#101-150 Physiological Integrity Practice Questions

140. A client diagnosed with gestational diabetes is at 36 weeks of gestation. The client has had weekly reactive nonstress tests for the last 3 weeks. This week, the nonstress test was nonreactive after 40 minutes. Based on these results, the nurse would prepare the client for which intervention? 1. A contraction stress test 2. Immediate induction of labor 3. Hospitalization with continuous fetal monitoring 4. A return appointment in 2 days to repeat the nonstress test

Answer: 1 Rationale: A nonreactive nonstress test needs further assessment. A contraction stress test is the next test needed to further assess the fetal status. There are not enough data in the question to indicate that the procedures in options 2 and 3 are necessary at this time. To send the client home for 2 days may place the fetus in jeopardy. Test-Taking Strategy: Focus on the subject, a change in nonstress test results from reactive to nonreactive. Options 2 and 3 can be eliminated first because they are unnecessary at this time. Option 4 can be eliminated next because repeating the test at a later time is not a safe intervention, especially considering the fact that previous test results were reactive. Priority Nursing Tip: A nonstress test is performed to assess placental function and oxygenation and evaluate the fetal heart rate response to fetal movement

106. The nurse is caring for a child recovering from a tonsillectomy. Which fluid or food item would be offered to the child? 1. Green Jell-O 2. Cold soda pop 3. Butterscotch pudding 4. Cool cherry-flavored Kool-Aid

Answer: 1 Rationale: After tonsillectomy, clear, cool liquids should be administered. Citrus, carbonated, and extremely hot or cold liquids need to be avoided because they may irritate the throat. Milk and milk products (pudding) are avoided because they coat the throat and cause the child to clear the throat, thus increasing the risk of bleeding. Red liquids need to be avoided because they give the appearance of blood if the child vomits. Test-Taking Strategy: Focus on the subject, care after tonsillectomy. Avoiding foods and fluids that may irritate or cause bleeding is the concern. This will assist in eliminating options 2 and 3. The words "cherry-flavored" in option 4 should be the clue that this is not an appropriate food item. Priority Nursing Tip: After tonsillectomy, position the client prone or side-lying to facilitate mouth drainage.

137. A client is scheduled for computed tomography (CT) of the kidneys to rule out renal cancer. Which would the nurse assess the client for before the procedure to best assure the client's safety? 1. Allergies 2. Familial renal disease 3. Frequent antibiotic use 4. Long-term diuretic therapy

Answer: 1 Rationale: The client undergoing any type of diagnostic testing involving possible dye administration should be questioned about allergies, specifically an allergy to shellfish or iodine. This is essential to identify the risk for potential allergic reaction to contrast dye, which may be used. The other items are also useful as part of the assessment but are not as critical as the allergy determination in the preprocedure period in the attempt to maximize client safety. Test-Taking Strategy: Note the strategic word, best, and focus on the subject, preprocedural CT scan. Because the question indicates that CT of the kidneys is planned, the items in the options are evaluated against their potential connection to this aspect of care. Recalling that contrast dye may be used during CT to enhance visualization of the kidneys will direct you to the correct option. Priority Nursing Tip: The nurse should ask the client if he or she ever had an allergic reaction to contrast media used for diagnostic testing. If so, the client is at high risk for experiencing another reaction if contrast media is administered

144. The nurse is assigned to care for an infant on the first postoperative day after a surgical repair of a cleft lip. Which nursing intervention is appropriate when caring for this child's surgical incision? 1. Rinsing the incision with sterile water after feeding 2. Cleaning the incision only when serous exudate forms 3. Rubbing the incision gently with a sterile cotton-tipped swab 4. Replacing the Logan bar carefully after cleaning the incision

Answer: 1 Rationale: The incision should be rinsed with sterile water after every feeding. Rubbing alters the integrity of the suture line. Rather, the incision should be patted or dabbed. The purpose of the Logan bar is to maintain the integrity of the suture line. Removing the Logan bar on the first postoperative day would increase tension on the surgical incision. Test-Taking Strategy: Focus on the subject, cleft lip repair. Eliminate options 2 and 3 first because of the word "only" in option 2 and "rubbing" in option 3. Focus on the words "first postoperative day." This should assist in eliminating option 4. Priority Nursing Tip: After cleft lip repair, avoid positioning the infant on the side of the repair or in the prone position because these positions can cause rubbing of the surgical site on the mattress.

138. The nurse assists a client diagnosed with pyelonephritis in collecting a 24-hour urine specimen. Which instruction does the nurse provide to the client to ensure proper collection of the 24-hour urine specimen? 1. Void at the start time and discard the specimen. 2. Strain the specimen before pouring the urine into the container. 3. Save all urine, beginning with the urine voided at the start time. 4. Once completed, refrigerate the urine collection until you can bring it to the laboratory.

Answer: 1 Rationale: The nurse instructs the client to void at the beginning of the collection period and discard this urine sample because this urine has been stored in the bladder for an undetermined length of time. All urine thereafter is saved in an iced or refrigerated container. The client is asked to void at the finish time, and this sample is the last specimen added to the collection. Straining the urine is not done for timed urine collections. The container is labeled, placed on fresh ice, and brought to the laboratory immediately after the 24-hour urine collection has ended. Test-Taking Strategy: Focusing on the subject, a 24-hour urine collection, will assist in eliminating options 2 and 4. Straining the urine is not done, and the urine must be sent to the laboratory immediately after the collection time has ended. For the remaining options, think about the procedure. Remember that it is best to discard the first specimen. Priority Nursing Tip: If the client is collecting a 24-hour urine specimen, check with the laboratory about the need to restrict certain foods or avoid taking certain medications before and during the collection. Some foods and medications affect test results.

147. The nurse monitoring a postoperative client would recognize which behaviors as indicators that the client is in pain? Select all that apply. 1. Gasping 2. Lip biting 3. Muscle tension 4. Pacing activities 5. Staring out the window 6. Asking for the television to be turned off

Answer: 1, 2, 3, 4 Rationale: The nurse should assess verbalization, vocal response, facial and body movements, and social interaction as indicators of pain. Behavioral indicators of pain include gasping, lip biting (facial expressions), muscle tension, pacing activities, moaning, crying, grunting (vocalizations), grimacing, clenching teeth, wrinkling the forehead, tightly closing or widely opening the eyes or mouth, restlessness, immobilization, increased hand and finger movements, rhythmic or rubbing motions, protective movements of body parts (body movement), avoidance of conversation, focusing only on activities for pain relief, avoiding social contacts and interactions, and reduced attention span. Options 5 and 6 are not to be assumed as pain-related behaviors because there can be a variety of reasons for such actions. Test-Taking Strategy: Focus on the subject, behavioral indicators of pain. Think about the physiological and psychosocial responses that occur during the pain experience as you read each option. This will assist in answering correctly. Priority Nursing Tip: It is important for the nurse to monitor for behavioral indicators of pain, particularly if the client is unable to verbalize the presence of pain.

108. The nurse monitoring a preterm newborn infant for manifestations of respiratory distress syndrome (RDS) would assess the infant for which manifestations? Select all that apply. 1. Cyanosis 2. Tachypnea 3. Retractions 4. Nasal flaring 5. Acrocyanosis 6. Grunting respirations

Answer: 1, 2, 3, 4, 6 Rationale: The newborn infant with RDS may present with clinical manifestation of cyanosis, tachypnea or apnea, chest wall retractions, audible grunts, or nasal flaring. Acrocyanosis, the bluish discoloration of the hands and feet, is associated with immature peripheral circulation and is not uncommon in the first few hours of life. Test-Taking Strategy: Focus on the subject, manifestations of respiratory distress syndrome. Think about the pathophysiology associated with this disorder. Also, recalling that acrocyanosis may be a normal sign in a newborn infant will assist in eliminating it as an option. Priority Nursing Tip: The presence of retractions indicates respiratory distress and possible hypoxemia.

148. A client who experienced a stroke and has dysphagia is receiving enteral nutrition. The nurse plans care considering which conditions that place the client receiving enteral nutrition at increased risk for aspiration? Select all that apply. 1. Sedation 2. Coughing 3. An artificial airway 4. Head-elevated position 5. Nasotracheal suctioning 6. Decreased level of consciousness

Answer: 1, 2, 3, 5, 6 Rationale: A serious complication associated with enteral feedings is aspiration of formula into the tracheobronchial tree. Some common conditions that increase the risk of aspiration include sedation, coughing, an artificial airway, nasotracheal suctioning, decreased level of consciousness, and lying flat. A head-elevated position does not increase the risk of aspiration. Test-Taking Strategy: Focus on the subject, the risks associated with aspiration. Recall that aspiration is the inhalation of foreign material into the tracheobronchial tree. Next read each option and think about the effect it produces with regard to aspiration. This will direct you to the correct options. Priority Nursing Tip: The nurse must assess the client for conditions that place him or her at risk of aspiration. Aspiration can result in airway obstruction.

130. The nurse in the postpartum unit is assessing for signs of breastfeeding problems demonstrated by either the newborn or the mother. Which findings indicate a problem? Select all that apply. 1. The infant exhibits dimpling of the cheeks. 2. The infant makes smacking or clicking sounds. 3. The mother's breast gets softer during a feeding. 4. Milk drips from the mother's breast occasionally. 5. The infant falls asleep after feeding less than 5 minutes. 6. The infant can be heard swallowing frequently during a feeding.

Answer: 1, 2, 5 Rationale: It is important for the nurse to identify breast-feeding problems while the mother is hospitalized so that the nurse can teach the mother how to prevent and treat any problems. Infant signs of breast-feeding problems include dimpling of the cheeks; making smacking or clicking sounds; falling asleep after feeding less than 5 minutes; refusing to breast-feed; tongue thrusting; failing to open the mouth at latch-on; turning the lower lip in; making short, choppy motions of the jaw; and not swallowing audibly. Softening of the breast during feeding, noting milk in the infant's mouth or dripping from the mother's breast occasionally, and hearing the infant swallow are signs that the infant is receiving adequate nutrition. Test-Taking Strategy: Focus on the subject, signs of breast-feeding problems. Think about the process of feeding and visualize the effect of each observation identified in the options. This will direct you to the correct options. Priority Nursing Tip: If the mother is breast-feeding, calorie needs increase by 200 to 500 calories per day; increased fluids and the continuance of prenatal vitamins and minerals are important.

149. A client, experiencing a sudden onset of chest pain and dyspnea, is diagnosed with a pulmonary embolus. The nurse immediately implements which expected prescriptions for this client? Select all that apply. 1. Supplemental oxygen 2. High-Fowler's position 3. Semi-Fowler's position 4. Morphine sulfate intravenously 5. Meperidine hydrochloride intravenously 6. Two tablets of acetaminophen with codeine

Answer: 1, 3, 4 Rationale: Standard therapeutic intervention for the client with pulmonary embolus includes proper positioning, oxygen, and intravenous analgesics. The head of the bed is placed in semi-Fowler's position. High-Fowler's is avoided because extreme hip flexure slows venous return from the legs and increases the risk of new thrombi. The usual analgesic of choice is morphine sulfate administered intravenously. This medication reduces pain, alleviates anxiety, and can diminish congestion of blood in the pulmonary vessels because it causes peripheral venous dilation. Test-Taking Strategy: Note the strategic word, immediately. Eliminate option 2 first because a high-Fowler's position could place the client at risk for development of new thrombi. From the remaining options, recall that morphine is used for its vasodilating effects as well as its opioid effects for a client experiencing chest pain. Priority Nursing Tip: Clients prone to pulmonary embolism are those at risk for deep vein thrombosis.

124. A magnetic resonance imaging (MRI) scan is prescribed for a client with a suspected brain tumor. Which prescription would the nurse expect to be prescribed for the client before the procedure? 1. An opioid 2. A mild sedative 3. A corticosteroid 4. An antihistamine

Answer: 2 Rationale: An MRI scan is a noninvasive diagnostic test that visualizes the body's tissues, structure, and blood flow. For an MRI, the client is positioned on a padded table and moved into a cylindershaped scanner. Relaxation techniques, an eye mask, and sedation are used before the procedure to reduce claustrophobic effects; however, because the client must remain very still during the scan, the nurse avoids oversedating the client to ensure client cooperation. There is no useful purpose for administering an opioid, corticosteroid, or antihistamine. Open MRI systems are available in some diagnostic facilities and this method of testing can be used for clients with claustrophobia. Test-Taking Strategy: Focus on the subject, magnetic resonance imaging (MRI) scan. Recalling that claustrophobia is a concern will direct you to the correct option. Priority Nursing Tip: In an MRI scan, magnetic fields are used to produce an image. Therefore, all metallic objects such as a watch, other jewelry, clothing with metal fasteners, and metal hair fasteners must be removed.

136. A client in labor has a diagnosis of sickle cell anemia. Which action would the nurse take to assist in preventing the client from experiencing a sickling crisis during labor? 1. Being reassuring 2. Administering oxygen 3. Preventing bearing down 4. Maintaining strict asepsis

Answer: 2 Rationale: During the labor process, the client with sickle cell anemia is at high risk for being unable to meet the oxygen demands of labor. Administering oxygen will prevent sickle cell crisis during labor. Intravenous (IV) fluid therapy will also reduce the risk of a sickle cell crisis. Options 1 and 4 are appropriate actions but are unrelated to sickle cell crisis. Option 3 is inappropriate. Test-Taking Strategy: Focus on the client's diagnosis and use the ABCs—airway, breathing, and circulation—to direct you to the correct option. Priority Nursing Tip: During labor, the client with sickle cell anemia needs to receive oxygen and fluids to prevent hypoxemia and dehydration because these conditions stimulate the sickling process.

142. When the nasogastric (NG) tube of a client diagnosed with acute pancreatitis stops draining, which intervention would the nurse implement to maintain client safety? 1. Remove and replace the tube. 2. Verify the tube placement according to agency procedure. 3. Clamp the tube for 2 hours to allow the drainage to accumulate. 4. Retract the tube by 2 inches so that it is above a possible obstruction.

Answer: 2 Rationale: If a client's nasogastric tube stops draining, the nurse verifies placement first to ensure that the tube remains in the stomach. After checking placement and verifying a prescription for tube irrigation, the nurse irrigates the tube with 30 to 60 mL of the fluid per agency procedure. Clamping the tube increases the risk of aspiration and is contraindicated; besides, this intervention cannot unclog a tube. Retracting the tube may displace the tube and place the client at risk for aspiration. Replacement of the tube is the last step if other actions are unsuccessful. Test-Taking Strategy: Focus on the subject, the NG tube stopped draining. Eliminate option 1 because this would be done only if other interventions are unsuccessful. Next, eliminate options 3 and 4 because these interventions increase client risk of aspiration. Also use the steps of the nursing process; option 2 is the only assessment action. Priority Nursing Tip: Accurate placement of a gastrointestinal tube is always checked before instilling feeding solutions, medications, or any other solution.

150. A client is scheduled to have a percutaneous transluminal coronary angioplasty (PTCA) to treat coronary artery disease. What information about the balloon-tipped catheter would the nurse plan to include when providing client education concerning the procedure? 1. A mesh-like device within the catheter will be inflated causing it to spring open. 2. The catheter will be used to compress the plaque against the coronary blood vessel wall. 3. The catheter will cut away the plaque from the coronary vessel wall using an embedded blade. 4. The catheter will be positioned in a coronary artery to take pressure measurements in the vessel.

Answer: 2 Rationale: In PTCA, a balloon-tipped catheter is used to compress the plaque against the coronary blood vessel wall. Option 1 describes placement of a coronary stent, option 3 describes coronary atherectomy, and option 4 describes part of the process used in cardiac catheterization. Test-Taking Strategy: Focus on the subject, percutaneous transluminal coronary angioplasty (PTCA). Look at the name of the procedure. "Angioplasty" refers to repair of a blood vessel; this will assist in eliminating options 1 and 4. From the remaining options, recalling that a procedure that cuts something away would have the suffix -ectomy will assist in eliminating option 3. Priority Nursing Tip: Complications of PTCA include arterial dissection or rupture, embolization of plaque fragments, spasm, and acute myocardial infarction.

128. The nurse providing diet teaching to a client experiencing heart failure instructs the client to avoid which food item? 1. Sherbet 2. Steak sauce 3. Apple juice 4. Leafy green vegetables

Answer: 2 Rationale: Steak sauce is high in sodium. Leafy green vegetables, any juice (except tomato or V8 brand vegetable), and sherbet are all low in sodium. Clients with heart failure should monitor sodium intake. Test-Taking Strategy: Focus on the subject, a client with heart failure. Note the word "avoid." This word asks you to select an inappropriate food choice. Note that options 1, 3, and 4 are comparable or alike in that they are low-sodium foods. Recalling that the client with heart failure should limit sodium intake will direct you to the correct option. Priority Nursing Tip: Clients with heart failure need to monitor sodium intake because sodium causes the retention of fluid.

146. A client being treated for a bowel obstruction is receiving total parenteral nutrition (TPN) via a central venous catheter (CVC) and is scheduled to receive an intravenous (IV) antibiotic. Which intervention would the nurse implement before administering the antibiotic? 1. Turn off the TPN for 30 minutes. 2. Ensure a separate IV access route. 3. Flush the CVC with normal saline. 4. Check for compatibility with TPN.

Answer: 2 Rationale: The TPN line is used only for the administration of the TPN solution to prevent crystallization in the CVC tubing and disruption of the TPN infusion. Any other IV medication must be administered through a separate IV access site, including a separate infusion port of the CVC catheter. Therefore, options 1, 3, and 4 are incorrect actions. Test-Taking Strategy: Focus on the subject, total parenteral nutrition. Eliminate options 1, 3, and 4 because they are comparable or alike in that they involve using the TPN line for the administration of the antibiotic. Priority Nursing Tip: Parenteral nutrition solutions that are cloudy or darkened should not be used for administration and should be returned to the pharmacy.

117. A clinical nurse specialist is asked to present a clinical conference to the student group about brain tumors in children younger than 3 years. The nurse would include which information in the presentation? 1. Radiation is the treatment of choice. 2. The most significant symptoms are headache and vomiting. 3. Head shaving is not required before removal of the brain tumor. 4. Surgery is not normally performed because of the increased risk of functional deficits.

Answer: 2 Rationale: The classic symptoms of children with brain tumors are headaches and vomiting. The treatment of choice is total surgical removal of the tumor. Before surgery, the child's head will be shaved, although every effort is made to shave only as much hair as is necessary. Radiation therapy is avoided in children younger than 3 years because of the toxic side effects on the developing brain, particularly in very young children. Test-Taking Strategy: Focus on the subject, brain tumors in children. Eliminate options 3 and 4 first because of the closed-ended word "not." From the remaining options, recalling that radiation therapy is avoided in children younger than 3 years because of the toxic side effects on the developing brain will lead you to the correct option. Priority Nursing Tip: The headache associated with a brain tumor in a child is worse on awakening and improves during the day.

115. The nurse is monitoring a child with mumps for complications. Which manifestation is a sign of the most common complication of this disease? 1. Pain 2. Nuchal rigidity 3. Impaired hearing 4. A red swollen testicle

Answer: 2 Rationale: The most common complication of mumps is aseptic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. Muscular pain, parotid pain, or testicular pain may occur, but pain does not indicate a sign of a common complication. Although mumps is one of the primary causes of unilateral nerve deafness, it does not occur frequently. A red swollen testicle may be indicative of orchitis. Although this complication appears to cause most concern among parents, it is not the most common complication. Test-Taking Strategy: Focus on the subject, the most common complication of mumps, and the strategic word, most. Recalling that aseptic meningitis is the most common complication of mumps will direct you to the correct option. Priority Nursing Tip: Transmission of mumps is via direct contact or droplet spread from an infected person.

109. The nurse assessing the apical heart rates of several different newborn infants notes that which heart rate is normal for this newborn population? 1. 90 beats/min 2. 140 beats/min 3. 180 beats/min 4. 190 beats/min

Answer: 2 Rationale: The normal heart rate in a newborn infant is approximately 100 to 160 beats/min. Options 1, 3, and 4 are incorrect. Option 1 indicates bradycardia, and options 3 and 4 indicate tachycardia. Test-Taking Strategy: Focus on the subject, a newborn infant heart rate. Recalling the normal heart rate for a newborn infant will direct you to the correct option. Priority Nursing Tip: To measure the apical heart rate of a newborn infant, the nurse should place the stethoscope at the fourth intercostal space and auscultate for 1 full minute.

114. What action would the nurse take to assess the pharyngeal reflex on a child prescribed liquids post-appendectomy? 1. Ask the client to swallow. 2. Pull down on the lower eyelid. 3. Shine a light toward the bridge of the nose. 4. Stimulate the back of the throat with a tongue depressor.

Answer: 2 Rationale: The pharyngeal (gag) reflex is tested by touching the back of the throat with an object, such as a tongue depressor. A positive response to this reflex is considered normal. Asking the client to swallow assesses the swallowing reflex. To assess the palpebral conjunctiva, the nurse would pull down and evert the lower eyelid. The corneal light reflex is tested by shining a penlight toward the bridge of the nose at a distance of 12 to 15 inches (light reflection should be symmetrical in both corneas). Test-Taking Strategy: Focus on the subject, pharyngeal reflex. Recalling that "pharyngeal" refers to the pharynx, or back of the throat, will assist in determining how this reflex is tested and direct you to the correct option. Priority Nursing Tip: If a client receives a local throat anesthetic for a diagnostic or other procedure, the client must remain nothing by mouth (NPO) until the gag reflex returns.

118. The nurse caring for a child admitted to the hospital with a diagnosis of viral pneumonia describes the treatment plan to the parents. The nurse determines the need for further teaching when the parents make which statement regarding the treatment? 1. "We need to be very careful since oxygen is extremely flammable." 2. "It's important that the child isn't allergic to the antibiotic that is prescribed." 3. "It's difficult to watch the needle be inserted when intravenous fluids are needed." 4. "Chest physiotherapy will loosen the congestion, so coughing will clear the lungs."

Answer: 2 Rationale: The therapeutic management for viral pneumonia is supportive. Antibiotics are not given unless the pneumonia is bacterial. More severely ill children may be hospitalized and given oxygen, chest physiotherapy, and intravenous fluids. Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Also note the word "viral" in the question. Recalling that viral infections are not treated with antibiotics will direct you to option 2. Oxygen, intravenous fluids, and chest physiotherapy are all appropriate interventions for this child. Priority Nursing Tip: If a specimen culture is prescribed, the culture is obtained before prescribed antibiotics are initiated.

102. The nurse is reviewing the records of recently admitted clients to the postpartum unit. The nurse determines that which clients would have an increased risk for developing a puerperal infection? Select all that apply. 1. A client who has given birth to a set of twins 2. A client with a history of previous infections 3. A client who had numerous vaginal examinations 4. A client who has experienced three previous miscarriages 5. A client who underwent a vaginal delivery of the newborn 6. A client who experienced prolonged rupture of the membranes

Answer: 2, 3, 6 Rationale: Risk factors associated with puerperal infection include a history of previous infections, excessive number of vaginal examinations, cesarean births, prolonged rupture of the membranes, prolonged labor, trauma, and retained placental fragments. A vaginal delivery, a history of miscarriages, and the delivery of twins are not considered as risk factors for developing a puerperal infection. Test-Taking Strategy: Focus on the subject, risks for developing a puerperal infection. Think about the causes of infection and select the options that present a pathway for bacteria to enter into the woman's body. Priority Nursing Tip: The temperature may be elevated during the first 24 hours postpartum because of the dehydrating effects of labor. However, a temperature higher than 100.4° F needs to be reported to the primary health care provider because it is an indication of infection

105. The nurse is caring for a client with a diagnosis of pemphigus vulgaris. On assessment of the client, the nurse would look for which sign characteristic of this condition? 1. Turner's sign 2. Chvostek's sign 3. Nikolsky's sign 4. Trousseau's sign

Answer: 3 Rationale: A hallmark sign of pemphigus vulgaris is Nikolsky's sign, which occurs when the epidermis can be rubbed off by slight friction or injury. Other characteristics include flaccid bullae that rupture easily and emit a foul-smelling drainage, leaving crusted, denuded skin. The lesions are common on the face, back, chest, and umbilicus. Even slight pressure on an intact blister may cause spread to adjacent skin. Turner's sign refers to a grayish discoloration of the flanks and is seen in clients with acute pancreatitis. Chvostek's sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Trousseau's sign is a sign for tetany, in which carpal spasm can be elicited by compressing the upper arm with a blood pressure cuff inflated above the systolic pressure and causing ischemia to the nerves distally. Test-Taking Strategy: Focus on the subject, pemphigus vulgaris. Eliminate options 2 and 4 first because they are comparable or alike and both relate to tetany. From the remaining options, recalling that Turner's sign is related to pancreatitis will direct you to the correct option. Priority Nursing Tip: Pemphigus vulgaris is a rare autoimmune disease that causes blister (bullae) formation. The nurse needs to provide gentle care to prevent disruption of the skin lesions.

121. The nurse is performing pin-site care on a client in skeletal traction. Which normal finding would the nurse expect to note when assessing the pin sites? 1. Numbness at the pin sites 2. Warm skin around the pin sites 3. Clear drainage from the pin sites 4. Redness and swelling around the pin sites

Answer: 3 Rationale: A small amount of clear drainage ("weeping") may be expected after cleaning and removing crusting around the pin sites of skeletal traction. Warmth, numbness, redness and swelling around the pin sites may be indicative of an infection. Test-Taking Strategy: Focus on the subject, pin-site care. Option 1 is not an expected finding and can be eliminated first because it could indicate a neurovascular problem. Eliminate options 2 and 4 next because they are comparable or alike and indicate signs of infection. Priority Nursing Tip: Skeletal traction is applied mechanically to the bone with pins, wires, or tongs. Because skin integrity is disrupted, the client is at risk for infection.

143. The nurse is planning to give a tepid tub bath to a child experiencing hyperthermia. Which action would the nurse plan to perform? 1. Obtain isopropyl alcohol to add to the bath water. 2. Allow 5 minutes for the child to soak in the bath water. 3. Have cool water available to add to the warm bath water. 4. Warm the water to the same body temperature as the child's.

Answer: 3 Rationale: Adding cool water to an already warm bath allows the water temperature to slowly drop. The child is able to gradually adjust to the changing water temperature and will not experience chilling. Alcohol is toxic, can cause peripheral vasoconstriction, and is contraindicated for tepid sponge or tub baths. The child should be in a tepid tub bath for 20 to 30 minutes to achieve maximum results. To achieve the best cooling results, the water temperature should be at least 2 degrees lower than the child's body temperature. Test-Taking Strategy: Focus on the subject, tepid water bath. Eliminate option 1, recalling that alcohol is toxic, as well as irritating, to the skin. Eliminate option 4 because water that is the same as body temperature will not reduce hyperthermia. Eliminate option 2 because of the 5-minute time frame. Priority Nursing Tip: Perform a complete assessment on a child with a fever. Assessment findings associated with the fever provide important indications of the seriousness of the fever.

111. The nurse managing a child's post-supratentorial craniotomy care would assure that the client is maintained in which position? 1. Prone 2. Supine 3. Semi-Fowler's 4. Dorsal recumbent

Answer: 3 Rationale: After supratentorial surgery (surgery above the brain's tentorium sometimes preformed for glioma tumor removal), the client's head is usually elevated 30 degrees to promote venous outflow through the jugular veins and modulate intracranial pressure (ICP). Options 1, 2, and 4 are incorrect positions after this surgery because they are likely to increase ICP. Test-Taking Strategy: Focus on the subject, supratentorial craniotomy. A helpful strategy is to remember the following: supra, above the brain's tentorium, head up. Also note that options 1 and 2 are comparable or alike in that they are flat positions; option 4 is eliminated because the increased intraabdominal pressure from this position is more likely to inhibit venous return from the brain. Priority Nursing Tip: To prevent increased ICP, position the client to avoid extreme hip or neck flexion and maintain the head in a midline, neutral position.

129. The nurse is developing a plan of care for a client diagnosed with type 1 diabetes mellitus who is also experiencing acute gastroenteritis. To maintain food and fluid intake in order to prevent dehydration, which action would the nurse plan to include? 1. Offering only water until the client is able to tolerate solid foods 2. Withholding all fluids until vomiting has ceased entirely for at least 4 hours 3. Encouraging the client to take 8 to 12 ounces of fluid every hour while awake 4. Maintaining a clear liquid diet for at least 5 days before advancing to solid foods

Answer: 3 Rationale: Dehydration needs to be prevented in the client with type 1 diabetes mellitus because of the risk of diabetic ketoacidosis (DKA). Small amounts of fluid may be tolerated, even when vomiting is present. The client should be offered liquids containing both glucose and electrolytes. The diet should be advanced as tolerated and include a minimum of 100 to 150 g of carbohydrates daily. Offering water only and maintaining liquids for 5 days will not prevent dehydration but may promote it in this client. Test-Taking Strategy: Focus on the subject, type 1 diabetes mellitus. Eliminate options 1 and 2 because of the closed-ended words "only" and "all" in these options, respectively. From the remaining options, note the words "for at least 5 days" in option 4. Thinking about the subject, a client with diabetes mellitus and preventing dehydration, will assist in eliminating this option. Priority Nursing Tip: Diabetic ketoacidosis is a life-threatening complication of type 1 diabetes mellitus that develops when a severe insulin deficiency occurs.

132. The nurse suspects that an air embolism has occurred when the client's central venous catheter disconnects from the intravenous (IV) tubing. The nurse immediately places the client on her or his left side in which position? 1. Fetal 2. High-Fowler's 3. Trendelenburg's 4. Lateral recumbent

Answer: 3 Rationale: If the client develops an air embolism, the immediate action is to place the client in Trendelenburg's position on the left side. This position raises the client's feet higher than the head and traps any air in the right atrium. If necessary, the air can then be directly removed by intracardiac aspiration. Option 2 is incorrect because that position elevates the head, putting the air in a dependent position, and increasing the risk of a cerebral embolism; lying flat in either the lateral and fetal position does not help trap the air in the right atrium. Test-Taking Strategy: Focus on the subject, air embolism. Note the strategic word, immediately. Visualize each position in the options and recall cardiac anatomy. Recalling that the goal of action is to trap air in the right atrium will direct you to the correct option. Priority Nursing Tip: If an air embolism is suspected, the intravenous tubing is clamped off immediately.

145. A client is in ventricular tachycardia and the primary health care provider prescribes intravenous (IV) lidocaine. The nurse would dilute the concentrated solution of lidocaine with which solution? 1. Lactated Ringer's 2. Normal saline 0.9% 3. 5% Dextrose in water 4. Normal saline 0.45%

Answer: 3 Rationale: Lidocaine for IV administration is dispensed in concentrated and dilute formulations. The concentrated formulation must be diluted with 5% dextrose in water. Therefore, options 1, 2, and 4 are incorrect. Test-Taking Strategy: Focus on the subject, IV lidocaine. Eliminate options 2 and 4 first because they are comparable or alike since they are similar solutions. From the remaining options, it is necessary to know that the concentrated formulation must be diluted with 5% dextrose in water. Priority Nursing Tip: When administering lidocaine, be sure that resuscitative equipment is readily available.

125. A dose of ondansetron is prescribed for a client receiving chemotherapy for a brain tumor. The nurse anticipates that the primary health care provider will prescribe the medication by which route during the chemotherapy infusion? 1. Oral 2. Intranasal 3. Intravenous 4. Subcutaneous

Answer: 3 Rationale: Ondansetron is an antiemetic used to control nausea, vomiting, and motion sickness. It is available for administration by the oral, intramuscular (IM), or intravenous (IV) routes. The IV route is the route used when relief of nausea is needed in the client receiving chemotherapy. The IM route may be used when the medication is used as an adjunct to anesthesia. Option 1 should not be used in clients who are nauseated. Options 2 and 4 are not routes of administration of this medication. Test-Taking Strategy: Focus on the subject, ondansetron administration to a client receiving chemotherapy. Noting that the client is receiving chemotherapy will direct you to the correct option. Priority Nursing Tip: Antiemetics can cause drowsiness and hypotension; therefore, a priority intervention is to protect the client from injury.

110. The primary health care provider prescribes a dose of intravenous (IV) potassium chloride for a client diagnosed with a cardiac dysrhythmia. When administering the IV potassium chloride, which action would the nurse take? 1. Inject it as a bolus. 2. Use a filter in the IV line. 3. Dilute it per medication instructions. 4. Apply cool compresses to the IV site.

Answer: 3 Rationale: Potassium chloride is very irritating to the vein and must be diluted to prevent phlebitis and is administered using an IV pump. Potassium chloride is never administered as a bolus injection because it can cause cardiac arrest. A filter is not necessary for potassium solutions. Cool compresses would constrict the blood vessel, which could possibly be more irritating to the vein. Test-Taking Strategy: Focus on the subject, intravenous potassium administration. Recalling that potassium chloride is always diluted before administration will eliminate option 1. From the remaining options, noting the words "per medication instructions" in option 3 will direct you to the correct option. Priority Nursing Tip: After adding potassium to an intravenous (IV) solution, rotate and invert the solution bag to ensure that the potassium is distributed evenly throughout the IV solution. It is also important to rotate and invert the solution bag frequently during the infusion.

116. An adolescent is hospitalized with a diagnosis of Rocky Mountain spotted fever (RMSF). The nurse anticipates that which medication will be prescribed? 1. Ganciclovir 2. Amantadine 3. Doxycycline 4. Amphotericin B

Answer: 3 Rationale: The nursing care of an adolescent with RMSF includes the administration of doxycycline. An alternative medication is chloramphenicol. Ganciclovir is used to treat cytomegalovirus. Amantadine is used to treat Parkinson's disease. Amphotericin B is used for fungal infections. Test-Taking Strategy: Focus on the subject, Rocky Mountain spotted fever (RMSF). Knowledge regarding the treatment plan associated with RMSF is required to answer this question. Remember that RMSF is treated with doxycycline. Priority Nursing Tip: The agent that causes RMSF is Rickettsia rickettsii; transmission is via the bite of an infected tick.

113. The nurse is checking postoperative prescriptions and planning care for a 110-pound child after spinal fusion. Morphine sulfate, 8 mg subcutaneously every 4 hours PRN for pain, is prescribed. The pediatric medication reference states that the safe dose is 0.1 to 0.2 mg/kg/dose every 3 to 4 hours. From this information, the nurse determines what about the prescription? 1. The dose is too low. 2. There is no safe range for children 3. The dose is within the safe dosage range. 4. There is not enough information to determine the safe dose.

Answer: 3 Rationale: Use the formula to determine the dosage parameters. Convert pounds to kilograms by dividing the weight by 2.2. Therefore, 110 lb ÷ 2.2 = 50 kg. Dosage parameters: 0.1 mg/kg/dose x 50 kg = 5 mg 0.2 mg/kg/dose x 50 kg = 10 mg Rationale: Dosage is within the safe dosage range. Test-Taking Strategy: Focus on the subject, a medication calculation. Identify the important components of the question and what the question is asking. In this case, the question asks for the safe dosage range for medication for a child. Change pounds to kilograms. Calculate the dosage parameters using the safe dose range identified in the question and the child's weight in kilograms. Use a calculator to verify the answer. Priority Nursing Tip: Conversion is the first step in the calculation of medication doses.

122. The nurse, caring for a client who has been placed in Buck's extension traction while awaiting surgical repair of a fractured femur, would perform a complete neurovascular assessment of the affected extremity that includes which interventions? Select all that apply. 1. Vital signs 2. Bilateral lung sounds 3. Pulse in the affected extremity 4. Level of pain in the affected leg 5. Skin color of the affected extremity 6. Capillary refill of the affected toes

Answer: 3, 4, 5, 6 Rationale: A complete neurovascular assessment of an extremity includes color, sensation, movement, capillary refill, and pulse of the affected extremity. Options 1 and 2 are not related to neurovascular assessment. Test-Taking Strategy: Focus on the subject, complete neurovascular assessment. Eliminate options that are not considered components of a neurovascular assessment. Also, use the ABCs—airway, breathing, and circulation—to direct you to the correct option. Priority Nursing Tip: Buck's extension traction is a type of skin traction used to alleviate muscle spasms and immobilize a lower limb. It is applied by using elastic bandages or adhesive, a foam boot, or a sling, and counter weights, and the foot of the bed is elevated to provide the traction.

131. The nurse has completed tracheostomy care for a client whose tracheostomy tube has a nondisposable inner cannula. Which intervention will the nurse implement immediately before reinserting the inner cannula? 1. Rinsing it in sterile water 2. Suctioning the client's airway 3. Tapping it gently against a sterile basin 4. Drying it with the sterile gauze or specialized pipe cleaner

Answer: 4 Rationale: After washing and rinsing the inner cannula, the nurse taps it dry to remove large water droplets and then uses sterile gauze or pipe cleaners specifically for use with a tracheostomy to dry it; then the nurse inserts the cannula into the tracheostomy and turns it clockwise to lock it into place. The nurse should avoid shaking or tapping the inner cannula to prevent contamination. A wet cannula should not be inserted into a tracheostomy because water is a lung irritant. Suctioning is not performed without an inner cannula in place. Test-Taking Strategy: Note the strategic word, immediately. Also note the word "nondisposable" and visualize the procedure. Eliminate option 1 because a wet cannula should not be inserted and option 2 because you would not suction a client without the inner cannula in place. Eliminate option 3 because tapping could contaminate the inner cannula. Priority Nursing Tip: Keep a tracheostomy obturator and a tracheostomy tube of the same size by the bedside for emergency replacement if the tracheostomy is dislodged.

134. An echocardiogram, chest x-ray (CXR), and computed axial tomography (CAT) scan are prescribed for a client being evaluated for possible coronary artery disease who has been demonstrating activity intolerance. In which order would the nurse plan to schedule the procedures to meet the needs of this client safely and effectively? 1. CAT scan and CXR in the morning and echocardiogram on the following morning 2. CXR and echocardiogram together in the morning and CAT scan in the afternoon of the same day 3. Echocardiogram in the morning and CXR and CAT scans together in the afternoon of the same day 4. CXR in the morning, echocardiogram in the afternoon, and CAT scan in the morning of the following day

Answer: 4 Rationale: CAT scans are always performed in radiology, and CXR and echocardiograms can be done at the bedside; however, the best results usually occur when the test is performed in the related department. As long as the client is stable and transportation is provided, the nurse can schedule each procedure in its department with two procedures on the first day separated by a rest period, and the remaining procedure the next day. The nurse should plan the CXR and echocardiogram on the same day because if the client's condition deteriorates after the first procedure, the nurse can obtain a portable CXR or echocardiogram. Test- Taking Strategy: Focus on the subject, scheduling multiple diagnostic procedures for the client with heart failure who has activity intolerance. Note the strategic word, ef ectively. Recalling that the client will do best if activities are spaced will direct you to the correct option. Priority Nursing Tip: The nurse should instruct the client with heart failure to balance periods of rest and activity and avoid performing isometric activities because they increase pressure in the heart.

120. A child hospitalized with a diagnosis of lead poisoning is prescribed chelation therapy. The nurse caring for the child would prepare to administer which medication? 1. Ipecac syrup 2. Activated charcoal 3. Sodium bicarbonate 4. Sodium calcium edetate (sodium calcium EDTA)

Answer: 4 Rationale: EDTA is a chelating agent that is used to treat lead poisoning. Ipecac syrup may be prescribed by the primary health care provider for use in the hospital setting but would not be used to treat lead poisoning. Activated charcoal is used to decrease absorption in certain poisoning situations. Sodium bicarbonate may be used in salicylate poisoning. Test-Taking Strategy: Focus on the subject, treatment related to lead poisoning. Think about the classifications of the medications in the options. Recalling that EDTA is a chelating agent will direct you to the correct option. Priority Nursing Tip: During chelation therapy, provide adequate hydration and monitor kidney function for nephrotoxicity because the medication is excreted via the kidneys.

126. The nurse is teaching the parents of a child diagnosed with celiac disease about dietary measures. The nurse would instruct the parents to take which measure? 1. Restrict corn and rice in the diet. 2. Restrict fresh vegetables in the diet. 3. Substitute grain cereals with pasta products. 4. Avoid foods that contain hidden sources of gluten.

Answer: 4 Rationale: Gluten is found primarily in the grains of wheat, rye, barley, and oats. Gluten is added to many foods as hydrolyzed vegetable protein that is derived from cereal grains; therefore, labels need to be read. Corn and rice, as well as vegetables, are acceptable in a gluten-free diet, and corn and rice become substitute foods. Many pasta products contain gluten. Grains are frequently added to processed foods for thickness or fillers. Test-Taking Strategy: Focus on the subject, celiac diet. Recall that a gluten-free diet is required in celiac disease. Select option 4 because it is the umbrella option. Priority Nursing Tip: Celiac crisis is precipitated by fasting, infection, or the ingestion of gluten. It causes profuse watery diarrhea and vomiting, leading to rapid dehydration, electrolyte imbalance, and severe acidosis

103. After assisting with a vaginal delivery, what would the nurse do to prevent heat loss via conduction in the newborn? 1. Wrap the newborn in a blanket. 2. Close the doors to the delivery room. 3. Dry the newborn with a warm blanket. 4. Place the newborn on a warm crib pad.

Answer: 4 Rationale: Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress. Warming the crib pad will assist in preventing hypothermia by conduction. Radiation occurs when heat from the newborn radiates to a colder surface. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth will prevent hypothermia via evaporation. Test-Taking Strategy: Focus on the subject, preventing heat loss in the newborn. Note the word "conduction" in the question to assist in selecting the correct option. Recalling that conduction occurs when a baby is on a cold surface will assist in directing you to the correct option. Priority Nursing Tip: Newborns do not shiver to produce heat. Instead, they have brown fat deposits, which produce heat.

141. The nurse is administering magnesium sulfate to a client experiencing severe preeclampsia. What intervention would the nurse implement during the administration of magnesium sulfate for this client? 1. Schedule a daily ultrasound to assess fetal movement. 2. Schedule a nonstress test every 4 hours to assess fetal well-being. 3. Assess the client's temperature every 2 hours because the client is at high risk for infection. 4. Assess for signs and symptoms of labor since the client's level of consciousness may be altered.

Answer: 4 Rationale: Magnesium sulfate is a central nervous system depressant and anticonvulsant. Because of the sedative effect of the magnesium sulfate, the client may not perceive labor. Daily ultrasounds are not necessary for this client. A nonstress test may be done, but not every 4 hours. This client is not at high risk for infection. Test-Taking Strategy: Focus on the subject, magnesium sulfate administration. Use the steps of the nursing process to answer the question. Assessment is the first step; therefore, eliminate options 1 and 2. From the remaining options, knowledge that the client is not at high risk for infection will assist in directing you to the correct option. Priority Nursing Tip: Calcium gluconate is the antidote to magnesium sulfate.

112. An infant has been found to be human immunodeficiency virus (HIV) positive. When teaching condition-specific care, which action would the nurse instruct the mother to take to minimize the infant's risk for condition-related injury? 1. Check the anterior fontanel for bulging and the sutures for widening each day. 2. Feed the infant in an upright position with the head and chest tilted slightly back to avoid aspiration. 3. Feed the infant with a special nipple and burp the infant frequently to decrease the tendency to swallow air. 4. Provide meticulous skin care to the infant and change the infant's diaper after each voiding or stool.

Answer: 4 Rationale: Meticulous skin care helps protect the HIV-infected infant from secondary infections. Bulging fontanels, feeding the infant in an upright position, and using a special nipple are unrelated to the pathology associated with HIV. Test-Taking Strategy: Focus on the subject, a newborn with HIV. Read the question carefully. The question specifically asks for instructions to be given to the mother regarding HIV. Although options 1, 2, and 3 may be correct or partially correct, the content does not specifically relate to care of the infant infected with HIV. Priority Nursing Tip: Newborns born to HIV-positive clients may test positive because the mother's antibodies may persist in the newborn for 18 months after birth.

135. The nurse is preparing to initiate an intravenous nitroglycerin drip on a client who has experienced an acute myocardial infarction. In the absence of an arterial monitoring line, the nurse prepares to have which piece of equipment for use at the bedside to help assure the client's safety? 1. Defibrillator 2. Pulse oximeter 3. Central venous pressure (CVP) tray 4. Noninvasive blood pressure monitor

Answer: 4 Rationale: Nitroglycerin dilates arteries and veins (vasodilator), causing peripheral blood pooling, thus reducing preload, afterload, and myocardial workload. This action accounts for the primary side effect of nitroglycerin, which is hypotension. In the absence of an arterial monitoring line, the nurse should have a noninvasive blood pressure monitor for use at the bedside. None of the other options would monitor blood pressure. Additionally, the client should be on a cardiac monitor. Test-Taking Strategy: Focus on the subject, initiating an intravenous nitroglycerin drip on a client with acute myocardial infarction. Note the words "arterial monitoring line." Recalling the purpose of this type of monitoring device and the action of nitroglycerin will direct you to the correct option. Priority Nursing Tip: An intravenous infusion device such as a pump or controller must be used when administering nitroglycerin via the intravenous route.

101. A nursing childbirth educator tells a class of expectant parents that it is standard routine to instill the ophthalmic ointment form of which medication into the eyes of a newborn infant as a preventive measure against ophthalmia neonatorum? 1. Penicillin 2. Neomycin 3. Vitamin K 4. Erythromycin

Answer: 4 Rationale: Ophthalmic erythromycin 0.5% ointment is a broadspectrum antibiotic and is used prophylactically to prevent ophthalmia neonatorum, an eye infection acquired from the newborn infant's passage through the birth canal. Infection from these organisms can cause blindness or serious eye damage. Erythromycin is effective against Neisseria gonorrhoeae and Chlamydia trachomatis. Vitamin K is administered in an injectable form to the newborn infant to prevent abnormal bleeding, and it promotes liver formation of the clotting factors II, VII, IX, and X. Options 1 and 2 are incorrect and are not medications routinely used in the newborn. Test-Taking Strategy: Focus on the subject, eye medication used for the prophylaxis of ophthalmia neonatorum. This will assist in eliminating option 3, an injection. From the remaining options, recalling that erythromycin is a broad-spectrum antibiotic will direct you to the correct option. Priority Nursing Tip: Administer prophylactic eye medication to a newborn within 1 hour after birth.

133. An anxious client enters the emergency department seeking treatment for a laceration of the finger. The client's vital signs are pulse 106 beats/min, blood pressure (BP) 158/88 mm Hg, and respirations 28 breaths/min. After cleansing the injury and reassuring the client, the nurse rechecks the vital signs and notes a pulse of 82 beats/min, BP 130/80 mm Hg, and respirations 20 breaths/min. Which factor likely accounts for the change in vital signs? 1. Cooling effects of the cleansing agent 2. Client's adaptation to the air conditioning 3. Early clinical indicators of cardiogenic shock 4. Decline in sympathetic nervous system discharge

Answer: 4 Rationale: Physical or emotional stress triggers sympathetic nervous system stimulation. Increased epinephrine and norepinephrine cause tachycardia, high blood pressure, and tachypnea. Stress reduction then returns these parameters to baseline as the sympathetic discharge falls. Options 1 and 2 are unrelated to the changes in vital signs. Based on the vital signs and injury type, the client exhibits no indication of cardiogenic shock. Test-Taking Strategy: Focus on the subject, stress effects on vital signs. Eliminate options 1 and 2 first because they are comparable or alike in that they are not related to factors that could notably change the vital signs. Next, note that the client is anxious and has an injury. These two pieces of information guide you to think about the body's response to stress. Recalling the relationship of stress to the sympathetic nervous system will direct you to the correct option. Priority Nursing Tip: Anxiety can cause an increase in the pulse rate, respiratory rate, and blood pressure.

139. The nurse is caring for a client in active labor. Which intervention would the nurse implement to prevent fetal heart rate decelerations? 1. Discourage the client from walking. 2. Increase the rate of the oxytocin infusion. 3. Monitor the fetal heart rate every 30 minutes. 4. Encourage upright or side-lying maternal positions.

Answer: 4 Rationale: Side-lying and upright positions such as walking, standing, and squatting can improve venous return and encourage effective uterine activity. There are many nursing actions to prevent fetal heart rate decelerations without necessitating surgical intervention. Monitoring the fetal heart rate every 30 minutes will not prevent fetal heart rate decelerations. The nurse should discontinue an oxytocin infusion in the presence of fetal heart rate decelerations, thereby reducing uterine activity and increasing uteroplacental perfusion. Test-Taking Strategy: Focus on the subject, preventing fetal heart rate decelerations. Options 1, 2, and 3 will not prevent fetal heart rate decelerations. Side-lying and upright positions will improve venous return and encourage effective uterine activity. Priority Nursing Tip: Early fetal heart rate decelerations are not associated with fetal compromise and require no intervention. Late decelerations indicate impaired placental exchange or uteroplacental insufficiency.

104. After assessment and diagnostic evaluation, it has been determined that the client has a diagnosis of Lyme disease, stage II. The nurse assesses the client for which manifestation that is most indicative of this stage? 1. Lethargy 2. Headache 3. Erythematous rash 4. Cardiac dysrhythmias

Answer: 4 Rationale: Stage II of Lyme disease develops within 1 to 3 months in most untreated individuals. The most serious problems in this stage include cardiac dysrhythmias, dyspnea, dizziness, and neurological disorders such as Bell's palsy and paralysis. These problems are not usually permanent. Flulike symptoms (headache and lethargy), muscle pain and stiffness, and a rash appear in stage I. Test-Taking Strategy: Note the strategic word, most. Focus on the subject, Lyme disease. Recalling that a rash and flulike symptoms occur in stage I will assist you in eliminating options 1, 2, and 3 and direct you to the correct option. Priority Nursing Tip: The typical ring-shaped rash of Lyme disease does not occur in all clients. Additionally, if a rash does occur, it can occur anywhere on the body, not only at the site of the tick bite.

107. The nurse provides a class to new mothers on newborn care. When teaching cord care, the nurse would instruct the mothers to take which action? 1. If antibiotic ointment has been applied to the cord, it is not necessary to do anything else to it. 2. All that is necessary is to wash the cord with antibacterial soap and allow it to air-dry once a day. 3. Apply alcohol thoroughly to the cord, being careful not to move the cord because it will cause pain to the newborn infant. 4. Apply the prescribed cleansing agent to the cord, ensuring that all areas around the cord are cleaned two to three times a day.

Answer: 4 Rationale: The cord and base should be cleansed with an agent as prescribed (some agencies use alcohol) thoroughly, two to three times per day. The steps are (1) lift the cord; (2) wipe around the cord, starting at the top; (3) clean the base of the cord; and (4) fold the diaper below the umbilical cord to allow the cord to air-dry and prevent contamination from urine. Antibiotic ointment is not normally prescribed. Continuation of cord care is necessary until the cord falls off within 7 to 14 days. Water and antibacterial soap are not necessary; in fact, the cord should be kept from getting wet. The infant does not feel pain in this area. Test-Taking Strategy: Focus on the subject, umbilical cord care. Simply recalling that the cord should be cleansed two to three times a day will direct you to the correct option. Also, note the words "prescribed cleansing agent" in the correct option. Priority Nursing Tip: The nurse needs to teach the parents of a newborn about the importance of providing cord care because the umbilical cord stump provides a medium for bacterial growth and can easily become infected.

123. The nurse prepares to transfer the client with a newly applied arm cast into the bed using which method? 1. Placing ice on top of the cast 2. Supporting the cast with the fingertips only 3. Asking the client to support the cast during transfer 4. Using the palms of the hands and soft pillows to support the cast

Answer: 4 Rationale: The palms or the flat surface of the extended fingers should be used when moving a wet cast to prevent indentations. Pillows are used to support the curves of the cast to prevent cracking or flattening of the cast from the weight of the body. Half-full bags of ice may be placed next to the cast to prevent swelling, but this would be done after the client is placed in bed. Asking the client to support the cast during transfer is inappropriate. Test-Taking Strategy: Focus on the subject, cast care. Eliminate option 1 because ice can be used for swelling after the client is placed in bed. Eliminate option 2 because of the closed-ended word "only" in this option. Eliminate option 3 because it is inappropriate to ask the client to support the cast. Priority Nursing Tip: Instruct the client with a cast not to stick objects inside the cast because the object can disrupt skin integrity and result in infection. If the skin under the cast is itchy, instruct the client to direct cool air from a hair dryer inside the cast.

127. A client, admitted to the hospital for evaluation of recurrent runs of ventricular tachycardia, is scheduled for electrophysiology studies (EPS). Which statement would the nurse include in a teaching plan for this client? 1. "You will continue to take your medications until the morning of the test." 2. "You will be sedated during the procedure and will not remember what has happened." 3. "This test is a noninvasive method of determining the effectiveness of your medication regimen." 4. "The test uses a special wire to increase the heart rate and produce the irregular beats that cause your signs and symptoms."

Answer: 4 Rationale: The purpose of EPS is to study the heart's electrical system. During this invasive procedure, a special wire is introduced into the heart to produce dysrhythmias. To prepare for this procedure, the client should be nothing by mouth (NPO) for 6 to 8 hours before the test, and all antidysrhythmics are held for at least 24 hours before the test to study the dysrhythmias without the influence of medications. Because the client's verbal responses to the rhythm changes are extremely important, sedation is avoided if possible. Test-Taking Strategy: Focus on the subject, electrophysiology studies (EPS). Note the relationship between the words "recurrent runs of ventricular tachycardia" in the question and "produce the irregular beats" in option 4. Priority Nursing Tip: Inducing a dysrhythmia during electrophysiology studies assists the primary health care provider in making a diagnosis and determining the appropriate treatment.

119. Tretinoin gel has been prescribed for a client with acne. What is the nurse's response when the client calls and reports that, "My skin has become very red and is beginning to peel"? 1. "Discontinue the medication immediately." 2. "Come to the clinic immediately for an assessment." 3. "I'll notify your primary health care provider of these results." 4. "This is a normal occurrence with the use of this medication."

Answer: 4 Rationale: Tretinoin decreases cohesiveness of the epithelial cells, increasing cell mitosis and turnover. It is potentially irritating, particularly when used correctly. Within 48 hours of use, the skin generally becomes red and begins to peel. Options 1, 2, and 3 are incorrect statements to the client. Test-Taking Strategy: Focus on the subject, tretinoin. Options 2 and 3 can be eliminated first because they are comparable or alike. Eliminate option 1 next because it is not within the scope of nursing practice to advise a client to discontinue a medication. Priority Nursing Tip: Tretinoin is a derivative of vitamin A; therefore, vitamin A supplements need to be discontinued during therapy with tretinoin.