Nursing questions

The nurse is teaching a group of parents about gross motor development of the toddler. Which behavior is an example of the normal gross motor skill of a toddler? A. She can pull a toy behind her B. She can copy a horizontal line C. She can build a tower of eight blocks D. She can broad-jump

Correct Answer: A. She can pull a toy behind her Option A: The Denver Developmental Screening Test (DDST) is a tool used to screen for the development of gross motor, language, fine-motor, and personal- social in infants and preschool children. According to the test, the child can pull a toy behind her by the age of 2 years.

A client hospitalized with a fractured mandible is to be discharged. Which piece of equipment should be kept on the client with a fractured mandible? A. Wire cutters B. Oral airway C. Pliers D. Tracheostomy set

Correct Answer: A. Wire cutters Option A: The client with a fractured mandible should keep a pair of wire cutters with him at all times to release the device in case of choking or aspiration. Option B: The wires would prevent the insertion of an oral airway. Option C: Pliers would be of no use in releasing the wires. Option D: Tracheostomy set would be used only as a last resort in case of airway obstruction.

Which activity is best suited to the 12-year-old with juvenile rheumatoid arthritis? A. Playing video games B. Swimming C. Working crossword puzzles D. Playing slow-pitch softball

Correct Answer: B. Swimming

Which of the following meal choices is suitable for a 6-month-old infant? A. Pea puree, formula, and orange juice B. Honey cereals, carrot stick, apple juice C. Rice cereal, mashed sweet potato, formula D. Melba toast, banana puree, whole milk

Correct Answer: C. Rice cereal, mashed sweet potato, formula

A client with schizoaffective disorder is exhibiting Parkinsonian symptoms. Which medication is responsible for the development of Parkinsonian symptoms? A. Cogentin (benztropine mesylate) B. Benadryl (diphenhydramine) C. Zyprexa (olanzapine) D. Depakote (divalproex sodium)

Correct Answer: C. Zyprexa (olanzapine)

An 8-year-old is admitted with a sore throat, drooling, muffled phonation, high pitched-sound upon breathing (stridor), and a temperature of 102°F. The nurse should immediately notify the doctor because the child's symptoms are suggestive of: A. Primary Ciliary Dyskinesia B. Subglottic hemangioma C. Sinusitis D. Epiglottitis

Correct Answer: D. Epiglottitis

The physician has ordered cultures for cytomegalovirus (CMV). Which statement is true regarding the collection of cultures for cytomegalovirus? A. Stool cultures are obtained for definitive diagnosis. B. Pregnant caregivers may obtain cultures C. Collection of one specimen is sufficient D. Fresh specimens are preferred

Correct Answer: D. Fresh specimens are preferred

A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to: A. Obtain a new prescription in case the infection recurs B. Determine whether the ear infection has affected her hearing C. Make sure that she has taken all the antibiotic D. Document that the infection has completely cleared

Correct Answer D. Document that the infection has completely cleared

The physician has ordered dressings with Sulfamylon cream for a client with full-thickness burns of the hands and arms. Before dressing changes, the nurse should give priority to: A. Administering pain medication B. Checking the adequacy of urinary output C. Requesting a daily complete blood count D. Obtaining a blood glucose by finger stick

Administering pain medication Option A: Sulfamylon produces a painful sensation when applied to the burn wound; therefore, the client should receive pain medication before dressing changes. Options B, C, and D: These do not pertain to dressing changes for the client with burns, so they are incorrect.

A 3-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents? A. Keep the bed flat, with a small pillow beneath the cast B. Provide crayons and a coloring book for play activity C. Increase her intake of high-calorie foods for healing D. Tuck a disposable diaper beneath the cast at the perineal opening

Correct Answer: D. Tuck a disposable diaper beneath the cast at the perineal opening

The nurse is teaching the mother of a child with cystic fibrosis how to do postural drainage. The nurse should tell the mother to: A. Use the heel of her hand during percussion B. Change the child's position every 20 minutes C. Do percussion after the child eats and at bedtime D. Use cupped hands during percussion

Correct Answer: D. Use cupped hands during percussion

The mother of a child with hemophilia asks the nurse which over-the-counter medication is suitable for her child's joint discomfort. The nurse should tell the mother to purchase: A. Aspirin (acetylsalicylic acid) B. Naproxen (Naprosyn) C. Tylenol (acetaminophen) D. Advil (ibuprofen)

Co Option C: The nurse should recommend acetaminophen for the child's joint discomfort because it will have no effect on the bleeding time.

The client scheduled for electroconvulsive therapy tells the nurse, "I'm so afraid. What will happen to me during the treatment?" Which of the following statements is most therapeutic for the nurse to make? A. "You will be given medicine to relax you during the treatment." B. "The treatment will produce a controlled grand mal seizure." C. "The treatment might produce nausea and headache." D. "You can expect to be sleepy and confused for a time after the treatment."

Correct Answer: A. "You will be given medicine to relax you during the treatment." Option A: Electroconvulsive therapy (ECT) is a medical procedure that is used as a treatment for mental illnesses such as depression and other mood disorders. Before the procedure, the client will receive medication that relaxes skeletal muscles and produces mild sedation. Options B and D: These statements may increase the client's anxiety level. Option C: Nausea and headache are not associated with ECT.

A newborn weighed 7 pounds at birth. At 6 months of age, the infant could be expected to weigh: A. 14 pounds B. 18 pounds C. 25 pounds D. 30 pounds

Correct Answer: A. 14 pounds

A client with hypertension has begun an aerobic exercise program. The nurse should tell the client that the recommended exercise regimen should begin slowly and build up to: A. 20-30 minutes three times a week B. 45 minutes two times a week C. 1 hour four times a week D. 1 hour two times a week

Correct Answer: A. 20-30 minutes three times a week

Which play activity is best suited to the gross motor skills of the toddler? A. Ball B. Coloring book and crayons C. Building cubes D. Swing set

Correct Answer: A. Ball

Which of the following statements reflects Kohlberg's theory of the moral development of the preschool-age child? A. Behavior is determined by consequences B. Showing care about the effect of their actions on others C. Following the rules of authorities is seen as important D. Pleasing others is viewed as good behavior

Correct Answer: A. Behavior is determined by consequences

Which statement best describes the difference between the pain of angina and the pain of myocardial infarction? A. Pain associated with myocardial infarction is referred to the left arm B. Pain associated with angina is confined to the chest area C. Pain associated with myocardial infarction can last for 5-7 minutes D. Pain associated with angina is relieved by nitroglycerin

Option D: Pain associated with angina is relieved by nitroglycerin since the medication can relax the coronary arteries, decreasing the amount of blood that flows back to the heart thus easing the workload of the heart.

Which antibiotic is contraindicated for the treatment of infections in infants and young children? A. E-Mycin (erythromycin) B. Amoxil (amoxicillin) C. Cefotan (cefotetan) D. Tetracyn (tetracycline)

er: D. Tetracyn (tetracycline) Option D: Tetracycline is contraindicated for use in infants and young children because it stains the teeth and arrests bone development.

Which of the following skin lesions is associated with Lyme's disease? A. Bull's eye rash B. Spider veins C. Bullae D. Scaly, silvery skin patches

Correct Answer: A. Bull's eye rash Option A: Lyme's disease produces a characteristic annular or circular rash sometimes described as a "bull's eye" rash. Option B: Telangiectasia (spider veins) are dilated blood vessels that appear near the skin surface and are often associated with lupus, scleroderma, and dermatomyositis. Option C: Bullae are clear fluid-filled blisters that are associated with burns, drug reactions, allergic contact dermatitis, or bites. Option D: Scaly, silvery, sharply defined skin patches are associated with psoriasis.

When assessing the urinary output of a client who has had extracorporeal lithotripsy, the nurse can expect to find: A. Cherry-red urine that gradually becomes clearer B. Orange-tinged urine containing particles of calculi C. Dark red urine that becomes cloudy in appearance D. Dark, smoky-colored urine with high specific gravity

Correct Answer: A. Cherry-red urine that gradually becomes clearer

The physician has ordered Basaljel (aluminum carbonate gel) for a client with recurrent indigestion. The nurse should teach the client common side effects of the medication, which include: A. Constipation B. Diarrhea C. Urinary retention D. Confusion

Correct Answer: A. Constipation

The nurse is caring for a client following the reimplantation of the thumb and index finger. Which finding should be reported to the physician immediately? A. Coolness and discoloration of the digits B. Temperature of 100°F C. Complaints of pain D. Difficulty moving the digits

Correct Answer: A. Coolness and discoloration of the digits

A client with pancreatitis has requested pain medication. Which pain medication is indicated for the client with pancreatitis? A. Demerol (meperidine) B. Toradol (ketorolac) C. Morphine (morphine sulfate) D. Codeine (codeine)

Correct Answer: A. Demerol (meperidine)

The nurse is caring for a client with an ileostomy. The nurse should pay careful attention to care around the stoma because: A. Digestive enzymes cause skin breakdown B. Stools are less watery and contain more solid matter C. The stoma will heal after one year D. It is difficult to fit the appliance to the stoma site

Correct Answer: A. Digestive enzymes cause skin breakdown

An 18-month-old is scheduled for a cleft palate repair. The usual type of restraints for the child with a cleft palate repair are: A. Elbow restraints B. Full arm restraints C. Wrist restraints D. Mummy restraints

Correct Answer: A. Elbow restraints Option A: The least restrictive restraint for the infant with cleft lip and cleft palate repair is elbow restraints. Options B, C, and D: These restraints are more restrictive and unnecessary.

Which of the following conditions is most likely related to the development of renal calculi? A. Gout B. Pancreatitis C. Fractured femur D. Disc disease

Correct Answer: A. Gout

A client with congestive heart failure has been receiving Digoxin (lanoxin). Which finding indicates that the medication is having a desired effect? A. Increased urinary output B. Stabilized weight C. Improved appetite D. Increased pedal edema

Correct Answer: A. Increased urinary output

The nurse is preparing to discharge a client following a laparoscopic cholecystectomy. The nurse should: A. Instruct the client to avoid a tub bath for 48 hours B. Instruct the client to expect clay-colored stools C. Instruct the client that she can expect lower abdominal pain for the next week D. Instruct the client that she can resume a regular diet in the next 24 hours

Correct Answer: A. Instruct the client to avoid a tub bath for 48 hours

A client is admitted with acute adrenal crisis. During the intake assessment, the nurse can expect to find that the client has: A. Low blood pressure B. Slow, regular pulse C. Warm, flushed skin D. Increased urination

Correct Answer: A. Low blood pressure

The doctor has prescribed a diet high in vitamin B12 for a client with pernicious anemia. Which foods are highest in B12? A. Meat, eggs, dairy products B. Oysters, raisins, veal C. Broccoli, cauliflower, cabbage D. Shrimp, legumes, bran cereals

Correct Answer: A. Meat, eggs, dairy products

The nurse is caring for a client with acromegaly. Following a transsphenoidal hypophysectomy, the nurse should: A. Monitor the client's blood sugar B. Suction the mouth and pharynx every hour C. Place the client in a low Trendelenburg position D. Encourage the client to cough

Correct Answer: A. Monitor the client's blood sugar

A child is hospitalized with a fractured femur involving the epiphysis. Epiphyseal fractures are serious because: A. Normal bone growth is affected B. Callus formation prevents bone healing C. Bone marrow is lost through the fracture site D. Blood supply to the bone is obliterated

Correct Answer: A. Normal bone growth is affected

The nurse has been teaching the role of diet in regulating blood pressure to a client with hypertension. Which meal selection indicates that the client understands his new diet? A. Oatmeal, apple juice, dry toast, and coffee B. Pancakes, ham, tomato juice, and coffee C. Cornflakes, whole milk, banana, and coffee D. Scrambled eggs, bacon, toast, and coffee

Correct Answer: A. Oatmeal, apple juice, dry toast, and coffee

The physician has ordered an external monitor for a laboring client. If the fetus is in the left occipital posterior (LOP) position, the nurse knows that the ultrasound transducer will be located: A. Over the fetal back B. Over the fetal abdomen C. Near the symphysis pubis D. Near the umbilicus

Correct Answer: A. Over the fetal back Option A: In the left occipito posterior position, the heart sounds will be heard loudest through the fetal back.

The nurse is caring for a client with an above-the-knee amputation (AKA). An important intervention that the nurse should do is: A. Place the client in a prone position 15-30 minutes thrice a day B. Keep the foot of the bed elevated on shock blocks C. Place trochanter rolls on either side of the affected leg D. Keep the client's leg elevated on two pillows

Correct Answer: A. Place the client in a prone position 15-30 minutes twice a day

A 4-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on: A. Preventing infection B. Administering antinausea C. Keeping the skin free of moisture D. Limiting oral fluid intake

Correct Answer: A. Preventing infection

The nurse is caring for a 4-year-old with cerebral palsy. Which nursing intervention will help ready the child for rehabilitative services? A. Providing suckers and pinwheels to help strengthen tongue movement B. Patching one of the eyes to strengthen the muscles C. Encouraging play with a video game to improve muscle coordination D. Providing musical tapes to provide auditory training

Correct Answer: A. Providing suckers and pinwheels to help strengthen tongue movement

The physician has ordered chloramphenicol ear drops for a 2-year-old with otitis media. To administer the ear drops, the nurse should: A. Pull the ear down and back B. Pull the ear straight out C. Pull the ear up and back D. Leave the ear undisturbed

Correct Answer: A. Pull the ear down and back

Physician's orders for a client with acute pancreatitis include the following: strict NPO, NG tube to low intermittent suction. The nurse recognizes that these interventions will: A. Reduce the secretion of pancreatic enzymes B. Decrease the client's need for insulin C. Prevent secretion of gastric acid D. Eliminate the need for analgesia

Correct Answer: A. Reduce the secretion of pancreatic enzymes

A client with angina has an order for nitroglycerin ointment. Before applying the medication, the nurse should: A. Remove the previously applied ointment B. Tell the client he will experience pain relief in 15 minutes C. Apply the ointment to the previous application D. Obtain both a radial and an apical pulse

Correct Answer: A. Remove the previously applied ointment Option A: The nurse should remove any remaining ointment before applying the medication again. This will allow the newly applied ointment to release the nitroglycerin properly.

Before administering a nasogastric feeding to a client hospitalized following a CVA, the nurse aspirates 40mL of residual. The nurse should: A. Replace the aspirate and administer the feeding B. Discard the aspirate and withhold the feeding C. Discard the aspirate and begin the feeding D. Replace the aspirate and withhold the feeding

Correct Answer: A. Replace the aspirate and administer the feeding

A 9-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of polymigratory arthritis? A. Swelling, inflammation, and effusion of the joints B. Faint areas of red demarcation over the back and abdomen C. Irregular movements of the extremities and facial grimacing D. Painless swelling over the extensor surfaces of the joints

Correct Answer: A. Swelling, inflammation, and effusion of the joints

The physician has ordered a blood test for H. pylori. The nurse should prepare the client by: A. Telling the client that no special preparation is needed B. Withholding antibiotics for at least 4 weeks prior to the test C. NPO for 1 hour before the exam D. Withholding proton pump inhibitor for at least 2 weeks prior the test

Correct Answer: A. Telling the client that no special preparation is needed

The glycosylated hemoglobin of a 40-year-old client with diabetes mellitus is 2.5%. The nurse understands that: A. The client has good control of her diabetes B. The client has poor control of her diabetes C. The client can have a higher-calorie diet D. The client requires adjustment in her insulin dose

Correct Answer: A. The client has good control of her diabetes

Robert is diagnosed with varicella. He went to a clinic with a mild fever, loss of appetite, and rashes on the chest area. When he asked about the disease. Which statement describes the contagious stage of varicella? A. The contagious stage is 1 day before the onset of the rash until all the lesions are crusted. B. The contagious stage is 1 day before the onset of the rash until the appearance of vesicles. C. The contagious stage lasts during the vesicular and crusting stages of the lesions. D. The contagious stage is from the onset of the rash until the rash disappears.

Correct Answer: A. The contagious stage is 1 day before the onset of the rash until all the lesions are crusted.

The physician has prescribed supplemental iron for a prenatal client. The nurse should tell the client to take the medication with: A. Tomato juice, to increase absorption B. Milk, to prevent stomach upset C. Oatmeal, to prevent constipation D. Water, to increase serum iron levels

Correct Answer: A. Tomato juice, to increase absorption Option A: Iron supplements should be taken with a source of vitamin C to promote absorption.

While caring for a client with cervical cancer, the nurse notes that the radioactive implant is lying in the bed. The nurse should: A. Use tongs to pick up the implant and return it to a lead-lined container B. Place the implant in a biohazard bag and return it to the lab C. Give the client a pair of gloves and ask her to reinsert the implant D. Discard the implant in the commode and double-flush

Correct Answer: A. Use tongs to pick up the implant and return it to a lead-lined container

A client with diabetes mellitus has a prescription for Glucotrol XL (glipizide). The client should be instructed to take the medication: A. With breakfast B. Before lunch C. After dinner D. At bedtime

Correct Answer: A. With breakfast

A client newly diagnosed with diabetes is started on Precose (acarbose). The nurse should tell the client that the medication should be taken: A. With the first bite of a meal B. 1 hour before meals C. 30 minutes after meals D. Daily at bedtime

Correct Answer: A. With the first bite of a meal

The nurse is teaching a client with a history of obesity and hypertension regarding dietary requirements during pregnancy. Which statement indicates that the client needs further teaching? A. "I need to drink at least a quart of milk a day." B. "I need to reduce my daily intake to 1,200 calories a day." C. "I shouldn't add salt when I am cooking." D. "I need to eat more protein and fiber each day."

Correct Answer: B. "I need to reduce my daily intake to 1,200 calories a day." Option B: The client does not need to drastically reduce her caloric intake during pregnancy. Doing so would not provide adequate nourishment for the proper development of the fetus.

A client is admitted with burns of the right arm, front chest, and head. According to the Rule of Nines, the percent of burn injury is: A. 18% B. 27% C. 36% D. 45%

Correct Answer: B. 27%

A client who was admitted with chest pain and shortness of breath has a standing order for oxygen via mask. Standing orders for oxygen mean that the nurse can apply oxygen at: A. 2L per minute B. 6L per minute C. 10L per minute D. 12L per minute

Correct Answer: B. 6L per minute

Which of the following is a common complaint of the client with end-stage renal failure? A. Weight loss B. Itching C. Ringing in the ears D. Bruising

Correct Answer: B. Itching Option B: Pruritus or itching is caused by the presence of uric acid crystals on the skin, which is common in the client with end-stage renal failure. Options A, C, and D: Weight loss, ringing in the ear, and bruising are not associated with end-stage renal failure.

An obstetrical client calls the clinic with complaints of morning sickness. The nurse should tell the client to: A. Drink a glass of whole milk before going to sleep at night B. Keep a dry toast at the bedside for eating before she arises C. Skip breakfast but eat a larger lunch and dinner D. Drink a glass of orange juice after adding a couple of teaspoons of sugar

Correct Answer: B. Keep a dry toast at the bedside for eating before she arises

A client is hospitalized with hepatitis A. Which of the client's regular medications is contraindicated due to the current illness? A. Premarin (conjugated estrogens) B. Lipitor (atorvastatin) C. Prilosec (omeprazole) D. Synthroid (levothyroxine)

Correct Answer: B. Lipitor (atorvastatin)

A child with a croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the tent is to: A. Provide a moist environment with oxygen at 50% B. Moisten secretions and relieve laryngospasm C. Prevent insensible water loss D. Prevent dehydration and reduce fever

Correct Answer: B. Moisten secretions and relieve laryngospasm

The nurse is caring for a client with systemic lupus erythematosus (SLE). The major complication associated with systemic lupus erythematosus is: A. Meningitis B. Nephritis C. Cardiomegaly D. Desquamation

Correct Answer: B. Nephritis Option B: Systemic lupus erythematosus is a form of lupus and an autoimmune disease in which the antibodies attack the body's own cells and tissue causing inflammation and damage to organs such as the kidneys resulting in complications such as nephritis.

Which of the following findings is associated with right-sided heart failure? A. Shortness of breath B. Nocturnal polyuria C. Daytime oliguria D. Crackles in the lungs

Correct Answer: B. Nocturnal polyuria Option B: A decreased renal perfusion during the day leads to excessive fluid retention. As the patient lies down to sleep, renal perfusion improves, and the kidney starts working by excreting the retained fluid, thus experiencing nocturnal polyuria. Options A and D: Shortness of breath and crackles in the lungs are symptoms of left-sided heart failure. Option C: Daytime oliguria does not relate to the client's diagnosis.

The nurse is completing an assessment history of a client with pernicious anemia. Which complaint differentiates pernicious anemia from other types of anemia? A. Difficulty in breathing after exertion B. Numbness and tingling in the extremities C. A faster-than-usual heart rate D. Feelings of lightheadedness

Correct Answer: B. Numbness and tingling in the extremities

The nurse is teaching a client with Parkinson's disease ways to prevent curvatures of the spine associated with the disease. The nurse should tell the client to: A. Sleep on either side but keep his back straight B. Periodically lie prone without a neck pillow C. Sleep only in dorsal recumbent position D. Rest in supine position with his head elevated

Correct Answer: B. Periodically lie prone without a neck pillow

The treatment protocol for a client with acute lymphatic leukemia includes prednisone, methotrexate, and cimetidine. The purpose of the cimetidine is to: A. Promote peristalsis B. Prevent a common side effect of prednisone C. Decrease the secretion of pancreatic enzymes D. Enhance the effectiveness of methotrexate

Correct Answer: B. Prevent a common side effect of prednisone

A client with a history of emboli is receiving Lovenox (enoxaparin). Which drug is given to counteract the effects of enoxaparin? A. Methergine B. Protamine sulfate C. Calcium gluconate D. Aquamephyton

Correct Answer: B. Protamine sulfate

A client is admitted to the emergency room with symptoms of delirium tremens. After admitting the client to a private room, a priority nursing intervention is to: A. Obtain a history of his alcohol use B. Provide seizure precautions C. Keep the room cool and dark D. Administer thiamine and zinc

Correct Answer: B. Provide seizure precautions

The diagnostic work-up of a client hospitalized with complaints of progressive weakness and fatigue confirms a diagnosis of myasthenia gravis. The medication used to treat myasthenia gravis is: A. Atropine (atropine sulfate) B. Pyridostigmine (neostigmine) C. Didronel (etidronate) D. Tensilon (edrophonium)

Correct Answer: B. Pyridostigmine (neostigmine)

The nurse is to administer digoxin elixir to a 6-month-old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100 beats per minute. The nurse should: A. Record the heart rate and call the physician B. Record the heart rate and administer the medication C. Administer the medication and recheck the heart rate in 15 minutes D. Hold the medication and recheck the heart rate in 30 minutes

Correct Answer: B. Record the heart rate and administer the medication Option B: The infant's apical heart rate is within the accepted range for administering the medication. Options A, C, and D: The apical heart rate is suitable for giving the medication.

The doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is to: A. Prevent addiction B. Reduce pain C. Facilitate mobility D. Prevent nausea

Correct Answer: B. Reduce pain

The chart of a client with schizophrenia states that the client has perseveration. The nurse can expect the client to: A. Speak using words that rhyme B. Say the same thing over and over C. Include irrelevant details in conversation D. Make up new words with new meanings

Correct Answer: B. Say the same thing over and over

A nurse has an African American patient who is bedridden for 3 months due to Guillain barre syndrome. During a routine assessment, which characteristic of pressure ulcer will the nurse first identify? A. Skin feels soft and cold B. Skin looks shiny or bluish in color C. Skin looks Reddish in color D. Skin returns to normal color after pressing it for 10 minutes

Correct Answer: B. Skin looks shiny or bluish in color

What information should the nurse give a new mother regarding the introduction of solid foods for her infant? A. Solid foods should not be given until the extrusion reflex disappears, at 7-9 months of age. B. Solid foods should be introduced one at a time, with 4 to 7-day intervals. C. Solid foods can be mixed in a bottle or infant feeder to make feeding easier. D. Solid foods should begin with fruits and vegetables.

Correct Answer: B. Solid foods should be introduced one at a time, with 4 to 7-day intervals.

The LPN is reviewing the lab results of an elderly client when she notes a urine specific gravity of 1.006. The nurse recognizes that: A. The client has impaired renal function B. The client has a normal specific gravity C. The client has mild dehydration D. The client has low sodium level in the blood

Correct Answer: B. The client has a normal specific gravity

A client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client's medication? A. The client complains of difficulty in urination B. The client is unable to control his or her leg C. The client complains of hyperventilation D. The client is unable to sleep

Correct Answer: B. The client is unable to control his or her leg

An adolescent with borderline personality is hospitalized with suicidal ideation and self-mutilation. Which goal is both therapeutic and realistic for this client? A. The client will remain in her room when feeling overwhelmed by sadness. B. The client will seek out a staff member to verbalize feelings of anger and sadness. C. The client will leave group activities to pace when feeling anxious. D. The client will request medication when feeling loss of emotional control.

Correct Answer: B. The client will seek out a staff member to verbalize feelings of anger and sadness. Option B: Verbalizing feelings of anger and sadness to a staff member is an appropriate therapeutic goal for the client with a risk of self-directed violence.

A client with a bowel resection and anastomosis returns to his room with an NG tube attached to intermittent suction. Which of the following observations indicates that the nasogastric suction is working properly? A. The client is able to swallow B. The client's abdomen is soft C. The client has active bowel sounds D. The client's abdominal dressing is dry and intact

Correct Answer: B. The client's abdomen is soft

Which instruction should be included in the discharge teaching for the client with cataract surgery? A. Over-the-counter eye drops can be used to treat redness and irritation B. The eye shield should be worn at night C. It will be necessary to wear special cataract glasses D. A prescription for medication to control post-operative pain will be needed

Correct Answer: B. The eye shield should be worn at night

When performing a newborn assessment, the nurse measures the circumference of the neonate's head and chest. Which assessment finding is expected in the normal newborn? A. The head and chest circumference are the same B. The head is 2cm larger than the chest. C. The head is 3cm smaller than the chest D. The head is 4cm larger than the chest

Correct Answer: B. The head is 2cm larger than the chest

Assessment of a newborn male reveals that the infant has hypospadias. The nurse knows that: A. The infant should be circumcised to facilitate voiding B. The infant should not be circumcised C. Surgical correction will be done by 6 months of age D. Surgical correction is delayed until 6 years of age

Correct Answer: B. The infant should not be circumcised

The nurse has taken the blood pressure of a client hospitalized with methicillin-resistant staphylococcus aureus (MRSA). Which action by the nurse indicates an understanding regarding the care of clients with MRSA? A. The nurse cleans the stethoscope with alcohol and returns it to the exam room. B. The nurse leaves the stethoscope in the client's room for future use. C. The nurse uses the stethoscope to assess the blood pressure of other assigned clients. D. The nurse cleans the stethoscope with water, dries it, and returns it to the nurse's station.

Correct Answer: B. The nurse leaves the stethoscope in the client's room for future use.

A high school student returns to school following a 3-week absence due to mononucleosis. The school nurse knows it will be important for the client: A. To complete antiviral medication for 7-14 days B. To avoid contact sports for 1-2 months C. To have a snack twice a day to prevent hypoglycemia D. To continue antibiotic therapy for 6 months

Correct Answer: B. To avoid contact sports for 1-2 months

The nurse is teaching the parents of a newborn with osteogenesis imperfecta. The nurse should tell the parents: A. That the baby will need daily calcium supplements B. To lift the baby by the buttocks when diapering C. That the condition is a temporary one D. That only the bones are affected by the disease

Correct Answer: B. To lift the baby by the buttocks when diapering

A 6-year-old is diagnosed with Legg-Calve Perthes disease. An important part of the child's care includes instructing the parents: A. To increase the amount of dietary protein B. To prevent weight bearing on the affected leg C. About relaxation exercises to minimize pain in the shoulder D. About exercises to strengthen affected muscles

Correct Answer: B. To prevent weight bearing on the affected leg Option B: The child with Legg-Calve Perthes disease should be prevented from bearing weight on the affected extremity until revascularization has occurred.

The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is: A. Decreased urine output B. Tremors C. Vision changes D. Hypotension

Correct Answer: B. Tremors

Angela has been experiencing tinnitus, vertigo and ear stuffiness caused by Meniere's disease. The following food items she is discouraged to eat, except: A. Green tea B. Unsalted pretzels C. Grapefruit D. Smoked fish

Correct Answer: B. Unsalted pretzels Option B: Meniere's disease causes fluid build up in the inner ear, a diet rich in sodium can make the symptoms worse since the salt attracts water retention which can increase inner ear fluid pressure, therefore food such as unsalted pretzel which is low in sodium is allowed.

The LPN is preparing to administer an injection of vitamin K to the newborn. The nurse should administer the injection in the: A. Rectus femoris muscle B. Vastus lateralis muscle C. Deltoid muscle D. Dorsogluteal muscle

Correct Answer: B. Vastus lateralis muscle

A client is admitted with a diagnosis of hypothyroidism. An initial assessment of the client would reveal: A. Slow pulse rate, weight loss, diarrhea, and cardiac failure B. Weight gain, lethargy, slowed speech, and decreased respiratory rate C. Rapid pulse, constipation, and bulging eyes D. Decreased body temperature, weight loss, and increased respirations

Correct Answer: B. Weight gain, lethargy, slowed speech, and decreased respiratory rate

A 3-year-old is admitted due to suspected intussusception. Which finding is associated with intussusception? A. Projectile vomiting B. Loose-foul smelling stools C. " Red currant jelly" stools D. "Ribbon-like" stools

Correct Answer: C. "Red currant jelly" stools

A mother brought her 5 year old child to a clinic. The nurse notes that the child's appearance looks older than she is. After a genetic test, the doctor diagnosed the child with Hutchinson-Gilford syndrome. What is the average life expectancy of the child with this kind of disorder? A. 7 years B. 10 years C. 13 years D. 21 capsules

Correct Answer: C. 13 years

A client with insulin-dependent diabetes takes 20 units of NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at: A. 8 a.m. B. 10 a.m. C. 3 p.m. D. 5 a.m.

Correct Answer: C. 3 p.m.

A client with Type II diabetes has an order for regular insulin 10 units SC each morning. The client's breakfast should be served within: A. 15 minutes B. 20 minutes C. 30 minutes D. 45 minutes

Correct Answer: C. 30 minutes Option C: The client's breakfast should be served within 30 minutes to coincide with the onset of the client's regular insulin.

A client with schizophrenia is receiving depot injections of Haldol Decanoate (haloperidol decanoate). The client should be told to return for his next injection in: A. 1 week B. 2 weeks C. 4 weeks D. 6 weeks

Correct Answer: C. 4 weeks

The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority? A. Alteration in skin integrity B. Alteration in comfort C. Alteration in mobility D. Alteration in O2 perfusion

Correct Answer: C. Alteration in mobility

Which of the following meal selections is appropriate for the client with celiac disease? A. Ramen noodles and dumplings B. French croissants and donuts C. Bacon and egg D. Pepperoni pizza and ginger ale

Correct Answer: C. Bacon and egg

The physician has ordered a low-potassium diet for a child with acute glomerulonephritis. Which fruit is suitable for the child with potassium restrictions? A. Raisins B. Cantaloupe C. Blueberries D. Apricots

Correct Answer: C. Blueberries

A client with diverticulitis is admitted with nausea, vomiting, and dehydration. Which finding suggests a complication of diverticulitis? A. Abdominal distention B. Pain in the left lower quadrant C. Board-like abdomen D. Low-grade fever

Correct Answer: C. Board-like abdomen

Which finding is the best indication that a client with ineffective airway clearance needs suctioning? A. Oxygen saturation B. Respiratory rate C. Breath sounds D. Arterial blood gases

Correct Answer: C. Breath sounds

Which of the following snacks would be suitable for the child with gluten-induced enteropathy? A. Ice cold ale B. Pumpkin loaf cake C. Buckwheat kasha D. Oatmeal cookies E. Linguine with lemon and tomatoes

Correct Answer: C. Buckwheat kasha Option C: Gluten-induced enteropathy also known as celiac disease is a digestive disorder caused by an intolerance to gluten, a protein found in wheat, oats, barley, or rye. Buckwheat is a grain-like seed and is gluten-free. Options A, B, D, and E: These foods are rich in gluten that can worsen the client's condition.

A nurse is caring for a 5th month old boy who suffered physical injuries from fall. Which of the following is the most appropriate pain assessment that the nurse will use? A. Numerical pain scale B. Mcgill pain scale C. CRIES scale D. Mankoski pain scale

Correct Answer: C. CRIES scale Option C: CRIES scale is a commonly used pain scale appropriate for clients ages 6 months and below. It assesses crying, oxygenation, vital signs, facial expression, and sleeplessness of an infant.

The mother of a child with cystic fibrosis tells the nurse that her child makes "snoring" sounds when breathing. The nurse is aware that many children with cystic fibrosis have: A. Enlarged adenoids B. Choanal atresia C. Chronic sinusitis D. Septal deviations

Correct Answer: C. Chronic sinusitis

Which of the following medication orders needs further clarification? A. Darvocet 65 mg PO q 4-6 hrs. PRN B. Nembutal 100 mg PO at bedtime C. Coumadin 10mg PO D. Estrace 2 mg PO q day

Correct Answer: C. Coumadin 10mg PO Option C: There is no specified time or frequency for the ordered medication. Options A, B, and D: These medications are completely and correctly written.

The 5-minute Apgar of a baby delivered by C-section is recorded as 9. The most likely reason for this score is: A. The mottled appearance of the trunk B. The presence of conjunctival hemorrhages C. Cyanosis of the hands and feet D. Respiratory rate of 20-28 per minute

Correct Answer: C. Cyanosis of the hands and feet

A client with glaucoma has been prescribed Timoptic (timolol) eye drops. Timolol should be used with caution in the client with a history of: A. Benign Prostatic Hyperplasia B. Gastric Ulcers C. Diabetes Mellitus D. Pancreatitis

Correct Answer: C. Diabetes Mellitus Option C: Beta-blockers such as timolol (Timoptic) may mimic the signs and symptoms of hypoglycemia and therefore are used in caution with patients with diabetes mellitus. Options A, B, and D: Timoptic is not contraindicated for use in clients with benign prostatic hyperplasia, gastric ulcers, or pancreatitis.

The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort lessens when he: A. Skips a meal B. Rests in low fowler's position C. Eats a meal D. Sits upright after eating

Correct Answer: C. Eats a meal

A client with breast cancer is returned to the room following a right total mastectomy. The nurse should: A. Keep the client's right arm on the bed beside her B. Place the client's right arm in a dependent sling C. Elevate the client's right arm on pillows D. Place the client's right arm across her body

Correct Answer: C. Elevate the client's right arm on pillows

The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephrotic syndrome. The nurse should: A. Provide additional warmth for swollen, inflamed joints B. Bathe the client using only mild soap and water C. Encourage the client to drink extra fluids D. Request a low-protein diet for the client

Correct Answer: C. Encourage the client to drink extra fluids

The nurse is assessing a multigravida, 36 weeks gestation for symptoms of pregnancy-induced hypertension and preeclampsia. The nurse should give priority to assessing the client for: A. Ankle edema B.Diminished reflexes C. Facial swelling D.Pulse deficits

Correct Answer: C. Facial swelling Option C: The nurse should pay close attention to swelling in the client with preeclampsia. Facial swelling indicates that the client's condition is worsening and blood pressure will be increased.

A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is: A. Brittle nails B. Alopecia C. Hoarseness D. Weight gain

Correct Answer: C. Hoarseness

The primary cause of anemia in a client with chronic renal failure is: A. Poor iron absorption B. Destruction of red blood cells C. Insufficient erythropoietin D. Lack of intrinsic factor

Correct Answer: C. Insufficient erythropoietin

A 2-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization: A. Will need to be repeated when the child is 4 years of age B. Is given to determine whether the child is susceptible to pertussis C. Is one of a series of injections that protects against DPT and Hib D. Is a one-time injection that protects against MMR and varicella

Correct Answer: C. Is one of a series of injections that protects against DPT and Hib

An elderly client with dementia is admitted to the psychiatric unit from the nursing home. Transfer information indicates that the client has become confused and disoriented, with behavioral problems. The client will also likely show a loss of ability in: A. Balance B. Speech C. Judgment D. Endurance

Correct Answer: C. Judgment Option C: Dementia affects a person's ability to make appropriate decisions or judgments since the part of the brain that is involved in processing information, remembering, and understanding is affected.

The nurse is providing dietary instructions for a client with hemochromatosis. Which food items should the client consume, except? A. Grains B. Coffee C. Lamb D. Legumes

Correct Answer: C. Lamb

The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid: A. Offering sterile water B. Holding the infant C. Offering a pacifier D. Providing a mobile

Correct Answer: C. Offering a pacifier

A newborn has been diagnosed with exstrophy of the bladder. The nurse should position the newborn: A. Prone B. Supine C. On either side D. With the head elevated

Correct Answer: C. On either side

A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should anticipate the physician to: A. Withhold all morning medications B. Order CBC and CPK C. Prescribe dantrolene C. Prescribe dantrolene D. Transfer the client to a medical unit

Correct Answer: C. Prescribe dantrolene

A client with a laryngectomy returns from surgery with a nasogastric tube in place. The primary reason for the placement of the nasogastric tube is to: A. Prevent swelling and dysphagia B. Decompress the stomach via suction C. Prevent contamination of the suture line D. Promote healing of the oral mucosa

Correct Answer: C. Prevent contamination of the suture line

A client receiving chemotherapy for breast cancer has an order for Zofran (ondansetron) 8 mg PO to be given 30 minutes before induction of the chemotherapy. The purpose of the medication is to: A. Prevent anemia B. Promote relaxation C. Prevent nausea D. Increase neutrophil counts

Correct Answer: C. Prevent nausea

A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication: A. Will cause gray staining on the surrounding skin B. Produces a cooling sensation when applied C. Produces a burning sensation when applied D. Will cause unusual hair growth in the treated areas

Correct Answer: C. Produces a burning sensation when applied

A client with human immunodeficiency syndrome has gastrointestinal symptoms, including diarrhea. The nurse should teach the client to avoid: A. Processed meat B. Pasteurized milk C. Raw fruits and vegetables D. Calcium-rich foods

Correct Answer: C. Raw fruits and vegetables

The physician has ordered Amoxil (amoxicillin) 500 mg capsules for a client with esophageal varices. The nurse can best care for the client's needs by: A. Giving the medication as ordered B. Providing extra water with the medication C. Requesting an alternate form of the medication D. Giving the medication with an antacid

Correct Answer: C. Requesting an alternate form of the medication

A client with oxalate renal calculi should be taught to avoid eating: A. Grapefruit B. Milk C. Rhubarb D. Oranges

Correct Answer: C. Rhubarb Option C: The client with oxalate renal calculi should avoid sources of oxalate, which include rhubarb, spinach, rice bran, almonds, and miso soup.

The chart indicates that a client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with: A. Comprehending spoken words B. Recognizing and using an object correctly C. Speaking and writing D. Carrying out a purposeful motor activity

Correct Answer: C. Speaking and writing

A postoperative client has an order for Demerol (meperidine) 75mg and promethazine (Phenergan) 25mg IM every 3-4 hours as needed for pain. The combination of the two medications produces a/an: A. Antagonist effect B. Excitatory effect C. Synergistic effect D. Agonist effect

Correct Answer: C. Synergistic effect

A 5-month-old infant is admitted to the ER with a temperature of 106°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for: A. Negative scarf sign B. Positive Babinski reflex C. Tenseness of the anterior fontanel D. Periorbital edema

Correct Answer: C. Tenseness of the anterior fontanel

An 18-month-old is being discharged following hypospadias repair. Which instruction should be included in the nurse's discharge teaching? A. Diapering or supportive underwear should be avoided for 7 days B. Refrain from giving Tylenol C. The child should not play on his rocking horse D. The child will need a special diet to promote healing

Correct Answer: C. The child should not play on his rocking horse

Which of the following pediatric clients is at greatest risk for latex allergy? A. The child with coxa plana B. The child with rheumatic fever C. The child with a myelomeningocele D. The child with epispadias

Correct Answer: C. The child with a myelomeningocele

A client with schizophrenia has been taking chlorpromazine (Thorazine) 200 mg four times a day. Which finding should be reported to the doctor immediately? A. The client complains of thirst B. The client has gained 4 pounds in the past 2 months C. The client complains of a sore throat D. The client naps throughout the day

Correct Answer: C. The client complains of a sore throat

A client taking Dilantin (phenytoin) for grand mal seizures is preparing for discharge. Which information should be included in the client's discharge care plan? A. The medication can cause dental staining B. The client will need to avoid a high-carbohydrate diet C. The client will need a regularly scheduled CBC D. The medication can cause problems with drowsiness

Correct Answer: C. The client will need a regularly scheduled CBC

A client with tuberculosis asks the nurse how long he will have to take medication. The nurse should tell the client that: A. Medication is rarely needed after 2 weeks B. He will need to take medication for the rest of his life C. The course of therapy is usually 18-24 months D. He will be re-evaluated in 1 month to see if further medication is needed

Correct Answer: C. The course of therapy is usually 18-24 months

The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client's cancer is located in: A. The body of the pancreas B. The tail of the pancreas C. The head of the pancreas D. The entire pancreas

Correct Answer: C. The head of the pancreas

The physician has discussed the need for medication with the parents of an infant with congenital hypothyroidism. The nurse can reinforce the physician's teaching by telling the parents that: A. The medication is given one time daily every other day B. The medication schedule can be arranged to allow for drug holidays C. The medication will be needed throughout the child's lifetime D. The medication will be needed only during times of rapid growth

Correct Answer: C. The medication will be needed throughout the child's lifetime

The physician has ordered aspirin therapy for a client with severe rheumatoid arthritis. A sign of acute aspirin toxicity is: A. Confusion B. Lactic acidosis C. Tinnitus D. Hypoxia

Correct Answer: C. Tinnitus

The nurse is teaching the client with insulin-dependent diabetes the signs of hypoglycemia. Which of the following signs is associated with hypoglycemia? A. Nausea B. Flushed skin C. Tremulousness D. Slow pulse

Correct Answer: C. Tremulousness

Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis? A. Cold shower B. Plyometrics C. Using wide-gripped utensils during breakfast D. Running in the park

Correct Answer: C. Using wide-gripped utensils during breakfast

A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should: A. Apply an occlusive dressing to the site B. Apply a lanolin-based lotion to the skin C. Wash the skin with water and pat dry D. Cover the area with a petroleum gauze

Correct Answer: C. Wash the skin with water and pat dry

The nurse is caring for a client with a history of diverticulitis. The client complains of abdominal pain, fever, and diarrhea. Which food was responsible for the client's symptoms? A. Eggs B. Yogurt C. Whole-grain cereal D. Baked fish

Correct Answer: C. Whole-grain cereal

A 6-year-old with cystic fibrosis has an order for Creon (pancrelipase). The nurse knows that the medication will be given: A. Daily in the morning B. Twice daily C. With meals and snacks D. At bedtime

Correct Answer: C. With meals and snacks

Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 52. The appropriate nursing intervention is to: A. Record the pulse rate and administer the medication B. Administer the medication and monitor the heart rate C. Withhold the medication and notify the doctor D. Withhold the medication until the heart rate increases

Correct Answer: C. Withhold the medication and notify the doctor

The nurse is caring for a client who is unconscious following a fall. Which comment by the nurse will help the client become reoriented when he regains consciousness? A. "I am your nurse and I will be taking care of you today." B. "Can you tell me your name and where you are?" C. "I know you are confused right now, but everything will be alright." D. "You were in an accident that hurt your head. You are in the hospital."

Correct Answer: D. "You were in an accident that hurt your head. You are in the hospital." Option D: Telling the client what happened and where he is helps with reorientation.

A camp nurse is applying sunscreen to a group of children enrolled in swim classes. Chemical sunscreens are most effective when applied: A. Just before sun exposure B. 5 minutes before sun exposure C. 15 minutes before sun exposure D. 30 minutes before sun exposure

Correct Answer: D. 30 minutes before sun exposure

The mother of a 6-month-old asks when her child will have all his baby teeth. The nurse knows that most children have all their primary teeth by age: A. 15 months B. 18 months C. 27 months D. 33 months

Correct Answer: D. 33 months

At the 6-week check-up, the mother asks when she can expect the baby to sleep all night. The nurse should tell the mother that most infants sleep all night by age: A. Newborn B. 2 month old C. 3 month old D. 5-6 months

Correct Answer: D. 5-6 months

A neurological consult has been ordered for a pediatric client with suspected petit mal seizures. The client with petit mal seizures can be expected to have: A. Short, abrupt muscle contraction B. Quick, bilateral severe jerking movements C. Abrupt loss of muscle tone D. A brief lapse in consciousness

Correct Answer: D. A brief lapse in consciousness

A client has been hospitalized with a diagnosis of laryngeal cancer. Which factor is most significant in the development of laryngeal cancer? A. A family history of laryngeal cancer B. Chronic inhalation of noxious fumes C. Frequent straining of the vocal cords D. A history of alcohol and tobacco use

Correct Answer: D. A history of alcohol and tobacco use

The nurse is assessing an infant with Hirschsprung's disease. The nurse can expect the infant to: A. Fixed plantar flexion (equinus) of the ankle B. Sonorous seal-bark cough C. Strawberry tongue D. Abdominal distention

Correct Answer: D. Abdominal distention Option D: Hirschsprung's disease (aganglionic megacolon) is a condition where certain nerve cells in the wall of the colon do not form properly, which results in the blockage of the intestine. Symptoms in infants will show an absence of bowel movement in the first 48 hours and abdominal distention.

A client with tuberculosis has a prescription for Myambutol (ethambutol HCl). The nurse should tell the client to notify the doctor immediately if he notices: A. Tingling sensation in the feet B. Changes in hearing C. Red discoloration of bodily fluids D. Changes in color vision

Correct Answer: D. Changes in color vision

The nurse is caring for a client hospitalized with bipolar disorder, manic phase. Which of the following meals would be best for the client with mania? A. Canned beans B. Grapefruit juice C. Coffee D. Cold-water fish

Correct Answer: D. Cold-water fish

A client with a hiatal hernia has been taking magnesium hydroxide for relief of heartburn. Overuse of magnesium-based antacids can cause the client to have: A. Constipation B. Weight gain C. Anorexia D. Diarrhea

Correct Answer: D. Diarrhea

Which of the following symptoms is associated with relapse of multiple sclerosis? A. Diarrhea B. Hearing loss C. Jaundice D. Diplopia

Correct Answer: D. Diplopia

The nurse calculates the amount of an antibiotic for injection to be given to an infant. The amount of medication to be administered is 1.25mL. The nurse should: A. Give the medication in one injection in the ventrogluteal muscle B. Give the medication in one injection in the dorsogluteal muscle C. Divide the amount into two injections and give one in the ventrogluteal muscle and one in the vastus lateralis muscle D. Divide the amount into two injections and administer in each vastus lateralis muscle

Correct Answer: D. Divide the amount into two injections and administer in each vastus lateralis muscle

Phototherapy is ordered for a newborn with physiologic jaundice. The nurse caring for the infant should: A. Place the baby on enteric isolation B. Apply lotion, or oil on the baby's skin to prevent drying C. Wear a gown, gloves, and a mask while caring for the infant D. Encourage the mother to continue breastfeeding

Correct Answer: D. Encourage the mother to continue breastfeeding Option D: Breastfeeding will

A client has returned to his room following an esophagoscopy. Before offering fluids, the nurse should give priority to assessing the client's: A. Level of consciousness B. Movement of extremities C. Urinary output D. Gag reflex

Correct Answer: D. Gag reflex

The nurse is preparing to give a liquid oral potassium supplement. The nurse should: A. Give the medication on an empty stomach B. Give the medication with warm water C. Give the medication without diluting it D. Give the medication with 4 oz. of juice

Correct Answer: D. Give the medication with 4 oz. of juice

A client with AIDS complains of a weight loss of 20 pounds in the past month. Which diet is suggested for the client with AIDS? A. High calorie, low carbohydrate, high fat B. High calorie, high carbohydrate, low protein C. High calorie, high protein, high fat D. High calorie, high protein, low fat

Correct Answer: D. High calorie, high protein, low fat

A client admitted to the psychiatric unit claims to be the Son of God and insists that he will not be kept away from his followers. The most likely explanation for the client's delusion is: A. A religious experience B. A stressful event C. Overwhelming anxiety D. High self-esteem

Correct Answer: D. High self-esteem

The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately? A. Reluctance to swallow B. Drooling of blood-tinged saliva C. An axillary temperature of 99°F D. High-pitched sound when breathing

Correct Answer: D. High-pitched sound when breathing

According to Erikson's stage of growth and development, the developmental task of an 8-year old child is: A. Trust B. Initiative C. Independence D. Industry

Correct Answer: D. Industry

The physician has ordered Stadol (butorphanol) for a postoperative client. The nurse knows that the medication is having its intended effect if the client: A. States that he is feeling less nauseated B. Has an increased urinary output C. Asks for extra servings on his meal tray D. Is asleep 30 minutes after the injection

Correct Answer: D. Is asleep 30 minutes after the injection

The doctor has prescribed aspirin 325 mg daily for a client with transient ischemic attacks. The nurse knows that aspirin was prescribed to: A. Prevent headaches B. Boost coagulation C. Prevent cerebral anoxia D. Keep platelets from clumping together

Correct Answer: D. Keep platelets from clumping together

An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help decrease the client's confusion by: A. Assigning a nursing assistant to sit with him until he falls asleep B. Allowing the client to room with another elderly client C. Administering a bedtime sedative D. Leaving a nightlight on during the evening and night shifts

Correct Answer: D. Leaving a nightlight on during the evening and night shifts Option D: Leaving a nightlight on during the evening and night shifts help the client remain oriented to the environment and fosters independence. Options A and B: Assigning a nursing assistant to sit with him and allowing the client to room with another client will not decrease the client's confusion.

The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal? A. Antabuse (disulfiram) B. Romazicon (flumazenil) C. Dolophine (methadone) D. Librium (chlordiazepoxide)

Correct Answer: D. Librium (chlordiazepoxide)

Which information should be given to the client taking Dilantin (phenytoin)? A. Taking the medication with meals will increase its effectiveness B. The medication decreases the effects of oral contraceptives C. The medication can cause sleep disturbances D. More frequent dental appointments will be needed for special gum care

Correct Answer: D. More frequent dental appointments will be needed for special gum care. Option D: Gingival hyperplasia is a side effect of phenytoin. The client will need more frequent dental visits. Options A, B, and C: These do not apply to the medication.

A client with iron-deficiency anemia is taking an oral iron supplement. The nurse should tell the client to take the medication with: A. Apple juice B. Water only C. Milk D. Orange juice

Correct Answer: D. Orange juice

A 5-year-old is admitted with acute leukemia. It will be most important to monitor the child for: A. Petechiae and mucosal ulcers B. Bruising and fatigue C. Anorexia and abdominal pain D. Pallor and bleeding

Correct Answer: D. Pallor and bleeding

A client hospitalized with chronic dyspepsia is diagnosed with gastric cancer. Which of the following is associated with an increased incidence of gastric cancer? A. Dairy products B. Carbonated beverages C. Refined sugars D. Luncheon meats

Luncheon meats

The nurse is caring for a client following the removal of the thyroid. Immediately post-op, the nurse should: A. Maintain the client in a semi-Fowler's position with the head and neck supported by pillows B. Encourage the client to turn her head side to side, to promote drainage of oral secretions C. Maintain the client in a supine position with sandbags placed on either side of the head and neck D. Encourage the client to cough and breathe deeply every 2 hours, with the neck in a flexed position

Maintain the client in a semi-Fowler's position with the head and neck supported by pillows.

n 8-year-old admitted with an upper-respiratory infection has an order for O2 saturation via pulse oximeter. To ensure an accurate reading, the nurse should: A. Place the probe on the child's abdomen B. Calibrate the oximeter at the beginning of each shift C. Apply the probe and wait 15 minutes before obtaining a reading D. Place the probe on the child's finger

Correct Answer: D. Place the probe on the child's finger Option D: The pulse oximeter should be placed on the child's finger or earlobe because blood flow to these areas is most accessible for measuring oxygen concentration. Option A: The probe cannot be secured to the abdomen. Option B: Pulse oximeter should be recalibrated before application. Option C: Reading from a pulse oximeter is obtained within seconds, not minutes.

The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis? A. Ascending paralysis and loss of motor function B. Visual disturbances, including diplopia C. Cogwheel rigidity and loss of coordination D. Progressive weakness that is worse at the day's end

Correct Answer: D. Progressive weakness that is worse at the day's end

The primary purpose for using a continuous passive motion (CPM) machine for the client with a total knee repair is to help: A. Inhibit lactic acid production in the leg muscles B. Prevent contractures C. Decrease the pain associated with early ambulation D. Promote flexion of the artificial joint

Correct Answer: D. Promote flexion of the artificial joint

The physician has ordered Dilantin (phenytoin) for a client with generalized seizures. When planning the client's care, the nurse should: A. Maintain strict intake and output B. Check the pulse before giving the medication C. Continue breastfeeding as instructed D. Provide oral hygiene and gum care every shift

Correct Answer: D. Provide oral hygiene and gum care every shift

A client with AIDS is admitted for the treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract? A. Thoroughly cooking all foods B. Offering yogurt and buttermilk between meals C. Forcing fluids D. Providing small, frequent meals

Correct Answer: D. Providing small, frequent meals

A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is: A. Loss of sensation in the lower extremities B. Back pain that lessens when standing C. Decreased urinary output D. Pulsations in the periumbilical area

Correct Answer: D. Pulsations in the periumbilical area

A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should: A. Remove the unsightly markings with acetone or alcohol B. Put a little baby powder over the irradiated area C. Cover the radiation site with a loose gauze dressing D. Refrain from using soap or lotion on the marked area

Correct Answer: D. Refrain from using soap or lotion on the marked area

The nurse is providing dietary teaching for a client with gout. Which dietary selection is suitable for the client with gout? A. Broiled liver, macaroni, and cheese, spinach B. Stuffed crab, steamed rice, peas C. Lamb, pasta salad, asparagus casserole D. Roast chicken breast, baked potato, tossed salad

Correct Answer: D. Roast chicken breast, baked potato, tossed salad

Which development milestone puts the 4-month-old infant at greatest risk for injury? A. Switching objects from one hand to another B. Crawling C. Standing D. Rolling over

Correct Answer: D. Rolling over

The doctor has prescribed Cortisone (cortisone) for a child with systemic lupus erythematosus. Which instruction should be given to the client? A. Take the medication 30 minutes before eating B. Report changes in appetite and weight C. Wear sunglasses to prevent cataracts D. Schedule a time to take the influenza vaccine

Correct Answer: D. Schedule a time to take the influenza vaccine

The nurse is formulating a plan of care for a client with a cognitive disorder. Which activity is most appropriate for the client with confusion and a short attention span? A. Meeting with an assertiveness training group B. Participating in unit community goal setting C. Going on a field trip with a group of clients D. Taking part in a reality-orientation group

Correct Answer: D. Taking part in a reality-orientation group

A 4-year old child is brought by her grandmother in the emergency room due to fever, chills, and difficulty walking. The nurse tries to remove the excessive clothing of the child but is reluctant. After a thorough assessment, the nurse also noted bruises around the genital area. Which of the following interventions should the nurse do first? A. Collect the clothing and underwear of the child B. Provide privacy and disregard the behavior of the child C. Inform the law enforcement for a possible child abuse D. Record all the findings

Inform the law enforcement for a possible child abuse

A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial personality disorder. In reviewing the client's record, the nurse would expect to find: A. A history of consistent employment B. A below-average intelligence C. A history of cruelty to animals D. An expression of remorse for his actions

A history of cruelty to animal

A client receiving hydrochlorothiazide is instructed to increase her dietary intake of potassium. The best snack for the client requiring increased potassium is: A. Pear B. Apple C. Orange D. Avocado

Avocado

The nurse is planning dietary changes for a client following an episode of pancreatitis. Which diet is suitable for the client? A. Low calorie, low carbohydrate B. High fiber, low fat C. High protein, high fat D. Low protein, high carbohydrate

Correct Answer: B. High fiber, low fat

An infant with Tetralogy of Fallot is discharged with a prescription of lanoxin elixir 0.5 mL once a day PO. The nurse should instruct the mother to: A. Administer the medication using a nipple B. Administer the medication using the calibrated dropper in the bottle C. Administer the medication using a plastic baby spoon D. Administer the medication in a baby bottle with 1oz. of water

Correct Answer: B. Administer the medication using the calibrated dropper in the bottle Option B: Lanoxin elixir should be administered using the calibrated dropper to provide accurate administration of medication. For doses less than 0.2 mL, use another calibrated measuring device. Options A and C: Using less precise measuring tools such as nipple and plastic baby spoon may provide an inaccurate dosage of medication. Option D: Part or all of the medication will not be administered if the child does not finish the bottle.

Which of the following nursing interventions has the highest priority for the client scheduled for an intravenous pyelogram? A. Providing the client with a favorite meal for dinner B. Asking if the client has allergies to shellfish C. Encouraging fluids the evening before the test D. Telling the client what to expect during the test

Correct Answer: B. Asking if the client has allergies to shellfish

A client develops tremors while withdrawing from alcohol. Which medication is routinely administered to lessen physiological effects of alcohol withdrawal? A. Dolophine (methadone) B. Ativan (lorazepam) C. Narcan (Naloxone) D. Antabuse (disulfiram)

Correct Answer: B. Ativan (lorazepam) Option B: Benzodiazepines such as clonazepam and lorazepam are given to the client withdrawing from alcohol.

Following a generalized seizure, the nurse can expect the client to: A. Be unable to move the extremities B. Be drowsy and prone to sleep C. Remember events before the seizure D. Have a drop in blood pressure

Correct Answer: B. Be drowsy and prone to sleep Option B: When a generalized seizure ends, the client is experiencing the postictal phase, which is the recovery period following the seizure. The client in this phase shows symptoms of drowsiness, confusion, and sleepiness.

An elderly client is hospitalized for transurethral resection of the prostate (TURP). Which finding postoperatively should be reported to the doctor immediately? A. Hourly urinary output of 40-50 cc B. Bright red urine output with many clots C. Dark red urine output with few clots D. Requests for pain med q 4 hrs.

Correct Answer: B. Bright red urine with many clots

The mother of a 3-month-old with esophageal reflux asks the nurse what she can do to lessen the baby's reflux. The nurse should tell the mother to: A. Feed the baby only when he is hungry B. Burp the baby frequently throughout the feeding C. Place the baby supine with head elevated D. Burp the baby after the feeding is completed

Correct Answer: B. Burp the baby frequently throughout the feeding

A mother of a 3-year-old hospitalized with lead poisoning asks the nurse to explain the treatment for her daughter. The nurse's explanation is based on the knowledge that lead poisoning is treated with: A. Gastric lavage B. Chelating agents C. Antiemetics D. Activated charcoal

Correct Answer: B. Chelating agents Option B: Chelating agents are used to treat the client with poisonings from heavy metals such as lead and iron. Options A and D: Gastric lavage and activated charcoal are used to remove noncorrosive poisons. Option C: Antiemetics prevents vomiting only and would not treat lead poisoning.

The nurse is providing dietary teaching for a client with elevated cholesterol levels. Which cooking oil is not suggested for the client on a low-cholesterol diet? A. Canola oil B. Coconut oil C. Safflower oil D. Sunflower oil

Correct Answer: B. Coconut oil

A factory worker is brought to the nurse's office after a metal fragment enters his right eye. The nurse should: A. Attempt to remove the metal with a cotton-tipped applicator B. Cover both eyes and transport the client to the ER C. Cover the right eye with a sterile 4×4 D. Flush the eye for 10 minutes with running water

Correct Answer: B. Cover both eyes and transport the client to the ER

A client with nontropical sprue has an exacerbation of symptoms. Which meal selection is responsible for the recurrence of the client's symptoms? A. Mixed fruit and yogurt B. Cream of tomato soup and crackers C. Baked potato with sour cream and chives D. Tossed salad with oil and vinegar dressing

Correct Answer: B. Cream of tomato soup and crackers

The nurse is caring for a client with stage III Alzheimer's disease. A characteristic of this stage is: A. Inability to remember details in their life history B. Difficulty in organizing and planning C. Difficulty dressing appropriately D. Loss of bowel and bladder control

Correct Answer: B. Difficulty in organizing and planning

A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she: A. Uses an electric blanket at night B. Dresses in extra layers of clothing C. Applies a heating pad to her feet D. Takes a hot bath morning and evening

Correct Answer: B. Dresses in extra layers of clothing

A teen hospitalized with anorexia nervosa is now permitted to leave her room and eat in the dining room. Which of the following nursing interventions should be included in the client's plan of care? A. Weighing the client after she eats B. Having a staff member remain with her for 1 hour after she eats C. Placing high-protein foods in the center of the client's plate D. Providing the client with child-size utensils

Correct Answer: B. Having a staff member remain with her for 1 hour after she eats

Which diet is associated with an increased risk of colorectal cancer? A. High protein, simple carbohydrates B. High fat, refined carbohydrates C. Low carbohydrates, complex proteins D. Low protein, complex carbohydrates

Correct Answer: B. High fat, refined carbohydrates

A client with schizophrenia is receiving Thorazine (chlorpromazine) 400mg twice a day. An adverse side effect of the medication is: A. Photosensitivity B. High fever C. Weight gain D. Elevated blood pressure

Correct Answer: B. High fever Option B: The client is experiencing neuroleptic malignant syndrome, which is a life-threatening adverse reaction of neuroleptics such as chlorpromazine that is characterized by extreme elevations in temperature. Options A and C: Photosensitivity and weight gain are expected side effects. Option D: Elevations in blood pressure are associated with reactions between foods containing tyramine and MAOI.

Which home remedy is suitable to relieve the itching associated with varicella? A. Applying a paste of baking soda and water B. Dusting the lesions with baby powder C. Using cool compresses of normal saline D. Applying gauze saturated in hydrogen peroxide

Option A: Applying a paste of baking soda and water soothes the itching and helps to dry the vesicles.

The nurse is developing a bowel-retraining plan for a client with multiple sclerosis. Which measure is likely to be least helpful to the client: A. Elevating the toilet seat for easy access B. Limiting fluid intake to 1000 mL per day C. Establishing a regular schedule for toileting D. Providing a high-roughage diet

Option B: Bowel retraining plan is a behavioral program that helps people with chronic constipation or bowel loss control such as in multiple sclerosis. The program includes increasing fluid intake to at least 6 to 8 glasses of water, fiber therapy, and kegel exercise.

The nurse is providing dietary teaching for a client with Meniere's disease. Which statement indicates that the client understands the role of diet in triggering her symptoms? A. "I can help control problems with vertigo if I avoid breads and cereals." B. "I need to eat fewer foods that are high in potassium, such as raisins and bananas." C. "I need to limit foods that taste salty or that contain a lot of sodium." D. "I can expect to see more problems with tinnitus if I eat a lot of dairy products."

Option C: Since sodium attracts water retention, foods high in salt will make the symptoms worse. The recommended daily intake of sodium of a patient with Meniere's disease is 1500mg/day.

Jeremiah, a clinical instructor, is discussing the list of controlled substances schedules. The following are considered to be under Schedule I controlled substances, except: A. Cannabis B. Methaqualone C. Lysergic acid diethylamide (LSD) D. Oxycodone

Option D: Oxycodone falls under Schedule II. The substances that belong to this category have a high potential for abuse which may result in severe physical or psychological dependence.

A newborn male has been diagnosed with hypospadias with chordee. The nurse understands that the infant will have altered patterns of urination because: A. The bladder lies outside the abdominal cavity B. The ureters will reflux urine into the kidneys C. The urinary meatus is on the top of the penis D. The urinary meatus is on the dorsum of the penis

Option D: The infant with hypospadias has altered patterns of urinary elimination caused by the location of the urinary meatus on the dorsum, or underside, of the penis.

The licensed vocational nurse may not assume the primary care for a client: A. In the fourth stage of labor B. Two days post-appendectomy C. With a venous access device D. With bipolar disorder

With a venous access device.