NUR 113 FINAL REVIEW

Which assessment indicates the treatment for the client diagnosed with bacterial meningitis is effective? 1. There is a positive Brudzinski's sign and photophobia. 2. The client tolerates meals without nausea. 3. There is a positive Kernig's sign and an elevated temperature. 4. The client is able to flex the neck without pain.

1. A positive Brudzinski's sign—flexion of the knees and hip when the neck is flexed— indicates the presence of meningitis. Therefore, the treatment is not effective. Sensitivity to light is a common symptom of meningitis. 2. This does not indicate whether the meningitis is resolving. 3. Kernig's sign—the leg cannot be extended when the client is lying with the thigh flexed on the abdomen—is a sign of meningitis. An elevated temperature indicates the client still has meningitis. 4. The client does not have nuchal rigidity, which indicates the client's treatment is effective.

Which assessment data indicate the client has developed a deep vein thrombosis (DVT) in the left leg? 1. A negative Homan's sign of the left leg. 2. Increased left-leg calf circumference. 3. Elephantiasis of the left lower leg. 4. Brownish pigmentation of the left lower leg.

1. A positive Homans' sign would indicate a DVT. 2. The calf with deep vein thrombosis becomes edematous, so there is an increase in the size of the calf when compared to the other leg. 3. Elephantiasis is characterized by tremendous edema usually of the external genitalia and legs and is not associated with DVT. Elephantiasis is a lymphatic problem, not a venous problem. 4. The brownish discoloration is a sign/ symptom of chronic venous insufficiency.

The client is being evaluated to rule out Parkinson's disease. Which diagnostic test confirms this diagnosis? 1. A positive magnetic resonance imaging (MRI) scan. 2. A biopsy of the substantia nigra. 3. A sterotactic pallidotomy. 4. There is no test that confirms this diagnosis.

1. An MRI is not able to confirm the diagnosis of Parkinson's disease. 2. This is the portion of the brain where Parkinson's disease originates, but this area lies deep in the brain and cannot be biopsied. 3. This is a surgery that relieves some of the symptoms of Parkinson's disease. To be eligible for this procedure, the client must have failed to achieve an adequate response with medical treatment. 4. Many diagnostic tests are completed to rule out other diagnoses, but Parkinson's disease is diagnosed based on the clinical presentation of the client and the presence of two of the three cardinal manifestations: tremor, muscle rigidity, and bradykinesia.

Which assessment information is the most critical indicator of a neurological deficit? 1. Changes in pupil size. 2. Level of consciousness. 3. A decrease in motor function. 4. Numbness of the extremities.

1. Changes in pupil size are a late sign of a neurological deficit. 2. A change in level of consciousness is the first and most critical indicator of any neurological deficit. 3. A decrease in motor function occurs with a neurological deficit, but it is not the most critical indicator. 4. Numbness of the extremities occurs with a neurological deficit, but it is not the most critical indicator.

4 0. Which child is at highest risk for requiring hospitalization to treat respiratory syncytial virus (RSV)? 1. A 2-month-old who was born at 32 weeks. 2. A 16-month-old with a tracheostomy. 3. A 3-year-old with a congenital heart defect. 4. A 4-year-old who was born at 30 weeks.

1. RSV is not diagnosed by a blood test. 2. Nasal secretions are tested to determine whether a child has RSV. 3. The child is swabbed for nasal secretions. The secretions are tested to determine whether a child has RSV. 4. Viral cultures are not done very often because it takes several days to receive results. The culture does not have to be sent to an outside laboratory for evaluation.

The client diagnosed with atherosclerosis has coronary artery disease. The client experiences sudden chest pain when walking to the nurse's station. Which intervention should the nurse implement first? 1. Administer sublingual nitroglycerin. 2. Apply oxygen via nasal cannula. 3. Obtain a STAT electrocardiogram. 4. Have the client sit in a chair.

1. Sublingual nitroglycerin is the medication of choice for angina, but it is not the first intervention. 2. Applying oxygen is appropriate, but it is not the first intervention. 3. A STAT ECG should be ordered, but it is not the first intervention. 4. Stopping the client from whatever activity the client is doing is the first intervention because this decreases the oxygen demands of the heart muscle and may decrease or eliminate the chest pain.

1 6. Which laboratory result will provide the most important information regarding the respiratory status of a child with an acute asthma exacerbation? 1. CBC. 2. ABG. 3. BUN. 4. PTT.

1. The CBC gives the health-care team information about the child ' s red and white blood cell count and hemoglobin and hematocrit levels. The CBC indicates if the child has or is developing an infection, but it reveals nothing about the child ' s current respiratory status. 2. The ABG gives the health-care team valuable information about the child ' s respiratory status: level of oxygenation, carbon dioxide, and blood pH. 3. The BUN provides information about the patient ' s kidney function, but it reveals nothing regarding the patient ' s respiratory status. 4. The PTT provides information about how long it takes the patient ' s blood to clot, but it reveals nothing about the patient ' s respiratory status.

The client diagnosed with end-stage congestive heart failure is being cared for by the home health nurse. Which intervention should the nurse teach the caregiver? 1. Report any time the client starts having difficulty breathing. 2. Notify the HCP if the client gains more than 3 lb in a week. 3. Teach how to take the client's apical pulse for one (1) full minute. 4. Encourage the client to participate in 30 minutes of exercise a day.

1. The client diagnosed with CHF will be short of breath on exertion and with activity. The significant other should report difficulty breathing not subsiding with rest or stopping the activity. 2. Two (2) to three (3) pounds of weight gain reflects fluid retention as a result of heart failure, which warrants notifying the HCP. 3. The caregiver must not administer the digoxin if the radial pulse is less than 60 bpm. The apical pulse is more difficult to assess in a client than the radial pulse. 4. The client in end-stage CHF is dying and should not exercise daily; activity intolerance as a result of decreased cardiac output is the number-one life-limiting problem.

The UAP notifies the nurse the client diagnosed with COPD is complaining of shortness of breath and would like his oxygen level increased. Which intervention should the nurse implement? 1. Notify the respiratory therapist. 2. Ask the UAP to increase the oxygen. 3. Obtain a STAT pulse oximeter reading. 4. Tell the UAP to leave the oxygen alone.

1. The nurse can take care of this situation and does not need to notify the RT. 2. The UAP cannot increase oxygen. The nurse should treat oxygen as a medication. Also, increasing the oxygen level could cause the client to stop breathing as a result of carbon dioxide narcosis. 3. The pulse oximeter reading will be low because the client has COPD. 4. The oxygen level for a client with COPD must remain between two (2) and three (3) L/min because the client's stimulus for breathing is low blood oxygen levels. If the client receives increased oxygen, the stimulus for breathing will be removed and the client will stop breathing.

The nurse is initiating a blood transfusion. Which interventions should the nurse implement? Select all that apply. 1. Assess the client's lung fields. 2. Have the client sign a consent form. 3. Start an IV with a 22-gauge IV catheter. 4. Hang 250 mL of D5W at a keep-open rate. 5. Check the chart for the HCP's order.

1. The nurse must make a decision on the amount of blood to infuse per hour. If the client is showing any sign of heart or lung compromise, the nurse would infuse the blood at the slowest possible rate. 2. Blood products require the client to give specific consent to receive blood. 3. The IV should be started with an 18-gauge catheter if possible; the smallest possible catheter is a 20-gauge. Smaller gauge catheters break down the blood cells. 4. Blood is not compatible with D5W; the nurse should hang 0.9% normal saline (NS) to keep open. 5. The nurse should verify the HCP's order before having the client sign the consent form.

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical floor. Which nursing task could be delegated to the UAP? 1. Retake the BP on a client who received a STAT nitroglycerin sublingual. 2. Notify the health-care provider of the client's elevated blood pressure. 3. Obtain and document the routine vital signs on all the clients on the floor. 4. Call the laboratory technician and discuss a hemolyzed blood specimen.

1. This client is unstable and received medication for chest pain. The nurse cannot delegate any task for a client who is unstable. 2. The UAP cannot notify the HCP because UAPs are not allowed to take verbal or telephone orders. 3. The UAP can take routine vital signs. The nurse must evaluate the vital signs and take action if needed. The nurse should not delegate teaching, assessing, evaluating, or any client who is unstable. 4. This is outside the level of a UAP's expertise.

The nurse observes the unlicensed assistive personnel (UAP) taking vital signs on an unconscious client. Which action by the UAP warrants intervention by the nurse? 1. The UAP uses a vital sign machine to check the BP. 2. The UAP takes the client's temperature orally. 3. The UAP verifies the blood pressure manually. 4. The UAP counts the respirations for 30 seconds.

1. Using the vital sign machine to take the client's BP is an appropriate intervention. 2. The body temperature of an unconscious client should never be taken by mouth because the client is unable to safely hold the thermometer. 3. Verifying the blood pressure manually is an appropriate intervention if the UAP questions the automatic blood pressure reading. This action should be praised. 4. Counting the respiration for 30 seconds and multiplying by two (2) is appropriate.

The nurse is planning care for the client with multiple stage IV pressure ulcers. Which complication results from these pressure ulcers? 1. Wasting syndrome 2. Osteomyelitis 3. Renal calculi 4. Cellulitis

1. Wasting syndrome occurs in clients with protein-calorie malnutrition. This syndrome leads to the pressure ulcers not healing, but it is not a complication of the pressure ulcers. 2. Stage IV pressure ulcers frequently extend to the bone tissue, predisposing the client to developing a bone infection— osteomyelitis—which can rarely be treated effectively. 3. Renal calculi may be a result of immobility, but they are not a complication of pressure ulcers. 4. Cellulitis is an inflammation of the skin, which is not a complication of pressure ulcers.

19. The nurse is caring for a 4-month-old with gastroesophageal refl ux (GER). The infant is due to receive rantadine (Zantac). Based on the medication ' s mechanism of action, when should this medication be administered? 1. Immediately before a feeding. 2. 30 minutes after the feeding. 3. 30 minutes before the feeding. 4. At bedtime.

19. 1. If rantadine (Zantac) is administered immediately before a feeding, the medication will not have enough time to take effect. 2. This medication should be administered prior to a feeding to be effective. 3. Rantadine (Zantac) decreases gastric acid secretion and should be administered 30 minutes before a feeding. 4. This medication should be administered prior to a feeding to be effective.

13. While assessing a newborn with respiratory distress, the nurse auscultates a machine-like heart murmur. Other fi ndings are a wide pulse pressure, periods of apnea, increased Pa CO2, and decreased P O2. The nurse suspects that the newborn has: 1. Pulmonary hypertension. 2. Patent ductus arteriosus (PDA). 3. Ventricular septal defect (VSD). 4. Bronchopulmonary dysplasia.

13. 1. Pulmonary hypertension is a pulmonary condition, which does not create a heart murmur. 2. The main identifier in the stem is the machine-like murmur, which is the hallmark of a PDA. 3. A VSD does not produce a machine-like murmur. 4. Bronchopulmonary dysplasia is a pulmonary condition, which does not create a heart murmur

14. The nurse is caring for an infant newly diagnosed with Hirschsprung disease. What does the nurse understand about this infant ' s condition? Select all that apply. 1. There is a lack of peristalsis in the large intestine and an accumulation of bowel contents, leading to abdominal distention. 2. There is excessive peristalsis throughout the intestine, resulting in abdominal distention. 3. There is a small-bowel obstruction, leading to ribbon-like stools. 4. There is infl ammation throughout the large intestine, leading to accumulation of intestinal contents and abdominal distention. 5. There is an accumulation of bowel contents, leading to non-passage of stools.

14. 1, 5. 1. In Hirschsprung disease, a portion of the large intestine has an area lacking in ganglion cells. This results in a lack of peristalsis as well as an accumulation of bowel contents and abdominal distention. 2. There is a lack of peristalsis at the aganglionic section of the bowel. 3. Hirschsprung disease does not include a small-bowel obstruction. 4. Hirschsprung disease does not present with infl ammation throughout the large intestine. 5. There is accumulation of stool above the aganglionic bowel, which does not allow stool to pass through.

15. The nurse is caring for a 3-month-old being evaluated for possible Hirschsprung disease. His parents call the nurse and show her his diaper containing a large amount of mucus and bloody diarrhea. The nurse notes that the infant is irritable and his abdomen appears very distended. Which should be the nurse ' s next action? 1. Reassure the parents that this is an expected fi nding and not uncommon. 2. Call a code for a potential cardiac arrest and stay with the infant. 3. Immediately obtain all vital signs with a quick head-to-toe assessment. 4. Obtain a stool sample for occult blood.

15. 1. All cases of bloody diarrhea need to be evaluated because this may be a sign of enterocolitis, which is a potentially fatal complication of Hirschsprung disease. 2. Although this is a potentially critical complication, calling a code is not necessary at this time because the infant is irritable and not unconscious. 3. All vital signs need to be evaluated because the child with enterocolitis can quickly progress to a state of shock. A quick head-to-toe assessment will allow the nurse to evaluate the child ' s circulatory system. 4. It is not a priority to test the stool for occult blood, because there is obvious blood in the sample.

15. Which should the nurse include in the teaching plan for a child started on metoclopramide (Reglan)? 1. The drug increases gastrointestinal motility. 2. The drug decreases tone in the lower esophageal sphincter. 3. The drug prevents diarrhea. 4. The drug induces the release of acetylcholine.

15. 1. Metoclopramide (Reglan) is a gastrointestinal stimulant that increases motility of the gastrointestinal tract, shortens gastric emptying time, and reduces the risk of the esophagus being exposed to gastric content. 2. Decreased tone in the esophageal sphincter increases the risk of gastric contents being regurgitated upward into the esophagus. 3. There can be an increase in diarrhea because of the increase in gastrointestinal motility. 4. Methyl scopolamine blocks effects of acetylcholine and relaxes sooth muscles.

16. The nurse is caring for an 8-week-old male who has just been diagnosed with Hirschsprung disease. The parents ask what they should expect. Which is the nurse ' s best response? 1. "It is really an easy disease to manage. Most children are placed on stool softeners to help with constipation until it resolves." 2. "A permanent stool diversion, called a colostomy, will be placed by the surgeon to bypass the narrowed area." 3. "Daily bowel irrigations will help your child maintain regular bowel habits." 4. "Although your child will require surgery, there are different ways to manage the disease, depending on how much bowel is involved."

16. 1. The constipation will not resolve with stool softeners. The affected bowel needs to be removed. 2. Most colostomies are not permanent. The large intestine is usually reattached, and the colostomy is taken down. 3. The child with Hirschsprung disease requires surgery to remove the aganglionic portion of the large intestine. 4. The aganglionic portion needs to be removed. Although most children have a temporary colostomy placed, many infants are able to bypass the colostomy and have the bowel immediately reattached.

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

17. 1. Routine circumcision is recommended by the American Academy of Pediatrics; it is not contraindicated in most children. 2. It is not recommended that circumcision of children with hypospadias be done immediately because the foreskin may be needed later for repair of the defect. 3. It is usually recommended that circumcision be delayed in the child with hypospadias because the foreskin may be needed for repair of the defect. 4. Circumcision can usually be performed in the child with hypospadias when the defect is corrected.

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

17. 3, 4, 5, 6. 1. Heart defects are no longer classifi ed as cyanotic or acyanotic. 2. Heart defects are no longer classifi ed as cyanotic or acyanotic. 3. Heart defects are now classifi ed as defects with increased or decreased pulmonary blood fl ow, mixed, obstructive, or acquired. 4. Heart defects are now classifi ed as defects with increased or decreased pulmonary blood fl ow, mixed, obstructive or acquired. 5. Heart defects are now classifi ed as defects with increased or decreased pulmonary blood fl ow mixed, obstructive, or acquired. 6. Heart defects are now classifi ed as defects with increased or decreased pulmonary blood fl ow, mixed, obstructive, or acquired. 7. A murmur may be heard with a CHD, but a murmur does not classify the defect.

1 8. Which is the nurse ' s best response to parents who ask what impact asthma will have on the child ' s future in sports? 1. "As long as your child takes prescribed asthma medication, the child will be fi ne." 2. "The earlier a child is diagnosed with asthma, the more signifi cant the symptoms." 3. "The earlier a child is diagnosed with asthma, the better the chance the child has of growing out of the disease." 4. "Your child should avoid playing contact sports and sports that require a lot of running."

18. 1. It is essential that the child take all of the scheduled asthma medications, but there is no guarantee the child will be fi ne and be able to play all sports. 2. When a child is diagnosed with asthma at an early age, the child is more likely to have signifi cant symptoms on aging. 3. Children diagnosed at an early age usually exhibit worse symptoms than those diagnosed later in life. 4. Children with asthma are encouraged to participate in sports.

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

18. 1. Laying the child fl at would increase preload, increasing blood to the heart, therefore making respiratory distress worse. 2. Laying the child fl at with legs elevated would increase preload, increasing blood to the heart, therefore making respiratory distress worse. 3. Sitting the child on the parent ' s lap with legs dangling might possibly help, but it would not be as effective as the knee-chest position in occluding the venous return. 4. The increase in the SVR would increase afterload and increase blood return to the pulmonary artery.

1 9. Which statement by the parent of a child using an albuterol inhaler leads the nurse to believe that further education is needed on how to administer the medication? 1. "I should administer two quick puffs of the albuterol inhaler using a spacer." 2. "I should always use a spacer when administering the albuterol inhaler." 3. "I should be sure that my child is in an upright position when administering the inhaler." 4. "I should always shake the inhaler before administering a dose."

19. 1. The parent of an asthmatic child should always give one puff at a time and wait 1 minute before administering the second puff. 2. A spacer is recommended when administering medications by metered dose inhaler (MDI) to children. 3. The child should be in an upright position when medications are administered by MDI. 4. The inhaler should always be shaken before administering a dose of the medication.

The 54-year-old female client is diagnosed with osteoporosis. Which interventions should the nurse discuss with the client? Select all that apply. 1. Instruct the client to swim 30 minutes every day. 2. Encourage drinking milk with added vitamin D. 3. Determine if the client smokes cigarettes. 4. Recommend the client not go outside. 5. Teach about safety and fall precautions.

2.3.5 1. The nurse should suggest walking daily because bones need stress to maintain strength. 2. Vitamin D helps the body absorb calcium. 3. Smoking interferes with estrogen's protective effects on bones, promoting bone loss. 4. Lack of exposure to sunlight results in decreased vitamin D, which is necessary for calcium absorption and normal bone mineralization. The client should go outside. 5. The client is at risk for fractures; therefore, a fall could result in serious complications.

20. The nurse is administering omeprazole (Prilosec) to a 3-month-old with gastroesophageal refl ux (GER). The child ' s parents ask the nurse how the medication works. Which is the nurse ' s best response? 1. "Prilosec is a proton pump inhibitor that is commonly used for refl ux in infants." 2. "Prilosec decreases stomach acid, so it will not be as irritating when your child spits up." 3. "Prilosec helps food move through the stomach quicker, so there will be less chance for refl ux." 4. "Prilosec relaxes the pressure of the lower esophageal sphincter."

20. 1. Although this is an accurate description of the mechanism of action, it does not tell the parents how the medication functions. 2. This accurate description gives the parents information that is clear and concise. 3. Omeprazole (Prilosec) does not increase the rate of gastric emptying. 4. Omeprazole (Prilosec) does not relax the pressure of the lower esophageal sphincter.

2 0. Which should the nurse administer to provide quick relief to a child with asthma who is coughing, wheezing, and having diffi culty catching her breath? 1. Prednisone. 2. Montelukast (Singulair). 3. Albuterol. 4. Fluticasone (Flovent).

20. 1. Prednisone, a corticosteroid, is often given to children with asthma, but it is not a quickrelief medication. The prednisone will take time to relieve the child ' s symptoms. 2. Montelukast (Singulair) is an allergy medication that should be taken daily by asthmatics with signifi cant allergies. Allergens are often triggers for asthmatics, so treating the child for allergies can help avoid an asthma attack. Montelukast (Singulair), however, does not help a child immediately with the symptoms of a particular asthma attack. 3. Albuterol is the quick-relief bronchodilator of choice for treating an asthma attack. 4. Fluticasone (Flovent) is a long-term therapy medication for asthmatics and is used daily to help prevent asthma attacks.

20. A 6-month-old who has episodes of cyanosis after crying could have the congenital heart defect (CHD) of decreased pulmonary blood fl ow called _____________________.

20. Tetralogy of Fallot (TOF). "Tet" spells are characteristic of TOF. TEST-TAKING HINT: Know the congenital heart defect classifi cations.

2 1. Which child with asthma should the nurse see first? 1. A 12-month-old who has a mild cry, is pale in color, has diminished breath sounds, and has an oxygen saturation of 93%. 2. A 5-year-old who is speaking in complete sentences, is pink in color, is wheezing bilaterally, and has an oxygen saturation of 93%. 3. A 9-year-old who is quiet, is pale in color, and is wheezing bilaterally with an oxygen saturation of 92%. 4. A 16-year-old who is speaking in short sentences, is wheezing, is sitting upright, and has an oxygen saturation of 93%.

21. 1. This child is exhibiting signs of severe asthma. This child should be seen first. The child no longer has wheezes and now has diminished breath sounds. 2. This child is exhibiting symptoms of mild asthma and should not be seen before the other children. 3. This child is exhibiting signs of moderate asthma and should be watched but is not the patient of highest priority. 4. This child is exhibiting signs of moderate asthma and is not the patient of highest priority.

The client is newly diagnosed with epilepsy. Which statement indicated the client needs clarification of the discharge teaching? 1. "I can drive as soon as I see my HCP for my follow-up visit. 2. "I should get at least eight hours of sleep at night." 3. "I should take my medication every day even if I am sick." 4. "I will take showers instead of taking tub baths."

21. 1. This statement indicates the client does not understand the discharge teaching. The client will not be able to drive until the client is seizure free for a certain period of time. The laws in each state differ. 2. Lack of sleep is a risk factor for having seizures. 3. Noncompliance with medication is a risk factor for having a seizure. 4. If the client has a seizure in the bathtub, the client could drown.

21. When a child is suspected of having osteomyelitis, the nurse can prepare the family to expect which of the following? Select all that apply. 1. Pain medication is contraindicated so that symptoms are not masked. 2. Blood cultures will be obtained. 3. Pus will be aspirated from the subperiosteum. 4. An intravenous line with antibiotics will be started. 5. Surgery will be necessary.

21. 2, 3, 4. 1. Medication will be given regularly to help with the pain. 2. Blood cultures will be obtained to determine the organism causing the infection. 3. Pus will be aspirated from the subperiosteum. 4. Antibiotics will be given via an intravenous line. 5. Surgery is indicated only when medication fails.

24. Which is most important when teaching a parent about preventing osteomyelitis? 1. Parents can stop worrying about bone infection once their child reaches school age. 2. Parents need to clean open wounds thoroughly with soap and water. 3. Children will always get a fever if they have osteomyelitis. 4. Children should wear long pants when playing outside because their legs might get scratched.

24. 1. Osteomyelitis can occur in children older than school age. 2. Because bacteria from an open wound can lead to osteomyelitis, thorough cleaning with soap and water is the best prevention. 3. Children with osteomyelitis do not always have a fever. 4. It is not necessary to require children to wear long pants whenever playing outside.

25. The nurse caring for a child with osteomyelitis assesses poor appetite. Which intervention is most appropriate for this child? Select all that apply. 1. Offer high-calorie liquids. 2. Offer favorite foods. 3. Do not worry about intake, because appetite loss is expected. 4. Suggest removal of the intravenous line to encourage oral intake. 5. Decrease pain medication that might cause nausea. 6. Offer frequent small meals.

25. 1, 2, 6. 1. High-calorie liquids are sometimes received better when the child has a poor appetite. 2. Offering favorite foods can sometimes tempt the child to eat, even with a poor appetite. 3. Although decreased appetite is expected, it is something that needs nursing intervention in order to promote healing. 4. An intravenous line is necessary for antibiotics, so it cannot be removed to encourage oral intake. 5. Although some pain medications cause nausea, their use is important. If clients are in pain, they are not likely to want to eat. 6. Frequent small meals might increase daily caloric intake.

25. A 16-year-old being treated for hypertension has a history of asthma. Which drug class should be avoided in treating this client ' s hypertension? 1. Beta blockers. 2. Calcium channel blockers. 3. ACE inhibitors. 4. Diuretics.

25. 1. Beta blockers are not generally used in clients with asthma and hypertension because of concern the beta agonist will cause severe asthma attacks. 2. Calcium channel blockers do not have the effect of causing asthma attacks. 3. ACE inhibitors do not have the effect of causing asthma attacks. 4. Diuretics do not have the effect of causing asthma attacks.

The client diagnosed with a transient ischemic attack (TIA) is being discharged from the hospital. Which medication should the nurse expect the HCP to prescribe? 1. The oral anticoagulant warfarin (Coumadin). 2. The antiplatelet medication, a baby aspirin. 3. The beta blocker propranolol (Inderal). 4. The anticonvulsant valproic acid (Depakote).

26. 1. An oral coagulant is ordered if the TIA was caused by atrial fibrillation, and that information is not presented in the stem. 2. Atherosclerosis is the most common cause of a TIA or stroke, and taking a baby aspirin every day helps prevent clot formation around plaques. 3. If the client had hypertension, a beta blocker may be prescribed, but this information is not in the stem. 4. Anticonvulsant medications are not prescribed to help prevent TIAs.

26. A nurse is caring for a child with congenital heart disease who is being treated with digoxin (Lanoxin). Which is included in the family ' s discharge teaching? 1. Make sure the medication is taken with food. 2. Repeat the dose if the child vomits. 3. Take the child ' s pulse prior to administration. 4. Weigh the child daily.

26. 1. Digoxin (Lanoxin) should not be taken with food. Administer the medication 1 hour before or 2 hours after a meal. 2. The dose should not be repeated if the child vomits. 3. The child ' s pulse should be monitored before each dose. The dose should be withheld according to the health-care provider ' s parameters. 4. Checking weight is not related to the medication.

26. The _____________________ serves as the septal opening between the atria of the fetal heart.

26. Foramen ovale. TEST-TAKING HINT: The foramen ovale is the septal opening between the atria of the fetal heart. The test taker needs to know basic fetal circulation.

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

3. 1, 2, 4, 6. 1. TOF is a congenital defect with a ventricular septal defect, right ventricular hypertrophy, pulmonary valve stenosis, and overriding aorta. 2. TOF is a congenital defect with ventricular septal defect, right ventricular hypertrophy, pulmonary valve stenosis, and overriding aorta. 3. TOF is a congenital defect with ventricular septal defect, right ventricular hypertrophy, pulmonary valve stenosis, and overriding aorta. 4. TOF is a congenital defect with ventricular septal defect, right ventricular hypertrophy, pulmonary valve stenosis, and overriding aorta. 5. TOF is a congenital defect with ventricular septal defect, right ventricular hypertrophy, pulmonary valve stenosis, and overriding aorta. 6. TOF is a congenital defect with ventricular septal defect, right ventricular hypertrophy, pulmonary valve stenosis, and overriding aorta. 7. PDA is not one of the defects in tetralogy of Fallot.

3. What time would the nurse most likely see signs and symptoms of hypoglycemia after administering NPH insulin at 0730? 1. 0930 to 1030. 2. 1130 to 1430. 3. 1130 to 1930. 4. 1530 to 1930.

3. 1. Peak time for regular insulin is 2 to 3 hours. 2. Peak time for Semilente insulin is 4 to 7 hours. 3. Peak time for NPH insulin is 4 to 12 hours. 4. Peak time for Lente insulin is 8 to 12 hours

The primary nurse is applying anti-embolism hose to the client who had a total hip replacement. Which situation warrants immediate intervention by the charge nurse? 1. Two fingers can be placed under the top of the band. 2. The peripheral capillary refill time is less than 3 seconds. 3. There are wrinkles in the hose behind the knees. 4. The nurse does not place a hose on the foot with a venous ulcer.

3. There should be no wrinkles in the hose after application. Wrinkles could cause constriction in the area, resulting in clot formation or skin breakdown; therefore, this would warrant immediate intervention by the charge nurse.

31. Which is the correct method to instill eardrops in a 5-year-old? 1. Pull the pinna of the ear downward and back for instillation. 2. Place cotton tightly in the ear after instillation. 3. Have the child remain upright after instillation. 4. Pull the pinna of the ear upward and back for instillation.

31. 1. Pull the pinna down and back for a child younger than age 3 years. 2. Placing the cotton in the ear tightly would be painful. The cotton could act as a wick and absorb the medication preventing its instillation. It will not help in the administration of the eardrops. 3. Having the child stay in an upright position after instillation does not affect administration of the eardrops. 4. The correct way to administer eardrops in a child older than 3 years of age is to pull the pinna up and back, the same as for an adult. TEST-TAKING HINT: In infants, the ear canal is curved upward; therefore, the pinna should be pulled down and back. With children older than 3 years of age, the canal curves downward and forward; therefore, the pinna should be pulled up and back.

3 1. Which statement by the parents of a toddler with repeated otitis media indicates they need additional teaching? 1. "If I quit smoking, my child may have a decreased chance of getting an ear infection." 2. "As my child gets older, he should have fewer ear infections, because his immune system will be more developed." 3. "My child will have fewer ear infections if he has his tonsils removed." 4. "My child may need a speech evaluation."

31. 1. Repeated exposure to smoke damages the cilia in the ear, making the child more prone to ear infections. 2. Children experience fewer ear infections as they age because their immune system is maturing. 3. Removing children ' s tonsils may not have any effect on their ear infections. Children who have repeated bouts of tonsillitis can have ear infections secondary to the tonsillitis, but there is no indication in this question that the child has a problem with tonsillitis. 4. Children who have repeated ear infections are at a higher risk of having decreased hearing during and between infections. Hearing loss directly affects a child ' s speech development.

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

32. 1. BPs would not need to be taken in both the upper and lower extremities in transposition of the great vessels. The aorta and pulmonary arteries are in opposite positions, which does not change the BP readings. 2. AS is a narrowing of the aortic valve, which does not affect the BP in the extremities. 3. With COA there is narrowing of the aorta, which increases pressure proximal to the defect (upper extremities) and decreases pressure distal to the defect (lower extremities). There will be high BP and strong pulses in the upper extremities and lower-than-expected BP and weak pulses in the lower extremities. 4. TOF is a congenital cardiac problem with four defects that do not affect the BP in the extremities.

3 3. Which should be included in instructions to the parent of a child prescribed amoxicillin to treat an ear infection? 1. "Continue the amoxicillin until the child ' s symptoms subside." 2. "Administer an over-the-counter antihistamine with the antibiotic." 3. "Administer the amoxicillin until all the medication is gone." 4. "Allow your child to administer his own dose of amoxicillin."

33. 1. The parent should administer all of the medication. Stopping the medication when symptoms subside may not clear up the ear infection and may actually cause more severe symptoms. 2. Antihistamines have not been shown to decrease the number of ear infections a child gets. 3. It is essential that all the medication be given. 4. The child is old enough to participate in the administration of medication but should do so only in the presence of the parents.

3 7. An infant is not sleeping well, is crying frequently, has yellow drainage from the ear, and is diagnosed with an ear infection. Which nursing objective is the priority for the family? 1. Educating the parents about signs and symptoms of an ear infection. 2. Providing emotional support for the parents. 3. Providing pain relief for the child. 4. Promoting the fl ow of drainage from the ear.

37. 1. It is important to educate the family about the signs and symptoms of an ear infection, but that is not the priority at this time. The infant has already been diagnosed with the infection. 2. The parents may need emotional support because they are likely suffering from a lack of sleep because their infant is ill. However, this will not solve their current problems with their infant. 3. Providing pain relief for the infant is essential. With pain relief, the child will likely stop crying and rest better, as will the parents. 4. Promoting drainage fl ow from the ear is important, but providing pain relief is the highest priority.

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

38. 1. Glucagon is given only for severe hypoglycemia. The child ' s symptoms are those of mild hypoglycemia. 2. Milk is best to give for mild hypoglycemia, which would present with the symptoms described. 3. Insulin is appropriate for elevated blood glucose, but the symptoms listed are those of hypoglycemia, not hyperglycemia. It is important for the test taker to be able to distinguish between the two. 4. Water is appropriate for mild hyperglycemia, but the symptoms listed are those of hypoglycemia.

3 8. A parent asks the nurse how it will be determined whether their child has respiratory syncytial virus (RSV). Which is the nurse ' s best response? 1. "We will do a simple blood test to determine whether your child has RSV." 2. "There is no specifi c test for RSV. The diagnosis is made based on the child ' s symptoms." 3. "We will swab your child ' s nose and send that specimen for testing." 4. "We will have to send a viral culture to an outside lab for testing."

38. 1. RSV is not diagnosed by a blood test. 2. Nasal secretions are tested to determine whether a child has RSV. 3. The child is swabbed for nasal secretions. The secretions are tested to determine whether a child has RSV. 4. Viral cultures are not done very often because it takes several days to receive results. The culture does not have to be sent to an outside laboratory for evaluation.

3 9. Which statement indicates the parent needs further teaching on how to prevent his other children from contracting respiratory syncytial virus (RSV)? 1. "I should make sure that both my children receive palivizumab (Synagis) injections for the remainder of this year." 2. "I should be sure to keep my infected child away from his brother until he has recovered." 3. "I should insist that all people who come in contact with my children thoroughly wash their hands before playing with them." 4. "I should insist that anyone with a respiratory illness avoid contact with my children until well."

39. 1. Palivizumab (Synagis) will not help the child who has already contracted the illness. Palivizumab (Synagis) is an immunization and a method of primary prevention. 2. RSV is spread through direct contact with respiratory secretions, so it is a good idea to keep the ill child away from the healthy one. 3. RSV is spread through direct contact with respiratory secretions, so it is a good idea to have all persons coming in contact with the child wash their hands. 4. RSV is spread through direct contact with respiratory secretions, so it is a good idea to have ill persons avoid any contact with the children until they are well.

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

4. 1. The increased pressure associated with evacuating hardened stool can result in the backfl ow of urine into the bladder, leading to infection. 2. To prevent infection, a female child should wipe from front to back. 3. Tub baths are not recommended because they may cause irritation of the urethra, leading to infection. 4. Increasing fluids will help flush the bladder of any organisms, encourage urination, and prevent stasis of urine.

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

40. 1. Type 2 DM is best managed by diet, exercise, and oral medication. 2. Proper diet and monitoring blood glucose are important in type 1 DM, but DM is characterized by insulin defi ciency. 3. Though insulin resistance can be one of the factors in type 1 DM, it is not the primary factor. 4. Individuals with type 1 DM do not produce insulin. If one does not produce insulin, type 1 DM is the diagnosis.

4 1. Which physical fi ndings would be of most concern in an infant with respiratory distress? 1. Tachypnea. 2. Mild retractions. 3. Wheezing. 4. Grunting

41. 1. Tachypnea, an increase in respiratory rate, should be monitored but is a common symptom of respiratory distress. 2. Retractions should be monitored; they can occur with respiratory distress. 3. Wheezing should be monitored and can occur with respiratory distress. 4. Grunting is a sign of impending respiratory failure and is a very concerning physical finding.

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

42. 1. Correct needle position is with the bevel facing upward. 2. Injection is subcutaneous, so tissue is not spread as it would be for intramuscular injection. 3. Aspiration for blood is not recommended for subcutaneous injections. 4. Skin tissue is elevated to prevent injection into the muscle when giving a subcutaneous injection. Insulin is only given subcutaneously.

4 2. How will a child with respiratory distress and stridor who is diagnosed with RSV be treated? 1. Intravenous antibiotics. 2. Intravenous steroids. 3. Nebulized racemic epinephrine. 4. Alternating doses of acetaminophen (Tylenol) and ibuprofen (Motrin).

42. 1. RSV is a viral illness and is not treated with antibiotics. 2. Steroids are not used to treat RSV. 3. Racemic epinephrine promotes mucosal vasoconstriction. 4. Acetaminophen (Tylenol) and ibuprofen (Motrin) can be given to the child for comfort, but they do not improve the child ' s respiratory status. TEST-TAKING HINT: Th

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

43. 1. Limiting fl uids is appropriate for a child presenting with the symptoms of DI, not DM. 2. Weight loss without the other presenting symptoms might be indicative of a need for a weight/nutrition consult. 3. Strict intake and output monitoring is included in the care of a child with DI. 4. Frequent blood glucose testing is included in the care of a child with type 1 DM. The symptoms described in the question are characteristic of a child just prior to the diagnosis of type 1 DM.

43. Which assessment finding should the nurse observe following administration of albuterol (Proventil)? 1. Decrease in wheezing. 2. Decrease in respiratory rate from 34 to 22. 3. Decrease in blood pressure. 4. Decrease in heart rate.

43. 1. The symptoms of an acute asthma attack are related to constriction of the airway, which leads to dyspnea and an increased respiratory rate. The albuterol (Proventil) is a beta-adrenergic agent that relaxes the smooth muscles of the bronchial tree, which will decrease wheezing. 2. The respiratory rate should return to normal. 3. Hypertension is a side effect of albuterol (Proventil). 4. Tachycardia is a side effect of albuterol (Proventil).

44. A child in the emergency room is being treated with albuterol (Proventil) aerosol treatments for an acute asthma attack. She requires treatments every 2 hours. Which adverse effect of the medication would the nurse expect? 1. Lethargy and bradycardia. 2. Decreased blood pressure and dizziness. 3. Nervousness and tachycardia. 4. Increased blood pressure and fatigue.

44. 1. One side effect of albuterol (Proventil) is tachycardia, not bradycardia. 2. Decreased blood pressure is not expected. Dizziness may occur from the tachycardia. 3. Potential side effects of this medication are stimulation of the central nervous system and cardiovascular system. Tachycardia is the most frequent side effect of albuterol (Proventil). 4. Increased blood pressure can occur, but the child will not experience lethargy until exhausted, which is a later effect.

45. A 3-month-old has been diagnosed with a ventricular septal defect (VSD). The fl ow of blood through the heart is _____________________.

45. Left to right. The pressures in the left side of the heart are greater, causing the fl ow of blood to be from an area of higher pressure to lower pressure, or left to right, increasing the pulmonary blood fl ow with the extra blood.

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

46. 1. Balanced diet, although important, is not determined by hemoglobin A1c. 2. Anemia would be a correct choice if the question asked about hemoglobin, not hemoglobin A1c. 3. Hemoglobin A1c, or glycosylated hemoglobin, refl ects average blood glucose levels over 2 to 3 months. Frequent high blood glucose levels would result in a higher hemoglobin A1c, suggesting that blood glucose needs to be in better control. 4. Presence of ketones in the blood, although associated with the absence of insulin and with high blood glucose levels, is not directly correlated with hemoglobin A1c.

46. The parents of a 3-month-old ask why their baby will not have an operation to correct a ventricular septal defect (VSD). The nurse ' s best response is: 1. "It is always helpful to get a second opinion about any serious condition like this." 2. "Your baby ' s defect is small and will likely close on its own by 1 year of age." 3. "It is common for health-care providers to wait until an infant develops respiratory distress before they do the surgery." 4. "With a small defect like this, they wait until the child is 10 years old to do the surgery."

46. 1. This is not a collegial response, and the nurse should explain to the parents why an operation is not necessary now. 2. Usually a VSD will close on its own within the first year of life. 3. It is not common for health-care providers to wait until respiratory distress develops because that puts the infant at greater risk for complications. The defect is small and will likely close on its own. 4. Small defects usually close on their own within the fi rst year.

47. The flow of blood through the heart with an atrial septal defect (ASD) is _____________________.

47. Left to right. The pressures in the left side of the heart are greater, causing the fl ow of blood to be from an area of higher pressure to lower pressure, or left to right, increasing the pulmonary blood fl ow with the extra blood.

48. The nurse is caring for a 5-month-old infant with a diagnosis of intussusception. The infant has periods of irritability during which the knees are brought to the chest and the infant cries, alternating with periods of lethargy. Vital signs are stable and within age-appropriate limits. The health-care provider elects to give an enema. The parents ask the purpose of the enema. Which is the nurse ' s most appropriate response? 1. "The enema will confi rm the diagnosis. If the test result is positive, your child will need to have surgery to correct the intussusception." 2. "The enema will confi rm the diagnosis. Although very unlikely, the enema may also help fi x the intussusception so that your child will not immediately need surgery." 3. "The enema will help confi rm the diagnosis and has a good chance of fi xing the intussusception." 4. "The enema will help confi rm the diagnosis and may temporarily fi x the intussusception. If the bowel returns to normal, there is a strong likelihood that the intussusception will recur."

48. 1. The enema is used for confi rmation of diagnosis and reduction. In most cases of intussusception in young children, an enema is successful in reducing the intussusception. 2. In most cases of intussusception in young children, an enema is successful in reducing the intussusception. 3. In most cases of intussusception in young children, an enema is successful in reducing the intussusception. 4. There is not a high likelihood that the intussusception will recur.

48. Which is a toxic reaction in a child taking digoxin (Lanoxin)? 1. Weight gain. 2. Tachycardia. 3. Nausea and vomiting. 4. Seizures.

48. 1. Weight gain is not a toxic reaction. 2. Bradycardia is a side effect of digoxin (Lanoxin). Tachycardia is not. 3. Digoxin (Lanoxin) toxicity in infants and children may present with nausea, vomiting, anorexia, or a slow, irregular, apical heart rate. 4. Seizures are not a toxic reaction that occur with digoxin (Lanoxin).

48. Patent ductus arteriosus causes what type of shunt? _____________________

48. Left to right. Blood flows from the higher-pressure aorta to the lower-pressure pulmonary artery, resulting in a left to right shunt.

5. A 12-year-old comes to the clinic with a diagnosis of Graves disease. What information should the nurse discuss with the child? 1. Suggest weight loss. 2. Encourage attending school. 3. Emphasize that the disease will go into remission. 4. Encourage the child to take responsibility for daily medications.

5. 1. Children with Graves disease have voracious appetites and lose weight. 2. Encouraging school and continuation of typical activities is better in terms of longterm management. Gym class and afterschool sports should be restricted until the child is euthyroid. 3. Graves disease may go into remission after 2 or 3 years; there are some children, however, for whom it does not. 4. Because the child is 12 years old, encouraging responsibility for health care is important. The child still needs family involvement and ongoing supervision but should not be completely dependent on family for care.

5. What should the nurse assess prior to administering digoxin (Lanoxin)? 1. Sclera. 2. Apical pulse rate. 3. Cough. 4. Liver function test.

5. 1. The sclera has nothing to do with CHF. 2. The apical pulse rate is assessed because digoxin (Lanoxin) decreases the HR; if the HR is <60, digoxin should not be administered. 3. Cough would not be assessed before administration. It is more commonly seen in patients who have been prescribed ACE inhibitors. 4. Liver function tests are not assessed before digoxin (Lanoxin) is administered. Digoxin can lower HR and cause dysrhythmias.

51. Which drug is most important in treating an infant with transposition of the great vessels? 1. Digoxin (Lanoxin). 2. Antibiotics. 3. Prostaglandin E. 4. Diuretics.

51. 1. Digoxin (Lanoxin) is given to treat congestive heart failure. 2. Antibiotics are used if there is an infection and prophylactically with invasive procedures. 3. Prostaglandin E is necessary to maintain patency of the patent ductus arteriosus and improve systemic arterial fl ow in children with inadequate intracardiac mixing. 4. Diuretics are given to treat congestive heart failure.

51. The nurse is taking care of a 10-year-old diagnosed with Graves disease. Which could the nurse expect this child to have recently had? 1. Weight gain, excessive thirst, and excessive hunger. 2. Weight loss, diffi culty sleeping, and heat sensitivity. 3. Weight gain, lethargy, and goiter. 4. Weight loss, poor skin turgor, and constipation.

51. 1. Graves disease is a type of hyperthyroidism. Gradual weight loss, not weight gain, is a sign. 2. Weight loss, increased activity, and heat intolerance can be expected when the thyroid gland is hyperfunctional. 3. Weight gain as a symptom makes this answer incorrect. 4. Constipation and dry skin with poor turgor are more likely in a patient with hypothyroidism.

51. Which medication should the nurse give to an infant diagnosed with transposition of the great vessels? 1. Ibuprofen (Motrin). 2. Betamethasone. 3. Prostaglandin E. 4. Indomethacin (Indocin).

51. 1. Ibuprofen (Motrin) blocks prostaglandins, which would speed up the closing of the PDA. 2. Betamethasone blocks prostaglandins, which would speed up the closing of the PDA. 3. Prostaglandin E inhibits closing of the PDA, which connects the aorta and pulmonary artery. 4. Indomethacin (Indocin) is used to treat osteoarthritis and gout.

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

52. 1. The fruity odor is that of acetone. The patient is exhibiting signs of ketoacidosis. The history of vomiting and the Kussmaul breathing preclude oral rehydration. 2. Although it is likely that ketones would be present, the child is in a life-threatening situation. Checking urine is not necessary. 3. This patient needs fl uid and electrolyte therapy to restore tissue perfusion prior to beginning IV insulin therapy. 4. The patient is hyperglycemic, not hypoglycemic.

53. The parent of a child being evaluated for celiac disease asks the nurse why it is important to make dietary changes. Which is the nurse ' s best response? 1. "The body ' s response to gluten causes damage to the mucosal cells in the intestine, leading to absorption problems." 2. "The body ' s response to consumption of anything containing gluten is to create special cells called villi, which leads to more diarrhea." 3. "The body ' s response to gluten causes the intestine to become more porous and hang on to more of the fat-soluble vitamins, leading to vitamin toxicity." 4. "The body ' s response to gluten causes damage to the mucosal cells, leading to malabsorption of water and hard, constipated stools."

53. 1. The inability to digest protein leads to an accumulation of an amino acid that is toxic to the mucosal cells and villi, leading to absorption problems. 2. Extra villi cells are not created. Instead, villi become damaged, leading to absorption problems. 3. The intestine does not become more porous. There is diffi culty with absorbing vitamins, leading to defi ciencies, not toxicity. 4. The child experiences diarrhea, not constipation.

5 4. Which statement about pneumonia is accurate? 1. Pneumonia is most frequently caused by bacterial agents. 2. Children with bacterial pneumonia are usually sicker than children with viral pneumonia. 3. Children with viral pneumonia are usually sicker than those with bacterial pneumonia. 4. Children with viral pneumonia must be treated with a complete course of antibiotics.

54. 1. Pneumonia is most frequently caused by viruses but can also be caused by bacteria such as Streptococcus pneumoniae. 2. Children with bacterial pneumonia are usually sicker than children with viral pneumonia. Children with bacterial pneumonia can be treated effectively, but they require a course of antibiotics. 3. Children with viral pneumonia are not usually as ill as those with bacterial pneumonia. Treatment for viral pneumonia includes maintaining adequate oxygenation and comfort measures.4. Treatment for viral pneumonia includes maintaining adequate oxygenation and comfort measures.

54. The nurse is caring for a 14-year-old with celiac disease. The nurse knows that the patient understands the diet instructions by ordering which of the following meals? 1. Eggs, bacon, rye toast, and lactose-free milk. 2. Pancakes, orange juice, and sausage links. 3. Oat cereal, breakfast pastry, and nonfat skim milk. 4. Cheese, banana slices, rice cakes, and whole milk.

54. 1. Rye toast contains gluten. 2. Unless otherwise indicated, pancakes are made of wheat fl our, which contains gluten. 3. Oat cereal and breakfast pastry contain gluten. 4. Cheese, banana slices, rice cakes, and whole milk do not contain gluten.

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

55. 1. Aspirin is not used to treat this condition. A PDA does not occur with RF. 2. Joint infl ammation is experienced in RF; aspirin therapy helps with infl ammation and pain. 3. Strawberry tongue is manifested in strep throat; aspirin is not used to treat this disease. 4. Aspirin is not used to treat this condition.

76. The client with chronic pancreatitis is admitted with an acute exacerbation of the disease. Which laboratory result warrants immediate intervention by the nurse? 1. The client's amylase is elevated. 2. The client's WBC count is WNL. 3. The client's blood glucose is elevated. 4. The client's lipase is within normal limits.

76. 1. The client's amylase would be elevated in an acute exacerbation of pancreatitis. 2. The WBC count is not elevated in this disease process. 3. In clients with chronic pancreatitis, the beta cells of the pancreas are affected and, therefore, insulin production is affected. An elevated glucose level would warrant the nurse assessing the client. 4. Lipase is an enzyme that is excreted by the pancreas. Normal lipase levels indicate a normally functioning pancreas.

Which child diagnosed with pneumonia would benefit most from hospitalization? 1. A 13-year-old who is coughing, has coarse breath sounds, and is not sleeping well. 2. A 14-year-old with a fever of 38.6°C (101.5°F), rapid breathing, and a decreased appetite. 3. A 15-year-old who has been vomiting for 3 days and has a fever of 38.5°C (101.3°F). 4. A 16-year-old who has a cough, chills, fever of 38.5°C (101.3°F), and wheezing.

55. 1. These are all common symptoms of pneumonia and should be monitored but do not require hospitalization. Most people with pneumonia are treated at home, with a focus on treating the symptoms and keeping the patient comfortable. Comfort measures include cool mist, chest physiotherapy (CPT), antipyretics, fl uid intake, and family support. 2. These are all common symptoms of pneumonia and should be monitored but do not require hospitalization. 3. The teen who has been vomiting for several days and is unable to tolerate oral fluids and medication should be admitted for intravenous hydration. 4. These are all common symptoms of pneumonia and should be monitored but do not require hospitalization.

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

56. 1. A carbohydrate is a carbohydrate, and insulin dosing is based on blood sugar level and carbohydrates to be eaten. 2. Snacks should be ingested before planned exercise rather than after. 3. Nutritional needs of children with DM do not differ from those without DM. 4. Weight loss is likely a factor in managing type 2 DM; type 1 DM is often preceded by dramatic weight loss. The nutritional needs of children with type 1 DM are essentially the same as those not affected.

5 8. A 3-year-old is brought to the ED with coughing and gagging. The parent reports that the child was eating carrots when she began to gag. Which diagnostic evaluation will be used to determine whether the child has aspirated carrots? 1. Chest x-ray. 2. Bronchoscopy. 3. Arterial blood gas (ABG). 4. Sputum culture.

58. 1. A chest x-ray will only show radiopaque items (items that x-rays cannot go through easily), so it is not helpful in determining whether the child aspirated a carrot. 2. A bronchoscopy will allow the physician to visualize the airway and will help determine whether the child aspirated the carrot. 3. A blood gas will identify whether the child has suffered any respiratory compromise, but the ABG cannot defi nitively determine the cause of the compromise. 4. A sputum culture may be helpful several days later to determine whether the child has developed aspiration pneumonia. Aspiration pneumonia may take several days or a week to develop following aspiration.

58. A 13-year-old is being seen for an annual physical examination. The child has lost 10 lb despite reports of excellent appetite. Appearance is normal, except for slightly protruding eyeballs, and the parents report the child has had diffi culty sleeping lately. The nurse should do which of the following? 1. Prepare the family for a neurology consult. 2. Explain the need for an ophthalmology consult. 3. Discuss the plan for thyroid function tests. 4. Explain the plan for an 8-hour fasting blood glucose test.

58. 1. The patient exhibits signs of Graves disease, a primary type of hyperthyroidism in children. A neurology consultation is not indicated. 2. Despite the exophthalmos, an eye consultation is not indicated. 3. Diagnostic evaluation for hyperthyroidism is based on thyroid function tests. It is expected in this case that T4 and T3 levels would be elevated, because the thyroid gland is overfunctioning. 4. Fasting blood glucose is used to help evaluate for other endocrine disorders, such as Cushing syndrome and DM.

58. During play, a toddler with a history of tetralogy of Fallot (TOF) might assume which position? 1. Sitting. 2. Supine. 3. Squatting. 4. Standing.

58. 1. The toddler will naturally assume a squatting position to decrease preload by occluding venous fl ow from the lower extremities and increasing afterload. Increasing SVR in this position increases pulmonary blood fl ow. 2. The toddler will naturally assume a squatting position to decrease preload by occluding venous flow from the lower extremities and increasing afterload. Increasing SVR in this position increases pulmonary blood flow. 3. The toddler will naturally assume this position to decrease preload by occluding venous fl ow from the lower extremities and increasing afterload. Increasing SVR in this position increases pulmonary blood flow. 4. The toddler will naturally assume a squatting position to decrease preload by occluding venous fl ow from the lower extremities and increasing afterload. Increasing SVR in this position increases pulmonary blood flow.

59. A 12-year-old with hyperthyroidism is being treated with standard antithyroid drug therapy. A parent calls the offi ce stating that the child has a sore throat and fever. Which is the nurse ' s best response? 1. "Bring your child to the offi ce or emergency department immediately." 2. "Slight fever and sore throat are normal side effects of the medication." 3. "Give your child the appropriate dose of ibuprofen and call back if symptoms worsen." 4. "Give your child at least 8 oz of clear fl uids and call back if symptoms worsen."

59. 1. A complication of antithyroid drug therapy is leukopenia. Fever and sore throat, therefore, need to be evaluated immediately. This is an essential component of discharge teaching for patients with Graves disease. 2. Common side effects of antithyroid drugs include rash, nausea, vomiting, headache, drowsiness, but not sore throat. 3. This is a tempting choice for the test taker, because fever and sore throat appear to be fairly benign symptoms. Because the question includes information regarding Graves disease and medication therapy, however, the test taker should eliminate this answer. 4. It is most likely that medication, not fl uid status, contributes to the child ' s symptoms.

6. The school nurse notices that a 14-year-old who used to be an excellent student and very active in sports is losing weight and acting very nervous. The teen was recently checked by the primary care provider (PCP), who noted the teen had a very low level of TSH. The nurse recognizes that the teen has which condition? 1. Hashimoto thyroid disease. 2. Graves disease. 3. Hypothyroidism. 4. Juvenile autoimmune thyroiditis.

6. 1. "Hashimoto thyroiditis" is a term that refers to hypothyroid disease. Laboratory tests would reveal a high TSH level. 2. Graves disease is hyperthyroidism and presents with low TSH levels, weight loss, and excessive nervousness. 3. Hypothyroidism is accompanied by a high TSH level. 4. "Juvenile autoimmune thyroiditis" is a term referring to hypothyroid disease. Laboratory tests would reveal a high TSH level.

6. Which statement by a parent of an infant with congestive heart failure (CHF) who is being sent home on digoxin (Lanoxin) indicates the need for further education? 1. "I will give the medication at regular 12-hour intervals." 2. "If he vomits, I will not give a make-up dose." 3. "If I miss a dose, I will not give an extra dose." 4. "I will mix the digoxin in some formula to make it taste better."

6. 1. This is appropriate for digoxin (Lanoxin) administration. 2. This is appropriate for digoxin administration. 3. This is appropriate for digoxin administration. 4. If the medication is mixed in his formula, and he refuses to drink the entire amount, the dose will be inadequate.

65. The nurse is assessing the client with a pneumothorax who has a closed-chest drainage system. Which data indicate the client's condition is stable? 1. There is fluctuation in the water-seal compartment. 2. There is blood in the drainage compartment. 3. The trachea deviates slightly to the left. 4. There is bubbling in the suction compartment.

65. 1. Fluctuation in the water-seal compartment with respirations indicates the system is working properly and the client is stable. 2. Blood in the drainage compartment indicates there is a problem because the client is diagnosed with a pneumothorax and there should not be any bleeding. 3. Any deviation of the trachea indicates a tension pneumothorax, a potentially life-threatening complication. 4. Bubbling in the suction compartment does not indicate a stable or unstable client.

67. The client has gastroesophageal reflux disease. Which HCP order should the nurse question? 1. Elevate the head of the client's bed with blocks. 2. Administer pantoprazole (Protonix) four (4) times a day. 3. A regular diet with no citrus or spicy foods. 4. Activity as tolerated and sit up in a chair for all meals.

67. 1. The HOB is elevated to prevent reflux of stomach contents into the esophagus. 2. Proton pump inhibitors are only administered once or twice a day; they should not be given four (4) times a day because the medication decreases gastric acidity and the stomach needs some gastric acid to digest foods. The nurse would question this order. 3. The client is not prescribed any special diet; limiting spicy and citrus foods decreases acid in the stomach. 4. Sitting upright after all meals decreases the reflux of stomach contents into the esophagus.

68. The client is diagnosed with an acute exacerbation of Crohn's disease. Which assessment data warrant immediate attention? 1. The client's WBC count is 10 (× 103 )/mm3 . 2. The client's serum amylase is 100 units/dL. 3. The client's potassium level is 3.3 mEq/L. 4. The client's blood glucose is 148 mg/dL.

68. 1. This white blood cell (WBC) level is WNL and would not warrant immediate intervention. 2. This amylase level is within normal limits (50 to 180 units/dL). 3. This potassium level is low as a result of excessive diarrhea and puts the client at risk for cardiac dysrhythmias. Therefore, these assessment data warrant immediate intervention. 4. The client's blood glucose level is elevated, but it would not warrant immediate intervention for a client with Crohn's disease who has hypokalemia

70. The client diagnosed with peptic ulcer disease is being discharged. Which nursing task can be delegated to a trained unlicensed assistive personnel (UAP)? 1. Complete the discharge instructions sheet. 2. Remove the client's saline lock. 3. Clean the client's room after discharge. 4. Check the client's hemoglobin and hematocrit.

70. 1. The discharge instruction sheet is teaching, which cannot be delegated to a UAP. 2. The trained UAP can remove a saline lock from a stable client. 3. The UAP does not clean hospital rooms; this is the housekeeping department's responsibility. 4. The nurse cannot delegate evaluation, which is checking the client's laboratory data prior to discharge; this is out of the UAP's area of expertise

80. The client with type 2 diabetes mellitus asks the nurse, "What does it matter if my glucose level is high? I don't feel bad." Which statement by the nurse is most appropriate? 1. "The high glucose level can damage your eyes and kidneys over time." 2. "The glucose level causes microvascular and macrovascular problems." 3. "As long as you don't feel bad, everything will probably be all right." 4. "A high blood glucose level will cause you to get metabolic acidosis."

80. 1. The long-term complications of increased blood glucose levels to organs are the primary reasons for keeping the blood glucose level controlled. 2. This is the medical explanation for keeping the glucose under control, but this answer is not appropriate for laypeople. 3. The client with type 2 diabetes often doesn't feel bad, but the organs are still being damaged as a result of increased blood glucose levels. 4. Metabolic acidosis occurs in clients with type 1 diabetes, not type 2. Clients with type 2 diabetes have hyperosmolar hyperglycemic nonketotic syndrome (HHNS).

81. The client with type 1 diabetes asks the nurse, "What causes me to get dehydrated when my glucose level is elevated?" Which statement would be the nurse's best response? 1. "The kidneys are damaged and cannot filter out the urine." 2. "The glucose causes fluid to be pulled from the tissues." 3. "The sweating as a result of the high glucose level causes dehydration." 4. "You get dehydrated with a high glucose because you are so thirsty."

81. 1. This is not the rationale as to why the client becomes dehydrated. 2. The glucose in the bloodstream is hyperosmolar, which causes water from the extracellular space to be pulled into the vessels, resulting in dehydration. 3. The client has diaphoresis in hypoglycemia, not hyperglycemia. 4. The dehydration causes the client to be thirsty; the thirst does not cause the dehydration.

82. The client calls the clinic first thing in the morning and tells the nurse, "I have been vomiting and having diarrhea since last night." Which response is appropriate for the nurse to make? 1. Encourage the client to eat dairy products. 2. Have the client go to the emergency department. 3. Request the client obtain a stool specimen. 4. Tell the client to stay on a clear liquid diet.

82. 1. Dairy products contain milk and increase flatus and peristalsis. These products should be discouraged. 2. Symptoms lasting less than 24 hours would not warrant the client going to the emergency department; if anything, an appointment at a clinic would be appropriate. 3. A stool specimen may be needed at some point but not this early in the disease process. 4. A clear liquid diet is recommended because it maintains hydration without stimulating the gastrointestinal tract; diarrhea/ vomiting lasting longer than 24 hours, along with dehydration and weakness, would warrant the client being evaluated.

85. The client is admitted into the medical unit diagnosed with heart failure and is prescribed the thyroid hormone levothyroxine (Synthroid) orally. Which intervention should the nurse implement? 1. Call the pharmacist to clarify the order. 2. Administer the medication as ordered. 3. Ask the client why he or she takes Synthroid. 4. Request serum thyroid function levels.

85. 1. There is no reason to question or clarify this order; the nurse is responsible for clarifying the order with the HCP, not the pharmacist. 2. Many elderly clients have comorbid conditions requiring daily medications, which are not the primary reason for admission into the hospital. 3. The nurse should know why the client is taking this medication; this medication is prescribed for only one reason, hypothyroidism. 4. The serum thyroid function levels are monitored by the HCP usually yearly after maintenance doses have been established.

86. Which client should the nurse consider at risk for developing acute renal failure? 1. The client diagnosed with essential hypertension. 2. The client diagnosed with type 2 diabetes. 3. The client who had an anaphylactic reaction. 4. The client who had an autologous blood transfusion.

86. 1. The client diagnosed with essential hypertension is at risk for chronic renal failure. 2. The client diagnosed with diabetes type 2 is at risk for chronic renal failure. 3. Anaphylaxis leads to circulatory collapse, which decreases perfusion of the kidneys and can lead to acute renal failure. 4. This is a transfusion of the client's own blood, which should not cause a reaction.

89. The unlicensed assistive personnel (UAP) empties the indwelling urinary catheter for a client who is four (4) hours postoperative transurethral resection of the prostate and informs the nurse the urine is red with some clots. Which intervention should the nurse implement first? 1. Assess the client's urine output immediately. 2. Notify the HCP that the client has gross hematuria. 3. Explain this is expected with this surgery. 4. Medicate for bladder spasms to decrease bleeding

89. 1. This is a normal postoperative expectation with this procedure. 2. This is gross hematuria, but it is expected with this type of surgery and the nurse should not call the surgeon. 3. The client has a three (3)-way indwelling 30-mL catheter inserted in surgery. This type of catheter instills an irrigant into the bladder to flush the clots and blood from the bladder; bloody urine is expected after this surgery. 4. The stem does not indicate the client is having bladder spasms and bladder spasms are not causing the bleeding. Clots left in the bladder and not flushed out can cause bladder spasms.

92. The client asks the nurse, "What are the risk factors for developing multiple sclerosis?" Which statement is a risk factor for multiple sclerosis (MS)? 1. A close relative with MS may indicate a risk for MS. 2. Living in the southern United States predisposes a person to MS. 3. Use of tobacco product is the number-one risk for developing MS. 4. A sedentary lifestyle can cause a person to develop MS.

92. 1. A close relation (parent or sibling) who has MS may indicate a risk for the client also to develop MS. Other common risk factors are age, race, gender, environment, immune factors, and smoking. 2. There is a higher incidence of MS in people who live in the northeastern United States and Canada, but there is no known reason for this occurrence. 3. Tobacco use is a risk factor but not the primary risk factor for MS. 4. A sedentary lifestyle does not predispose a person to develop MS.

99. The client is eight (8) hours postoperative small bowel resection. Which data indicate the client has had a complication from the surgery? 1. A hard, rigid, boardlike abdomen. 2. High-pitched tinkling bowel sounds. 3. Absent bowel sounds. 4. Complaints of pain at "6" on the pain scale.

99. 1. A hard, rigid, boardlike abdomen is the hallmark sign of peritonitis, which is a life-threatening complication of abdominal surgery. 2. This occurs when the client has a nasogastric tube connected to suction and has minimal peristalsis and is not a complication of the surgery 3. The client has had general anesthesia for this surgery, and absent bowel sounds at eight (8) hours postoperative does not indicate a complication. 4. The client with this type of surgery is expected to have pain at a "6" or higher on a 1-to-10 scale; this is not considered a complication.

11. For the child with hypoplastic left heart syndrome, which drug may be given to allow the patent ductus arteriosus (PDA) to remain open until surgery? _____________________

Prostaglandin E. TEST-TAKING HINT: Prostaglandin E maintains ductal patency to promote blood fl ow until the Norwood procedure is begun. Consider the opposite of wanting to close the PDA.