Practice Questions for Level 1 and Level 2 Preview

70. A Chinese-American client is menstruating, a condition considered to be yin (cold). The nurse anticipates that which type of food would be eaten by the client who is striving to promote balance? Select all that apply. A. Beef B. Eggs C. Fried foods D. Honey E. Broccoli

A, B, C: Beef, eggs, and fried food are considered warm foods, and, as such, would be a treatment for yin (cold) conditions. Honey and broccoli are considered cold foods, and would not be consumed with a cold condition.

55. A 4-year-old client is coming to the health care provider's office for a well-child visit. For which routine screenings does the nurse plan? Select all that apply. A. Blood pressure B. Vision C. Urinalysis D. Lead screening E. Hearing

A, B, E: Blood pressure screening is started at age 3 and continues with each visit. Vision screening is started at age 3 and continues with each visit. Hearing screening begins at age 4. Urinalysis is done at age 5, in adolescence, and otherwise only as indicated. Lead screening would only be done on an as-needed basis for a 4-year-old.

54. A 20-year-old female sees a health care provider for her first adult physical examination. The nurse anticipates that which screening measure will be done at this visit as a baseline for further reference? Select all that apply. A. Body mass index (BMI) measurement B. Blood glucose level C. Clinical breast exam (CBE) D. Mammography E. Serum cholesterol level

A, C, E: A body mass index (BMI) measurement is done at age 20 and at each health visit. Clinical breast exam is done at age 20 and may be done every 3 years or more frequently depending on risk. Serum cholesterol levels are started at age 20 and are recommended every 5 years. Blood glucose screening is recommended to begin at age 45 unless there is evidence of higher risk for diabetes. Mammography is done yearly starting at age 40.

35. The nurse concludes that a postpartum client is using good bottle-feeding technique after observing which behavior? Select all that apply. A. Keeps the nipple full of formula throughout the feeding. B. Props the bottle on a rolled towel. C. Points the bottle at the infant's tongue. D. Enlarges the nipple hole to allow for a steady stream of formula to flow. E. Keeps the infant close with head elevated.

A, E: Keeping the infant close with head elevated is an optimal position for bottle-feeding. Keeping the nipple full of formula prevents the infant from sucking air. Propping the bottle and enlarging the nipple opening can cause aspiration of formula. Pointing the bottle at the infant's tongue could cause the infant to gag and vomit.

37. An inexperienced mother is playing with her 8-month-old in the playroom. The nurse has taught the mother about toys that are developmentally appropriate for this child. The nurse will conclude that teaching has been successful when the mother selects which type of toy? Select all that apply. A. A set of blocks B. A ways C. A puzzle with large pieces D. A rattle E. A soft ball

A, E: Objects that can be grasped and banged together, such as blocks, develop manipulation skills and are most appropriate for an 8-month-old infant. Pleasure is experienced from the feel and sounds of these activities. Throwing or rolling a ball helps the infant to develop gross motor skills and is appropriate for this age. A wagon may be used by preschoolers and toddlers. A large-piece puzzle may be used by preschoolers and toddlers. Rattles are recommended for infants ages 1 to 6 months.

58. Which nursing intervention would be most appropriate to meet safety needs when caring for an older adult with sensory changes? A. Assist in preparing a bath because the client may be less able to feel intensity of heat. B. Use care when administering an injection because older adults experience more pain. C. Massage with additional pressure because tactile perception of older adults is diminished. D. Use minimal touch with an older adult because touch will feel uncomfortable.

A: Because of loss of skin receptors, the older adult has an increased threshold to pain, touch, and temperature. When feeding or bathing, remember that the older adult may be unable to distinguish hot or cold or to determine the intensity of heat. The older adult may feel less pain than younger adults and report only pressure or a minor sensation. The older adult, however, is the only one who can identify whether he or she has pain. An older client's sensory perception is less acute than that of younger adults, so when giving a massage, less pressure is needed. Everyone, and especially the older adult, needs touch.

19. A pregnant client, who is a vegetarian, is concerned about her folic acid intake and asks the nurse to recommend some foods that she should include in her diet. Which of the following should the nurse recommend? A. Peanuts B. Hamburger C. Bananas D. Apple juice

A: Both peanuts and hamburger are good sources of folic acid, but since the client is a vegetarian, peanuts are a better recommendation. Bananas and apple juice do not contain significant amounts of folic acid.

43. A 9-year-old client is brought to the pediatrician's office for a varicella virus vaccine. Before preparing the dose of the vaccine, the nurse would determine the child's status regarding what health history item? A. Recent blood product transfusion B. Allergy to milk C. Allergy to penicillin D. History of splenectomy

A: Contraindications to varicella virus vaccine include allergy to neomycin or gelatin, immunosuppression, or administration of immune serum globulin or blood products in the last 3 to 11 months. A history of spleen removal and allergies to penicillin or milk are irrelevant to safe use of this vaccine.

16. With regard to normal changes in the reproductive system during pregnancy, the nurse should teach the pregnant client about which of the following? A. Vaginal secretions will increase and thicken. B. Uterus will grow by adding many new cells. C. Breasts will become red and hard. D. Cervix will begin to dilate during the second trimester.

A: During pregnancy, increased estrogen production results in an increased amount and thickening of vaginal secretions. The uterus grows by cell hypertrophy, not by adding more cells. Red and hard breasts or a cervix dilating during the second trimester are not normal findings.

30. A postpartum client asks the nurse how to strengthen her perineal muscles. The nurse teaches the client to do which of the following? A. Try to start and stop the flow of urine. B. Bear down as though having a bowel movement. C. Gently squeeze the uterus while pushing downward on the fundus. D. Straighten the leg and point the toes toward the head.

A: Kegel exercises are designed to strengthen the muscles of the perineum. By alternately tensing and releasing the muscles of the perineum, as if to start and stop the flow of urine, muscle tone and strength are enhanced. Bearing down is the opposite type of exercise for this set of muscles. Squeezing the uterus and dorsiflexing the foot, and straightening the leg and pointing the toes toward the head are incorrect statements of technique.

29. A new mother calls the clinic 4 days after delivery. She is breast-feeding and is concerned that her baby is not getting enough milk. What is the most important question for the nurse to ask this mother? A. "How many wet diapers has your baby had in the last 24 hours?" B. "Do you have any red or tender areas on the breasts?" C. "Are your nipples sore or bleeding?" D. "Do your breasts tingle when you begin nursing?"

A: Once the mother's milk comes in, typically after the third postpartum day, breastfed babies should have 6-8 wet diapers each day. This would indicate the baby is getting enough milk. The other options address the mother, not the intake of the newborn. Red, tender areas or sore, bleeding nipples contribute to infection such as mastitis. Tingling is often used to describe the feeling mothers experience with the letdown reflex.

23. The nursing care plan for a client with a prolonged latent phase of labor includes which of the following as a priority measure? A. Encouraging rest and relaxation through the playing of soft music. B. IV hydration with either lactated Ringer's solution or 5% dextrose (D5W). C. Continuous internal fetal monitoring of the fetal response to contractions. D. Measuring maternal blood pressure, temperature, and pulse every 15 minutes.

A: Prolonged latent phase of labor is defined as greater than 20 hours in primigravida women and greater than 14 hours in multigravida women. Encouraging rest and relaxation during this phase will help the client have enough energy to push effectively during the second stage of labor. Music is often used effectively to induce relaxation. Encouraging a well-rested client to ambulate will also facilitate the latent phase. Intravenous hydration is given to women who are unable to take oral fluids. Internal monitoring is indicated if labor is being augmented or induced, the amniotic fluid is meconium-stained, or there is evidence of fetal distress by external monitoring. During the first stage of labor, maternal vital signs are obtained every hour.

66. While conducting an initial assessment of an infant, a home health nurse notices that the infant is wearing a soiled piece of braided yarn around the neck. Which action by the nurse is most appropriate? A. Leave the yarn in place but wash it with a cloth and mild soap. B. Ask about its significance and suggest that it be placed more safely on the body. C. Explain that the yarn offers no benefit and ask the parents to remove it. D. Remove the yarn because it is soiled and could lead to strangulation.

A: The action that demonstrates cultural sensitivity is the one that inquires about the significance of the braided necklace while taking into account issues of client safety (in this case risk of strangulation). Washing it addresses risk of infection but not safety, while options that remove it fail to demonstrate any cultural sensitivity.

41. A parent brings a 3-year-old child to the immunization clinic for a DTaP vaccine. During the interview, the mother indicates the child is just finishing a tapered dose of prednisone for a chronic respiratory problem. Which action should the nurse take at this time? A. Delay the vaccine administration for 1 month after the medication is completed. B. Provide the child with the vaccine as scheduled. C. Cleanse the injection site with sterile saline instead of alcohol. D. Keep the child in the clinic for 30 minutes after administration to assess the child's response.

A: The dose should be delayed for 1 month following any type of immunosuppressive therapy, such as prednisone. The other actions do not protect the client or uphold safe administration procedures for immunization.

50. When assessing a 1-month-old infant, the nurse finds a head circumference of 32 cm and a chest circumference of 30 cm. The nurse should draw which conclusion about this data? A. Consider this normal. B. Reevaluate the findings in 2 weeks. C. Expect the chest circumference to be larger than the head circumference. D. Report the finding to the physician.

A: The normal head circumference of a full-term infant is 32 to 38 cm, about 2 cm greater than the chest circumference. In the toddler, both measures are about equal; after the age of 2, the chest circumference exceeds that of the head.

68. A home health nurse is assigned to an Asian American client who refuses to take the blood pressure medication prescribed by the physician. The client is using acupuncture treatments and does not believe in taking pills. How can the nurse best help this client? A. Notify physician of the client's health practices, and monitor the condition for an impending crisis. B. Ask supervisor to transfer the client to an Asian American primary nurse. C. Advocate for client's decision, and explain that pills may not help based on the client's beliefs. D. Discharge client and advise client to call if he or she wishes to obtain home care services at a later date.

A: The nurse should notify the health care provider of the client's practices and should continue to monitor the client to promote safe management of the health problem. It is unnecessary to ask for a nurse of the same culture to be assigned. The nurse would not indicate that the medication would not work because of health beliefs. It would be punitive to discharge the client from services because of culturally based health practices.

31. The nurse observes that when a newborn is supine and the head is turned to one side, the extremities straighten to that side while the opposite extremities flex. How would the nurse document this finding? A. Tonic neck reflex B. Moro reflex C. Cremasteric reflex D. Babinski reflex

A: The tonic neck reflex, or fencing position, refers to the position the newborn assumes when supine with the head turned to one side. The extremities on that side will extend, and the extremities on the opposite side will flex. The Moro reflex occurs when the newborn is startled and responds by abducting and extending arms, which fingers fanning out and the arms forming a "C". The cremasteric reflex refers to retraction of the testes when chilled, or when the inner thigh is stroked. The Babinski reflex refers to the flaring of the toes when the sole of the foot is stroked upward.

17. During a prenatal visit in the second trimester, which item reported by the client would be a cause for concern? A. Thirst and urinary frequency B. +1 deep tendon reflexes C. Constipation D. Backache in the lower sacral area

A: Urinary frequency usually disappears in the second trimester. Thirst and urinary frequency may be signs of developing gestational diabetes and warrant further investigation. Deep tendon reflexes are assessed during a physical examination and are not reported to a health care provider by the client. Constipation is a typical finding because of the pressure exerted by the growing

26. After delivering a 9-pound, 10-ounce baby, a client who is a gravida 5, para 5 is admitted to the postpartum unit. What would be a priority in delivering nursing care to this client? A. Palpate the fundus because she is at risk for uterine atony. B. Offer fluids, since multiparas generally dehydrate faster during labor. C. Perform passive range of motion on extremities because she is at risk for thromboembolism. D. Assess client's diet because she is at risk for anemia.

A: Uterine atony is the most common cause of early postpartum hemorrhage. This client is at greater risk for hemorrhage because she had an overdistended uterus with a large baby, and she is a grand multipara. Parity does not influence dehydration. The client may be at risk for thromboembolism, but there is no indication passive range of motion should be implemented rather than early ambulation. Nutritional assessment is important, but there is no indication that client is anemic and this action is not the priority for the client.

10. The nurse is preparing to leave the room of a client on transmission-based precautions. Place in the correct order the steps the nurse would follow to remove personal protective equipment and perform hand hygiene.A. Remove gown B. Remove gloves C. Remove mask D. Remove eye protection E. Wash hands

B, D, A, C, E: per the CDC this is the proper order. An alternative acceptable method per the CDC is to remove the gown and roll it down the arms and take the gloves off with the gown inside the gloves. Then removing the eye protection (goggles or face shield), then removing the mask, followed by hand hygiene last.

45. The pediatric nurse is seeing a 2-month-old infant in the outpatient clinic for routine immunizations. The nurse should select which immunization teaching sheets to give to the mother before preparing the immunizations appropriate for this visit? Select all that apply. A. Varicella B. Diphtheria, tetanus, and acellular pertussis (DTaP) C. Measles, mumps, and rubella (MMR) D. Haemophilus influenzae type b (Hib) E. Inactivated polio (IPV)

B, D, E: Diphtheria, tetanus and acellular pertussis (DTaP), Haemophilus influenzae type b (Hib), inactivated polio vaccine (PCV) are the routine immunizations scheduled for the 2-month well-child visit. The MMR is given first at 12 to 15 months, and the varicella can be given at or anytime after 12 months.

8. Which actions by the nurse comply with core principles of surgical asepsis? Select all that apply.

B, D: Keeping the sterile field in view and holding items 6 inches above the sterile field are core principles of surgical asepsis. Washing hands after providing care and wearing personal protective equipment are core principles of medical asepsis. The outer 1 inch of a sterile field is considered contaminated, not 1.5 inches.

3. An adult female ambulatory care client receiving an oral anticoagulant is given aspirin for a headache while visiting a neighbor, who is a nurse. The client subsequently has a bleeding episode because of a drug interaction. The legal nurse consultant interprets that which necessary elements of malpractice are missing from this case? Select all that apply. A. Breach of duty B. Duty owed C. Injury experienced D. Causation between nurse's action and injury E. Intent to cause harm or injury

B, E: There was no nurse-client relationship because the nurse was acting as a neighbor and not in an employment capacity. Thus, there can be no duty owed. Intent is not a necessary element of malpractice, because malpractice can occur because of unintended actions as well. There was no breach of duty because there was no official nurse-client relationship, which accompanies an employment situation. There was injury experienced because of this event. The bleeding was caused by the interaction of the aspirin with the anticoagulant.

32. The nurse anticipates that a newborn male, estimated to be 39 weeks' gestation, would exhibit which characteristic? A. Extended posture when at rest B. Testes descended into the scrotum C. Abundant lanugo over his entire body D. The ability to move his elbow past his sternum

B: A full-term male infant will have both testes in his scrotum, with rugae present. Good muscle tone results in a more flexed posture when at rest and inability to move his elbow past midline. Only a moderate amount of lanugo is present, usually on the shoulders and back.

2. A nurse forgets to administer a client's diuretic and the client experiences an episode of pulmonary edema. The charge nurse would consider the medication error to constitute negligence because the situation contains which element? A. Purposeful failure to perform a health care procedure B. Unintentional failure to perform a health care procedure C. Act of substituting a different medication for the one ordered D. Failure to follow a direct order by a physician

B: Negligence is the unintentional failure of an individual to perform or not perform an act that a reasonable person would or would not do in the same or similar circumstances. A purposeful failure to perform a procedure would be the opposite of negligence, which is unintentional. Substituting a different medication does not fit the description of the situation in the question. Failure to follow a direct order does not fit the description in the situation in the question.

40. The nurse admitting four children to the hospital unit learns that none of the parents will be staying with the children. The nurse would be most concerned with adjustment to hospitalization and separation from parents in the infant or child of which age? A. 2 months old B. 13 months old C. 8 years old D. 14 years old

B: The 13-month-old will experience toddler hospitalization reaction, which is primarily related to separation from the parents. The 2-month-old has not recognized object permanence and will not suffer from the hospitalization as long as his or her needs are met in a consistent fashion. The 8-year-old and the 14-year-old are accustomed to separation from parents and working with new adults.

34. A new mother overhears a nurse mention "first period of reactivity" and asks the nurse for an explanation of the term. Which statement would be best to include in a response? A. "The period begins when the infant awakens from a deep sleep." B. "The period is an excellent time to acquaint the parents with the newborn." C. "The period is an excellent for the mother to sleep and recover from labor and delivery." D. "The period ends when the amount of respiratory mucus has decreased."

B: The first period of reactivity lasts up to 30-60 minutes after birth. The newborn is alert, and it is a good time for the newborn to interact with parents. The second period of reactivity begins when the newborn awakens from a deep sleep. The amount of respiratory mucus may still be noted during this period. Mothers may sleep and recover during the newborn's sleep state.

53. The nurse is participating in a health promotion fair. When discussing aerobic exercise, the nurse should include which point? A. Exercise should be done 7 days per week B. Fast walking is a good form of aerobic exercise C. If one cannot talk when exercising, then the appropriate level of energy is being used D. Each exercise session should last for at least 45 minutes, and preferably 60

B: The latest recommendations indicate that clients should exercise most days of the week for a minimum of 30 minutes for best effectiveness of exercise. If one cannot speak when exercising, it is too strenuous and should be decreased in speed or amount.

61. A nurse is trying to establish whether a client who appears unconscious can communicate. What would be the best approach for the nurse to use? A. Ask open-ended questions. B. Ask client to blink once or twice in response to questions. C. Observe for facial grimaces during verbal stimuli from the nurse. D. Assess for response to painful stimuli.

B: To evaluate an unresponsive client's ability to communicate, it is best for the nurse to ask questions that will elicit a single act or response by the client. Asking open-ended questions is not appropriate for the client's condition. Facial grimacing and response to pain may be noted during neurological assessment but do not relate to communication.

52. When a client comes into the emergency department (ED) reporting constipation and abdominal pain, what would be the most common risk factors for constipation for the nurse to assess for? A. History of diverticulitis or diverticulosis B. Dietary and exercise patterns C. Nutritional intake of proteins and fatty acids D. Level of nutrition understanding and laxative abuse

B: Two common and key factors that increase risk of constipation are a diet low in fiber and fluids and inadequate exercise to stimulate bowel motility, which could lead to impaction and abdominal pain. Diverticulitis is something to assess for but is not as frequently an etiology as inadequate exercise and low-fiber diet. In addition, diverticulosis does not give rise to signs and symptoms. Intake of protein and fatty acids are irrelevant to the client's complaint. Nutrition intake and laxative abuse are too vague to be correct.

7. The nurse would take which action to protect the client from infection at the portal of entry? A. Place sputum specimen in a biohazard bag for transport to the lab. B. Empty Jackson-pratt drain using sterile technique. C. Dispose of soiled gloves in waste container. D. Wash hands after providing client care.

B: Using sterile technique to empty wound drains is aimed at interrupting the portal-of-entry link in the chain of infection. By using sterile technique, the nurse reduces the risk of introducing pathogens into the client's wound via the drain. Proper handling of specimens interrupts the chain of infection at the reservoir link. Disposing of gloves properly and washing hands after providing care break the chain of infection at the mode of transmission link.

25. The nurse is teaching a group of expectant parents about cardinal movements, or changes in position, that occur as the fetus with a cephalic presentation passes through the birth canal. Order the cardinal movements in proper sequence for the nurse's presentation. All options must be used. A. Expulsion B. External rotation C. Flexion D. Internal rotation E. Restitution

C, D, E, B, A: In order, the cardinal movements (position changes) of the fetus are engagement, descent, flexion, internal rotation, extension, restitution, external rotation, and expulsion. These movements represent the normal adaptation of the fetus in a cephalic presentation to the maternal pelvis and facilitate vaginal birth.

4. A nurse and teacher are discussing legal issues related to the practice of their professions. The teacher asks what the functions are of the Nurse Practice Act (NPA) in that state. The nurse would include which thoughts in a response? Select all that apply. A. Accredit schools of nursing B. Enforce ethical standards of behavior C. Protect the public D. Define the scope of nursing practice E. Determine liability insurance rates

C, D: A state's NPA serves to protect the public by setting minimum qualifications for nursing in relation to skills and competencies. One way it fulfills responsibility to protect the public is by defining the scope of nursing practice in that state. The state board of nursing approves schools to operate but does not accredit them. The state board of nursing does not enforce ethical standards. A state NPA has no role in setting liability insurance rates for nurses.

15. Which statements indicate to the nurse that a male client understands how to correctly apply a condom? Select all that apply. A. "I need to put it on before the penis is erect." B. "I should unroll the condom, then place it on the penis." C. "When putting on the condom, I need to leave some space at the tip to collect the sperm." D. "I can use oil-based lubricants if needed." E. "I can use a water-based lubricant if needed."

C, E: The male condom is placed when the penis is erect, then rolled down. Leaving space at the end of the condom to collect semen can prevent breakage or spillage after ejaculation. Water-based lubricants can be used to provide additional comfort, if needed. Oil-based lubricants are contraindicated.

62. A client who is legally blind has been admitted to the cardiac unit. Which action by the nurse would be best to promote adjustment to the environment? A. Speak slowly and in a low-pitched voice while facing the client. B. Post a sign on the door indicating the client is blind. C. Explain unit noises and physical surroundings. D. Give clear, concise, simple instructions to the client.

C: A client who is blind does not have the benefit of nonverbal cues to facilitate communication and understanding of the environment. It is important for the nurse to explain physical surroundings and noises because the client cannot determine these without the added benefit of sight. Speaking slowly while facing the client and giving simple explanations are approaches that are useful with a client who is hearing impaired. Placing a sign on the client's door encroaches on confidentiality.

56. The nurse prepares to teach a class about normal aging changes to a group of nursing assistants. The nurse should select which teaching technique as most appropriate? A. Demonstrate use of incontinence pads for clients who become incontinent of urine. B. Teach crutch walking because of high risk of falls and fractures in older adults. C. Discuss a case study in which an older adult with an infection had a temperature of 98 degrees F. D. Show how to use a blood glucose monitoring device and how to disinfect it because of increased incidence of diabetes.

C: A normal body temperature of an older adult person may range from 96.5 degrees to 99 degrees F (35.9 degrees to 37.3 degrees C). Therefore, a temperature of 98.6 degrees F (37 degrees C) may signify a fever in an older person. Incontinence is not a normal age-related change. Not all older adults have altered mobility needs, and those who do are more likely to use a cane or walker than crutches (which are used for injury). Use of blood glucose devices is generic or related to a diagnosis of diabetes and is not specifically related to normal aging changes.

46. The nurse notes unexpectedly during a routine screening examination that the client has a thread pulse. In what other way could this finding be documented? A. A 2+ pulse B. Pulse rate irregular and forceful C. Pulse difficult to palpate and easy to obliterate D. Pressure with the index finger causes pulsation

C: A weak, thread pulse is one that is difficult to palpate and easily diminished by slight pressure. A 2+ pulse indicates one that is easily palpable and normal. A forceful pulse and a pulsation felt with pressure from the index finger may be labeled as "full" or "bounding."

13. Which client being seen in the outpatient clinic would be the best candidate for insertion of an intrauterine device (IUD)? A. A client who is married, has one child, and wants to get pregnant in about 6 months B. A client who is unmarried, has no children, and has numerous sexual partners C. A client who is married, has two children, and does not want more children for at least 3 years D. A client who is unmarried, has one child, and has a history of pelvic inflammatory disease (PID)

C: An IUD is a long-term method of contraception usually recommended for women who have been pregnant and are in a monogamous relationship so that they are at a low risk for sexually transmitted infection. The clients in the incorrect options have one or more factors that should guide them to select a different contraceptive method. 14. The woman's health clinic nurse determines that which

49. When assessing the heart sounds of a 10-year-old, the nurse notices that the rate varies with inspiration and expiration. The nurse concludes that which action is most appropriate? A. Discuss a referral to a cardiologist for further workup. B. Question the child about caffeine intake. C. Do nothing, this is a normal finding. D. Schedule an electrocardiogram following the exam.

C: An irregular heart rate that increases with inspiration and decreases with expiration is a sinus arrhythmia, which is common in children. It requires no action on the part of the nurse. Further evaluation is not necessary, and an assessment of caffeine (such as in carbonated beverages) is not indicated.

1. A client is referred to a surgeon by the general practitioner. After meeting the surgeon, the client decides to find a different surgeon to continue treatment. The nurse supports the client's action, utilizing which ethical principle?A. Beneficence B. Veracity C. Autonomy D. Privacy

C: Autonomy is the right of individuals to take action for themselves. Beneficence is an ethical principle to do good and applies when the nurse has a duty to help others by doing what is best for them. Veracity refers to truthfulness. Privacy is the nondisclosure of information by the health care team.

18. The nurse is examining a client who is at 12 weeks' gestation. The examiner would expect to find the fundus at which location at this time? A. 3 cm below the sternum B. The level of the umbilicus C. The level of the symphysis pubis D. 3 cm below the umbilicus

C: By the 12th week of gestation, the uterus should have increased in size to be palpable at the symphysis pubis. Factors affecting this finding include abnormal fetal growth or the presence of a multiple gestation.

36. A mother brings her 15-month-old son to the clinic. During the nursing assessment, the mother makes the following comments. Which comment merits further investigation? A. "My son cries at times when I leave him at his grandparents' home." B. "My son always takes his blanket with him." C. "My son is not crawling yet." D. "My son likes to eat mashed potatoes."

C: Infants crawl or pull their body along the floor using their arms by age 8 to 10 months, which is a growth and development milestone. An inability to crawl by age 15 months is an abnormal finding, and should be referred to the pediatrician for follow-up. It is a normal response for a 15-month-old to cry when left with others. Infants and toddlers are often attached to security items, such as a blanket. Toddlers begin to display food preferences.

9. The nurse is assisting a client who has methicillin-resistant Staphylococcus aureus (MRSA) in collecting a clean-catch urine specimen. Which protective equipment is necessary? A. N95 particulate respirator B. Gown C. Eye protection D. Sterile gloves

C: Methicillin-resistant Staphylococcus aureus (MRSA) requires transmission-based contact precautions. Eye protection would be worn to protect the mucous membranes of the eyes when splatters of body fluids or excretions are possible. A gown would be worn when the nurse is in direct contact with the client. Contact precautions require gloves. N95 respirators are needed when caring for the client with tuberculosis, so it is inappropriate for this scenario.

60. On admission, a 78-year-old client states he uses laxatives three times a week for constipation. What is the nurse's best response? A. "As people age, they need laxatives to stimulate defecation." B. "Eat a balanced diet if you use laxatives." C. "Long-term use of laxatives can actually lead to constipation." D. "Please use laxatives two times a week at night."

C: Prolonged use of laxatives can lead to dependence on them for stimulation of defecation and can actually lead to uncontrollable defecation and constipation. Laxatives are not necessarily required to stimulate defecation in older adults. A proper diet, adequate fluid intake and sufficient activity will help to maintain normal bowel function during later years. A balanced diet is important even if not using laxatives. Laxatives should be used only as needed.

69. The nurse is checking the dietary trays that have been delivered to the nursing unit. A client of Orthodox Jewish faith has received a tray containing a chicken dinner with vegetables, tea, and a carton of 2% milk. What action by the nurse is best? A. Instruct nursing assistant to deliver the meal tray after removing the tea. B. Remove the chicken from the dietary tray. C. Have dietary department replace the entire meal tray. D. Ask client if lactose-free milk would be preferred.

C: The Jewish religion prohibits the ingestion of meat and dairy products during the same meal. The nurse should ask that the entire meal tray be replaced by the dietary department. Removing the tea does not address the culturally-based dietary issue. Removing the chicken from the dietary tray is not sufficient because Kosher law says meat and dairy cannot be combined in any way, which would include being on the same meal tray. The use of lactose-free milk will not resolve the dietary issue.

24. A primigravida client is in the second stage of labor. The nurse determines that teaching has been effective when the client makes which of the following statements?A. "I'll push two or three times and the baby will be born." B. "It's not the baby, I have to have a bowel movement." C. "I know I'll have to push a while. This is hard work." D. "My doctor will come and pull the baby out now."

C: The average duration of the second stage of labor for primigravidas is 2 hours. Many women feel rectal pressure, as if they were having a bowel movement, as the baby descends deeper into the pelvis. The use of vacuum extraction or forceps to assist delivery is not routine.

63. Which statement by the nurse best encourages a client to express feelings and allows the nurse to genuinely respond to those feelings? A. "You mentioned that you broke your leg last year. Can you tell me more about how that happened?" B. "You shared with me much information about your history of depression. It sounds as if medication alone may not be controlling your symptoms as you hoped." C. "You said your back pain has not gone away since surgery. How difficult has it been to adapt to having pain during everyday activities?" D. "You said you have had asthma since you were 11 years old and that medication therapy requires adjustment every 8 to 10 months or so. Is that right?"

C: The communication technique of reflection occurs when the nurse directs feelings and questions back to the client to encourage elaboration. The nurse uses the technique of focusing by asking questions to help the client focus on a specific area of concern. With the use of summarizing, the nurse highlights important points of the conversation. The nurse uses restarting by repeating back to clients the main points or content of the conversation.

44. The neonatal nurse is providing anticipatory guidance to the mother of a newborn infant. When discussing immunization schedules, the nurse explains that the first dose of inactivated poliovirus (IPV) is given at what age? A. 1 week B. 1 month C. 2 months D. 4 months

C: The first dose of IPV is given at 2 months, with subsequent doses at 4 months, 12 to 18 months, and 4 to 6 years, for a total of four doses. The other time frames do not match the time of the initial dose in the administration schedule for this vaccine.

42. A child is brought to the pediatric ambulatory clinic with a runny nose and a low-grade fever. He is scheduled to receive the MMR (measles, mumps, and rubella) and DTaP (diphtheria, pertussis, and tetanus toxoid) vaccines. What should the nurse do at this time? A. Get special permission from the physician to administer the vaccine. B. Defer both vaccines until the child is well. C. Administer the vaccines as scheduled. D. Administer the DTaP vaccine but defer the MMR.

C: The immunizations should be administered as scheduled. They would be withheld for clients who are immunosuppressed or have moderate to severe febrile illnesses. The presence of a runny nose and low-grade fever is not a contraindication according to the literature and CDC.

20. During the first prenatal assessment, the nurse discovers that the client has not had a second vaccination for measles, mumps, and rubella (MMR). What is the best plan for this client? A. Administer the vaccine during this visit B. Wait until the third trimester to administer the vaccine C. Administer the vaccine following delivery D. Omit the vaccine because these are childhood diseases not acquired by adults

C: The measles, mumps, and rubella (MMR) vaccine contains live, attenuated virus and could cause disease and harm to the fetus during pregnancy. It should be given after delivery, and the woman should avoid conceiving for 3 months.

12. The client, who is married and has three children, has come to the family planning clinic asking about a birth control method that is most effective and sanctioned by the Roman Catholic Church. What would be the nurse's best recommendation?A. Billings or cervical assessment method B. Ovulation testing kit C. Symptothermal method D. Basal body temperature (BBT) method

C: The symptothermal method combines cervical mucus and BBT measurements and results in a lower failure rate than either BBT or cervical mucus as a single assessment of the fertile period. This method is completely natural and congruent with beliefs of this religious group. Ovulation testing kits do not give enough warning of ovulation to prevent pregnancy.

38. The nurse is caring for a 7-year-old child scheduled for surgery in the morning. While conducting preoperative teaching, the nurse would choose which aid to enhance the child's learning about the perioperative experience? A. Videotape B. Colorful brochure C. Doll or puppet D. A visit from the surgeon

C: The use of a doll or puppet may decrease a 7-year-old child's anxiety and fear if the nurse uses such aids to explain what is expected. Videotapes and brochures are useful with explanations to adolescents. A visit from the surgeon is informative primarily with the parents.

39. The nurse discusses the risk of aspiration with the parents of an 18-month-old. To minimize this risk, the nurse recommends the parents avoid giving their child which food items? A. Oranges, crackers, and applesauce B. Apples, fruit juice, and raisins C. Cherries, peanuts, and hard candy D. Cheerios, toast, and bananas

C: Toddlers chew well but may have difficulty swallowing large pieces of food. Young children cannot discard pits (such as from cherries). Firm foods such as peanuts and hard candies are easily aspirated, while softer ones, such as cereal or raisins, are better tolerated.

65. While talking with the nurse, a client says, "You are just like my mother; you don't trust me or like me. You and she wish I were dead." The nurse interprets this statement as indicating which process? A. Psychosis B. Countertransference C. Transference D. Projection

C: Transference is the unconscious process of displaying feelings for significant people in the client's past onto the nurse in the present relationship. Psychosis is a state in which a client is unable to comprehend reality and has difficulty relating to others. Countertransference is the nurse's emotional reaction to clients based on feelings for significant people in the nurse's past. Projection is a defense mechanism in which blame for unacceptable desires, thoughts, shortcomings, and mistakes is attached to others in the environment.

6. The nurse would perform which action when washing hands as part of medical asepsis before caring for a client in an outpatient clinic? Select all that apply. A. Wash hands with the hands held higher than the elbows. B. Adjust temperature of water to the hottest possible. C. Scrub hands and nails with a scrub brush for 5 minutes. D. Use a clean paper towel to turn water off. E. Rub vigorously using firm circular motions.

D, E: A paper towel is used to shut off the faucet because the faucet is considered contaminated. Rubbing vigorously using firm circular motions creates friction on the skin to assist in cleansing. The hands are considered to be more contaminated than the elbows, and the hands should be held down so water flows from least contaminated to the most contaminated. Hot water can result in burns to the nurse. Warm water protects from burns and removes less protective skin oil than hot water. A surgical scrub is performed over 5 minutes while in medical asepsis hands are washed for at least 10-15 seconds.

14. The woman's health clinic nurse determines that which clients would be appropriate candidates for use of emergency postcoital contraception? Select all that apply. A. Had unprotected intercourse 4 days ago B. Took her oral contraceptive 7 hours late C. Removed her cervical cap 40 hours after intercourse D. Had her last Depo-Provera injection 4 months ago E. Had been sexually assaulted the previous day

D, E: Emergency contraception must be initiated within 72 hours of unprotected intercourse, sexual assault, or method failure. Oral contraceptive may be taken up to 12 hours late and cervical caps may be left in up to 48 hours without compromising safety. Depo-Provera is given every 80-90 days, after which a repeat dose is needed or emergency contraceptive protection is indicated.

28. The nurse should notify the physician immediately of which assessment finding? A. Three pea-sized clots passed 4 hours after delivery B. Musty odor to lochia 48 hours postpartum C. Scant amount of rubra lochia after cesarean delivery D. Firm uterus with steady trickle of blood 2 hours after delivery

D: A steady trickle of blood in the presence of a firm uterus could indicate the presence of a vaginal or cervical laceration. The physician should be notified immediately so further evaluation can be initiated. The other findings are normal.

5. A staff nurse concerned about maintaining client confidentiality would take which action while carrying out assigned duties? A. Read the records of clients not assigned to the nurse to become more familiar with disease processes. B. Share information about a client with nurses from the unit to which the client may eventually be transferred. C. Allow the client's family to review the medical record to obtain answers to their questions. D. Share information about the client with those involved in planning nursing care.

D: Client confidentiality is maintained when the nurse shares client information only with those currently involved in the plan of care. Staff should only access information about clients currently assigned to their care and should not access information about clients on the unit not assigned to them. Client information should not be shared with nurses who are not currently working with the client. Family members would need approval from the client and the health care provider prior to reviewing a medical record.

64. What would be the best approach for a nurse to use to encourage a client with psychological distress to develop an awareness of feelings and express them effectively? A. Challenge the client. B. Offer reassurance. C. Suggest coping strategies. D. Offer empathy.

D: Empathy is the ability of the nurse to see the client's perception of the world, which aids in therapeutic communication and the nurse-client relationship. Challenging clients is not helpful and often triggers them to defend themselves from what appears to be an attack by the nurse. False reassurance can be seen as a way to encourage clients how to feel and ignores their distress. Advising occurs when the nurse tells clients what to do, preventing them from exploring problems and using the problem-solving process to find solutions.

27. Although a client initially wanted to breast-feed, she has now decided to bottle-feed her newborn. The nurse concludes that teaching regarding breast care for this client has been effective when the client makes which statement? A. "I'll pump 2-3 times each day until my milk supply decreases." B. "I'll rub lotion on my breasts if they are sore." C. "I'll soak my breasts in a warm tub twice daily for the first week." D. "I'll wear a snug bra continuously until my breasts are soft again."

D: Mothers who are bottle-feeding should be encouraged to suppress milk production by wearing a snug bra or breast binder, applying cold compresses, and avoiding breast stimulation until primary engorgement subsides. Pumping the breasts and applying lotion to them are forms of breast stimulation that should be avoided. Applying heat via a warm bath will also stimulate the breasts and should not be done.

57. A 75-year-old woman with a pathological fracture of the arm asks, "How did I get a broken bone?" The nurse most appropriately responds by stating that which problem is most likely to be responsible for the fracture? A. Decreased mobility B. Osteoarthritis C. Scoliosis D. Osteoporosis

D: Osteoporosis, a decrease in bone density, makes the older adult more prone to pathological fractures. Decreased mobility, osteoarthritis, and scoliosis do not cause pathological fractures. Scoliosis is a curvature of the spine, usually diagnosed in adolescents.

59. A nurse teaches an older adult client about misuse of medications. Which subsequent behavior by the client indicates that the instruction was effective? A. Combining prescribed medications with over-the-counter medications B. Having prescriptions from several physicians C. Using someone else's medications D. Taking medications on time and, if a dose is missed, taking the next one on time

D: Proper self-administration of medications includes taking medications on time and, if a dose is missed, taking the next one on time. Misuse of medications by older adults includes behaviors such as combining prescribed and over-the-counter medications, having prescriptions from different physicians, failing to tell each doctor what has previously been prescribed and taking someone else's medications.

47. The nurse performing the Rinne test during a physical examination expects to gather data that could support which nursing diagnosis? A. Impaired physical mobility B. Impaired thought processes C. Impaired swallowing D. Altered sensory/perception: auditory

D: The Rinne test involves the examiner using a turning fork to compare air conduction to bone conduction related to transmission of sound. Mobility, thought processes, and swallowing are not assessed with this examination.

48. When asking a client newly admitted to the hospital about dietary history, which question by the nurse would be most important? A. "What time of day do you eat each meal?" B. "Do you eat alone or with family members?" C. "How often do you eat meals at restaurants?" D. "Do you have any dietary restrictions?"

D: The client may have restrictions based on a medical condition (e.g., low-sodium for heart disease), food allergies (e.g., shellfish), or religious convictions (e.g., abstaining from pork if Jewish or Muslim). The nurse must note these restrictions and communicate with the nursing and dietary staff in order to avoid a potentially harmful occurrence. The other questions are pertinent for a dietary history but would not lead to a physiologic alteration if changed while hospitalized.

51. The nurse is most concerned with providing further teaching for the client with diabetes who does which of the following? A. Drinks orange juice each morning B. Eats an apple and cheese before going to bed C. Buys canned fruit instead of fresh because it is cheaper D. Eats six meals per day

D: The client who has diabetes needs to have regular meals that are evenly spaced throughout the day and may need to supplement meals with snacks. Eating six meals per day is excessive and could lead to inadequate glucose control. Drinking orange juice and eating apples and cheese pose no risk as long as they are in the client's meal pattern. Canned fruit is acceptable as long as it is packed in 100% juice or water instead of syrup.

33. If a newborn does not pass meconium during the first 36 hours of life, what is the most important appropriate action by the nurse? A. Observe the anal area for fissures B. Notify the physician C. Increase the amount of oral feedings D. Measure the abdominal girth

D: The first meconium stool should be passed within the first 24 hours after birth; if not, the abdominal girth should be measured to evaluate distention and the possibility of obstruction. The presence of anal fissures will not prevent the passage of a meconium stool. Notifying the physician will not provide more information. Increasing the amount of feedings will not provide more information, and if there is an obstruction, will complicate that problem.

22. The nurse's plan of care for the pain of a laboring client would incorporate which of the following concepts? A. Childbirth pain is caused only by physical factors. B. The expression of pain is universal. C. Having the presence of a supportive partner eliminates pain. D. Labor pain has physiological and psychological components.

D: The pain of labor and childbirth have both physiologic and psychologic components. A support person's presence has been shown to decrease the perceived pain of childbearing. However, the expression of pain through nonverbal cues or verbalization is highly culturally based (not universal), having been learned in early childhood.

67. A male nurse needs to check the vital signs and oxygen saturation level of a female client from a different culture. As the nurse approaches, the client moves to the other side of the bed and draws up the blanket. What is the best nursing action at this time? A. Invite a family member to be present and to assist with the oxygen saturation reading. B. Ask a female nurse to perform the procedures. C. Perform the assessments without acknowledging her reaction because she will adjust over time to hospital procedures. D. Before touching the client, explain the procedure and ask for permission to continue.

D: The response that shows cultural sensitivity is one that respects the personal boundaries of the client and asks permission to engage in care activities. There is no need for family or a female nurse to assist in these noninvasive procedures at this time without assessing first what the client's issues may be. The nurse should also not ignore the nonverbal communication being sent by the client; this would not be therapeutic.

11. Which client statement indicates that teaching about cervical mucus changes as an indicator of ovulation has been understood?A. "If my cervical mucus is yellowish and thick, I am probably fertile." B. "The thin, clear mucus will block sperm from getting to my cervix." C. "If my cervical mucus is thick and white, I will need to avoid intercourse or use a backup method of contraception." D. "If my cervical mucus is thin and stretchable, I am probably fertile."

D: Thin and clear cervical mucus indicates a rising level of estrogen and impending ovulation. Stretchability of the cervical mucus, or spinnbarkeit, is indicative of the fertile period and promotes motility of the sperm. Thick cervical mucus occurs during the infertile period when sexual intercourse is unlikely to result in pregnancy.

21. After administration of an epidural block for labor analgesia, the client's blood pressure decreases from 130/75mmHg to 90/50mmHg. The nurse should assist the woman to do which of the following? A. Lie in a supine position B. Assume a semi-Fowler's position C. Empty her bladder D. Turn to the side to a left lateral position

D: Vasodilation occurs with epidural analgesia and anesthesia, which can result in hypotension. The client who is hypotensive after epidural administration should be turned to a left lateral position and have the IV fluid rate increased to increase the circulation to the fetus and increased circulating volume, respectively. Lying supine allows the gravid uterus to place pressure on the aorta and can reduce further circulation to the fetus. A semi-Fowler's position