NCLEX #301-350
NO.325 The nurse is preparing a 6-year-old child for an IV insertion. Which one of the following statements by the nurse is appropriate when preparing a child for a potentially painful procedure? A. "Some say this feels like a pinch or a bug bite. You tell me what it feels like." B. "This is going to hurt a lot; close your eyes and hold my hand." C. "This is a terrible procedure, so don't look." D. "This will hurt only a little; try to be a big boy."
Answer: A Explanation: (A) Educating the child about the pain may lessen anxiety. The child should be prepared for a potentially painful procedure but avoid suggesting pain. The nurse should allow the child his own sensory perception and evaluation of the procedure. (B) The nurse should avoid absolute descriptive statements and allow the child his own perception of the procedure. (C) The nurse should avoid evaluative statements or descriptions and give the child control in describing his reactions. (D) False statements regarding a painful procedure will cause a loss of trust between the child and the nurse.
NO.308 A 64-year-old client is admitted to the hospital with benign prostatic hypertrophy (BPH). He has a history of adult-onset diabetes and hypertension and is scheduled to undergo a resection of the prostate. When recording his health history, the nurse asks about his chief complaint. The most serious symptom that may accompany BPH is: A. Acute urinary retention B. Hesitancy in starting urination C. Increased frequency of urination D. Decreased force of the urinary stream
Answer: A Explanation: (A) Acute urinary retention requires urgent medical attention. If measures such as a warm tub bath or warm tea do not occur after 6 hours, the client should go to the ED for catheterization. (B, C, D) This choice is a symptom of BPH, but it is not serious or life threatening.
NO.323 Following a gastric resection, a 70-year-old client is admitted to the postanesthesia care unit. He was extubated prior to leaving the suite. On arrival at the postanesthesia care unit, the nurse should: A. Check airway, feeling for amount of air exchange noting rate, depth, and quality of respirations B. Obtain pulse and blood pressure readings noting rate and quality of pulse C. Reassure the client that his surgery is over and that he is in the recovery room D. Review physician's orders, administering medications as ordered
Answer: A Explanation: (A) Adequate air exchange and tissue oxygenation depend on competent respiratory function. Checking the airway is the nurse's priority action. (B) Obtaining the vital signs is an important action, but it is secondary to airway management. (C) Reorienting a client to time, place, and person after surgery is important, but it is secondary to airway and vital signs. (D) Airway management takes precedence over physician's orders unless they specifically relate to airway management.
NO.326 A 38-year-old female client with a history of chronic schizophrenia, paranoid type, is currently an outpatient at the local mental health and mental retardation clinic. The client comes in once a week for medication evaluation and/or refills. She self-administers haloperidol 5 mg twice a day and benztropine 1 mg once a day. During a recent clinic visit, she says to the nurse, "I can't stay still at night. I toss and turn and can't fall asleep." The nurse suspects that she may be experiencing: A. Akathisia B. Akinesia C. Dystonia D. Opisthotonos
Answer: A Explanation: (A) Akathisia, or motor restlessness, is a reversible EPS frequently associated with the administration of antipsychotic drugs such as haloperidol. (B) Akinesia, or muscular or motor retardation, is an example of reversible EPS frequently associated with the administration of major tranquilizers such as haloperidol. (C) Acute dystonic reactions, bizarre and severe muscle contractions usually of the tongue, face, neck or extraocular muscles, are examples of EPS. (D) Opisthotonos, a severe type of whole-body dystonic reaction in which the head and heels are bent backward while the body is bowed forward, is an example of EPS.
NO.319 A 3-year-old female client is brought into the pediatric clinic because she limps. She has not been to the clinic since she was 9 months old. The nurse practitioner describes the limp as a "Trendelenburg gait." This gait is characteristic of: A. Scoliosis B. Dislocated hip C. Fractured femur D. Fractured pelvis
Answer: B Explanation: (A, C, D) A Trendelenburg gait is not characteristic of any of these disorders. (B) The downward slant of one hip is a positive sign of dislocation in the weight-bearing hip. If one hip is dislocated, the child walks with a characteristic limp known as the Trendelenburg gait.
NO.345 On the first postpartal day, a client tells the nurse that she has been changing her perineal pads every 1/2 hour because they are saturated with bright red vaginal drainage. When palpating the uterus, the nurse assesses that it is somewhat soft, 1 fingerbreadth above the umbilicus, and midline. The nursing action to be taken is to: A. Gently massage the uterus until firm, express any clots, and note the amount and character of lochia B. Catheterize the client and reassess the uterus C. Begin IV fluids and administer oxytocic medication D. Administer analgesics as ordered to relieve discomfort
Answer: A Explanation: (A) Gentle massage and expression of clots will let the fundus return to a state of firmness, allowing the uterus to function as the "living ligature." (B) A distended bladder may promote uterine atony; however, after determining the bladder is distended, the nurse would have the client void. Catheterization is only done if normal bladder function has not returned. (C) Oxytocic medications are ordered and administered if the uterus does not remain contracted after gentle massage and determining if the bladder is empty. (D) The client is not complaining of discomfort or pain; therefore, analgesics are not necessary.
NO.318 Diabetes mellitus is a disorder that affects 3.1 out of every 1000 children younger than 20 years old. It is characterized by an absence of, or marked decrease in, circulating insulin. When teaching a newly diagnosed diabetes client, the nurse includes information on the functions of insulin: A. Transport of glucose into body cells and storage of glycogen in the liver B. Glycogenolysis and facilitation of glucose use for energy C. Glycogenolysis and catabolism D. Catabolism and hyperglycemia
Answer: A Explanation: (A) Lack of insulin causes glycogenolysis, catabolism, and hyperglycemia. (B) Insulin promotes the conversion of glucose to glycogen for storage and regulates the rate at which carbohydrates are used by cells for energy. (C) Insulin is anabolic in nature. (D) Glucose stimulates protein synthesis within the tissue and inhibits the breakdown of protein into amino acids.
NO.341 During the admitting mental health assessment, a client demonstrates involuntary muscular activity. He has a marked facial tic around the mouth that is distracting to the nurse during the interview. The nurse recognizes the behavior and documents it as: A. Dyskinesia B. Akathisia C. Echopraxia D. Echolalia
Answer: A Explanation: (A) The client is demonstrating dyskinesia, which is involuntary muscular activity, such as tic, spasm, or myoclonus. (B) Akathisia is regular rhythmic movements usually of the lower limbs, such as constant motor restlessness. (C) Echopraxia is mimicking the movements of another person. (D) Echolalia is mimicking the speech of another person.
NO.320 Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality. When evaluating the pregnant client, the nurse knows the recommended serum glucose range during pregnancy is: A. 70 mg/dL and 120 mg/dL B. 100 mg/dL and 200 mg/dL C. 40 mg/dL and 130 mg/dL D. 90 mg/dL and 200 mg/dL
Answer: A Explanation: (A) The recommended range is 70-120 mg/dL to reduce the risk of perinatal mortality. (B, C, D) These levels are not recommended. The higher the blood glucose, the worse the prognosis for the fetus. Hypoglycemia can also have detrimental effects on the fetus.
NO.311 A client who was started on antipsychotic medication 2 weeks ago is preparing for discharge from the hospital. Compliance with the medication regimen is important despite the mild side effects encountered. In order to increase the likelihood of medication compliance, the nurse would: A. Discuss the disease process and the importance of the medication in prevention of symptoms. B. Inform the client that additional side effects are to be expected and need not be reported. C. Discuss the importance of getting blood drawn weekly to determine medication therapeutics. D. Inform the client to cease taking the medication when all psychotic symptoms have cleared.
Answer: A Explanation: (A) This answer is correct. If the client is well informed about what reactions to expect from her medication, she is more likely to follow the treatment regimen. (B) This answer is incorrect. There are many side effects that are reversible by medication, and these must be reported to the nurse or physician. There are also more severe side effects, such as neuroleptic malignant syndrome, characterized by fever, tachycardia, and diaphoresis, which can be life threatening. (C) This answer is incorrect. There is no need for weekly blood tests if the drug regimen has been followed properly. (D) This answer is incorrect. The client should continue the medication until the physician recommends any change in the drug regimen. Symptoms will usually reappear if medication is discontinued.
NO.330 A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse's most therapeutic response will be: A. "I don't see your mother in the room. Let's talk about how you're feeling." B. "OK, I'll come back later when you're feeling more like taking your medicine." C. "She may be here, but I can't see her." D. "Why don't you finish talking to her, and I'll wait."
Answer: A Explanation: (A) This response uses the principle of reality orientation by the nurse telling the client that he or she does not see anything, but it does recognize his feelings. (B) This response does not make it clear that the nurse does not see anyone else in the room, and the nurse leaves the client alone to continue hallucinating. (C) This response leaves room for doubt; the nurse is further confusing the client by this statement. (D) This response reinforces the hallucination and implies that the nurse sees his mother, too.
NO.321 A 4-year-old boy is brought to the emergency room with bruises on his head, face, arms, and legs. His mother states that he fell down some steps. The nurse suspects that he may have been physically abused. In accordance with the law, the nurse must: A. Tell the physician her concerns B. Report her suspicions to the authorities C. Talk to the child's father D. Confront the child's mother
Answer: B Explanation: (A) Although the nurse probably would talk to the physician about these concerns, the nurse is not required by law to do so. (B) All healthcare workers are required by the Federal Child Abuse Prevention and Treatment Act of 1974 to report suspected and actual cases of child abuse and/or neglect. (C) Talking to the child's father may or may not help the child, and the nurse is not required by law to do so. (D) Confrontation may not be indicated; the nurse is not required by law to confront the child's mother with these suspicions.
NO.309 A 47-year-old male client is admitted for colon surgery. Intravenous antibiotics are begun 2 hours prior to surgery. He has no known infection. The rationale for giving antibiotics prior to surgery is to: A. Provide cathartic action within the colon B. Reduce the risk of wound infection from anaerobic bacteria C. Relieve the client's concern regarding possible infection D. Reduce the risk of intraoperative fever
Answer: B Explanation: (A) Cathartic drugs promote evacuation of intestinal contents. (B) The client undergoing intestinal surgery is at increased risk for infection from large numbers of anaerobic bacteria that inhabit the intestines. Administering antibiotics prophylactically can reduce the client's risk for infection. (C) Antibiotics are indicated in the treatment of infections and have no effect on emotions. (D) Antipyretics are useful in the treatment of elevated temperatures. Antibiotics would have an effect on infection, which causes temperature elevation, but would not directly affect such an elevation.
NO.336 A 42-year-old client on an inpatient psychiatric unit comments that he was brought to the hospital by his wife because he had taken too many pills and states, "I just couldn't take it anymore." The nurse's best response to this disclosure would be: A. "You shouldn't do things like that, just tell someone you feel bad." B. "Tell me more about what you couldn't take anymore." C. "I'm sure you probably didn't mean to kill yourself." D. "How long have you been in the hospital."
Answer: B Explanation: (A) Disapproving gives the impression that the nurse has a right to pass judgment on the client's thoughts, actions, or ideas. (B) Giving a broad opening gives the client encouragement to continue with verbalization. (C) Failing to acknowledge the client's feelings conveys a lack of understanding and empathy. (D) Changing the subject takes the conversation away from the client and is indicative of the nurse's anxiety or insensitivity.
NO.338 A client has developed congestive heart failure secondary to his myocardial infarction. Discharge diet instructions should emphasize the reduction or avoidance of: A. Fresh vegetables and fruit B. Canned vegetables and fruit C. Breads, cereals, and rice D. Fish
Answer: B Explanation: (A) Fresh vegetables and fruits are excellent sources of essential vitamins. (B) Canned and frozen foods have a high sodium content. Labels of all canned foods should be read to determine if sodium is used in any form. (C) Bread, cereal, and rice are excellent sources of carbohydrates. (D) Fish is an excellent source of protein.
NO.327 A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because: A. Warmed solution helps keep the body temperature maintained within a normal range during instillation B. Warmed solution helps dilate the peritoneal blood vessels C. Warmed solution decreases the risk of peritoneal infection D. Warmed solution promotes a relaxed abdominal muscle
Answer: B Explanation: (A) Instilling a cool solution does not significantly lower the body temperature during peritoneal dialysis. (B) Warmed solution does help dilate the peritoneal blood vessels, facilitating the exchange of fluids. (C) Warming the dialysate does not decrease the risk of peritoneal infection. Sterile technique decreases this risk. (D) Relaxing the abdominal muscles does not facilitate peritoneal dialysis.
NO.328 The nurse would expect to include which of the following when planning the management of the client with Lyme disease? A. Complete bed rest for 6-8 weeks B. Tetracycline treatment C. IV amphotericin B D. High-protein diet with limited fluids
Answer: B Explanation: (A) The client is not placed on complete bed rest for 6 weeks. (B) Tetracycline is the treatment of choice for children with Lyme disease who are over the age of 9. (C) IV amphotericin B is the treatment for histoplasmosis. (D) The client is not restricted to a high-protein diet with limited fluids.
NO.302 A client is in active labor and has been admitted to the labor and delivery unit. The RN has just done a sterile vaginal exam and determines that the client is dilated 5 cm, effaced 85%, and the fetus's head is at 0 station. She asks if she could have a lumbar epidural now. The epidural is started, and the anesthetic agent used is bupivacaine (Marcaine). After the client has received her lumbar epidural, it is important for the RN to monitor her for which of the following side effects: A. Hypertension B. Hypotension C. Hypoglycemia D. Hyperglycemia
Answer: B Explanation: (A) The medication bupivacaine will cause vasodilation in the vascular system, and this does not result in elevation of the ma-ternal blood pressure. (B) The medication bupivacaine will cause vasodilation in the vascular system, and this will result in lowering the maternal blood pressure. (C) Bupivacaine does not interfere with the functioning of the endocrine system. (D) Bupivacaine does not interfere with the functioning of the endocrine system.
NO.337 A client suffering from schizophrenia has been taking chlorpromazine (Thorazine) for 6 months. On one of his follow-up visits to the mental health center, the nurse reports to the physician that he has developed tardive dyskinesia. Which of the following symptoms might she have observed in the client to support this conclusion? A. High fever, tachycardia, stupor, renal failure B. Lip smacking, chewing, blinking, lateral jaw movements C. Photosensitivity, orthostatic hypotension, dry mouth D. Constipation, blurred vision, drowsiness
Answer: B Explanation: (A) These symptoms are found in clients with neuroleptic malignant syndrome. (B) These symptoms are found in clients with tardive dyskinesia. (C) These are normal side effects found in clients taking antipsychotic medications. (D) These are also normal side effects found in clients taking antipsychotic medications.
NO.306 As a nurse works with an adolescent with cystic fibrosis, the nurse begins to notice that he appears depressed and talks about suicide and feelings of worthlessness. This is an important factor to consider in planning for his care because: A. It may be a bid for attention and an indication that more diversionary activity should be planned for him B. No threat of suicide should be ignored or challenged in any way C. He needs to be observed carefully for signs that his depression has been relieved D. He needs to be confronted with his feelings and forced to work through them
Answer: B Explanation: (A) Threats of suicide should always be taken seriously. (B) This client has a life-threatening chronic illness. He may be concerned about dying or he may actually be contemplating suicide. (C) Sometimes clients who have made the decision to commit suicide appear to be less depressed. (D) Forcing him to look at his feelings may cause him to build a defense against the depression with behavioral or psychosomatic disturbances.
NO.322 An 18-month-old child has been playing in the garage. His mother brings him to a nurse's home complaining of his mouth being sore. His lips and mouth are soapy and white, with small ulcerated areas beginning to form. The child begins to vomit. His pulse is rapid and weak. The nurse suspects that the child has: A. Inhaled gasoline fumes B. Ingested a caustic alkali C. Eaten construction chalk D. Lead poisoning
Answer: B Explanation: (A, C, D) These agents would not cause ulcerations on mouthand lips. (B) Strong alkali or acids will cause burns and ulcerationson the mucous membranes.
NO.303 A 35-year-old client is receiving psychopharmacological treatment of his major depression with tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO) inhibitor. The nurse teaches the client that while he is taking this type of antidepressant, he needs to restrict his dietary intake of: A. Potassium-rich foods B. Tryptophan C. Tyramine D. Saturated fats
Answer: C Explanation: (A) The client may need to avoid some potassium-rich foods (such as bananas, raisins, etc.). However, this is not because of the potassium content of these foods. (B) Tryptophan is an essential amino acid that is present in high concentrations in animal and fish protein. (C) The client will need to watch his dietary intake of tyramine. Tyramine is a by-product of the conversion of tyrosine to epinephrine. Tyramine is found in a variety of foods and beverages, ranging from aged cheese to caffeine drinks. Ingestion of tyramine-rich foods while taking a MAO inhibitor may lead to an increase in blood pressure and/or a life-threatening hypertensive crisis. (D) To maintain a healthy lifestyle, restriction of dietary saturated fats is advisable.
NO.304 A male client receives 10 U of regular human insulin SC at 9:00 AM. The nurse would expect peak action from this injection to occur at: A. 9:30 AM B. 10:30 AM C. 12 noon D. 4:00 PM
Answer: C Explanation: (A) This is too early for peak action to occur. (B) This is too early for peak action to occur. (C) Regular insulin peak action occurs 2-4 hours after administration. (D) This is too late for peak action to occur.
NO.314 A term neonate has experienced no distress at birth and has an Apgar score of 9. Her mother has asked to breastfeed her following delivery. Immediately after birth, the neonate was most susceptible to heat loss. The most appropriate intervention to conserve heat loss and promote bonding is to: A. Place her under the radiant warmer B. Dry her with blankets C. Place her to her mother's breast D. Place her on a heated pad
Answer: C Explanation: (A) A radiant warmer maintains an optimal thermal environment by use of a thermal skin sensor taped to the infant. The warmer limits parental attachment, so, although appropriate, it is not an intervention that promotes infant attachment. (B) Warmed blankets prevent heat loss in the neonate by conduction. In addition, tactile stimuli promote crying and lung expansion. This intervention does not promote attachment, however. (C) Skin-toskin contact is an effective way to conserve heat after delivery and promotes parental attachment following birth in the healthy term infant. The first period of reactivity lasts approximately 30 minutes following birth. A strong sucking reflex and an active, awake newborn characterize this period. (D) Surfaces of objects warmer than the infant promote overheating by conduction, and neonatal hyperthermia may result.
NO.333 The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of: A. Prolonged bed rest B. The client's maintaining a semi-Fowler position C. Cerebral hypoxia D. IV fluids of 2.5-3 liters in 24 hours
Answer: C Explanation: (A) Maintaining bed rest helps to decrease the O2 needs of the tissues, which decreases dyspnea and workload on the respiratory system. (B) The semi-Fowler or high-Fowler position is necessary to aid in lessening pressure on the diaphragm from the abdominal organs, which facilitates comfort and easier breathing patterns. (C) Cerebral hypoxia causes the client with pneumonia to be increasingly irritable and restless and results from the client not obtaining enough O2 to meet metabolic needs. (D) Proper hydration facilitates liquefaction of mucus trapped in the bronchioles and alveoli and enhances expectoration. Unless contraindicated, a reasonable amount of IV fluids to be administered is at least 2.5-3 liters in a 24-hour period.
NO.331 A client who is 7 months pregnant is diagnosed with pyelonephritis. The nurse anticipates the physician ordering: A. Oxytocin B. Magnesium sulfate (MgSO4) C. Ampicillin D. Tetracycline
Answer: C Explanation: (A) Oxytocin is prescribed to stimulate uterine contractions. (B) MgSO4is a central nervous system depressant prescribed to prevent and control convulsions related to preeclampsia. (C) Ampicillin is a penicillin derivative with no known teratogenic effects. This is the safest antibiotic during pregnancy. (D) Tetracycline stains teeth yellow and is not as safe as ampicillin during pregnancy.
NO.342 The mother of a client is apprehensive about taking home her 2 year old who was diagnosed with asthma after being admitted to the emergency room with difficulty breathing and cyanosis. She asks the nurse what symptoms she should look for so that this problem will not happen again. The nurse instructs her to watch for the following early symptoms: A. Fever, runny nose, and hyperactivity B. Changes in breathing pattern, moodiness, fatigue, and edema of eyes C. Fatigue, dark circles under the eyes, changes in breathing pattern, glassy eyes, and moodiness D. Fever, cough, paleness, and wheezing
Answer: C Explanation: (A) The child with asthma may not have fever unless there is an underlying infection. (B) Edema of the eyes will not be present because the child with asthma is more likely to have dehydration related to excessive water loss during the work of breathing. (C) All of these symptoms indicate decreased oxygenation and are early symptoms of asthma. (D) Coughing and wheezing are not early signs of difficulty.
NO.317 After an infant is delivered by cesarean delivery and placed on the warmer, the RN dries and assesses the infant. At 1 and 5 minutes after birth, the RN does the Apgar scoring of the infant. The RN knows that because this infant was delivered by cesarean section, he is at increased risk for having which one of the following: A. Cold stress B. Cyanosis C. Respiratory distress syndrome D. Seizures
Answer: C Explanation: (A) The infant is placed on the warmer and dried after birth. Cold stress occurs when the infant is not dried and kept warm. (B) The fact that this infant was born by cesarean delivery does not place him at a greater risk for cyanosis than an infant delivered vaginally. Cyanosis occurs when infants cannot oxygenate their blood after the umbilical cord is severed. (C) Infants born by cesarean delivery are at a higher risk for developing respiratory distress syndrome because these infants do not pass through the pelvis, where the chest is compressed and fluid is able to escape from the lungs. (D) Cesarean- delivered infants are not at greater risk for seizures than infants delivered vaginally.
NO.315 Which of the following activities would be most appropriate during occupational therapy for a client with bipolar disorder? A. Playing cards with other clients B. Working crossword puzzles C. Playing tennis with a staff member D. Sewing beads on a leather belt
Answer: C Explanation: (A) This activity is too competitive, and the manic client might become abusive toward the other clients. (B) During mania, the client's attention span is too short to accomplish this task. (C) This activity uses gross motor skills, eases tension, and expands excess energy. A staff member is better equipped to interact therapeutically with clients. (D) This activity requires the use of fine motor skills and is very tedious.
NO.340 A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of violence that she has been experiencing in her relationship with her husband of 5 years. In the "tension-building phase," the nurse might expect the client to describe which of the following? A. Promises of gifts that her husband made to her B. Acute battering of the client, characterized by his volatile discharge of tension C. Minor battering incidents, such as the throwing of food or dishes at her D. A period of tenderness between the couple
Answer: C Explanation: (A) This description is characteristic of the "honeymoon" or "respite" phase. (B) This description is characteristic of the "battering" phase. (C) This description is characteristic of the "tension- building" phase prior to the volatile discharge of tension found in the battering phase. (D) This description is characteristic of the "honeymoon" or "respite" phase.
NO.316 A postoperative prostatectomy client is preparing for discharge from the hospital the next morning. The nurse realizes that additional instructions are necessary when he states: A. "If I drink 10 to 12 glasses of fluids each day, that will help to prevent any clot formation in my urine." B. "The isometric exercises will help to strengthen my perineal muscles and help me control my urine." C. "If I feel as though I have developed a fever, I will take a rectal temperature, which is the most accurate." D. "I do not plan to do any heavy lifting until I visit my doctor again."
Answer: C Explanation: (A) This is correct health teaching. Drinking 10-12 glasses of clear liquid will help increase urine volumes and prevent clot formation. (B) This is correct health teaching. These types of exercises are prescribed by physicians to assist postprostatectomy clients to strengthen their perineal muscles. (C) This action is not recommended post-TURP because of the close proximity of the prostate and rectum. (D) This is correct healthcare teaching. The client should limit walking long distances, lifting heavy objects, or driving a car until these activities are cleared by the physician at the first office visit.
NO.344 A client delivered a stillborn male at term. An appropriate action of the nurse would be to: A. State, "You have an angel in heaven." B. Discourage the parents from seeing the baby. C. Provide an opportunity for the parents to see and hold the baby for an undetermined amount of time. D. Reassure the parents that they can have other children.
Answer: C Explanation: (A) This is not a supportive statement. There are also no data to indicate the family's religious beliefs. (B) Seeing their baby assists the parents in the grieving process. This gives them the opportunity to say "good-bye." (C) Parents need time to get to know their baby. (D) This is not a comforting statement when a baby has died. There are also no guarantees that the couple will be able to have another child.
NO.301 A client presents to the psychiatric unit crying hysterically. She is diagnosed with severe anxiety disorder. The first nursing action is to: A. Demand that she relax B. Ask what is the problem C. Stand or sit next to her D. Give her something to do
Answer: C Explanation: (A) This nursing action is too controlling and authoritative. It could increase the client's anxiety level. (B) In her anxiety state, the client cannot rationally identify a problem. (C) This nursing action conveys a message of caring and security. (D) Giving the client a task would increase her anxiety. This would be a late nursing action.
NO.348 A female client is started on warfarin (Coumadin) 5 mg po bid. To adequately evaluate the effectiveness of the warfarin therapy, the nurse must know that this medication: A. Dissolves any clots already formed in the arteries B. Prevents the conversion of prothrombin to thrombin C. Interferes with the synthesis of vitamin K-dependent clotting factors D. Stimulates the manufacturing of platelets
Answer: C Explanation: (A) Thrombolytic agents (e.g., streptokinase) directly activate plasminogen, dissolving fibrin deposits, which in turn dissolves clots that have already formed. (B) Heparin prevents the formation of clots by potentiating the effects of antithrombin III and the conversion of prothrombin to thrombin. (C) Warfarin prevents the formation of clots by interfering with the hepatic synthesis of the vitamin K- dependent clotting factors. (D) Platelets initiate the coagulation of blood by adhering to each other and the site of injury to form platelet plugs.
NO.339 Which of the following nursing actions is essential to prevent drug-resistant tuberculosis? A. Monitor liver function. B. Monitor renal function. C. Assess knowledge of respiratory isolation. D. Monitor compliance with drug therapy.
Answer: D Explanation: (A) Monitoring liver function will not prevent the development of drug-resistant organisms. (B) Monitoring renal function will not prevent the development of drug-resistant organisms. (C) Knowledge of respiratory isolation will reduce transmission of tuberculosis but will not prevent development of drug-resistant organisms. (D) Noncompliance with prescribed antituberculosis drug regimen is the primary cause of drug-resistant organisms. Noncompliance permits the mutation of organisms.
NO.335 The nurse documents a client's surgical incision as having red granulated tissue. This indicates that the wound is: A. Infected B. Not healing C. Necrotic D. Healing
Answer: D Explanation: (A) The wound is not infected. An infected wound would contain pus, debris, and exudate. (B) The wound is healing properly. (C) A necrotic wound would appear black or brown. (D) The wound is healing properly and is filled with red granulated tissue and fragile capillaries.
NO.343 A post-lung surgery client is placed on a chest tube drainage system. When explaining to the family how the system works, the nurse states that the water-seal bottle of a three-bottle chest drainage system serves which of the following purposes? A. Collection bottle for drainage B. Pressure regulator C. Preventing accumulation of blood around the heart D. Preventing air from entering the chest upon inspiration
Answer: D Explanation: (A) There is a separate collection bottle for drainage as part of a chest drainage system. (B) In a three-bottle chest drainage system, one bottle serves only as a pressure regulator. (C) Mediastinal chest tubes prevent accumulation of blood around the heart immediately following heart surgery. (D) The purpose of the water-seal bottle in any chest drainage setup is to allow air out of the chest, but not back in. This negative pressure promotes lung expansion.
NO.346 A 5-year-old child cries continually in her bed. Her parents have been unsuccessful in assisting her in expressing her feelings. Which activity should the nurse provide the child to assist her in expressing her feelings? A. Books with colorful pictures B. Music C. Riding toys D. Puppets
Answer: D Explanation: (A) Books increase cognition, assist with fine motor skills, and augment language development. (B) Music provides auditory stimulation and large-muscle activity. (C) Riding toys provide large-muscle activity. (D) Puppets allow expression of feelings and fears that otherwise could not be directly communicated.
NO.324 A 29-year-old client is admitted for a hysterectomy. She has repeatedly told the nurses that she is worried about having this surgery, has not slept well lately, and is afraid that her husband will not find her desirable after the surgery. Shortly into the preoperative teaching, she complains of a tightness in her chest, a feeling of suffocation, lightheadedness, and tingling in her hands. Her respirations are rapid and deep. Assessment reveals that the client is: A. Having a heart attack B. Wanting attention from the nurses C. Suffering from complete upper airway obstruction D. Hyperventilating
Answer: D Explanation: (A) Classic symptoms of a heart attack include heaviness or squeezing pain in the chest, pain spreading to the jaw, neck, and arm. Nausea and vomiting, sweating, and shortness of breath may be present. The client does not exhibit these symptoms. (B) Clients suffering from anxiety or fear prior to surgical procedures may develop hyperventilation. This client is not seeking attention. (C) Symptoms of complete airway obstruction include not being able to speak, and no airflow between the nose and mouth. Breath sounds are absent. (D) Tightness in the chest; a feeling of suffocation; lightheadedness; tingling in the hands; and rapid, deep respirations are signs and symptoms of hyperventilation. This is almost always a manifestation of anxiety.
NO.329 A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position the client? A. Head of bed elevated 30 degrees on nonoperative side B. Head of bed elevated 30 degrees on operative side C. Bed flat on operative side D. Bed flat on nonoperative side
Answer: D Explanation: (A) Elevation of head on nonoperative side would be the position for the late postoperative period. (B) Positioning on operative side puts pressure on the suture lines and on the shunt valve. Elevation of head in immediate postoperative period may cause rapid reduction of cerebrospinal fluid. (C) Placement on operative side puts pressure on the suture lines and shunt valve. (D) Flat position on nonoperative side in the immediate postoperative period prevents pressure on shunt valve and rapid reduction in cerebrospinal fluid.
NO.305 A female client who has chronic obstructive pulmonary disease (COPD) has presented in the emergency department with cough productive of yellow sputum and increasing shortness of breath. On room air, her blood gases are as follows: pH 7.30 mm Hg, PCO2 60 mm Hg, PO2 55 mm Hg, HCO3 32 mEq/L. These arterial blood gases reflect: A. Compensated respiratory acidosis B. Normal blood gases C. Uncompensated metabolic acidosis D. Uncompensated respiratory acidosis
Answer: D Explanation: (A) In compensated respiratory acidosis, the pH level is normal, the PCO2level is elevated, and the HCO3level is elevated. The client's primary alteration is an inability to remove CO2from the lungs, so over time, the kidneys increase reabsorption of HCO3to buffer the CO2. (B) Normal ranges for arterial blood gases for adults and children are as follows: pH 7.35-7.45, PO280-100 mm Hg, PCO235-45 mm Hg, HCO321-28 mEq/L. (C) In uncompensated metabolic acidosis the pH level is decreased, the PCO2level is normal, and the HCO3level is decreased. The client's primary alteration is an inability to remove excess acid via the kidneys. The lungs are unable to clear the increased acid. (D) In uncompensated respiratory acidosis, the pH level is decreased, the PCO2level is increased, and the HCO3level is normal. In a person with long-standing COPD, the HCO3level will rise gradually over time to compensate for the gradually increasing PCO2, and the person's pH level will be normal. When a person with COPD becomes acutely ill, the kidneys do not have time to increase the reabsorption of HCO3, so the person's pH level will reflect acidosis even though the HCO3is elevated.
NO.334 A client delivered a term infant 1 hour ago. Her uterus on assessment is boggy and is U +1 in contrast to the previous assessment of U _2. The immediate nursing response is to: A. Administer methergine IM B. Remove the retained placental fragments C. Assist the client to the bathroom and provide cues to stimulate urination D. Massage the fundus until firm
Answer: D Explanation: (A) Methergine is given following placental delivery to promote uterine contractions and prevent hemorrhage. Methergine may be administered in this clinical situation, but fundal massage would be the first response. (B) Removal of retained placental fragments is done by the physician and is not the first response. (C) If the fundus rises and is deviated, particularly to theright, the nurse should suspect bladder distention secondary to bladder and urethral trauma associated with birth and decreased bladder tone following delivery. Therefore, women have a diminished sensation to void. (D) A boggy fundus rises and is indicative of blood pooling, predisposing the woman to clot formation. Massage the uterus until firm. Too vigorous massage will result in atonia. Clots may be expelled by a kneading motion of the uterus by the nurse.
NO.310 A client has just received an epidural block. She is laboring on her right side. The nurse notes that her blood pressure has dropped from 132/68 to 78/42 mm Hg. The nurse's first action would be to: A. Call the physician immediately and give dopamine IM B. Turn her on her left side and recheck her blood pressure in 5 minutes C. Administer oxytocin (Pitocin) immediately and increase the rate of IV fluids D. Increase the rate of IV fluids and start O2 by mask
Answer: D Explanation: (A) Nursing measures to support fetal oxygenation and promote maternal blood pressure would precede calling the physician. (B) Systolic pressures below 100 mm Hg or a reduction in the systolic pressure of>30% necessitate treatment. Assessing the blood pressure in 5 minutes may allow for further fetal and/or maternal compromise. Turning the client on her left side will promote uteroplacental perfusion and is appropriate. (C) Oxytocin (Pitocin) increases the strength of uterine contractions and may cause maternal hypotension; thus it is an inappropriate drug for use in this clinical situation. IV fluids would be increased to expand the circulating blood volume and promote increased blood pressure. (D) Turning the mother to her left lateral side promotes uteroplacental perfusion. IV fluids are administered to increase the circulating blood volume, and O2 is administered to promote fetal oxygenation and decrease the nausea accompanying the hypotension.
NO.350 A husband and wife and their two children, age 9 and age 5, are requesting family therapy. Which of the following strategies is most therapeutic for the nurse to use during the initial interaction with a family? A. Always allow the most vocal person to state the problem first. B. Encourage the mother to speak for the children. C. Interpret immediately what seems to be going on within the family. D. Allow family members to assume the seats as they choose.
Answer: D Explanation: (A) One will always hear what the most vocal person has to say. It is best to start with the quietest family member to encourage that person to express emotions. (B) All family members are encouraged to speak for themselves. (C) In the initial family assessment, only data collection occurs; interpretations are made later. (D) Allowing family members to choose their own seats will assist the nurse in assessing the family system and in determining who feels closer to whom.
NO.332 A baby who was diagnosed with pyloric stenosis has continued to have projectile vomiting. With prolonged vomiting, the infant is prone to: A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
Answer: D Explanation: (A) Respiratory acidosis is the result of problematic ventilation. Plasma pH decreases, while plasma PCO2 and plasma HCO3 increase. (B) Respiratory alkalosis results from increased respiratory rate and depth. Plasma pH increases, while plasma PCO2 and plasma HCO3 decrease. (C) Metabolic acidosis occurs when there is strong acid gain in the body. Plasma pH, PCO2, and HCO3 decrease. (D) Increased risk for metabolic alkalosis is due to a loss of hydrogen ions; depletion of potassium, sodium, and chloride when vomiting occurs. Plasma pH and plasma PCO2 increase; plasma HCO3 may decrease and then increase to compensate.
NO.312 A 40-year-old client is admitted to the coronary care unit with chest pain and shortness of breath. The physician diagnosed an anterior wall myocardial infarction. What tests should the nurse anticipate? A. Reticulocyte count, creatinine phosphokinase (CPK) B. Aspartate transaminase, alanine transaminase C. Sedimentation rate, WBC count D. Lactic dehydrogenase, CPK
Answer: D Explanation: (A) Reticulocyte count measures the number of immature erythrocytes. CPK is an enzyme released from injured myocardial tissue. (B) Aspartate transaminase is an enzyme released from injured myocardial tissue. Alanine transaminase is an enzyme released for general tissue destruction, which is specific for liver injury. (C) Sedimentation rate is a nonspecific test for inflammation. (D) Lactic dehydrogenase and CPK are enzymes released from injured myocardial tissue.
NO.307 As a postoperative cholecystectomy client completes tomorrow's dinner menu, the nurse knows that one of the following meal choices will best provide the essential vitamin(s) necessary for proper tissue healing? A. Liver, white rice, spinach, tossed salad, custard pudding B. Fish fillet, carrots, mashed potatoes, butterscotch pudding C. Roast chicken, gelatin with sliced fruit D. Chicken breast fillet in tomato sauce, potatoes, mustard greens, orange and strawberry slices
Answer: D Explanation: (A) This meal choice provides more of the vitamins A, D, and K than of vitamin C. (B) This meal choice provides more of the vitamins A, B12, and D than of vitamin C. (C) This meal choice provides more of the vitamins A, B1 (thiamine), niacin, and microminerals than of vitamin C. (D) This meal choice provides foods rich in vitamin C, which are essential in tissue healing.
NO.349 An 8-year-old child comes to the physician's office complaining of swelling and pain in the knees. His mother says, "The swelling occurred for no reason, and it keeps getting worse." The initial diagnosis is Lyme disease. When talking to the mother and child, questions related to which of the following would be important to include in the initial history? A. A decreased urinary output and flank pain B. A fever of over 103F occurring over the last 2-3 weeks C. Rashes covering the palms of the hands and the soles of the feet D. Headaches, malaise, or sore throat
Answer: D Explanation: (A) Urinary tract symptoms are not commonly associated with Lyme disease. (B) A fever of 103F is not characteristic of Lyme disease. (C) The rash that is associated with Lyme diseasedoes not appear on the palms of the hands and the soles of the feet. (D) Classic symptoms of Lyme disease include headache, malaise, fatigue, anorexia, stiff neck, generalized lymphadenopathy, splenomegaly, conjunctivitis, sore throat, abdominal pain, and cough.
NO.313 In working with mental health clients who are prescribed medication that must be taken on a routine basis, it is important for education to begin when the drug therapy is initiated. One of the first steps in the teaching process is to: A. Explain the side effects of the medication B. Discuss the danger of overmedication C. Distribute written material to supplement verbal instructions D. Explore the client's perception regarding medication therapy
Answer: D Explanation: (A, B, C) The nurse must first obtain information regarding the client's perception of the medication regimen. (D) The first step in the teaching process is to determine the client's perception.
NO.347 A client had a vaginal delivery 3 days ago and is discharged from the hospital on the 2nd day postpartum. She told the RN, "I need to start exercising so that I can get back into shape. Could you suggest an exercise I could begin with?'' The RN could suggest which one of the following? A. Push-ups B. Jumping jacks C. Leg lifts D. Kegel exercises
Answer: D Explanation: (A, B, C) This exercise is too strenuous at this time. (D) This exercise is recommended for the first few days after delivery. It helps to stimulate muscle tonus in the area of the perineum and the area around the urinary meatus and vagina.
