Saunders 4th Edition - Part 1

34) A nurse employed in an emergency department is assigned to triage clients arriving to the emergency room for treatment on the evening shift. The nurse should assign highest priority to which of the following clients? a. A client complaining of muscle aches, a headache, and malaise b. A client who twisted her ankle when she fell while rollerblading c. A client with a minor laceration on the index finger sustained while cutting an eggplant d. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce Source: Saunders 4th

ANS: D Rationale: In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, acute neurological deficits, and those who have sustained chemical splashes to the eyes are classified as emergent and are the number 1 priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as number 2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are the number 3 priority. Strategy: Note the strategic words highest priority. Use the ABCs—airway, breathing, and circulation—to direct you to option 4. A client experiencing chest pain is always classified as priority number 1 until a myocardial infarction has been ruled out. Review the triage classification system commonly used in a hospital emergency department if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 161-162). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1846). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

51) A nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium? a. Obtaining a controlled IV infusion pump b. Monitoring urine output during administration c. Diluting in appropriate amount of normal saline d. Preparing the medication for bolus administration Source: Saunders 4th

ANS: D Rationale: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via a pump or controller. The usual concentration of IV potassium chloride is 20 to 40 mEq/L. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is recommended, but dextrose solution is avoided because this type of solution increases intracellular potassium shifting. The IV bag containing the potassium chloride is always gently agitated before hanging. The IV site is monitored closely because potassium chloride is irritating to the veins and the risk of phlebitis exists. The nurse monitors urinary output during administration and contacts the physician if the urinary output is less than 30 mL/hr. Strategy: Use the process of elimination and knowledge regarding the administration of potassium chloride intravenously. Noting the strategic word unprepared in the question and bolus in option 4 will direct you to the correct option. Review the administration of potassium chloride if you had difficulty with this question. Reference: Gahart, B., & Nazareno, A. (2006). 2006 intravenous medications (22nd ed., p. 1022). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Pharmacology Alternate Question Types -> Multiple Choice

52) A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that the food item lowest in potassium is: a. Apples b. Carrots c. Spinach d. Avocado Source: Saunders 4th

ANS: A Rationale: A medium apple provides about 159 mg of potassium. A large carrot provides 341 mg, spinach (3½ oz) provides 470 mg, and a medium avocado provides 1097 mg of potassium. Strategy: Note the strategic words lowest in potassium. Recalling the potassium content of the foods identified in the options will direct you to option 1. Review the foods that are high and low in potassium content if you had difficulty with this question. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach. (3rd ed., p. 611). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Evaluation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

50) A nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the electrocardiogram as a result of the laboratory value? a. U waves b. Absent P waves c. Elevated T waves d. Elevated ST segment Source: Saunders 4th

ANS: A Rationale: A serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalance and is potentially life threatening. Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia. Strategy: From the information in the question, you need to determine that the client is experiencing hypokalemia. From this point, you must know the electrocardiographic changes that are expected when hypokalemia exists. If you had difficulty with this question, review the electrocardiographic changes that occur in hypokalemia. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 342-344). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

18) A client arrives in the emergency room and is assessed by the nurse. The client is staggering, confused, and verbally abusive, complains of a headache from drinking alcohol, and is asking for medication. The nurse explains to the client that the physician will need to perform an assessment before the administration of medication. When the client becomes verbally abusive, the nurse obtains leather restraints and threatens to place the client in the restraints. With which of the following can the client legally charge the nurse as a result of the nursing action? a. Assault b. Battery c. Negligence d. Invasion of privacy Source: Saunders 4th

ANS: A Rationale: An assault occurs when a person puts another person in fear of a harmful or offensive contact. For this intentional tort to be actionable, the victim must be aware of the threat of harmful or offensive contact. Battery is the actual contact with one's body. Negligence involves actions below the standards of care. Invasion of privacy occurs with unreasonable intrusion into the individual's private affairs. Strategy: Use the process of elimination. Note the strategic word threatens in the question. This word should direct you to option 1. If you had difficulty with this question, review the descriptions associated with the terms in each option. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 413). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

71) A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas determination. Before the blood is drawn, an Allen's test is performed to determine the adequacy of the: a. Ulnar circulation b. Carotid circulation c. Femoral circulation d. Popliteal circulation Source: Saunders 4th

ANS: A Rationale: Before radial puncture for obtaining an arterial specimen for arterial blood gases, you should perform an Allen's test to determine adequate ulnar circulation. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Options 2, 3, and 4 are incorrect options. Strategy: Use the process of elimination and knowledge regarding the purpose and procedure for the Allen's test. Remember that the purpose of this test is to assess the adequacy of the ulnar circulation. Review the purpose and procedure of the Allen's test if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 248). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 731-732). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

45) A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for deficient fluid volume? a. A client with a colostomy b. A client with congestive heart failure c. A client with decreased kidney function d. A client receiving frequent wound irrigations Source: Saunders 4th

ANS: A Rationale: Causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with congestive heart failure or decreased kidney function, or a client receiving frequent wound irrigations, is at risk for excess fluid volume. Strategy: Read the question carefully, noting that it asks for the client at risk for a deficit. Read each option and think about the fluid imbalance that can occur in each. The clients presented in options 2, 3, and 4 retain fluid. The only condition that can cause a deficit is the condition noted in option 1. If you had difficulty with this question, review the causes of deficient fluid volume. Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed., pp. 223, 2494). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1324). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

19) The nurse calls the physician regarding a new medication order because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the physician and the medication is due to be administered. Which action should the nurse take? a. Contact the nursing supervisor. b. Administer the dose prescribed. c. Hold the medication until the physician can be contacted. d. Administer the recommended dose until the physician can be located. Source: Saunders 4th

ANS: A Rationale: If the physician writes an order that requires clarification, the nurse's responsibility is to contact the physician for clarification. If there is no resolution regarding the order because the physician cannot be located or because the order remains as it was written after talking with the physician, the nurse then should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the order until obtaining clarification. Strategy: Use the process of elimination and eliminate options 2 and 4 first because they are comparative or alike and are unsafe actions. Holding the medication can result in client injury. The nurse needs to take action. Option 1 clearly identifies the required action in this situation. Review nursing responsibilities related to the physician's orders if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 419). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

73) A nurse caring for a client with an ileostomy understands that the client is most at risk for developing which acid-base disorder? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis Source: Saunders 4th

ANS: A Rationale: Intestinal secretions are high in bicarbonate and may be lost through enteric drainage tubes or an ileostomy, or with diarrhea. These conditions result in metabolic acidosis. Options 2, 3, and 4 are incorrect because they do not occur in the client with an ileostomy. Strategy: Use the process of elimination. Note that the client's condition described in the question is a gastrointestinal disorder. This will direct you toward a metabolic disorder. Remembering that intestinal fluids are primarily alkaline will assist you in selecting the correct option. When excess bicarbonate is lost, acidosis will result. If you had difficulty with this question, review the causes of metabolic acidosis. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1327). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

2) A nurse is providing discharge instructions to a Chinese client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. Which nursing action is appropriate? a. Continue with the instructions, verifying client understanding. b. Walk around the client so that the nurse constantly faces the client. c. Give the client a dietary booklet and return later to continue with the instructions. d. Tell the client about the importance of the instructions for the maintenance of health care. Source: Saunders 4th

ANS: A Rationale: Most Chinese maintain a formal distance with others, which is a form of respect. Many Chinese are uncomfortable with face-to-face communications, especially when eye contact is direct. If the client turns away from the nurse during a conversation, the most appropriate action is to continue with the conversation. Walking around to the client so that the nurse faces the client is in direct conflict with the cultural practice. The client may consider returning later to continue with the explanation as a rude gesture. Telling the client about the importance of the instructions for the maintenance of health care may be viewed as degrading. Strategy: Use the process of elimination. Eliminate options 3 and 4 first because these actions are nontherapeutic. From the remaining options, option 1 is the therapeutic action. If you had difficulty with this question, review the communication practices of this cultural group. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., pp. 68, 70). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

5) An ambulatory care nurse is discussing preoperative procedures with a Chinese-American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. The nurse interprets this nonverbal behavior as: a. Reflecting a cultural value b. An acceptance of the treatment c. The client is agreeable to the required procedures d. The client understands the preoperative procedures Source: Saunders 4th

ANS: A Rationale: Nodding or smiling by a Chinese-American client may reflect only the cultural value of interpersonal harmony. This nonverbal behavior may not be an indication of agreement with the speaker, an acceptance of the treatment, or an understanding of the procedure. Strategy: Use the process of elimination. Eliminate options 2 and 3 first because they are comparative or alike. From the remaining options, select option 1 because it is characteristic of Chinese-American culture. In addition, option 4 is an incorrect interpretation of the client's nonverbal behavior. Review the cultural characteristics of the Chinese-American population if you had difficulty with this question. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., p. 65). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

98) The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse plans to provide dietary teaching focusing on foods high in which vitamin that may be lacking in a vegan diet? a. Vitamin A b. Vitamin B₁₂ c. Vitamin C d. Vitamin E Source: Saunders 4th

ANS: B Rationale: Vegans do not consume any animal products. Vitamin B₁₂ is found in animal products and therefore would most likely be lacking in a vegan diet. Vitamins A, C, and E are found in fresh fruits and vegetables, which are consumed in a vegan diet. Strategy: Focus on the subject, a vegan diet. Recalling the food items eaten and restricted in this diet will direct you to the correct option. Review vegan diets and sources of vitamins if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 972). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

44) A nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 mL daily." The nurse understands that this type of fluid loss can occur through: a. The skin b. Urinary output c. Wound drainage d. The gastrointestinal tract Source: Saunders 4th

ANS: A Rationale: Sensible losses are those of which the person is aware, such as through wound drainage, gastrointestinal tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Strategy: Note that the subject of the question is insensible fluid loss. Use the process of elimination, noting that options 2, 3, and 4 are comparative or alike. In options 2, 3 and 4, these types of losses can be measured for accurate output. Fluid loss through the skin cannot be measured accurately, only approximated. If you had difficulty with this question, review the difference between sensible and insensible fluid loss. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 203). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Communication and Documentation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

60) A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client? a. Twitching b. Negative Trousseau's sign c. Hypoactive bowel sounds d. Hypoactive deep tendon reflexes Source: Saunders 4th

ANS: A Rationale: Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea. Strategy: Use the process of elimination, noting that options 2, 3, and 4 are comparative or alike in that they reflect a hypoactivity. The option that is different is option 1. Review the assessment signs and symptoms noted in hypocalcemia if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 238). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

33) A new unit nurse manager is holding her first staff meeting. The manager greets the staff and comments that she has been employed to bring about performance improvement. The manager provides a plan that she developed, as well as a list of tasks and activities for which each staff member must volunteer to perform. In addition, she instructs staff members to report any problems directly to her. What type of leadership style do the new manager's characteristics suggest? a. Autocratic b. Situational c. Democratic d. Laissez-faire Source: Saunders 4th

ANS: A Rationale: The autocratic leader is focused, maintains strong control, makes decisions, and, addresses all problems. Furthermore, the autocrat dominates the group and commands rather than seeks suggestions or input. In this situation, the manager addresses a problem (performance improvement) with the staff, designs a plan without input, and wants all problems reported directly back to her. A situational leader will use a combination of styles, depending on the needs of the group and the tasks to be achieved. The situational leader would work with the group to validate that the information that the leader gained as a new employee was accurate and that a problem existed, and would then take the time to get to know the group and determine which approach to change (if needed) would work best according to the needs of the group and the nature and substance of the change that was required. A democratic leader is participative and would likely meet with each staff person individually to determine the staff member's perception of the problem. The democratic leader would also speak with the staff about any issues and ask the staff for input with developing a plan. A laissez-faire leader is passive and nondirective. The laissez-faire leader would state what the problem was and inform the staff that the staff needed to come up with a plan to "fix it." Strategy: Focus on the data in the question and note the strategic words provides a plan that she developed, each staff member must volunteer to perform and instructs staff members to report any problems directly to her. Remember, autocratic managers take control and dominate. Review the various types of leadership styles if you had difficulty with this question. Reference: Marriner-Tomey, A. (2004). Guide to nursing management and leadership (7th ed., pp. 167-176). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Leadership and Management Alternate Question Types -> Multiple Choice

17) The nurse has just assisted a client back to bed after a fall. The nurse and physician have assessed the client, and have determined that the client is not injured. After completing the incident report, the nurse should take which action next? a. Reassess the client. b. Conduct a staff meeting to describe the fall. c. Document in the nurse's notes that an incident report was completed. d. Contact the nursing supervisor to update information regarding the fall. Source: Saunders 4th

ANS: A Rationale: The client's fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only those participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is desired. After a client's fall, the nurse must frequently reassess the client, because potential complications do not always appear immediately after the fall. Strategy: Focus on the data in the question and the subject, the next nursing action. Using the steps of the nursing process will direct you to option 1. Review guidelines related to incident reports and care to the client after sustaining a fall if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 411, 419). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

97) The nurse instructs a client with renal failure who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu? a. Cream of wheat, blueberries, coffee b. Sausage and eggs, banana, orange juice c. Bacon, cantaloupe melon, tomato juice d. Cured pork, grits, strawberries, orange juice Source: Saunders 4th

ANS: A Rationale: The diet for a client with renal failure who is receiving hemodialysis should include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids. Options 2, 3, and 4 are high in sodium, phosphorus and potassium. Strategy: Use the process of elimination and focus on the client's diagnosis. Noting the items sausage (option 2), bacon (option 3), and cured pork (option 4) will assist in eliminating these options. Review dietary guidelines for the client with renal failure if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 1215). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

16) Which of the following are low-risk therapies? Select all that apply. a. Herbs b. Prayer c. Touch d. Massage e. Relaxation f. Acupuncture Source: Saunders 4th

ANS: B ANS: C ANS: D ANS: E Rationale: Low-risk therapies include meditation, relaxation techniques, imagery, music therapy, massage, touch, laughter and humor, and spiritual measures, such as prayer. The other options are not considered low-risk therapies. Strategy: Use knowledge of low-risk complementary and alternative therapies. Focusing on the strategic words low-risk will direct you to the correct options. Review complementary and alternative medicine (CAM) and low-risk therapies if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 97-108). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Multiple

68) A nurse reviews the blood gas results of a client with Guillain-Barré syndrome. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which of the following validates the nurse's findings? a. pH 7.25, P<sc>CO</sc>₂ 50 mm Hg b. pH 7.35, P<sc>CO</sc>₂ 40 mm Hg c. pH 7.50, P<sc>CO</sc>₂ 52 mm Hg d. pH 7.52, P<sc>CO</sc>₂ 28 mm Hg Source: Saunders 4th

ANS: A Rationale: The normal pH is 7.35 to 7.45. The normal Pco₂ is 35 to 45 mm Hg. In respiratory acidosis, the pH is decreased and the Pco₂ is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition. Option 4 identifies respiratory alkalosis. Strategy: Use the process of elimination. Remember that in a respiratory imbalance you will find an opposite response between the pH and the Pco₂. Also, remember that the pH is decreased in an acidotic condition. Option 2 reflects a normal blood gas result. Options 3 and 4 reflect an elevated pH, which indicates an alkalotic condition. Option 1 is the only option that reflects an acidotic condition. Review blood gas analysis if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 245). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D. & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1009). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

59) A nurse is reviewing a client's laboratory report and notes that the serum calcium level is 4.0 mg/dL. The nurse understands that which condition most likely caused this serum calcium level? a. Prolonged bed rest b. Renal insufficiency c. Hyperparathyroidism d. Excessive ingestion of vitamin D Source: Saunders 4th

ANS: A Rationale: The normal serum calcium level is 8.6 to 10.0 mg/dL. A client with a serum calcium level of 4.0 mg/dL is experiencing hypocalcemia. The excessive ingestion of vitamin D and hyperparathyroidism are causative factors associated with hypercalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. Strategy: Note the strategic words most likely. First, you must determine that the client is experiencing hypocalcemia. This should assist in eliminating option 4. Next, you must recall the causative factors associated with hypocalcemia to direct you to option 1. If you had difficulty with the question, review the causative factors associated with hypocalcemia. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1142). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

88) An adult client who had preadmission testing before surgery had blood drawn for serum electrolyte testing. The nurse should report which of the following abnormal values to the surgeon's office preoperatively? a. Sodium, 148 mEq/L b. Chloride, 101 mEq/L c. Potassium, 3.8 mEq/L d. Bicarbonate, 26 mEq/L Source: Saunders 4th

ANS: A Rationale: The normal serum electrolyte ranges for adults are as follows: sodium, 135 to 145 mEq/L; potassium, 3.5 to 5.1 mEq/L; chloride, 98 to 107 mEq/L; and bicarbonate (venous), 22 to 29 mEq/L. The only abnormal value identified in the options is the serum sodium level. The nurse reports any abnormal preoperative laboratory value to the surgeon's office. Strategy: Use the process of elimination and knowledge of the normal serum electrolyte values to direct you to option 1. If this question was difficult, memorize these common laboratory values. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 492). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

63) A nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level? a. Alcoholism b. Renal insufficiency c. Hypoparathyroidism d. Tumor lysis syndrome Source: Saunders 4th

ANS: A Rationale: The normal serum phosphorus level is 2.7 to 4.5 mg/dL. The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Malnutrition is associated with alcoholism. Hypoparathyroidism, tumor lysis syndrome, and renal insufficiency are causative factors of hyperphosphatemia. Strategy: First you must determine that the client is experiencing hypophosphatemia. From this point, you must know the causes of hypophosphatemia. If you had difficulty with this question, review the causative factors associated with hypophosphatemia. Reference: Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., p. 119). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

89) A client with a history of cardiac disease is due for a morning dose of furosemide (Lasix). Which serum potassium level should be reported to the surgeon before administering the dose of furosemide? a. 3.2 mEq/L b. 3.8 mEq/L c. 4.2 mEq/L d. 4.8 mEq/L Source: Saunders 4th

ANS: A Rationale: The normal serum potassium level in the adult is 3.5 to 5.1 mEq/L. Option 1 is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. Options 2, 3, and 4 are within the normal range. Strategy: Use the process of elimination and knowledge of the normal serum potassium level to answer this question. This will assist you in identifying the value that is not within normal range. Remember, the normal serum potassium level in the adult is 3.5 to 5.1 mEq/L. If this question was difficult, memorize this common laboratory value. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 887). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

86) The nurse checks the laboratory result for a serum digoxin level that was determined for a client earlier in the day and notes that the result is 2.4 ng/mL. Which of the following is the most important action on the part of the nurse? a. Notify the physician. b. Check the client's last pulse rate. c. Record the normal value on the client's flow sheet. d. Administer the next dose of the medication as scheduled. Source: Saunders 4th

ANS: A Rationale: The normal therapeutic range for digoxin is 0.5 to 2.0 ng/mL. A level of 2.4 ng/mL exceeds the therapeutic range and indicates toxicity. The most important action is to notify the physician, who may give further orders about holding further doses of digoxin. Option 3 is incorrect because the level is not normal. The next dose should not be administered because the serum digoxin level exceeds the therapeutic range. Checking the client's last pulse rate is not incorrect but may have limited value in this situation. Depending on the time that has elapsed since the last assessment, a current assessment of the client's status may be more useful. Strategy: Use the process of elimination and note the strategic words most important action. To choose correctly, you must be familiar with the therapeutic range for this medication and note that the level of 2.4 ng/mL is a toxic one. If this question was difficult, review the information on this commonly used medication and measurement of its therapeutic serum level. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 477). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

95) The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which of the following? a. 2,000 cells/mm³ b. 5,800 cells/mm³ c. 8,400 cells/mm³ d. 11,500 cells/mm³ Source: Saunders 4th

ANS: A Rationale: The normal white blood cell count ranges from 4,500 to 11,000/mm³. The client who is immunosuppressed has a decrease in the number of circulating white blood cells. The nurse implements neutropenic precautions when the client's values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. Options 2, 3, and 4 are normal values. Strategy: Use the process of elimination. Recalling that the normal white blood cell count is 4,500 to 11,000/mm³ will direct you to option 1. Review this hematological test if you had difficulty with this question. Reference: Pagana, K., & Pagana, T. (2006). Mosby's manual of diagnostic and laboratory tests (3rd ed., p. 537). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Oncology Alternate Question Types -> Multiple Choice

85) A client who takes theophylline for chronic obstructive pulmonary disease is seen in the urgent care center for respiratory distress. Once the client is stabilized, the nurse begins discharge teaching. The nurse would be especially vigilant to include information about complying with medication therapy if the client's baseline theophylline level was: a. 10 mcg/mL b. 12 mcg/mL c. 15 mcg/mL d. 18 mcg/mL Source: Saunders 4th

ANS: A Rationale: The therapeutic range for the serum theophylline level is 10 to 20 mcg/mL. If the level is below the therapeutic range, the client may experience frequent exacerbations of the disorder. Although all the options identify values within the therapeutic range, option 1 is the option that reflects a need for compliance with medication. Strategy: Use the process of elimination. Note the strategic words especially vigilant. Recalling the therapeutic level of theophylline will direct you to option 1. Review this therapeutic range if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 1040). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Respiratory Alternate Question Types -> Multiple Choice

96) Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Select the laboratory test results that are abnormal. a. Calcium, 7.0 mg/dL b. Magnesium, 1.0 mg/dL c. Phosphorus, 3.6 mg/dL d. Neutrophils, 1000/mm³ e. Serum creatinine, 1.0 mg/dL f. White blood cells, 3000/mm³ Source: Saunders 4th

ANS: A ANS: B ANS: D ANS: F Rationale: The normal values include the following: white blood cells, 4,500 to 11,000/mm³; neutrophils, 56%, or 1,800 to 7,800/mm³; phosphorus, 2.7 to 4.5 mg/dL; magnesium, 1.6 to 2.6 mg/dL; calcium, 8.6 to 10.0 mg/dL; and serum creatinine, 0.6 to 1.3 mg/dL. Strategy: Note the word abnormal in the question. Knowledge of the normal laboratory values for these studies will assist in answering this question. Review these normal values if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 700, 1034, 1163, 1263-1264). St. Louis: Mosby. Reference: Pagana, K., & Pagana, T. (2006). Mosby's manual of diagnostic and laboratory tests (3rd ed., p. 537). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Multiple

64) The nurse provides instructions to a client with a low magnesium level about the foods that are high in magnesium and tells the client to consume which foods? Select all that apply. a. Peas b. Bacon c. Oranges d. Cauliflower e. Peanut butter f. Canned white tuna Source: Saunders 4th

ANS: A ANS: D ANS: E ANS: F Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. Common food sources of magnesium include avocado, canned white tuna, cauliflower, green leafy vegetables such as spinach and broccoli, milk, oatmeal, peanut butter, peas, pork, beef, chicken, potatoes, raisins, and yogurt. Bacon is high in sodium. Oranges are high in potassium. Strategy: Focus on the subject, foods high in magnesium. Read each food item and recall that bacon is high in sodium and oranges are high in potassium. Review the food items high in magnesium if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 205, 207). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Multiple

13) An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that she would like to take an herbal substance to help lower her blood pressure. The nurse should take which appropriate action? a. Tell the client that herbal substances are not safe and should never be used. b. Advise the client to discuss the use of an herbal substance with the physician. c. Teach the client how to take her blood pressure so that it can be monitored closely. d. Tell the client that if she takes the herbal substance she will need to have her blood pressure checked frequently. Source: Saunders 4th

ANS: B Rationale: Although herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are being treated with conventional medication therapy should be advised to avoid herbal substances with similar pharmacological effects because the combination may lead to an excessive reaction or to unknown interaction effects. Therefore, the nurse would advise the client to discuss the use of the herbal substance with the physician. Options 1, 3, and 4 are inappropriate nursing actions. Strategy: Use the process of elimination. Eliminate option 1 first because of the close-ended word never. Next, eliminate options 3 and 4 because they are comparative or alike. Review the limitations associated with the use of herbal substances if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 922-923). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

11) Which of the following clients has the lowest risk of obesity and diabetes mellitus? a. A 45-year-old Native-American male b. A 23-year-old Asian-American female c. A 35-year-old Hispanic-American male d. A 40-year-old African-American female Source: Saunders 4th

ANS: B Rationale: Asian Americans have the lowest risk of obesity and diabetes mellitus from the options provided. Native Americans, African Americans, and Hispanic Americans have a high risk of obesity and diabetes mellitus. Strategy: Note the strategic words lowest risk, obesity, and diabetes mellitus. Think about the health practices of each cultural group to direct you to option 2. If you had difficulty with this question, review the characteristics of this culture. Reference: Giger, J.N., & Davidhizar, R.E. (2004). Transcultural nursing: Assessment and intervention (4th ed., pp. 201-202, 241-242, 267-268). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

69) A nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a P<sc>CO</sc>₂ of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? a. Sodium level of 145 mEq/L b. Potassium level of 3.0 mEq/L c. Magnesium level of 2.0 mg/dL d. Phosphorus level of 4.0 mg/dL Source: Saunders 4th

ANS: B Rationale: Clinical manifestations of respiratory alkalosis include headache, tachypnea, paresthesias, tetany, vertigo, convulsions, hypokalemia, and hypocalcemia. Options 1, 3, and 4 identify normal laboratory values. Option 2 identifies the presence of hypokalemia. Strategy: Use the process of elimination and knowledge regarding the clinical manifestations of respiratory alkalosis and normal laboratory values to answer the question. The only abnormal laboratory value is the potassium level, option 2. Review the clinical manifestations of respiratory alkalosis and normal laboratory values if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1144-1145). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

31) An 87-year-old woman is brought to the emergency room for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which of the following is the appropriate nursing response? a. "Oh, really. I will discuss this situation with your son." b. "This is a legal issue, and I must tell you that I will need to report it." c. "Let's talk about the ways you can manage your time to prevent this from happening." d. "Do you have any friends that can help you out until you resolve these important issues with your son." Source: Saunders 4th

ANS: B Rationale: Confidential issues are not to be discussed with nonmedical personnel or the client's family or friends without the client's permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. The nurse must report situations related to child or elder abuse, gunshot wounds, and certain infectious diseases. Options 1, 3, and 4 do not address the legal implications of the situation and do not ensure a safe environment for the client. Strategy: Use the process of elimination and knowledge regarding the nursing responsibilities related to reporting obligations. Options 1, 3, and 4 should be eliminated because they are comparative or alike in that they do not protect the client from injury. Review the nursing responsibilities related to reporting obligations if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 391-392, 433). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

81) A client is suspected of having a myocardial infarction. The nurse assesses for elevations in which of the following isoenzyme values reported with the creatine kinase level? a. MM b. MB c. BB d. MK Source: Saunders 4th

ANS: B Rationale: Creatine kinase (CK) is a cellular enzyme that can be fractionated into three isoenzymes. The MB band reflects CK from cardiac muscle. This is the level that elevates with myocardial infarction. The MM band reflects CK from skeletal muscle. The BB band reflects CK from the brain. There is no MK band. Strategy: To answer this question correctly, you must have specific knowledge of the isoenzymes produced with elevations in the CK level. Eliminate option 4 because there is no MK band. From the remaining options, recall that the MB band reflects CK from cardiac muscle. Review this important laboratory value for detecting myocardial infarction if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 845). Philadelphia: W.B. Saunders. Reference: Pagana, K., & Pagana, T. (2006). Mosby's manual of diagnostic and laboratory tests (3rd ed., p. 202). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

28) The nursing staff is sitting in the lounge taking their morning break. A nursing assistant tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the nursing assistant violated? a. Libel b. Slander c. Assault d. Negligence Source: Saunders 4th

ANS: B Rationale: Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group. Strategy: Use the process of elimination and eliminate options 3 and 4 first. Recalling that slander constitutes verbal defamation will direct you to option 2. If you had difficulty with this question, review the torts identified in each option. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 414). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

30) A client is brought to the emergency room by emergency medical services (EMS) after being hit by a car. The name of the client is not known and the client has sustained a severe head injury and multiple fractures, and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which of the following is the best action? a. Obtain a court order for the surgical procedure. b. Transport the victim to the operating room for surgery. c. Call the police to identify the client and locate the family. d. Ask the EMS team to sign the informed consent. Source: Saunders 4th

ANS: B Rationale: Generally, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option 1 will delay emergency treatment and option 4 is inappropriate. Although option 3 may be pursued, it is not the best action. Strategy: Use the process of elimination. Recalling that when an emergency is present and a delay in treatment for the purpose of obtaining informed consent could result in injury or death will direct you to option 2. Review the issues surrounding informed consent if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 857). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 416-417). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

55) A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level? a. The client with renal failure b. The client who is taking diuretics c. The client with hyperaldosteronism d. The client who is taking corticosteroids Source: Saunders 4th

ANS: B Rationale: Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with renal failure or hyperaldosteronism are at risk for hypernatremia. Strategy: Use the process of elimination. First, determine that the client is experiencing hyponatremia. Next, you must know the causes of hyponatremia to direct you to option 2. Review the normal serum sodium level and the causes of hyponatremia if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1141). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

72) A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis Source: Saunders 4th

ANS: B Rationale: Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. Options 1, 3, and 4 are incorrect. Strategy: Remembering that a client receiving nasogastric suction loses hydrochloric acid will direct you to the option identifying an alkalotic condition. Because the question addresses a situation other than a respiratory one, the acid-base disorder would be a metabolic condition. If you had difficulty with this question, review the causes of metabolic alkalosis. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 288-289). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1145). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

49) A nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because the client: a. Has renal failure. b. Requires nasogastric suction. c. Has a history of Addison's disease. d. Is taking a potassium-sparing diuretic. Source: Saunders 4th

ANS: B Rationale: Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with renal failure or Addison's disease and the client taking a potassium-sparing diuretic are at risk for hyperkalemia. Strategy: Use the process of elimination. Note that the subject of the question is a potassium deficit. Option 2 is the only option that identifies a loss of body fluid. If you had difficulty with this question, review the causes of hypokalemia. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 226-227). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1141-1142). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

47) A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for excess fluid volume? a. The client taking diuretics b. The client with renal failure c. The client with an ileostomy d. The client who requires gastrointestinal suctioning Source: Saunders 4th

ANS: B Rationale: The causes of excess fluid volume include decreased kidney function, congestive heart failure, the use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for deficient fluid volume. Strategy: Use the process of elimination and focus on the subject, excess fluid volume. Read each option and think about the fluid imbalance that can occur in each. The clients presented in options 1, 3, and 4 lose fluid. The only condition that can cause an excess is the condition noted in option 2. If you had difficulty with this question, review the causes of excess fluid volume. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1144). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

79) A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to: a. 3 mg/dL b. 15 mg/dL c. 29 mg/dL d. 35 mg/dL Source: Saunders 4th

ANS: B Rationale: The normal blood urea nitrogen level is 8 to 25 mg/dL. Values such as those in options 3 and 4 reflect continued dehydration. Option 1 reflects a lower than normal value, which may occur with fluid volume overload, among other conditions. Strategy: Use the process of elimination and knowledge of the normal blood urea nitrogen level to answer the question. Option 2 is the only option that identifies a normal value. Review this laboratory test if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 1111). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

70) A nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, P<sc>CO</sc>₂ of 30 mm Hg, and HCO₃^- of 22 mEq/L. The nurse analyzes these results as indicating which condition? a. Metabolic acidosis, compensated b. Respiratory alkalosis, compensated c. Metabolic alkalosis, uncompensated d. Respiratory acidosis, uncompensated Source: Saunders 4th

ANS: B Rationale: The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the P<sc>CO</sc>₂. In this situation, the pH is at the high end of the normal value and the P<sc>CO</sc>₂ is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the question indicate a respiratory alkalosis. Compensation occurs when the pH returns to a normal value. Because the pH is in the normal range at the high end, compensation has occurred. Strategy: Remember that in a respiratory imbalance you will find an opposite response between the pH and the P<sc>CO</sc>₂ as indicated in the question. Therefore, you can eliminate options 1 and 3. Also, remember that the pH increases in an alkalotic condition and compensation occurs, as evidenced by a normal pH. Option 2 reflects a respiratory alkalotic condition and compensation and describes the blood gas values as indicated in the question. Review the steps related to reading blood gas values if you had difficulty with this question. Reference: McLean, B. (2005). Acid-base imbalances. In Baird MS, Keen JH, Swearingen PL (Eds.): Manual of critical care nursing (5th ed., pp. 566-581). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1145). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

84) A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium (Coumadin) has a prothrombin time of 35 seconds. Based on the prothrombin time, the nurse anticipates which of the following orders? a. Adding a dose of heparin sodium b. Holding the next dose of warfarin c. Increasing the next dose of warfarin d. Administering the next dose of warfarin Source: Saunders 4th

ANS: B Rationale: The normal prothrombin time (PT) is 9.6 to 11.8 seconds (male adult) or 9.5 to 11.3 seconds (female adult). A therapeutic PT level is 1.5 to 2.0 times higher than the normal level. Because the value of 35 seconds is high (and perhaps near the critical range), the nurse should anticipate that the client would not receive further doses at this time. Strategy: Use the process of elimination, recalling that the normal PT is 9.6 to 11.8 seconds (male adult) or 9.5 to 11.3 seconds (female adult) and that a therapeutic PT level is 1.5 to 2.0 times higher than the normal level. If this question was difficult, review this laboratory test and the expected level if the client is receiving warfarin sodium. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 920). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

78) A 22-year-old adult has a cholesterol blood test done at a screening clinic sponsored by a local health club. The nurse volunteering at the screening teaches the client that diet and exercise should be used as health measures to keep the total cholesterol level below: a. 80 mg/dL b. 200 mg/dL c. 250 mg/dL d. 300 mg/dL Source: Saunders 4th

ANS: B Rationale: The nurse should counsel the client to keep the total cholesterol level under 200 mg/dL. This will aid in the prevention of atherosclerosis, which can lead to a number of cardiovascular disorders later in life. Options 3 and 4 are elevated values and place the client at risk for cardiovascular disease. Although option 1 is a low cholesterol level, option 2 identifies the realistic value to assist in preventing cardiovascular disease. Strategy: Recalling that the normal cholesterol level ranges from 140 to 199 mg/dL and noting the subject of the question will direct you to option 2. Because of the importance of the health problems caused by atherosclerosis and cardiovascular disease, review this laboratory test. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 369). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

57) A nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte results indicate a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L. Based on these laboratory findings, the nurse selects which solution to use for the nasogastric tube irrigation? a. Tap water b. Sterile water c. Sodium chloride d. Distilled water Source: Saunders 4th

ANS: C Rationale: A potassium level of 4.5 mEq/L is within normal range. A sodium level of 132 mEq/L is low, indicating hyponatremia. In clients with hyponatremia, sodium (isotonic) chloride should be used rather than water for gastrointestinal irrigations. Strategy: Use the process of elimination. Eliminate options 1, 2, and 4 because they are comparative or alike (sterile water, tap water, and distilled water). Also, recalling that the serum sodium level identified in the question indicates hyponatremia will direct you to option 3. If you had difficulty with this question, review the care of the client experiencing hyponatremia. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 235). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

14) A nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care when a staff member asks the nurse educator to describe the concept of acculturation. The appropriate response is which of the following? a. "It is a subjective perspective of the person's heritage and a sense of belonging to a group." b. "It is a group of individuals in a society who are culturally distinct and have a unique identity." c. "It is a process of learning a different culture to adapt to a new or changing environment." d. "It is a group that shares some of the characteristics of the larger population group of which it is a part." Source: Saunders 4th

ANS: C Rationale: Acculturation is a process of learning a different culture to adapt to a new or changing environment. Option 1 describes ethnic identity. Option 2 describes an ethnic group. Option 4 describes a subculture. Strategy: Knowledge regarding the descriptions and definitions of the foundational concepts related to culture is required to answer this question. Focusing on the word acculturation and thinking about its definition will direct you to option 3. Review these concepts if you are unfamiliar with them. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 120). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

9) When communicating with a culturally diverse client who speaks a different language, the best practice for the nurse is to: a. Speak loudly and slowly. b. Stand close to the client and speak loudly. c. Arrange for an interpreter when communicating with the client. d. Speak to the client and family together to increase the chances that the topic will be understood. Source: Saunders 4th

ANS: C Rationale: Arranging for an interpreter would be the best practice when communicating with a client who speaks a different language. Options 1 and 2 are inappropriate and are ineffective ways in which to communicate. Option 4 is inappropriate because it violates privacy and does not ensure correct translation. Strategy: Note the strategic words best practice in the question. To begin answering this question, eliminate options 1 and 2 because they are nontherapeutic actions. From the remaining options, focus on the strategic word best to direct you to option 3. Review these communication techniques if you had difficulty with this question. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., p. 68). Philadelphia: W.B. Saunders. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 27). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

48) The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present? a. Weight loss b. Flat neck and hand veins c. An increase in blood pressure d. A decreased central venous pressure (CVP) Source: Saunders 4th

ANS: C Rationale: Assessment findings associated with excess fluid volume include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, an elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and a decreased hematocrit. Options 1, 2, and 4 identify signs noted in deficient fluid volume. Strategy: Use the process of elimination and knowledge regarding the assessment findings in excess fluid volume. Note that options 1, 2, and 4 are similar or alike in that each of these signs reflects a decrease. Option 3 reflects an increase. If you had difficulty with this question, review the assessment findings noted in excess fluid volume. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 339). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

61) A nurse caring for a client with hypocalcemia would expect to note which of the following changes on the electrocardiogram? a. Widened T wave b. Prominent U wave c. Prolonged QT interval d. Shortened ST segment Source: Saunders 4th

ANS: C Rationale: Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A shortened ST segment and a widened T wave occur with hypercalcemia. Prominent U waves occur with hypokalemia. Strategy: Use knowledge regarding the electrocardiographic changes that occur in a calcium imbalance to answer the question. Remember that hypocalcemia causes a prolonged ST or QT interval. If you had difficulty with this question, review the electrocardiographic changes that occur in these conditions. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 696). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

8) A nursing student is discussing cultural diversity issues in a clinical conference when a nursing instructor asks the student to describe ethnocentrism. Which statement by the student indicates a lack of understanding of the issue of ethnocentrism? a. "It is a tendency to view one's own ways as best." b. "It is acting in a manner that is superior to other cultures." c. "It is imposing one's beliefs on individuals from another culture." d. "It is believing that one's own way is the only acceptable way." Source: Saunders 4th

ANS: C Rationale: Ethnocentrism is a tendency to view one's own way of life as the most desirable, acceptable, or best and to act in a superior manner toward another culture. Cultural imposition is the tendency to impose one's own beliefs, values, and patterns of behavior on individuals from another culture. Strategy: Use the process of elimination and note the strategic words indicates a lack of understanding in the question. Also, note that options 1, 2, and 4 are comparative or alike. If you had difficulty with this question, review culturally related concepts. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., p. 40). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

100) A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse would offer which full liquid item to the client? a. Tea b. Gelatin c. Custard d. Popsicle Source: Saunders 4th

ANS: C Rationale: Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, and strained vegetable juices. A clear liquid diet consists of foods that are relatively transparent. The food items in options 1, 2, and 4 are clear liquids. Strategy: Focus on the subject, a full liquid item. Remember that a clear liquid diet consists of foods that are relatively transparent. This will assist you in eliminating options 1, 2, and 4. Review food items allowed on a clear liquid diet and a full liquid diet if you had difficulty with this question. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed., p. 417). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

56) A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia were present? a. Dry skin b. Decreased urinary output c. Hyperactive bowel sounds d. Increased specific gravity of the urine Source: Saunders 4th

ANS: C Rationale: Hyperactive bowel sounds indicate hyponatremia. Options 1, 2, and 4 are signs of hypernatremia. In hyponatremia, increased urinary output and decreased specific gravity of the urine would be noted. Dry skin occurs in deficient fluid volume. Strategy: Focus on the data in the question and the subject of the question. Recalling the signs of hyponatremia will direct you to option 3. If you had difficulty with this question, review the assessment signs associated with hyponatremia and hypernatremia. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 234). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1141). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

35) A new nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that planning care delivery will be based on which characteristic of this type of nursing model of practice? a. A task approach method is used to provide care to clients. b. Managed care concepts and tools are used in providing client care. c. An RN (registered nurse) leads nursing personnel in providing care to a group of clients. d. A single RN is responsible for providing nursing care to a group of clients. Source: Saunders 4th

ANS: C Rationale: In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 4 identifies primary nursing. Strategy: Note that the subject of the question relates to team nursing. Keep this subject in mind and use the process of elimination. Option 3 is the only option that identifies the concept of a team approach. Review the various types of nursing delivery systems if you had difficulty with this question. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., pp. 317, 322). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 373). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Leadership and Management Alternate Question Types -> Multiple Choice

1) A nurse in an ambulatory care clinic is performing an admission assessment for an African-American client scheduled for a cataract removal with an intraocular lens implant. Which question would be inappropriate for the nurse to ask on an initial assessment? a. &quot;Do you ever experience chest pain?&quot; b. &quot;Do you have any difficulty breathing?&quot; c. &quot;Do you have a close family relationship?&quot; d. &quot;Do you frequently have episodes of headache?&quot; Source: Saunders 4th

ANS: C Rationale: In the African-American culture, asking personal questions on the initial contact or meeting is considered intrusive. African Americans are highly verbal and express feelings openly to family or friends, but what transpires within the family is viewed as private. Cardiovascular, respiratory, and neurological assessments include physiological assessments, which are the priority assessments. Strategy: Use Maslow's Hierarchy of Needs theory to answer the question. Note the strategic words inappropriate and initial. Options 1, 2, and 4 address physiological needs. Option 3 addresses the psychosocial need. Review characteristics of the African-American culture if you had difficulty with this question. Reference: Potter, P. & Perry, A. (2005) Fundamentals of nursing (6th ed., p. 124). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

4) Which of the following meal trays would be appropriate for the nurse to deliver to a client of Jewish faith who follows a kosher diet? a. Pork roast, rice, vegetables, mixed fruit, milk b. Crab salad on a croissant, vegetables with dip, potato salad, milk c. Sweet and sour chicken with rice and vegetables, mixed fruit, juice d. Fettucini Alfredo with shrimp and vegetables, salad, mixed fruit, iced tea Source: Saunders 4th

ANS: C Rationale: In the Jewish religion, those who are kosher believe that the dairy-meat combination is not acceptable. Pork and pork products are not allowed in the traditional Jewish religion. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven-hoofed, and ritually slaughtered. Strategy: Use the process of elimination, recalling that the dairy-meat combination is not acceptable in those in this religious group who follow the kosher tradition. Option 2 contains crab and milk, and option 1 contains pork roast and milk. Option 4 can be eliminated because it includes shrimp. Review the dietary rules of this religious group if you had difficulty with this question. Reference: Mahan, L.K., & Escott-Stump, S. (2004). Krause's food, nutrition, & diet therapy (11th ed., p. 385). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

12) A nurse is bathing a hospitalized Native American client of the Navajo culture and notes that the client avoids eye contact during the procedure. The nurse makes which interpretation about the client's behavior? a. The client is depressed. b. The client is displaying disrespectful mannerisms. c. The client is displaying behavior that is a common cultural action. d. The client is humiliated because of the need to be cared for by someone else. Source: Saunders 4th

ANS: C Rationale: Native American clients often avoid eye contact when being cared for by health care personnel. In this culture, eye contact is considered a sign of disrespect. Therefore, this client&#39;s action is culturally appropriate behavior. Options 1, 2, and 4 are inappropriate interpretations of the client&#39;s behavior. Strategy: Use the process of elimination and knowledge regarding the culturally appropriate behaviors of Navajo clients. Remember that, in this culture, eye contact is considered a sign of disrespect. If you had difficulty with this question, review the characteristics of this culture. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., pp. 68, 70). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

23) A nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. The appropriate initial action by the nurse is which of the following? a. Call security. b. Call the police. c. Call the nursing supervisor. d. Lock the co-worker in the medication room until help is obtained. Source: Saunders 4th

ANS: C Rationale: Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision of the impaired nurse. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities, such as the police, as required. The nurse may call security if a disturbance occurs, but no information in the question supports this need, and therefore this is not the initial action. Option 4 is an inappropriate and unsafe action. Strategy: Note the strategic words initial action. Eliminate option 4 first because this is an inappropriate and unsafe action. Recall the lines of organizational structure to assist in directing you to option 3. If you had difficulty with this question, review the nurse's responsibilities when substance abuse is suspected or occurs in the workplace. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 93). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

67) A nurse plans care for a client with chronic obstructive pulmonary disease, knowing that the client is most likely to experience what type of acid-base imbalance? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis Source: Saunders 4th

ANS: C Rationale: Respiratory acidosis is most often caused by hypoventilation. Chronic respiratory acidosis is most commonly caused by chronic obstructive pulmonary disease. In end-stage disease, pathological changes lead to airway collapse, air trapping, and disturbance of ventilation-perfusion relationships. Options 1, 2, and 4 are incorrect options. Strategy: Use the process of elimination. Note the strategic words most likely. Remembering that hypoventilation results in respiratory acidosis will direct you to option 3. Review the causes of respiratory acidosis if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 283, 598-599). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

62) A nurse caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.0 mg/dL. Which electrocardiographic change would the nurse expect to note based on the magnesium level? a. Prominent U waves b. Prolonged PR interval c. Depressed ST segment d. Widened QRS complexes Source: Saunders 4th

ANS: C Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL indicates hypomagnesemia. In hypomagnesemia, the nurse would note tall T waves and a depressed ST segment. Options 2 and 4 would be noted in a client experiencing hypermagnesemia. Prominent U waves occur with hypokalemia. Strategy: First, you must determine that the client is experiencing hypomagnesemia. Next, identify the electrocardiographic changes that occur in this condition. If you had difficulty with this question, review the normal magnesium level and the electrocardiographic changes that occur in hypomagnesemia and hypermagnesemia. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 243). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

26) The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report but instead receives a sexually oriented photograph. The appropriate initial nursing action is to: a. Call the police. b. Cut up the photograph and throw it away. c. Call the nursing supervisor and report the incident. d. Call the laboratory and ask for the individual's name that sent the photograph. Source: Saunders 4th

ANS: C Rationale: Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a co-worker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harassment by another worker. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option 1 is unnecessary at this time. Options 2 and 4 are not appropriate initial actions. Strategy: Note the strategic word initial. This may indicate that one or more than one of the options is partially or totally correct. Use the skills of prioritizing to select the correct option. Remember that using the organizational channels of communication is best. This will assist in directing you to option 3. Review nursing responsibilities when sexual harassment occurs in the workplace if you had difficulty with this question. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., pp. 679, 681, 683, 685). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

39) The RN has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client will the RN plan to care for first? a. A client who is ambulatory b. A client scheduled for physical therapy at 1 <SC>PM </SC> c. A client with a fever who is diaphoretic and restless d. A postoperative client who has just received pain medication Source: Saunders 4th

ANS: C Rationale: The RN would plan to care for the client who has a fever and is diaphoretic and restless first because this client's needs are the priority. Waiting for pain medication to take effect before providing care to the postoperative client is best. The client who is ambulatory and the client scheduled for physical therapy later in the day do not have priority needs related to care. Strategy: Note the strategic words care for first and use principles related to prioritizing. Noting the words diaphoretic and restless will assist in directing you to this option. Review the principles related to prioritizing if you had difficulty with this question. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., p. 167). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 267-268). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

29) The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds a client lying on the floor. The nurse performs a thorough assessment, assists the client back to bed, notifies the physician of the incident, and completes an incident report. Which of the following should the nurse document on the incident report? a. The client fell out of bed. b. The client climbed over the side rails. c. The client was found lying on the floor. d. The client became restless and tried to get out of bed. Source: Saunders 4th

ANS: C Rationale: The incident report should contain the client's name, age, and diagnosis. The report should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. Option 3 is the only option that describes the facts as observed by the nurse. Options 1, 2, and 4 are interpretations of the situation and are not factual information as observed by the nurse. Strategy: Use the process of elimination and read the information contained in the question to select the correct option. Remember to focus on factual information when documenting, and avoid including interpretations. This will direct you to option 3. Review documentation principles related to incident reports if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 481-482). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Communication and Documentation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

93) An adult female client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this result is most likely caused by which of the following conditions noted in the client's history? a. Dehydration b. Heart failure c. Iron deficiency anemia d. Chronic obstructive pulmonary disease Source: Saunders 4th

ANS: C Rationale: The normal hemoglobin level for an adult female client is 12 to 15 g/dL. Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body's need for more oxygen-carrying capacity. Strategy: Use the process of elimination. Evaluate each of the options in terms of whether each is likely to raise or lower the hemoglobin level. Also, note the relationship between hemoglobin level in the question and option 3. Review the normal hemoglobin level if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 639). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 894). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

32) A client involved in a head-on automobile crash has awakened from a coma and asks for her husband, who was killed in the same accident. The family does not want the client to know at this time that her husband has died. The family wants all nursing staff to tell the client that the husband was taken by helicopter to another hospital, has a head injury, and is in the intensive care unit. Because the American Nurses Association Code of Ethics requires the nurse to preserve integrity, but the nurse wants to follow the family's instruction, the nurse faces an ethical dilemma. Number in order the steps for systematic processing of the ethical dilemma. Number 1 is the first step and number 6 is the last step. a. Evaluate the action. b. Verbalize the problem. c. Negotiate the outcome. d. Consider possible courses of action. e. Gather all of the information relevant to the case. f. Examine and determine one's own values on the issues. Source: Saunders 4th

ANS: F ANS: C ANS: E ANS: D ANS: A ANS: B Rationale: Ethical reasoning is the process of thinking through what one ought to do in an orderly and systematic manner to provide justification for actions based on principles. First, the nurse determines whether or not the issue involves an ethical dilemma and gathers information that is relevant to the case. Next, the nurse undertakes personal value clarification and identifies his or her own values regarding the issue. Third, the nurse verbalizes the problem in a simple sentence. Fourth, the nurse considers possible courses of action. In this case, the nurse may choose to seek the counsel of the agency's ethicist regarding the issue. Fifth, the nurse negotiates the outcome by developing a confidence in her or his own point of view with deep respect for the opinions of others. In this case, the nurse may negotiate with the family to determine a course of action that will allow the nurse to preserve integrity and yet allow the family to determine when the client should be informed of the tragic loss. Finally, the nurse evaluates the action. Strategy: Focus on the subject, the systematic processing of an ethical dilemma. Use the steps of the nursing process to assist in determining the correct order of action. Review the steps for systematic processing of an ethical dilemma if you had difficulty with this question.<br /> Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 398). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Prioritize

91) An adult client with cirrhosis has been following a diet with optimal amounts of protein because neither an excess nor a deficiency of protein has been helpful. The nurse evaluates the client's status as being most satisfactory if the total protein level is which of the following values? a. 0.4 g/dL b. 3.7 g/dL c. 6.4 g/dL d. 9.8 g/dL Source: Saunders 4th

ANS: C Rationale: The normal range for total serum protein level in the adult client is 6.0 to 8.0 g/dL. The client with cirrhosis often has low total protein levels as a result of inadequate nutrition. Excess protein is not helpful, though, because a function of the liver is to metabolize protein. A diseased liver may not metabolize protein well. Options 1 and 2 identify low values, and option 4 identifies a high protein value. Strategy: Use the process of elimination. Note the strategic words most satisfactory. Recalling the normal total protein level will direct you to option 3. Review this laboratory range if you had difficulty with this question. Reference: Pagana, K., & Pagana, T. (2005). Mosby's diagnostic and laboratory test reference (7th ed., p. 758). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

77) The nurse is assigned to a 40-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of: a. 45 units/L b. 100 units/L c. 300 units/L d. 500 units/L Source: Saunders 4th

ANS: C Rationale: The normal serum amylase level is 25 to 151 units/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Options 1 and 2 are within normal limits. Option 4 is an extremely elevated level seen in acute pancreatitis. Strategy: Use the process of elimination and note the strategic word chronic in the question. Recalling the normal amylase level and focusing on the strategic word will direct you to option 3. Review this level and the findings in chronic pancreatitis if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 172). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1406). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

82) An adult client has had laboratory work done as part of a routine physical examination. The nurse interprets that the client may have a mild degree of renal insufficiency if which of the following serum creatinine levels is noted? a. 0.2 mg/dL b. 0.5 mg/dL c. 1.9 mg/dL d. 3.5 mg/dL Source: Saunders 4th

ANS: C Rationale: The normal serum creatinine level for adults is 0.6 to 1.3 mg/dL. The client with a mild degree of renal insufficiency would have a slightly elevated level. A creatinine level of 0.2 mg/dL is low, and a level of 0.5 mg/dL is just below normal. A creatinine level of 3.5 mg/dL may be associated with acute or chronic renal failure. Strategy: Note the strategic word mild. This tells you that the correct option will be an abnormal value but perhaps not the most abnormal of all the options. Recall the normal value for this common laboratory test to direct you to option 3. Review the normal value for this laboratory test if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 428). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1740). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Renal Alternate Question Types -> Multiple Choice

92) An adult client was diagnosed with acute pancreatitis 9 days ago. The nurse interprets that the client is recovering from this episode if the serum lipase level decreases to which of the following values, which is just below the upper limit of normal? a. 20 units/L b. 80 units/L c. 135 units/L d. 350 units/L Source: Saunders 4th

ANS: C Rationale: The normal serum lipase level is 10 to 140 units/L. The client who is recovering from acute pancreatitis usually has elevated lipase levels for about 10 days after the onset of symptoms. This makes lipase a valuable test in monitoring the client's pancreatic function because serum amylase levels usually return to normal 3 days after the onset of symptoms. Option 3 is the only option that contains a value just below the upper limit of normal. Strategy: Use the process of elimination and knowledge of the serum lipase level to answer this question. Noting the strategic words just below the upper limit of normal will assist in directing you to option 3. Review the range for this laboratory value if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 724). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

37) The RN is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? a. A client requiring colostomy irrigation b. A client receiving continuous tube feedings c. A client who requires urine specimen collections d. A client with difficulty swallowing food and fluids Source: Saunders 4th

ANS: C Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a nursing assistant would be to care for the client who requires urine specimen collections. The nursing assistant is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by unlicensed personnel. The client with difficulty swallowing food and fluids is at risk for aspiration. Strategy: Note the strategic words, most appropriate, and note the subject, an assignment to a nursing assistant. Eliminate option 4 first because of the words difficulty swallowing. Next, eliminate options 1 and 2 because they are comparative or alike and are both invasive procedures. Review the principles of delegation if you had difficulty with this question. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., p. 546). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 42, 350, 378). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

83) A client with a history of a seizure disorder that has been compliant with medication therapy is admitted to the hospital with seizure activity. Phenytoin (Dilantin) is administered to the client intravenously, and subsequently a sample for the serum phenytoin level is drawn. The nurse determines that the medication therapy has been most effective if the laboratory result is: a. 3 mcg/mL b. 8 mcg/mL c. 16 mcg/mL d. 24 mcg/mL Source: Saunders 4th

ANS: C Rationale: The therapeutic range for serum phenytoin (Dilantin) level is 10 to 20 mcg/mL. If the level is below the therapeutic range, the client may continue to experience seizure activity. If the level is too high, the client could experience phenytoin toxicity. Strategy: Use the process of elimination. Recalling that the therapeutic range is 10 to 20 mcg/mL will direct you to option 3. Learn this therapeutic range if you had difficulty with this question. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 869). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Evaluation Content Area -> Adult Health—Neurological Alternate Question Types -> Multiple Choice

80) A client arrives in the emergency room complaining of chest pain that began 4 hours ago. A troponin T blood specimen is obtained, and the results indicate a level of 0.6 ng/mL. The nurse interprets that this result indicates a: a. Normal level b. Low value that indicates possible gastritis c. Level that indicates a myocardial infarction d. Level that indicates the presence of possible angina Source: Saunders 4th

ANS: C Rationale: Troponin is a regulatory protein found in striated muscle. The troponins function together in the contractile apparatus for striated muscle in skeletal muscle and in the myocardium. Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. A troponin T value that is higher than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction. A normal troponin I level is lower than 0.6 ng/mL. Strategy: Note that the subject of the question relates to the troponin T. Knowing that a level higher than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction will direct you to option 3. Review this diagnostic test if you are unfamiliar with it. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 1094). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 694). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

90) An adult client with a history of gastrointestinal bleeding has a platelet count of 300,000 cells/mm³. Which action by the nurse is most appropriate after seeing the laboratory results? a. Report the abnormally low count. b. Report the abnormally high count. c. Place the client on bleeding precautions. d. Place the normal report in the client's medical record. Source: Saunders 4th

ANS: D Rationale: A normal platelet count ranges from 150,000 to 400,000 cells/mm³. The nurse should place the report containing the normal laboratory value in the client's medical record. A platelet count of 300,000 cells/mm³ is not an elevated count. The count also is not low; therefore, bleeding precautions are not needed. Strategy: Use the process of elimination. Remember that options that are comparative or alike are not likely to be correct. With this in mind, eliminate options 1 and 3 first. From the remaining options, you must be familiar with the normal range for this laboratory test. Review this normal laboratory value if you had difficulty with this question. Reference: Pagana, K., & Pagana, T. (2006). Mosby's manual of diagnostic and laboratory tests (3rd ed., p. 409). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Adult Health—Gastrointestinal Alternate Question Types -> Multiple Choice

53) A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a potassium value at this level? a. The client with colitis b. The client with Cushing's syndrome c. The client who has been overusing laxatives d. The client who has sustained a traumatic burn Source: Saunders 4th

ANS: D Rationale: A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia. Strategy: Use the process of elimination. Eliminate options 1 and 3 first because they are comparative or alike, with both reflecting a gastrointestinal loss. From the remaining options, recalling that cell destruction causes potassium shifts will assist in directing you to the correct option. Remember that Cushing's syndrome presents a risk for hypokalemia and that Addison's disease presents a risk for hyperkalemia. If you had difficulty with this question, review the risk factors associated with hyperkalemia. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1141-1142). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

54) A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value? a. ST depression b. Inverted T wave c. Prominent U wave d. Tall peaked T waves Source: Saunders 4th

ANS: D Rationale: A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Electrocardiographic changes include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. Strategy: From the information in the question, you need to determine that this condition is a hyperkalemic one. From this point, you must know the electrocardiographic changes that are expected when hyperkalemia exists. If you had difficulty with this question, review the normal serum potassium level and the electrocardiographic changes that occur in hyperkalemia. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 343). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

40) The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? a. A client scheduled for a chest x-ray b. A client requiring daily dressing changes c. A postoperative client preparing for discharge d. A client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift Source: Saunders 4th

ANS: D Rationale: Airway is always a highest priority, and the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options 1, 2, and 3 have needs that would be identified as intermediate priorities. Strategy: Use Maslow's Hierarchy of Needs theory and the ABCs—airway, breathing, and circulation—to answer the question. Remember that airway is always the highest priority. This will direct you to option 4. Review principles related to prioritizing if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 267-268, 1247). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

3) A nurse is preparing a plan of care for a client who is a Jehovah's Witness. The client has been told that surgery is necessary. The nurse considers the client's religious preferences in developing the plan of care and documents that: a. Faith healing is practiced primarily. b. Medication administration is not allowed. c. Surgery is prohibited in this religious group. d. The administration of blood and blood products is forbidden. Source: Saunders 4th

ANS: D Rationale: Among Jehovah's Witnesses, surgery is not prohibited, but the administration of blood and blood products is forbidden. Faith healing is forbidden in this religious group. Administration of medication is an acceptable practice, except if the medication is derived from blood products. Strategy: Use the process of elimination, recalling that the administration of blood and any associated blood products is forbidden in this religious group. Review the characteristics of this religious group if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 133). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Psychosocial Integrity Integrated Process -> Communication and Documentation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

46) A nurse caring for a client who has been receiving intravenous diuretics suspects that the client is experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this condition? a. Lung congestion b. Decreased hematocrit c. Increased blood pressure d. Decreased central venous pressure (CVP) Source: Saunders 4th

ANS: D Rationale: Assessment findings in a client with a deficient fluid volume include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 cm H₂O. A client with dehydration has a low CVP. The assessment findings in options 1, 2, and 3 are seen in a client with excess fluid volume. Strategy: Use the process of elimination and focus on the subject, deficient fluid volume. Eliminate options 1 and 3 first. Lung congestion is noted in excess fluid volume, as is increased blood pressure. From the remaining options, recall that central venous pressure reflects the pressure under which blood is returned to the superior vena cava and right atrium. Therefore, pressure (volume) would be decreased in a deficient fluid volume. If you had difficulty with this question, review the assessment findings noted in deficient fluid volume. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., p. 339). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1144). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

15) The nurse understands that which of the following statements regarding herbal therapies is true? a. Zinc is used for insomnia. b. Ginger is used to improve memory. c. Echinacea is used for erectile dysfunction. d. Black cohosh produces estrogen-like effects. Source: Saunders 4th

ANS: D Rationale: Black cohosh produces estrogen-like effects. Zinc stimulates the immune system and is used for its antiviral properties. Echinacea stimulates the immune system and ginger is used for nausea and vomiting. Strategy: Note the strategic word true and use the process of elimination and knowledge regarding herbal therapies. Options 1, 2 and 3 can be eliminated because the herb identified does not correlate with the correct therapeutic property. If you had difficulty with this question, review commonly used herbs and their therapeutic properties. Reference: Hodgson, B., & Kizior, R. (2007). Saunders nursing drug handbook 2007 (pp. 145, 1261). Philadelphia: W.B. Saunders. Reference: Mahan, L.K., & Escott-Stump, S. (2004). Krause's food, nutrition, & diet therapy (11th ed., pp. 482-487). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

65) A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 6 breaths/min. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/min. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which of the following? a. A decreased pH and an increased CO₂ b. An increased pH and a decreased CO₂ c. A decreased pH and a decreased HCO₃^- d. An increased pH with an increased HCO₃^- Source: Saunders 4th

ANS: D Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO₃^- to increase. Symptoms experienced by the client would include hypoventilation and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition. Option 3 reflects a metabolic acidotic condition. Strategy: Focus on the data in the question and note that the client is vomiting. Recalling that vomiting would most likely cause metabolic alkalosis will assist in directing you to option 4. Review the causes of metabolic alkalosis if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 351-352). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

7) The role of the nurse regarding complementary and alternative medicine (CAM) should include: a. Recommending herbal remedies that the client should use b. Educating the client about "good" versus "bad" therapies c. Discouraging the client from using any alternative therapies d. Educating the client about therapies that he or she is using or is interested in using Source: Saunders 4th

ANS: D Rationale: Complementary (alternative) therapies include a wide variety of treatment modalities that are used in addition to conventional therapy to treat a disease or illness. Educating the client about therapies that he or she uses or is interested in using is the nurse's role. Options 1, 2, and 3 are all inappropriate actions for the nurse to take. Strategy: Use therapeutic communication techniques. Eliminate options 1, 2, and 3 because they are nontherapeutic. Option 4 is the only option that is appropriate. Review therapeutic communication techniques if you had difficulty with this question. Reference: Mahan, L.K., & Escott-Stump, S. (2004). Krause's food, nutrition, & diet therapy (11th ed., pp. 491-492, 1227). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

36) The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. A nursing assistant is resistant to the change and is not taking an active part in facilitating the process of change. Which of the following is the best approach in dealing with the nursing assistant? a. Ignore the resistance. b. Exert coercion with the nursing assistant. c. Provide a positive reward system for the nursing assistant. d. Confront the nursing assistant to encourage verbalization of feelings regarding the change. Source: Saunders 4th

ANS: D Rationale: Confrontation is an important strategy to meet resistance head on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Option 1 will not address the problem. Option 2 may produce additional resistance. Option 3 may provide a temporary solution to the resistance but will not address the concern specifically. Strategy: Use the process of elimination. Options 1 and 2 easily can be eliminated first. From the remaining options, select option 4 over option 3 because this option specifically addresses the subject and would provide problem-solving measures. If you had difficulty with this question, review the strategies associated with dealing with resistance to change. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., p. 527). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 440). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Leadership and Management Alternate Question Types -> Multiple Choice

22) The nurse gives an inaccurate dose of a medication to a client. Following assessment of the client, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication dose understands that: a. The error will result in suspension. b. The incident will be reported to the board of nursing. c. The incident will be documented in the personnel file. d. An incident report needs to be completed and is a method of promoting quality care and risk management. Source: Saunders 4th

ANS: D Rationale: Documentation of unusual occurrences, incidents, and accidents and of the nursing actions taken as a result of the occurrence is internal to the institution or agency and allows the nurse and administration to review the quality of care and determine any potential risks present. Based on the information provided in the question, the nurse's error will not result in suspension, nor will it be documented in the personnel file. The error and the situation presented in the question are not a reason for notifying the board of nursing. Strategy: Focus on the information provided in the question. Use the process of elimination and knowledge regarding the purpose of incident reports to assist in eliminating options 1, 2, and 3. Note that the correct option is also the umbrella option. If you had difficulty with this question, review the purpose of incident reports. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 419, 497). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

21) The registered nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which action first? a. Call the hospital lawyer. b. Refuse to float to the ICU. c. Call the nursing supervisor. d. Report to the ICU and identify tasks that can be performed safely. Source: Saunders 4th

ANS: D Rationale: Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally, a nurse cannot refuse to float unless a union contract guarantees that nurses can work only in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountering this situation, the nurse should set priorities and identify potential areas of harm to the client. The nursing supervisor is called if the nurse is expected to perform tasks that he or she cannot safely perform. Calling the hospital lawyer is a premature action. Strategy: Use the process of elimination, noting the strategic word first. Eliminate option 2 first because of the word refuse. Next, eliminate options 1 and 3 because they are premature actions. Review nursing responsibilities related to floating if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 418-419). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

99) A client with hypertension has been told to maintain a diet low in sodium. A nurse who is teaching this client about foods that are allowed would plan to include which food item in a list provided to the client? a. Tomato soup b. Boiled shrimp c. Instant oatmeal d. Summer squash Source: Saunders 4th

ANS: D Rationale: Foods that are lower in sodium include fruits and vegetables (option 4), because they do not contain physiological saline. Highly processed or refined foods (options 1 and 3) are higher in sodium unless their food labels specifically state "low sodium." Saltwater fish and shellfish are high in sodium. Strategy: Use the process of elimination. Begin to answer this question by eliminating option 2, recalling that saltwater fish and shellfish are high in sodium. Next, eliminate options 1 and 3 because they are processed foods. Review the foods that are high in sodium if you had difficulty with this question. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed., p. 609). St. Louis: Mosby. Reference: Nix, S. (2005). Williams' basic nutrition and diet therapy (12th ed., p. 359). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Teaching and Learning Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

25) The nurse has made an error in documenting an assessment finding on a client and obtains the client's record to correct the error. The nurse corrects the error by: a. Documenting a late entry into the client's record b. Trying to erase the error for space to write in the correct data c. Using Wite-Out to delete the error to write in the correct data d. Drawing one line through the error, initialing and dating the line, and then documenting the correct information Source: Saunders 4th

ANS: D Rationale: If the nurse makes an error in documenting in the client's record, the nurse should follow agency policies to correct the error. This includes drawing one line through the error, initialing and dating the line, and then documenting the correct information. A late entry is used to document additional information not remembered at the initial time of documentation. Erasing data from the client's record and the use of Wite-Out are prohibited. Strategy: Use the process of elimination and principles related to documentation. Recalling that alterations to a client's record are to be avoided will assist in eliminating options 2 and 3. From the remaining options, focusing on the subject of the question and using knowledge regarding the principles related to documentation easily will direct you to option 4. Review these principles if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 836, 841). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Communication and Documentation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

42) The nurse manager of a critical care unit must speak to a staff nurse about an employment issue, tardiness. Nearly every day during the past week, the staff nurse has been from 5 to 20 minutes late, missing portions of the daily client status conferences. The manager had verbally counseled the staff nurse 3 months prior to the latest incidence of tardiness about the same issue. When they meet, the nurse manager's best approach to the staff nurse is to: a. Send the staff nurse to the Human Resources Department for counseling. b. Ask the staff nurse to tell the manager about the facts surrounding the tardiness. c. Inform the staff nurse that, based on unreliability caused by tardiness issues, the nurse is terminated. d. Provide the staff nurse with a detailed notice of intent to terminate if any further incident of tardiness occurs. Source: Saunders 4th

ANS: D Rationale: In general, the process for corrective action begins with an oral reprimand and then a written reprimand. In addition to the written reprimand, the manager should be prepared to work with the staff nurse to develop a plan of action. The manager must notify the staff nurse, in writing, of the potential for termination based on tardiness. If this were the first instance, the manager would ask the staff nurse to describe the facts surrounding the tardiness in order for the manager to assist the staff nurse with problem-solving strategies or to examine the need for moving the staff nurse to a different shift, if indicated. Managers are expected to deal with personnel issues, and tardiness is a frequent problem that managers face. Human resources serves as a support to the actions of the manager, but does not assume the role of dealing with the employee. Managers must give notice prior to termination as a risk management strategy. Strategy: Note that the series of tardinesses are the second offense. Remember that the process for corrective action begins with an oral reprimand and then a written reprimand. Review the principles and processes of disciplinary action if you had difficulty with this question. Reference: Marriner-Tomey, A. (2004). Guide to nursing management and leadership (7th ed., pp. 418-425) St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Leadership and Management Alternate Question Types -> Multiple Choice

94) A client with diabetes mellitus has a glycosylated hemoglobin A_1c level of 9%. Based on this test result, the nurse plans to teach the client about the need to: a. Avoid infection. b. Take in adequate fluids. c. Prevent and recognize hypoglycemia. d. Prevent and recognize hyperglycemia. Source: Saunders 4th

ANS: D Rationale: In the test result for glycosylated hemoglobin A_1c, 7% or less indicates good control, 7% to 8% indicates fair control, and 8% or higher indicates poor control. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus, the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes. Strategy: Use the process of elimination and knowledge regarding the values for this test and their significance to answer the question. Focusing on the level identified in the question will assist in directing you to option 4. If you had difficulty with this question or are unfamiliar with this test, review this content. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., p. 615). Philadelphia: W.B. Saunders. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., pp. 882, 1507). Philadelphia: W.B. Saunders. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Nursing Process—Planning Content Area -> Adult Health—Endocrine Alternate Question Types -> Multiple Choice

6) A Chinese-American client experiencing anemia, which is believed to be a yin disorder, is likely to treat it with: a. Magnetic therapy. b. Intercessory prayer. c. Foods considered to be yin. d. Foods considered to be yang. Source: Saunders 4th

ANS: D Rationale: In the yin and yang theory, health is believed to exist when all aspects of the person are in perfect balance. Yin foods are cold and yang foods are hot. Cold foods are eaten when one has a hot illness and hot foods are eaten when one has a cold illness. Options 1 and 2 are not associated with the yin and yang theory. Strategy: Use the process of elimination and knowledge regarding the theory of yin and yang. Remember that cold foods are eaten when one has a hot illness and hot foods are eaten when one has a cold illness. If you are unfamiliar with this theory, review its elements. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1286). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Nursing Process—Planning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

27) The nursing instructor provides a lecture to nursing students regarding the issue of client&#39;s rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which of the following, if identified by the student, indicates an understanding of a violation of this client right? a. Performing a procedure without consent b. Threatening to give a client a medication c. Telling the client that he or she cannot leave the hospital d. Observing care provided to the client without the client's permission Source: Saunders 4th

ANS: D Rationale: Invasion of privacy takes place with unreasonable intrusion into an individual's private affairs. Performing a procedure without consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment. Strategy: The strategic words in the question are invasion of client privacy. Focus on these strategic words to direct you to option 4. If you had difficulty with this question, review those situations that include invasion of privacy. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 413-414). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Safe and Effective Care Environment Integrated Process -> Caring Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

74) A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on this documentation, which of the following did the nurse observe? a. Respirations that cease for several seconds b. Respirations that are regular but abnormally slow c. Respirations that are labored and increased in depth and rate d. Respirations that are abnormally deep, regular, and increased in rate Source: Saunders 4th

ANS: D Rationale: Kussmaul's respirations are abnormally deep, regular, and increased in rate. Apnea is described as respirations that cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate. Strategy: Use the process of elimination and knowledge of the description of Kussmaul's respirations. Recalling that this type of respiration occurs in diabetic ketoacidosis will direct you to option 4. Review the characteristics of this type of respiration if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 1327). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 650, 1088). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

24) A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. The appropriate response to the client is which of the following? a. "I will sign as a witness to your signature." b. "You will need to find a witness on your own." c. "Whoever is available at the time will sign as a witness for you." d. "I will call the nursing supervisor to seek assistance regarding your request." Source: Saunders 4th

ANS: D Rationale: Living wills are required to be in writing and signed by the client. The client's signature must be witnessed by specified individuals or notarized. Many states prohibit any employee, including a nurse of a facility where the client is receiving care, from being a witness. Option 2 is nontherapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor. Strategy: Note the strategic word appropriate. Options 1 and 3 are comparative or alike and should be eliminated first. Option 2 is eliminated because it is a nontherapeutic response. Review legal implications associated with wills if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed., p. 106). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 409-410). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

20) A nursing graduate is employed as a staff nurse in a local hospital. During orientation, the new graduate asks the nurse educator about the need to obtain professional liability insurance. The appropriate response by the nurse educator is: a. "It is very expensive and not necessary." b. "The hospital's liability insurance will cover your actions." c. "The majority of suits are filed against physicians and the hospital." d. "Nurses are encouraged to have their own professional liability insurance." Source: Saunders 4th

ANS: D Rationale: Nurses need their own professional liability insurance for protection against malpractice law suits. Nurses erroneously assume that they are protected by an agency's professional liability policies. Usually, when a nurse is sued, the employer also is sued for the nurse's actions or inactions. Even though this is the norm, nurses are encouraged to have their own professional liability insurance. Strategy: Note that the subject of the question relates to "obtaining professional liability insurance." This subject should direct you to option 4. Review liability related to malpractice insurance if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 418). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Safe and Effective Care Environment Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

66) A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Pco₂ is 90 mm Hg, and HCO₃^- is 22 mEq/L. The nurse interprets the results as indicating which condition? a. Metabolic acidosis with compensation b. Respiratory acidosis with compensation c. Metabolic acidosis without compensation d. Respiratory acidosis without compensation Source: Saunders 4th

ANS: D Rationale: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Pco₂ is 35 to 45 mm Hg. In respiratory acidosis the pH is decreased and the Pco₂ is elevated. The normal bicarbonate (HCO₃^-) level is 22 to 27 mEq/L. Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. Therefore, the condition is without compensation. Options 1, 2, and 3 are incorrect. Strategy: Use the process of elimination. Remember that in a respiratory imbalance you will find an opposite response between the pH and the Pco₂. Also, remember that the pH is decreased in an acidotic condition and that compensation is reflected by a normal pH. Review the interpretation of arterial blood gas values if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 351-352). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

10) A nurse educator asks a student to list the five categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine (NCCAM), to a group of nursing students. Which of the following, if stated by the nursing student, would indicate an understanding of the five categories of CAM? a. Herbology, hydrotherapy, acupuncture, nutrition, and chiropractic care b. Mind-body medicine, traditional Chinese medicine, homeopathy, naturopathy, and healing touch c. Biologically based practices, body-based practices, magnetic therapy, massage therapy, and Trager body work d. Whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine Source: Saunders 4th

ANS: D Rationale: The five categories of complementary and alternative medicine (CAM) include whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine. The other options contain therapies within each category of CAM. Strategy: Use knowledge of the five categories of CAM to assist in answering this question. Noting that the question asks about categories, not therapies, will assist in answering correctly. Review CAM if you had difficulty with this question. Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp. 95-97). St. Louis: Mosby. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 913-915). St. Louis: Mosby. Level of Cognitive Ability -> Comprehension Client Needs -> Psychosocial Integrity Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

76) A client is brought to the emergency room stating that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to do which of the following next? a. Prepares to administer an antidote b. Draws a sample for type and crossmatch and transfuse the client c. Draws a sample for an activated partial thromboplastin time (aPTT) level d. Draws a sample for prothrombin (PT) and international normalized ratio (INR) level Source: Saunders 4th

ANS: D Rationale: The next action is to draw a sample for PT and INR level to determine the client's anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client if an antidote (vitamin K) or blood transfusion is needed. The aPTT monitors the effects of heparin therapy. Strategy: Use a process of elimination. Eliminate option 3 because it is unrelated to warfarin therapy and relates to heparin therapy. Next, eliminate options 1 and 2 because these therapies would not be implemented unless the PT and INR levels are known. Review care to the client receiving warfarin therapy and the purpose of the PT and INR if you had difficulty with this question. Reference: Lehne, R.A. (2004). Pharmacology for nursing care (5th ed., p. 552). St. Louis: W.B. Saunders. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

87) A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin (aPTT) time is 65 seconds. The client's baseline before the initiation of therapy was 30 seconds. The nurse anticipates that which action is needed? a. Discontinuing the heparin infusion b. Increasing the rate of the heparin infusion c. Decreasing the rate of the heparin infusion d. Leaving the rate of the heparin infusion as is Source: Saunders 4th

ANS: D Rationale: The normal activated partial thromboplastin time (aPTT) varies between 20 and 36 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal. Thus, the client's aPTT is within the therapeutic range, and the dose should remain unchanged. Strategy: To answer this question accurately, you must be familiar with the normal aPTT level and the therapeutic level needed following institution of heparin therapy. Remember that the normal range is 20 to 36 seconds and that the aPTT should be between 1.5 and 2.5 times normal when the client is receiving heparin therapy. If this question was difficult, review this laboratory test and the expected level if the client is receiving heparin. Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed., pp. 138-140). Philadelphia: W.B. Saunders. Reference: Gahart, B., & Nazareno, A. (2006). 2006 intravenous medications (22nd ed., p. 633). St. Louis: Mosby. Level of Cognitive Ability -> Analysis Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Analysis Content Area -> Adult Health—Cardiovascular Alternate Question Types -> Multiple Choice

58) A nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the physician and the physician prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid? a. Peas b. Cauliflower c. Low-fat yogurt d. Processed oat cereals Source: Saunders 4th

ANS: D Rationale: The normal serum sodium level is 135 to 145 mEq/L. A serum sodium level of 150 mEq/L indicates hypernatremia. Based on this finding, the nurse would instruct the client to avoid foods high in sodium. Low-fat yogurt, cauliflower, and peas are good food sources of phosphorus. Processed foods are high in sodium content. Strategy: First, you must determine that the client has hypernatremia. Next, note the strategic word avoid in the question. Eliminate options 1 and 2 first because these are vegetables. From the remaining options, note the word processed in option 4. Processed foods tend to be higher in sodium content. Review foods high in sodium content if you had difficulty with this question. Reference: Grodner, M., Long, S., & DeYoung, S. (2004). Foundations and clinical applications of nutrition: A nursing approach (3rd ed., p. 609). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Health Promotion and Maintenance Integrated Process -> Teaching and Learning Content Area -> Fundamental Skills Alternate Question Types -> Multiple Choice

41) The nurse is giving a bed bath to an assigned client when a nursing assistant enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The appropriate nursing action is which of the following? a. Finish the bed bath and then administer the pain medication to the other client. b. Ask the nursing assistant to find out when the last pain medication was given to the client. c. Ask the nursing assistant to tell the client in pain that medication will be administered as soon as the bed bath is complete. d. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. Source: Saunders 4th

ANS: D Rationale: The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the nursing assistant. Strategy: Use the process of elimination and principles related to priorities of care. Options 1 and 3 delay the administration of pain medication, and option 2 is not a responsibility of the nursing assistant. The appropriate action is to plan to administer the medication. Review principles related to priorities of care if you had difficulty with this question. Reference: Jarvis, C. (2004). Physical examination and health assessment (4th ed., p. 4). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 267-268, 1030). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Implementation Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

38) The RN employed in a long-term care facility is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has a licensed practical (vocational) nurse and three nursing assistants on a nursing team. Which of the following clients would the nurse most appropriately assign to the licensed practical (vocational) nurse? a. The client who requires a bed bath b. An older client requiring frequent ambulation c. A client who requires a 24-hour urine collection d. A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours Source: Saunders 4th

ANS: D Rationale: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Collecting a 24-hour urine sample, giving a bed bath, and assisting with frequent ambulation can be provided most appropriately by the nursing assistant. The licensed practical (vocational) nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care. Strategy: Use the process of elimination and knowledge regarding the principles of delegation and assignment making. Focus on the subject, assignment to a licensed practical/vocational nurse. Recall that education and job position as described by the nurse practice act and employee guidelines need to be considered when delegating activities and making assignments. Options 1, 2, and 3 easily can be eliminated because a nursing assistant can perform these tasks. If you had difficulty with this question, review the principles of delegation and assignment making. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., pp. 545-546). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 41-42, 378). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Delegating and Prioritizing Alternate Question Types -> Multiple Choice

43) Client assignment and nursing activities include the following: (see image)<br />The home health care nurse is planning client visits and nursing activities for the day. The nurse begins the visits at 9 <sc>AM</sc>. All clients live within a 5-mile radius. List in order of priority how the nurse should plan the order of the assignments for the day? (Number 1 is the first client and/or nursing activity for the day and number 6 is the last.) a. A client requiring twice daily abdominal dressing changes. b. A client with diabetes mellitus who needs a fasting blood glucose level drawn. c. A client who will be visited by home health aide at 10 AM, and the nurse needs to orient the aide and provide supervision of client care. d. A client whose spouse is performing daily dressing changes, and the nurse needs to supervise the spouse in performing the dressing change. e. A client who was discharged yesterday from the hospital following a diagnosis of pneumonia who needs to admitted to home health care. Source: Saunders 4th

ANS: E ANS: C ANS: D ANS: B ANS: F ANS: A Rationale: The nurse would plan to visit the client with diabetes mellitus first and draw the fasting blood glucose level because this client needs to remain NPO until the blood is drawn. This client would also not be able to take any medication, such as insulin, until the blood is drawn. The nurse would plan to see the client requiring twice-daily dressing changes next because the dressing changes should be spaced as far apart as possible. The nurse then would plan to see the client being visited by the home health aide and provide instructions and directions to the home health aide regarding care to the client. The nurse then would visit the client regarding supervision of the dressing change and would perform the admission last because that may take more time than the other clients. The nurse then would return to the client requiring the second twice-daily dressing change. Strategy: Note the needs of the client and the role of the nurse in caring for each of the clients. Noting that the client with diabetes mellitus needs to remain NPO until the blood is drawn will assist in determining that this client needs to be visited first. Noting that the client requiring twice-daily dressing changes will need to be seen twice will assist in determining the next and last client visit of the day, because dressing changes should be spaced as far apart as possible. Next, note that the home health aide will be with the client at 10 <sc>AM</sc>; this client will be seen next. From the remaining clients, select the client requiring a supervised dressing change to be seen next because the client admission may take time. If you had difficulty with this question, review the process of planning care and time management. Reference: Huber, D. (2006). Leadership and nursing care management (3rd ed., p. 83). Philadelphia: W.B. Saunders. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 377-378). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Safe and Effective Care Environment Integrated Process -> Nursing Process—Planning Content Area -> Delegating and Prioritizing Alternate Question Types -> Prioritize Chart

75) A nurse is preparing to obtain an arterial blood gas specimen from a client and plans to perform the Allen's test on the client. Number in order of priority the steps for performing the Allen's test. (Number 1 is the first step and number 6 is the last step.) a. Document the findings. b. Explain the procedure to the client. c. Release pressure from the ulnar artery. d. Apply pressure over the ulnar and radial arteries. e. Ask the client to open and close the hand repeatedly. f. Assess the color of the extremity distal to the pressure point. Source: Saunders 4th

ANS: F ANS: A ANS: D ANS: B ANS: C ANS: E Rationale: The Allen's test is performed before obtaining an arterial blood specimen from the radial artery to determine the presence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. The nurse first would explain the procedure to the client. To perform the test, the nurse applies direct pressure over the client's ulnar and radial arteries simultaneously. While applying pressure, the nurse asks the client to open and close the hand repeatedly; the hand should blanch. The nurse then releases pressure from the ulnar artery while compressing the radial artery and assesses the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used for obtaining a blood specimen. Finally, the nurse documents the findings. Strategy: Recalling that the procedure needs to be explained to the client will assist in determining the first action. Next, think about the purpose and reason for performing this test and visualize the procedure. This will assist in determining the steps for performing the Allen's test. Remember, the nurse would document the findings last. Review this test if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 731-732). St. Louis: Mosby. Level of Cognitive Ability -> Application Client Needs -> Physiological Integrity Integrated Process -> Nursing Process—Assessment Content Area -> Delegating and Prioritizing Alternate Question Types -> Prioritize