Answer: When drawing blood for electrolyte levels* Rationale: Oxygen administration may be prescribed for the infant with HF for stressful periods, especially during bouts of crying or invasive procedures. Drawing blood is an invasive procedure that would likely cause the child to cry.

*Question: The nurse documents that the client has a stage 2 pressure injury on the decubitus area. Which describes a stage 2 pressure injury?*

*Answer: The ulcer is superficial and characterizes an abrasion.* Rationale: In a stage 1 pressure injury, the skin is intact; the area is red and does not blanch with external pressure. In a stage 2 pressure injury, the skin is not intact; the ulcer is superficial and may be characterized as an abrasion, blister, or shallow crater. In stage 3, skin loss is full thickness, and the skin has a deep crater-like appearance. In stage 4, skin loss is full thickness with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures.

*Question: A client had thoracic surgery 2 days ago and has a chest tube in place connected to a closed chest tube system. The nurse notes continuous bubbling in the water seal chamber. The nurse determines which?*

*Answer: There is a leak in the system that requires immediate investigation and correction.* Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates that a leak exists somewhere in the system and air is being sucked into the apparatus. The nurse needs to assess the system and initiate corrective action that may include notifying the primary health care provider. Bubbling may occur intermittently with the evacuation of a pneumothorax, but it should not be continuous, especially with a client who had surgery 2 days earlier. Hemothorax results in accumulation of drainage in the collection chamber but does not cause bubbling in the water seal chamber. Application of suction to the system causes bubbling in the suction control chamber but not the water seal chamber.

*Question: The nurse notes redness, warmth, and a yellowish drainage at the insertion site of a central venous catheter in a client receiving parenteral nutrition. These findings indicate which potential complication?*

*Answer: There may be an infection at the central catheter site, which can lead to septicemia.* Rationale: Redness, warmth, and purulent drainage are signs of an infection, not an allergic reaction. Infiltration causes the surrounding tissue to become cool and pale.

*Question: A client with suspected opioid overdose has received a dose of nalmefene. The client subsequently becomes restless, starts to vomit, and complains of abdominal cramping. The blood pressure increases from 110/72 to 160/86 mm Hg. The nurse provides emotional support and reassurance while administering care to the client, knowing which statement is true?*

*Answer: These are signs of opioid withdrawal.* Rationale: Signs of opioid withdrawal include increased temperature and blood pressure, abdominal cramping, vomiting, and restlessness. They can occur at any time, from a few minutes to a few hours after administration of nalmefene, depending on the opioid involved, the degree of dependence, and the dose of nalmefene. Options 1, 3, and 4 are incorrect interpretations.

*Question: The nurse in the postpartum unit is assigned to care for a client who delivered a full-term, healthy baby. The nurse receives the report and is told that the mother had lost 500 mL of blood during the delivery. When checking the vital signs, the nurse notes that the woman's pulse is 90 beats per minute and is weak and thready. This finding would indicate which accurate interpretation to the nurse?*

*Answer: This may be a sign of hemorrhage or shock.* Rationale: A pulse range of 50 to 70 beats per minute is normal in a mother following delivery and may occur for the first 1 to 2 days after delivery. A weak and thready or rapid pulse is abnormal and may be a sign of hemorrhage or shock. Particular attention should be paid to the pulse rate when there has been a blood loss of 500 mL or greater during or after delivery. Normal pulse rate following delivery, excitement about the delivery, and a normal pulse rate following a loss of 500 mL of blood are incorrect interpretations.

*Question: A client has a newly fractured fibula that is plaster casted in the emergency department. Because the client will need to use crutches, the nurse plans to teach the client which crutch-walking gait before discharge?*

*Answer: Three-point gait* Rationale: The nurse teaches the client the three-point gait of crutch walking. The client with a new fracture that is casted with a plaster cast needs to avoid weight bearing. The three-point gait identifies a gait that allows non-weight bearing on the affected extremity. The client should not bear weight on the affected extremity until the primary health care provider evaluates the client on the follow-up examination.

*Question: A client is taking large doses of acetylsalicylic acid for rheumatoid arthritis. The nurse tells the client to report which signs/symptoms of ototoxicity?*

*Answer: Tinnitus, hearing loss, dizziness, ataxia* Rationale: Ototoxicity is damage to the eighth cranial nerve, which is responsible for 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.

*Question: The nurse is observing a nursing student preparing to suction a pediatric client through a tracheostomy. The nurse intervenes if the student verbalizes which intention?*

*Answer: To apply continuous suction when inserting the catheter* Rationale: The nurse would not use continuous suction on the catheter during insertion because this could cause tissue trauma; suction is applied only when withdrawing the catheter. Options 1, 3, and 4 represent correct interventions regarding this procedure.

*Question: The nurse is reviewing the preoperative prescriptions of a client with a colon tumor who is scheduled for abdominal perineal resection. The nurse notes that the primary health care provider has prescribed neomycin sulfate orally for the client. Which is the rationale for prescribing this medication?*

*Answer: To decrease the bacteria in the bowel* Rationale: Intestinal anti-infectives such as neomycin are administered to decrease the bacteria in the bowel. To reduce the risk of contamination at the time of surgery, the surgeon may prescribe that the bowel is emptied and cleansed. Laxatives and enemas are given to empty the bowel.

*Question: The nursing student is asked about the medication latanoprost and how this medication helps glaucoma. The student responds correctly by identifying which as the medication's mechanism of action?*

*Answer: To facilitate the outflow of aqueous humor* Rationale: Latanoprost, an analogue of prostaglandin F2 alpha, is used to treat glaucoma and is applied topically to lower intraocular pressure (IOP) in clients with open-angle glaucoma and ocular hypertension. Latanoprost lowers IOP by facilitating aqueous humor outflow, in part by relaxing the ciliary muscle. Sympathomimetics and beta-blocker eye medications reduce the production of aqueous humor.

*Question: Acetylsalicylic acid is prescribed for a client before a percutaneous transluminal coronary angioplasty (PTCA). When the nurse takes the acetylsalicylic acid to the client, the client asks the nurse about its purpose. What is the purpose of the acetylsalicylic acid?*

*Answer: To prevent the formation of clots* Rationale: Before PTCA, the client is usually given an anticoagulant, commonly acetylsalicylic acid, to help reduce the risk of occlusion of the artery during the procedure. Pain, fever, and inflammation are unrelated to the purpose of administering acetylsalicylic acid to this client.

*Question: A primary health care provider prescribes an intravenous fat emulsion solution for a client who will be receiving parenteral nutrition (PN). The nurse would explain to the client the administration of the fat emulsion solution is for which reason?*

*Answer: To provide essential fatty acids and additional calories* Rationale: Clients receiving their nutrition parenterally for a prolonged period of time are at risk for developing essential fatty acid deficiency. Fat emulsions are given to meet client nonprotein caloric needs and provide essential fatty acids, which cannot be met by PN administration alone. Preventing fluid volume deficit, adding bulk to the client's system, and increasing the amount of fluid intake are incorrect.

*Question: The nurse is preparing a client with a bowel tumor for surgery. The primary health care provider has informed the client that the surgery is palliative in the treatment of the tumor. Which rationale is the reason to perform this type of surgery?*

*Answer: To reduce pain* Rationale: Palliative surgery that can benefit the client with cancer and improve quality of life includes procedures that reduce symptoms including pain, relieve airway obstructions, relieve obstruction in the gastrointestinal and urinary tracts, relieve pressure on the brain and spinal cord, and prevent hemorrhage. Palliative surgery is not curative, does not reduce risk for metastasis, or improve appearance (cosmetic surgery).

*Question: Somatrem is administered to a client with pituitary dwarfism. Which is the expected therapeutic effect of this medication?*

*Answer: To stimulate linear growth* Rationale: Somatrem is a growth stimulator used in the long-term treatment of growth failure resulting from growth hormone deficiency. It stimulates linear growth and increases the number and size of muscle cells and red cell mass. It affects carbohydrate metabolism by antagonizing the action of insulin, increasing mobilization of fats, and increasing cellular protein synthesis.

*Question: The nurse reinforces instructions to a pregnant client regarding the administration of iron. The nurse determines that the teaching is effective if the client states that she will take the iron with which food items?*

*Answer: Tomato juice* Rationale: Foods containing ascorbic acid (vitamin C), such as tomato juice, may increase absorption of iron. Additionally, absorption of iron is affected by many substances. Calcium and phosphorus in milk and tannin in tea decrease iron absorption. Water will not act to increase the absorption of the iron.

*Question: A hospitalized client is dyspneic and has been diagnosed with left pneumothorax by chest x-ray. Which sign or symptom observed by the nurse clearly indicates that the pneumothorax is rapidly worsening?*

*Answer: Tracheal deviation to the right* Rationale: A pneumothorax is characterized by distended neck veins, displaced point of maximal impulse (PMI), subcutaneous emphysema, tracheal deviation to the unaffected side, decreased fremitus, and worsening cyanosis. The client could have pain with respiration even with a milder pneumothorax. The increased intrathoracic pressure causes the blood pressure to fall, not rise. A respiratory rate of 18 breaths per minute is within the normal range.

*Question: The nurse in the newborn nursery is preparing to feed a non-breastfeeding newborn a first feeding of sterile water. During the feeding, the newborn suddenly begins to cough, choke, and become cyanotic. Based on these signs, the nurse might suspect that the newborn has which condition?*

*Answer: Tracheoesophageal fistula* Rationale: The first feeding a non-breastfeeding newborn receives is either sterile water or a tiny amount of colostrum to assess whether the newborn might have one of the tracheoesophageal (TE) conditions. Although sterile water or colostrum is more easily absorbed and causes less aspiration than formula, the newborn with a suspected TE fistula condition will cough and choke during feedings. These signs are not associated with the conditions noted in options 1, 3, or 4.

*Question: The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level would be noted with which condition?*

*Answer: Traumatic burn* Rationale: A serum potassium level that exceeds 5.0 mEq/L is indicative of hyperkalemia. Clients who experience the cellular shifting of potassium, as in the early stages of massive cell destruction (i.e., with trauma, burns, sepsis, or metabolic or respiratory acidosis), are at risk for hyperkalemia. The client with Cushing's syndrome or diarrhea and the client who has been overusing laxatives are at risk for hypokalemia.

*Question: The nurse is assisting in teaching a series of classes on maintaining a healthy pregnancy. The goal for the class is "The pregnant woman will verbalize measures that may prevent physical traumatic conditions distressing to the fetus." Based on this goal, which topic would be a part of the teaching plan for this class?*

*Answer: Travel precautions and use of shoulder seat belts* Rationale: Placental separation as a result of uterine distortion can occur from trauma, such as in car accidents, and decreases or shuts off uteroplacental circulation. Partial placental separation will also result in fetal distress, with the amount of distress depending on the degree of separation. Complete separation leads to sudden severe fetal distress followed by fetal death. Use of the shoulder seat belt decreases the risk of placental separation by preventing the traumatic flexion of the woman's body from sharp braking or impact, if an accident occurs. Although consuming over-the-counter medications, exposure to fetotoxic substances in the workplace, and secondary effects of smoking are important teaching points, they are not related to physical trauma conditions affecting the fetus.

*Question: The nurse is working in the emergency department and is caring for a child who has been diagnosed with epiglottitis. Which is an indication that the child may be experiencing airway obstruction?*

*Answer: Tripod positioning and dyspnea* Rationale: Clinical manifestations that are suggestive of airway obstruction include tripod positioning (leaning forward supported by the hands and arms with the chin thrust out and the mouth open), nasal flaring, tachycardia, retractions, and dyspnea. Epiglottitis is the bacterial form of croup with symptoms of a high fever, sore throat, and an absence of spontaneous cough.

*Question: A primary health care provider asks the nurse to obtain a Salem sump tube for gastric intubation for a client with a bowel obstruction. The nurse would select which tube from the unit storage area?*

*Answer: Tube with a lumen and an air vent* Rationale: A Salem sump tube is used commonly for gastric intubation and has a large suction lumen and a small air vent. A Sengstaken-Blakemore tube is a tube used for gastroesophageal bleeding and has a balloon that controls bleeding. A Miller-Abbott tube is a long double-lumen tube used to drain and decompress the small intestine. Option 3 describes a Levin tube. A Levin tube does not have an air vent but is used for the same functions as a Salem sump tube.

*Question: After a tonsillectomy, the child begins to vomit bright red blood. Which is the initial nursing action?*

*Answer: Turn the child to the side.* Rationale: After a tonsillectomy, if bleeding occurs, the child is turned to the side and the RN or PHCP is notified. An NPO status would be maintained, and an antiemetic may be prescribed; however, the initial nursing action would be to turn the child to the side.

*Question: The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates and is unable to obtain any residual tube feeding. Which action would the nurse take next?*

*Answer: Turn the client to the side and attempt to aspirate again.* Rationale: The nurse aspirates before administering an intermittent tube feeding to determine how well the formula is being absorbed. All of the tube feeding may have been absorbed, but the end of the tube may be up against the stomach wall. In this case the nurse has the client turn to move the tube and attempts to aspirate again to check for residual. Depending on the type of tube (such as a gastrostomy tube), the nurse may be able to safely administer the tube feeding without obtaining aspirated residual to note characteristics or pH to verify correct placement of the tube. The next action is not to notify the primary health care provider, administer the tube feeding slowly, or auscultate bowel sounds. These actions may be reasonable, but none of them is the next action of the nurse.

*Question: The nurse has completed nutritional counseling with an overweight client about weight reduction to modify the risk for coronary artery disease (CAD). The nurse would determine the teaching is successful if the client states that which weight loss goal is safe?*

*Answer: Two pounds per week* Rationale: Most people, including the mildly and moderately obese, can lose only about 2 pounds per week of weight from fat loss. Weight loss beyond that level is probably due to protein and water loss alone.

*Question: Glucagon hydrochloride injection would most likely be prescribed for which disorder?*

*Answer: Type 1 diabetes mellitus* Rationale: Glucagon hydrochloride is a medication that can be administered subcutaneously or intramuscularly. It is prescribed to stimulate the liver to release glucose when a client is experiencing hypoglycemia and unable to take oral glucose replacement. It is important to teach a person other than the client how to administer the medication because the client's symptoms may prevent self-injection. Therefore, options 1, 2, and 4 are incorrect.

*Question: The primary health care provider has prescribed amantadine for a client admitted to the hospital for hip replacement surgery. The nurse recognizes that this medication was prescribed because the client's history showed recent exposure to which?*

*Answer: Type A influenza* Rationale: Antiviral medications may be used in specific client populations. If a person is known to be at high risk for influenza and has been exposed to type A influenza, the provider may choose to provide prophylaxis with an antiviral agent such as amantadine. Amantadine would not be prescribed to prevent bronchitis, pneumonia or tuberculosis.

*Question: The nurse is collecting data from a child with a diagnosis of diabetes insipidus. Which clinical finding is consistent with this diagnosis?*

*Answer: Urinary output is increased.* Rationale: A child with a diagnosis of diabetes insipidus experiences increased urinary output, increased serum sodium, and decreased urine specific gravity. Decreased urinary output, decreased serum sodium, and increased urine specific gravity are consistent with a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH).

*Question: The nurse is assessing a client with suspected acute kidney injury. Which finding would support a diagnosis of acute intrarenal failure?*

*Answer: Urine analysis positive for casts and cellular debris* Rationale: Acute tubular necrosis is responsible for 90% of acute intrarenal failure cases, and in these cases, the tubular epithelium is destroyed. The debris from the destruction of the epithelial cells can be detected in the urinalysis of a client with acute intrarenal failure. The BUN-to-creatinine ratio is normally 10:1. When the BUN-to-creatinine ratio is greater than 20:1, it generally indicates acute prerenal failure. Option 4 has a BUN-to-creatinine ratio of 40:1 indicating acute prerenal failure. However, if the client were to have elevated BUN and creatinine levels, but the ratio remains 10:1, this generally indicates intrarenal failure. A urine output of 30 mL/hr is an adequate urine output, and this does not indicate that the client has acute kidney injury. Ureteral calculi place the client at risk for postrenal failure.

*Question: The nurse working in a pediatric clinic is preparing to administer childhood vaccinations to a 15-month-old child. Which vaccine would be added to the child's routine immunizations at this time because the child is older than 12 months of age?*

*Answer: Varicella* Rationale: Varicella vaccine is recommended at any visit at or after age 12 months for susceptible children (i.e., children who lack a reliable history of chickenpox and have not been vaccinated). The other vaccines are administered on or before the age of 1 year.

*Question: The nurse is preparing to administer an intramuscular injection to a 1-year-old child. Which location would the nurse select to administer the medication?*

*Answer: Vastus lateralis muscle* Rationale: The vastus lateralis muscle is the best choice for all age groups and should always be used in children younger than 3 years of age. The ventrogluteal muscle is safe for children older than 18 months because it is free of major blood vessels and nerves. The dorsogluteal muscle develops with walking, so it should not be used until the child has been walking for at least 1 year. The dorsogluteal site is not recommended at any age because of the proximity of the sciatic nerve. The deltoid muscle is not used for children because the small muscle mass cannot hold large volumes of medication or medications that must be injected deep into the muscle mass.

*Question: The nurse is assisting a primary health care provider with the insertion of an endotracheal tube (ETT). The nurse would plan which as a final measure to determine correct tube placement?*

*Answer: Verify placement by a chest x-ray.* Rationale: The final measure to determine ETT placement is to verify it by a chest x-ray. The chest x-ray shows the exact placement of the tube in the trachea, which should be above the bifurcation of the right and left mainstream bronchi. The other options are incorrect because they are completed initially after tube placement.

*Question: The nurse is caring for a client with a diagnosis of pneumonia and a history of bleeding esophageal varices. Based on this information, the nurse would plan care knowing that which could most result in a potential complication?*

*Answer: Vigorous coughing* Rationale: Increased intrathoracic pressure contributes to rupturing of varices. Straining at stool, coughing, and vomiting all increase intrathoracic pressure. The nurse needs to implement measures that will prevent increased intrathoracic pressure. Options 1, 2, and 3 will not increase intrathoracic pressure.

*Question: A preoperative client is scheduled for adrenalectomy to remove a pheochromocytoma. The nurse would most closely monitor which assessment in the preoperative period?*

*Answer: Vital signs* Rationale: Hypertension is the hallmark of pheochromocytoma. Severe hypertension can precipitate a stroke or sudden blindness. Although all the items are appropriate nursing assessments for the client with pheochromocytoma, the priority is to monitor the vital signs, especially the blood pressure.

*Question: The nurse is reinforcing discharge instructions to a client who has had a total gastrectomy. The nurse instructs the client about the importance of returning as scheduled to the health care clinic for which priority assessment?*

*Answer: Vitamin B12 and folic acid studies* Rationale: Common nutritional problems following stomach removal include vitamin B12 and folic acid deficiency. This may result from a deficiency of an intrinsic factor and/or inadequate absorption because food enters the bowel too quickly. Option 3 may be a component of the assessment at a follow-up health care visit but is not a priority assessment. Options 1 and 2 are not necessary studies following a total gastrectomy.

*Question: A client diagnosed with chronic gastritis has been told that there is too little intrinsic factor being produced. The nurse would explain to the client that which therapy will be prescribed to treat the problem?*

*Answer: Vitamin B12 injections* Rationale: Insufficient intrinsic factor results in the inability to absorb vitamin B12, which must then be supplemented by the parenteral route. Vitamin B6 is absorbed when given orally. Vitamin B6, antibiotic therapy, and antacid use do not help treat the lack of intrinsic factor.

*Question: The nurse is assigned to care for a client who has just returned to the nursing unit after having hemodialysis for the first time. The nurse monitors the client carefully for which signs and symptoms of disequilibrium syndrome?*

*Answer: Vomiting and headaches* Rationale: A complication that can occur during early dialysis is disequilibrium syndrome. This syndrome results from a high osmotic gradient in the brain following the rapid removal of fluid that can occur during hemodialysis. Because solutes are not removed as quickly from the cerebrospinal fluid (CSF) and brain, fluid from the circulation shifts into the brain causing cerebral edema. The client may exhibit nausea and vomiting, confusion, headaches, restlessness, twitching, muscle cramps, and seizures. Options 2, 3, and 4 do not identify signs of disequilibrium syndrome.

*Question: The nurse is caring for a client who is receiving lithium carbonate for the treatment of bipolar disorder and monitors the client for signs/symptoms of lithium toxicity. Which sign/symptom would alert the nurse to the potential for toxicity?*

*Answer: Vomiting* Rationale: One of the most common early sign/symptom of lithium toxicity is the presence of gastrointestinal (GI) disturbances, such as nausea, vomiting, and diarrhea. The other signs/symptoms are unrelated to lithium toxicity.

*Question: A client newly diagnosed with gout has been prescribed allopurinol. The nurse would question the primary health care provider if the dose for which medication already prescribed has not changed?*

*Answer: Warfarin sodium* Rationale: Allopurinol is an antigout medication that may increase the effect of oral anticoagulants. Warfarin sodium is an anticoagulant, and if this medication was prescribed for the client, the nurse should verify the prescription. The dose of warfarin sodium may need to be decreased. Adenosine is an antidysrhythmic. Digoxin is a cardiac glycoside. Ergonovine maleate is an antimigraine medication.

*Question: A client with leukemia who had a bone marrow aspiration is thrombocytopenic. The nurse gives which instruction to the family as the client is discharged to home?*

*Answer: Watch the puncture site for bleeding for the next several days.* Rationale: The client who is thrombocytopenic is at risk for bleeding. The family should observe the puncture site for bleeding for several days after the procedure. Acetaminophen may be given for discomfort, and acetylsalicylic acid (aspirin) should be avoided because it can aggravate bleeding. It is unnecessary to monitor the client's temperature daily for a week. The client is not at added risk of infection with thrombocytopenia, which is a low platelet count. There is no reason to force fluids following this procedure.

*Question: The nurse inspects the skin of a client receiving external radiation therapy and documents a finding as moist desquamation. The nurse understands that moist desquamation is best described as which?*

*Answer: Weeping of the skin* Rationale: Moist desquamation occurs when the basal cells of the skin are destroyed. The dermal level is exposed, which results in the leakage of serum. Reddened skin, a rash, and dermatitis may occur with external radiation but are not described as moist desquamation.

*Question: The nurse is listening to the client's breath sounds and hears musical whistling noises on inspiration and expiration scattered throughout the right lung fields. How would the nurse interpret these noises?*

*Answer: Wheezes* Rationale: Wheezes are musical noises heard on inspiration, expiration, or both. They are the result of narrowed air passages. Crackles have the sound that is heard when a few strands of hair are rubbed together near the ear and indicate fluid in the alveoli. Rhonchi are usually heard on expiration when there is excessive production of mucus that accumulates in the air passages. 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 of the pleura and may be heard in both the inspiratory and expiratory phases of the respiratory cycle.

*Question: The nurse is assisting in performing pediculosis capitis (head lice) checks. Which finding indicates that a child has a "positive" head check?*

*Answer: White sacs attached to the hair shafts in the occipital area* Rationale: Pediculosis capitis is an infestation of the hair and scalp with lice. The nits are visible and attached firmly to the hair shaft near the scalp. The occiput is an area in which nits can be seen. Maculopapular lesions behind the ears or lesions that extend to the hairline or neck are indicative of an infectious process, not pediculosis. White flaky particles are indicative of dandruff.

*Question: A client, admitted to the emergency department, is suspected of having frostbite of the hands. Which finding would the nurse note in this condition?*

*Answer: White skin that is insensitive to touch* Rationale: Findings in frostbite include white or blue skin that is hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, blisters or blebs, or tissue edema appears. Gangrene develops in 9 to 15 days.

*Question: A urinary analgesic is prescribed for a client with a urinary tract infection. When would the nurse tell the client that it is best to take the medication?*

*Answer: With meals* Rationale: A urinary antiseptic is administered with meals to decrease gastrointestinal side effects. At bedtime, 1 hour before meals, and in the morning before breakast are incorrect.

*Question: Aluminum hydroxide is prescribed for the client with chronic kidney disease (CKD). When would the nurse instruct the client to take this medication?*

*Answer: With meals* Rationale: The client with chronic kidney disease who is receiving aluminum hydroxide should take the medication with meals. The phosphate-binding effect is best when it is taken with food. If tablets are used, they should be chewed well before swallowing.

*Question: A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed and conducting an initial assessment, the nurse assisting in caring for the client expects the cardiologist to write a prescription for the client to remain on bed rest. In which position would the bed be positioned?*

*Answer: With the head of bed elevated no more than 30 degrees* Rationale: Following cardiac catheterization, the extremity in which the catheter was inserted is kept straight for 4 to 6 hours. If the femoral artery was used, strict bed rest is enforced for 6 to 12 hours or per agency procedure. The client may turn from side to side. The affected leg is kept straight, and the head is elevated no more than 30 degrees until hemostasis is adequately achieved. The cardiologist's prescription for positioning is always followed. Some cardiologists may prescribe a supine position.

*Question: A client with glaucoma and an acute exacerbation of chronic obstructive pulmonary disease (COPD) has a new prescription to receive carteolol HCl eye drops. Which action by the nurse is most appropriate?*

*Answer: Withhold the dose and notify the registered nurse.* Rationale: Carteolol HCl is a beta-blocking agent that can constrict bronchial airways and cause narrowing if absorbed systemically. This can lead to bronchospasms. The nurse should notify the registered nurse because the client has pulmonary disease, and the condition may worsen with administration of a beta blocker. The medication would not be administered. The medication is not shaken vigorously. There is no reason to obtain a sample of eye drainage.

*Question: Which arterial blood gas (ABG) result would the nurse anticipate in a client who develops metabolic alkalosis after profuse vomiting for 2 days?*

*Answer: pH 7.49; Pco2 45; HCO3- 30* Rationale: Vomiting results in a loss of hydrogen ions from the gastrointestinal tract, which leads to an increase in serum bicarbonate. Metabolic alkalosis occurs with an excess in serum bicarbonate. In metabolic alkalosis the pH rises, as does the bicarbonate. The only option that indicates this characteristic is option 3, pH 7.49; Pco2 45; HCO3- 30. Option 1, pH 7.32; Pco2 35; HCO3- 20, indicates metabolic acidosis. Option 2, pH 7.30; Pco2 50; HCO3- 24, indicates respiratory acidosis. Option 4, pH 7.52; Pco2 30; HCO3- 20, indicates respiratory alkalosis.

*Question: The nurse is reviewing a chart of a child with a head injury. The nurse notices that the level of consciousness has been documented as obtunded. Which observation would the nurse expect to make during data collection of the child?*

*Answer: The child sleeps unless aroused and, once aroused, interacts poorly with the environment.* Rationale: Obtunded indicates that the child sleeps unless aroused and, once aroused, has limited interaction with the environment. Full consciousness indicates that the child is alert, awake, and oriented and interacts with the environment. Confusion indicates that the ability to think clearly and rapidly is lost, and disorientation indicates that the ability to recognize a place or person is lost.

*Question: The nurse is collecting data about how well a client diagnosed with a gastrointestinal (GI) disorder is able to absorb food. While doing this, the nurse recalls that absorption is most concerned with which bodily function?*

*Answer: The transfer of digested food molecules from the GI tract into the bloodstream* Rationale: Absorption is the transfer of digested food elements into the bloodstream. The blood then carries nutrients to the cells. Active transport is the process used to transfer nutrients into the cells. Digestion involves the mechanical and chemical breakdown of foods. Option 1 is an incorrect statement.

*Question: A newborn infant is diagnosed with gastroesophageal reflux (GER). The mother of the infant asks the nurse to explain the diagnosis. The nurse plans to base the response on which description of this disorder?*

*Answer: Gastric contents regurgitate back into the esophagus.* Rationale: Gastroesophageal reflux is regurgitation of gastric contents back into the esophagus. Option 2 describes esophageal atresia. Option 3 describes a congenital diaphragmatic hernia. Option 4 describes a hiatal hernia.

*Question: The nurse reinforces home care instructions to a client with sickle cell anemia. Which statement by the client indicates a need for further teaching?*

*Answer: "When I'm feeling better, I'm returning to the soccer team."* Rationale: Clients with sickle cell anemia are advised to avoid strenuous activities. Quiet activities as tolerated are recommended when the client is feeling well. Increasing fluid intake is encouraged to assist in preventing sickle cell crisis.

*Question: A client has had a partial gastrectomy, and the nurse is reinforcing discharge instructions. The nurse would reinforce instructions to the client about the need for which supplements? Select all that apply.*

** Rationale: Gastric surgery can have serious effects on the client's nutritional status. The absorption of vitamin B12, folic acid, iron, calcium, and vitamin D may be impaired, so supplements will be needed. Insufficient intrinsic factor results in the inability to absorb vitamin B12, which must then be supplemented by the parenteral route. Antibiotic therapy and antacid use would not help treat the lack of intrinsic factor or absorption of vitamins.

*Question: A client has had a midline episiotomy. In relation to clients with other types of episiotomies, the nurse anticipates that the client will generally experience which findings? Select all that apply.*

** Rationale: Midline episiotomies are effective, easily repaired, and generally result in less pain. The blood loss is greater and the repair is more difficult and painful with the mediolateral episiotomy than the midline episiotomy. A midline episiotomy may extend more readily with a difficult delivery than the mediolateral episiotomy. This midline episiotomy is no more likely to become infected than another type of episiotomy.

*Question: The nurse is admitting a newborn infant to the nursery and notes that the primary health care provider has documented that the newborn has an omphalocele. Which interventions are appropriate for the nurse to use with this newborn? Select all that apply.*

** Rationale: Omphalocele is an abdominal wall defect. It involves a large herniation of the gut into the umbilical cord. The viscera are outside of the abdominal cavity but inside of a translucent sac covered with peritoneum and amniotic membrane. Nursing intervention preoperatively includes protecting the defect from trauma and drying, keeping the sac moist with saline soaked dressings, maintaining thermoregulation, administering IV fluids, administering prophylactic antibiotics, providing nasogastric suction for gastric decompression, keeping the newborn NPO, and assessing for additional congenital defects. Monitoring mechanical ventilation should not be necessary because no provided data indicate that this is a problem, and the newborn should be kept NPO and not bottle fed.

*Question: The nurse is reinforcing discharge teaching to a client following right eye cataract surgery. The nurse determines that the client needs further teaching about ways to avoid strain on the operative eye when the client makes which statements? Select all that apply.*

** Rationale: The client should not lie on the operative side in order to reduce strain on the surgical eye. The eye shield should be worn at night. The statements in options 1, 3, and 4 are correct and indicate the client properly understands postoperative restrictions.

*Question: The nurse working in a long-term care facility is collecting data from a client experiencing chest pain. The nurse would interpret that the pain is likely a result of myocardial infarction (MI) if which observation is made by the nurse?*

*Answer: The pain has not been relieved by rest and nitroglycerin tablets.* Rationale: The pain of angina may radiate to the left shoulder, arm, neck, or jaw. It is often precipitated by exertion or stress, has few associated symptoms, and is relieved by rest and nitroglycerin. The pain of MI may also radiate to the left arm, shoulder, jaw, and neck. It typically begins spontaneously, lasts longer than 30 minutes, and is frequently accompanied by associated symptoms (such as nausea, vomiting, dyspnea, diaphoresis, or anxiety). The pain of MI is not relieved by rest and nitroglycerin and requires opioid analgesics such as morphine sulfate for relief.

*Question: The nurse is gathering data from a pregnant client about physiological risk factors. The nurse would be sure to obtain which priority data?*

*Answer: Weight and height* Rationale: Height and weight are important factors to assess when determining physiological risk factors. Although life stress, self-care needs, and support systems are important to determine, they are not directly related to physiological risk factors.

*Question: The nurse is teaching a client with a newly diagnosed hiatal hernia about measures to prevent recurrence of symptoms. Which statement is most appropriate to be included in the teaching?*

*Answer: "Avoid lying down for an hour after eating."* Rationale: Most clients with a hiatal hernia can be managed by conservative measures, which include a low-fat diet, avoiding lying down for an hour after eating, and raising the head of the bed.

*Question: An adolescent who has been reported for drawing sexually explicit scenes in her school textbooks says to the psychiatric nurse, "I just felt like it." Which response is therapeutic for the nurse to make in order to assess abuse-related symptoms?*

*Answer: "I am concerned about you. Are you now or have you ever been abused?"* Rationale: The behaviors that this child engaged in provide a warning signal of distress. Option 4 is the only statement that specifically addresses abuse. In option 1 the nurse is insensitive and sarcastic. In option 2 the nurse is assessing the client's destructive behaviors, not the possible sexual abuse history. Although the nurse is trying to assess the client's abuse-related symptoms in option 3, the nurse uses indirect means rather than straightforward expressions of the nurse's concern.

*Question: Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse contacts the primary health care provider (PHCP) who prescribed the medication if which condition is documented in the client's medical history?*

*Answer: Peripheral vascular disease* Rationale: Methylergonovine is an ergot alkaloid used to treat postpartum hemorrhage. Ergot alkaloids are contraindicated in clients with significant cardiovascular disease, peripheral vascular disease, hypertension, preeclampsia, or eclampsia. These conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. Options 1, 2, and 3 are not contraindications related to the use of ergot alkaloids.

*Question: A client is receiving heparin sodium by continuous intravenous (IV) infusion. The licensed practical nurse (LPN) is concerned that the client received a bolus of medication when the tubing was removed from the IV pump during a gown change. The LPN immediately notifies the registered nurse or primary health care provider and then checks to see whether which medication is available in the medication supply area in case it is prescribed?*

*Answer: Protamine sulfate* Rationale: If the tubing is removed from an IV pump and the tubing is not clamped, the client will receive a bolus of the solution and the medication contained in the solution. The client who receives a bolus dose of heparin is at risk for bleeding. A partial thromboplastin time (PTT) will be drawn and evaluated. If the results of the PTT are too high, a dose of protamine sulfate, the antidote for heparin, may be prescribed. Aminocaproic acid is an antifibrinolytic (inhibits clot breakdown). Enoxaparin is an anticoagulant. Vitamin K is the antidote for warfarin sodium.

*Question: The nurse has reinforced instructions to a new mother about how to perform postpartum exercises. The nurse determines that the client understands the instructions when she makes which statement?*

*Answer: "I should alternately contract and relax the muscles of the perineal area."* Rationale: Kegel exercises (alternately contracting and relaxing the muscles of the perineal area) are extremely important to strengthen the muscle tone of the perineal area. Postpartum exercises can begin soon after birth. The initial exercises should be simple, with progression to increasingly strenuous exercises. Women who maintain the perineal muscle tone may benefit in later life by the development of less stress urinary incontinence.

*Question: The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed?*

*Answer: "I will flush the eyes after instilling the ointment."* Rationale: Eye prophylaxis protects the newborn against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush would wash away the administered medication. Options 2, 3, and 4 are correct statements regarding the procedure for administering eye medication to the newborn.

*Question: The nurse is caring for a client with terminal cancer who is close to death. In reviewing the plan of care, the nurse determines that which action is a priority?*

*Answer: Maintain the client's dignity and self-esteem, and make the client as comfortable as possible.* Rationale: The nurse needs to focus on the needs of the client, keep the client comfortable, and maintain dignity and self-esteem. Although the nurse needs to control the pain, it is not necessary to keep the client sedated so that the client is totally unaware of what is happening. The client should be able to interact with family members and make care decisions. Family needs are important, but the client's needs are most important. Prescribed treatment needs to be carried out, but making the client comfortable and maintaining dignity are priorities.

*Question: The nurse is reinforcing instructions to the client about the use of ceftriaxone, an antibiotic, for treating cervical gonorrhea. The nurse would determine a need for further teaching if the client makes which statement?*

*Answer: "I will take the pills for 20 full days."* Rationale: If the client indicates she will be taking pills for 20 days, further teaching is needed. Cervical gonorrhea is treated with one (125 mg) injection of ceftriaxone or one (400 mg) oral dose of cefixime. Allergies to penicillin may contraindicate giving ceftriaxone, and slight discomfort at the injection site is common.

*Question: The nurse is reinforcing dietary instructions for a client diagnosed with peptic ulcer disease. Which action would the nurse encourage the client to do?*

*Answer: Eat anything as long as it does not aggravate or cause pain.* Rationale: The client may eat foods as long as they do not aggravate or cause pain. Increased GI motility should be avoided. A traditional bland diet is no longer recommended. It is unnecessary for the client to eat 6 small meals per day with this disorder, although smaller meals are better managed by the client.

*Question: The nurse has been reinforcing dietary teaching for a client diagnosed with gastroesophageal reflux disease (GERD) who has a routine follow-up visit. Which behavior is the best indicator of a successful outcome for this client?*

*Answer: A decrease in sour eructation* Rationale: A decrease in sour eructation (burping) represents a change in the client's health status and is an effective indicator of a successful outcome. Options 2 and 3 are not consistent with minimizing disease symptoms. Option 4 represents healthy behavior by the client, but it is not as positive as is the correct option.