NCLEX (Bomb Test) Review

1 The nurse in the psychiatric emergency room assesses 4 clients. Which of the following clients should the nurse see FIRST? 1- A patient was raped 30 minutes ago and expresses feelings of self- blame, anxiety, and worthlessness. 2- A patient indicates an intent to kill himself and says he has access to a gun. 3- A patient had a miscarriage last evening and is experiencing anger and resentment. 4- A patient witnessed a child stabbed to death 2 weeks ago and is experiencing anxiety.

Q1- Strategy: "FIRST" indicates priority. 1) need to assess physical needs and examine patient; second patient to see 2) CORRECT— patient is at risk for self-harm; client has intent and a way to carry out threat 3) allow client to verbalize feelings 4) allow client to verbalize feelings

10- A 25-year-old woman is receiving aminophylline 0.7 mg/kg/h by continuous IV infusion into her left arm. It is MOST important for the nurse to observe her for which of the following? 1- Slowed pulse and reduced blood pressure. 2- Constipation and decreased bowel sounds. 3- Palpitations and nervousness. 4- Difficulty voiding and oliguria.

Q10- Strategy: "MOST important" indicates discrimination is required to answer the question. 1) causes rapid pulse and dysrhythmias; decrease intake of colas, coffee, and chocolate because they contain xanthine 2) causes diarrhea, nausea, and vomiting; administer with food or full glass of water 3) CORRECT— effects of aminophylline include nervousness, nausea, dizziness, tachycardia, seizures 4) medication has no effect on the kidneys; encourage intake of 2,000 cc per day to decrease viscosity of airway secretions

11- The home care nurse visits a client diagnosed with type 1 diabetes being managed with insulin in the am and pm. The nurse identifies that which of the following BEST measures the overall therapeutic response to management of the diabetes? 1- Glycosylated hemoglobin (HbA 1 c) 5% of total Hb. 2- Fasting blood sugar 128 mg/dL. 3- Blood pressure 130/82. 4- Serum amylase 100 Somogyi U/dL.

Q11- Strategy: Think about each answer. 1) CORRECT— indicates overall glucose control for the previous 120 days; normal is 4.5-7.6% of total hemoglobin 2) normal fasting is 60-110 mg/dL; HbA 1 c more accurate indicator of glucose control 3) evaluates response to antihypertensive medication 4) elevated in acute pancreatitis; normal is 60-160 Somogyi U/dL

12- The nurse cares for a client in labor. The client's examination reveals that the cervix is 5 cm dilated and 100% effaced and the fetal head is at -1. The membranes rupture and the nurse notes clear fluid. Which of the following actions should the nurse take FIRST? 1- Ambulate the client for 15 minutes and evaluate the fetal heart rate every 30 minutes. 2- Prepare for delivery and notify the care provider. 3- Apply an electronic fetal monitor and start an IV. 4- Encourage the client to void every 1-2 hours and take her temperature every hour.

Q12- Strategy: "FIRST" indicates priority. 1) do not ambulate the client; head is too high, may cause cord to prolapse 2) too early to set up for delivery, has approximately 2-3 remaining hours of labor; sterile equipment should be opened for no more than 1 hour 3) no indication that the client is in trouble 4) CORRECT— facilitates descent of the fetal head; temperature evaluation is necessary because of ruptured membranes

13- The nurse cares for a client receiving a heparin drip via an infusion pump. The physician orders warfarin (Coumadin) 5 mg PO. Which of the following actions should the nurse take NEXT? 1- Administer medication as ordered. 2- Notify the physician. 3- Check the most recent serum partial prothrombin levels. 4- Assess client for signs/symptoms of bleeding.

Q13- Strategy: "NEXT" indicates priority 1) CORRECT— warfarin interferes with the hepatic synthesis of vitamin K-dependent clotting factors; oral anticoagulant therapy should be instituted 4 to 5 days before discontinuing the heparin therapy 2) no reason to notify the physician 3) partial thromboplastin time used to monitor effectiveness of heparin; therapeutic level is 1.5 to 2.5 times the control 4) warfarin takes 3 to 5 days to reach peak levels

14- The nurse plans care for a 14-year-old hospitalized with a diagnosis of anorexia nervosa. The nurse identifies that which of the following activities is MOST appropriate for this client? 1- Making jewelry with the occupational therapist. 2- Exercising in the physical therapy department. 3- Assisting the dietician to plan the week's menus. 4- Reading teen magazines with other patients her age.

Q14- Strategy: Determine the outcome of each answer. 1) CORRECT— one of the goals for a client with anorexia is to achieve a sense of self-worth and self-acceptance that is not based on appearance; this activity will promote socialization and increase self-esteem 2) goal is for client to achieve 85-95% of ideal body weight; may be able to exercise after short term goals are met 3) meal planning is a part of self-care activities, but more important for client to achieve a sense of self-worth 4) can read magazines in the presence of others without interacting

15- A mother reports to the clinic nurse that her daughter developed a large welt, red rash, and shortness of breath after being stung by a bee. The mother asks the nurse, "What should I do if she gets stung again?" Which of the following responses by the nurse is BEST? 1- "Make a paste of baking soda and water and apply it to the sting." 2- "Remove the stinger and immediately apply ice to the site." 3- "Give 12.5 mg of Benadryl by mouth." 4- "Administer 0.3 mg of epinephrine subcutaneously."

Q15- Strategy: Determine the outcome of each answer. Is it desired? 1) treatment for sting in persons not allergic to bee stings; treats local reaction 2) not appropriate for this child because she has demonstrated hypersensitivity to bee sting; if no previous hypersensitivity; initial action is to remove stinger as quickly as possible to decrease the amount of venom injected into wound, wash with soap and water, apply cool compress 3) will not work fast enough to prevent anaphylactic reaction 4) CORRECT— child who has demonstrated previous hypersensitivity should have an EpiPen available; instruct child to wear medical identification bracelet

16- The nurse counsels the mother of a child diagnosed with impetigo. The nurse notes that the infection has not improved and learns the mother has not been caring for the child's skin because it "takes too much time." It is MOST important for the nurse to assess for which of the following? 1- White patches on buccal mucosa. 2- Hearing loss. 3- Respiratory wheezing. 4- Periorbital edema.

Q16- Strategy: What indicates a complication? 1) describes Candida , a fungal infection 2) not caused by impetigo 3) not caused by impetigo 4) CORRECT— impetigo is caused by Staphylococcus and Streptococcus ; untreated, can cause acute glomerulonephritis; periorbital edema indicates poststreptococcal glomerulonephritis

17- The nurse on a college campus is informed by the microbiology department that they accidentally received a shipment of highly toxic, contagious bacteria. Which of the following actions should the nurse take FIRST? 1- Determine if there are adequate supplies of antibiotics and antipyretics. 2- Order necessary equipment and supplies. 3- Contact the Red Cross. 4- Identify who was exposed to the shipment.

Q17- Strategy: "FIRST" indicates priority. 1) may be required, but not the first action; affected people will most likely be treated in a treatment facility 2) more important to determine who was exposed to the bacteria 3) if exposure is widespread, they may send health care providers; determine scope of problem first 4) CORRECT— assess before implementing; after determining who has been exposed, appropriate treatment can be instituted

18- The nurse administers promethazine (Phenergan) 25 mg IM to a client complaining of nausea and vomiting. After receiving the medication, the client complains of dizziness when standing up. Which of the following actions should the nurse take FIRST? 1- Notify physician. 2- Monitor severity of symptoms. 3- Instruct client to ask for assistance before ambulating. 4- Assess client's hydration status.

Q18- Strategy: Complete assessment before implementing 1) complete assessment before contacting physician 2) is complaining of orthostatic hypotension; determine if fluid volume deficit contributing to dizziness 3) appropriate action, but nurse should first complete assessment 4) CORRECT— side effects include anorexia, dry mouth and eyes, constipation, orthostatic hypotension; client is at risk for fluid volume deficit due to vomiting, which exacerbates the orthostatic hypotension

19- The nurse in the outpatient clinic has four unscheduled clients waiting to see the physician. Which of the following clients should the nurse see FIRST? 1- A client complaining of a sore throat and nasal drainage. 2- A client with a history of kidney stones complaining of severe flank pain. 3- A client complaining of redness and pain in his left great toe. 4- A client receiving digoxin (Lanoxin) complaining of nausea and vomiting.

Q19- Strategy: "FIRST" indicates priority 1) symptoms consistent with viral rhinitis; encourage to gargle with salt water and increase fluid intake 2) second client that should be seen; administer opioid analgesics to prevent shock and syncope 3) indications of acute gout; attack subsides spontaneously in 3 to 4 days; administer colchicine (Colsalide) and NSAIDS 4) CORRECT— early effects of digitalis toxicity; hold medication and monitor client's symptoms

2 The nurse in a small town is called to a neighbor's house in the middle of a blizzard. The neighbor woman states she is in the 39th week of gestation with her second baby and has been having contractions for several hours. The woman has been unable to obtain assistance because the roads are impassable. The nurse determines that the woman is in the second stage of labor. It is MOST important for the nurse to take which of the following actions? 1- Time the frequency of the contractions. 2- Assess the type of vaginal discharge. 3- Monitor the strength of the contractions. 4- Observe the perineum.

Q2- Strategy: Assess before implementing. 1) priority is assessing if baby is crowning 2) priority is assessing if baby is crowning 3) labor is not the priority; nurse should determine if the birth is imminent 4) CORRECT— baby will descend into birth canal and may crown, major responsibility in second state of labor; support infant's head; apply slight pressure to control delivery

20- The nurse cares for a client diagnosed with a recurrence of colon cancer. The client tells the nurse that she is dreading taking chemotherapy again. Which of the following responses by the nurse is MOST appropriate? 1- "There are web sites that provide information about chemotherapy." 2- "Have you discussed this with your physician?" 3- "I can give you a handout about how to treat the side effects of chemotherapy." 4- "What are your concerns about taking chemotherapy?"

Q20- Strategy: Assessment before implementation 1) assumes that client needs more information about chemotherapy; nurse should respond to client's concerns 2) don't pass the buck; responding to client's concerns is a nursing responsibility 3) assess before implementing 4) CORRECT— think about the nursing process when selecting answers; allows nurse to gather data about what is concerning the client

21- The nurse in the outpatient clinic receives a call from a client who has been receiving continuous ambulatory peritoneal dialysis (CAPD) for 1 year. The client states that he infused 2 L of dialysate and 1200 cc returned. Which of the following statements by the nurse is BEST? 1- "Record the difference as intake." 2- "When was your last bowel movement?" 3- "Are you having shoulder pain?" 4- "Increase your fluid intake."

Q21- Strategy: Determine if it is appropriate to assess or implement. 1) the difference between inflow and outflow is counted as intake; ensure that all fluid has drained from the peritoneal cavity; change positions or ask client to walk around 2) CORRECT— full colon can create outflow problems; ensure that bowel evacuation has occurred 3) referred shoulder pain may be caused by rapid infusion of dialysate; instruct to decrease infusion rate; this client is having an outflow problem 4) will not affect outflow

22- The nurse evaluates assignments on the unit. The nurse determines that assignments are appropriate if the LPN/LVN is assigned to which client? 1- A client with type 1 diabetes scheduled for discharge. 2- A client newly admitted to the unit with chest pain. 3- A client receiving chemotherapy. 4- A client diagnosed with myasthenia gravis.

Q22- Strategy: Assign stable clients with expected outcomes. 1) requires teaching; LPN/LVN can reinforce teaching but cannot perform initial teaching 2) is not a stable client with an expected outcome; requires assessment 3) is not a stable client with an expected outcome; requires assessment 4) CORRECT— no indication that client is not stable; myasthenia gravis is deficiency of acetylcholine at myoneural junction; symptoms include muscular weakness produced by repeated movements that soon disappear following rest

23- An elderly client is brought to the emergency department complaining of acute back pain. The client denies any chronic illness, allergies, or previous hospitalizations. Which of the following is the BEST initial response for the nurse to make to this client? 1- "We'll get this pain under control in no time." 2- "Are you sure you've never been in the hospital?" 3- "Did you fall, lift something heavy, or turn the wrong way?" 4- "On a scale of 1 to 10, with 10 being the worst, rate the pain you are experiencing."

Q23- Strategy: "BEST" indicates priority. 1) false reassurance; nurse should complete assessment 2) confrontational response; pain assessment is priority 3) should first assess intensity of pain as well as location 4) CORRECT— assessment, is objective and clear, and responds directly to client's complaint; gives information for further intervention

24- A nurse observes a student nurse administer carvedilol (Coreg) to an elderly patient. The patient refuses medication, saying, "Go away. It makes me dizzy." The nurse should intervene if the student nurse states which of the following? 1- "If you don't take this medication, you will be restrained." 2- "This medication will help control your blood pressure." 3- "Side effects of this medication make some patients feel uncomfortable." 4- "When do you notice the dizziness?"

Q24- Strategy: "nurse should intervene" indicates something is wrong. 1) CORRECT— inappropriate action; client has the right to refuse medication; restraining client is an example of battery 2) Coreg is a nonselective beta-blocker used to treat hypertension and heart failure 3) side effects include dizziness, fatigue, weakness, orthostatic hypotension; instruct client to change positions slowly 4) allows nurse to teach about medication

25- The nurse cares the elderly client reporting muscle weakness and drowsiness. The nurse notes decreased deep tendon reflexes and hypotension. Which action should the nurse take first? 1- Escort the client to an emergency room unit. 2- Ask client if antacids have been taken. 3- Assess for Chvostek's sign. 4- Measure client's intake and output

Q25- Strategy: "FIRST" indicates priority 1) delegate to other personnel 2) CORRECT— increased intake of magnesium-containing antacids and laxatives can cause hypermagnesemia (greater than 2.3 mEq/L[0.95 mmol/L]); depresses CNS and cardiac impulse transmission; discontinue oral Mg, support ventilation, administer loop diuretics or IV calcium, teach about OTC drugs that contain Mg 3) seen with hypocalcemia; tap face just below and anterior to the ear to trigger facial twitching on that side of face 4) kidney disease can cause decreased excretion of magnesium; not appropriate for this setting

26- A tornado has just leveled a large housing division near the hospital, and a disaster alarm has been declared at the hospital. The nurse caring for clients on the maternal-child unit considers which of the following clients appropriate for discharge within the next hour? 1- A multipara client who delivered over an intact perineum 12 hours ago. 2- A postpartum client with an infection who has been on antibiotics for the past 24 hours. 3- A 3-year-old with newly diagnosed type 1 diabetes, diarrhea, and vomiting. 4- A 3-day-old breast-feeding infant with a total serum bilirubin of 14 mg/dL. 5- A client at 34 weeks' gestation diagnosed with generalized edema and complaints of epigastric pain. 6- A 2-day-old infant delivered of a mother receiving intrapartum antibiotic therapy for vaginal group B-streptococcus (GBS).

Q26- Strategy: Determine the most stable clients. 1) CORRECT— stable patient 2) do not know if antibiotics are effective or the current WBC count 3) requires frequent assessment of hydration status and blood glucose levels 4) CORRECT— phototherapy considered for the infant with total serum bilirubin of greater than 15 mg/dL at 72 hours of age 5) epigastric pain indicates pending eclampsia 6) CORRECT— group B streptococcal (GBS) disease causes sepsis; because mother received intrapartum prophylaxis, infant has 1-in-4,000 chance of developing sepsis due to GBS

27- The nurse cares for a client following a scleral buckling. Which of the following nursing actions is MOST important? 1- Remove all reading material. 2- Assess for nausea. 3- Assess drainage from affected eye. 4- Irrigate affected eye every 3 hours.

Q27- Strategy: "MOST important" indicates priority. 1) scleral buckling compresses the sclera to repair a detached retina; should take precautions to prevent moving eyes rapidly 2) CORRECT— nausea and vomiting increase intraocular pressure and could cause damage to the area repaired 3) wear eye shield; avoid sneezing, coughing, straining at stool 4) do not irrigate

28- The nurse supervises care for a patient admitted to the psychiatric unit with a diagnosis of bipolar disorder: manic phase. A student nurse plans activities for the patient. The nurse should intervene if the student nurse chooses which of the following activities? 1- Volleyball. 2- Painting. 3- Walking. 4- Dancing.

Q28- Strategy: "Nurse should intervene" indicates an incorrect action. 1) CORRECT— avoid competitive games because they increase agitation; assign to a single room away from activity; keep noise level low and lighting soft 2) appropriate activity; will not provoke or over-stimulate client 3) appropriate activity; activity that uses large movements until acute mania subsides 4) appropriate activity; provides structure and safety in the milieu

29- The nurse on the medical/surgical unit is approached by an LPN/LVN from a different team. The LPN/LVN expresses concern because one of her patients is diagnosed with COPD and the RN (a new graduate) is giving the patient oxygen at 2 L/min. Which of the following statements by the nurse is MOST appropriate? 1- "I will assess the patient for oxygen toxicity." 2- "Are you concerned about the oxygen or the new graduate's competency?" 3- "Please tell me more about your concerns." 4- "Leave the oxygen in place."

Q29- Strategy: "MOST appropriate" indicates discrimination is required to answer the question. 1) client is assigned to another nurse; usurps assigned nurse's authority 2) yes/no question; nontherapeutic; should allow LPN/LVN to express her concerns 3) CORRECT— open-ended statement; therapeutic; allows the LPN/LVN to express specific concerns and enables the nurse to further assess 4) not enough information to make a judgment; assess before implementing

3 The nurse receives a call from the emergency management team that 50 victims will be transported to the hospital in 15 minutes by ambulance. Which of the following actions should the nurse take FIRST? 1- Contact the nursing supervisor. 2- Tell the emergency management team they will have to re-route 25 victims. 3- Activate the hospital's disaster plan. 4- Inform the emergency department nurses they must work overtime.

Q3- Strategy: "FIRST" indicates priority. 1) CORRECT— nurse must follow chain of command 2) not the nurse's responsibility 3) must notify immediate supervisor about the call; disaster plans are hospital policies that detail how nurses are to perform duties 4) not the responsibility or role of the nurse

30- The nurse cares for an infant diagnosed with congenital heart disease. The nurse notes that the infant becomes easily fatigued during feedings and the infant's pulse and respirations increase. The nurse should take which action? 1- Feed the infant soon after awakening. 2- Change the infant's diaper before feeding. 3- Increase the caloric content of the feeding to 30 kcal/oz. 4- Mix rice cereal in the formula.

Q30- Strategy: Determine the outcome of each answer. Is it desired? 1) CORRECT— infant feeds better if well rested; offer small, frequent feeding every 3 hours; enlarge hole in nipple 2) will not affect infant's intake; pin diaper loosely to promote maximum chest expansion 3) allows infant to take in more calories in a smaller quantity; to prevent diarrhea, increase the calories by 2 kcal/oz/day; formulas provide 20 kcal/oz 4) infant would have to expend more energy to eat

31- The nurse instructs a client who is scheduled for a 24-hour creatinine clearance test. Which statement, if made by the client to the nurse, indicates further teaching is required? 1- "I will eat a high-protein meal before the test begins." 2- "I will use the specimen collection time to catch up on my reading." 3- "I will drink as much fluid as I want before and during the test." 4- "I will save all of my urine during the 24 hours and keep it in the refrigerator."

Q31- Strategy: "Further teaching is necessary" indicates incorrect information. 1) CORRECT— high-protein diet before the test may increase creatinine clearance and affect the accuracy of the test 2) appropriate action; avoid strenuous physical activity, will increase creatinine excretion and compromise the accuracy of the test 3) appropriate action 4) appropriate action; bottle should contain a preservative

32- The nurse prepares to admit a 6-month-old diagnosed with rotavirus, severe diarrhea, and dehydration. The nurse should place the infant in which of the following rooms? 1- In a semiprivate room with a 2-year-old in traction due to a fracture. 2- In a semiprivate room with a 9-month-old admitted for a shunt revision. 3- In a private room that is close to the nurse's station. 4- In any private room that is available.

Q32- Strategy: Think about the outcome of each answer. 1) a diapered or incontinent client diagnosed with rotavirus requires contact precautions for the duration of the illness; is a significant nosocomial pathogen 2) requires a private room; do not place a client with an infection in a room with a client who does not have an infection 3) CORRECT— rotavirus is spread by fecal-oral route and requires contact precautions if client is diapered or incontinent 4) due to severe nature of the symptoms requiring hospitalization, infant requires close observation for changes in condition

33- A patient returns from surgery for a total replacement of the right hip with a large surgical dressing and a Jackson-Pratt drain. Which of the following, if observed by the nurse 2 hours after surgery, necessitates calling the physician? 1- There is a small amount of bloody drainage on the surgical dressing. 2- The patient complains of increased hip pain. 3- A harsh, hollow sound is auscultated over the trachea. 4- The patient's blood pressure is 136/86.

Q33- Strategy: "necessitates calling the physician" indicates a complication. 1) expected outcome, complications of total hip replacement include dislocation of prosthesis, excessive wound drainage, thromboembolism, and infection 2) CORRECT— indicates dislocation of prosthesis; other indications include shortening of affected leg, leg rotation, soft popping sound heard when affected leg is moved; maintain abduction, use wedge pillow, avoid stopping, do not sleep on operated side until directed to do so, flex hip only 1/4 circle, never cross legs, avoid position of flexion during sexual activity, walking is excellent exercise, avoid overexertion; in 3 months will be able to resume ADLs, except strenuous sports 3) describes normal breathing sounds 4) within normal limits

34- An older client is placed in balanced suspension traction for a compound fracture of the femur. The client reports, "My hands, feet, and nose feel cold. Which action should the nurse take FIRST? 1- Provide the client with more blankets. 2- Assess for dependent edema. 3- Assess that client is exhaling when moving in bed. 4- Increase the temperature of the room.

Q34- Strategy: Determine if it is time to assess or implement. 1) treats a symptom, not the cause of the problem 2) CORRECT— because of recumbent position, cardiac workload increases; if heart is unable to handle increased workload, peripheral areas of body will be colder; more important to assess cardiovascular status; edema caused by heart's inability to handle increased workload; assess sacrum, legs, and feet; also assess peripheral pulses 3) Valsalva maneuver increases workload on heart; to prevent, teach immobilized clients about exhaling when moving about in bed; should first assess client complaints 4) assess the client; cold extremities may indicate heart is not able to tolerate increased workload

35- The nurse cares for a client at term in labor. The client's blood pressure is 182/88 and fetal heart rate (FHR) is 132-134 with minimal beat-to-beat variability. Her bloody show is dark red and there is more bleeding than anticipated. Her abdomen is firm between contractions and she complains of back pain. The nurse understands that the client is at risk for which of the following? 1- Placenta previa. 2- Abruptio placenta. 3- Miscarriage. 4- Imminent delivery.

Q35- Strategy: Think about each answer. 1) placenta is implanted near or over the cervical os; symptoms include painless, sudden, profuse bleeding in third trimester 2) CORRECT— premature separation of placenta; painful vaginal bleeding, abdomen is tender, painful, tense, possible fetal distress; prepare for immediate delivery 3) occurs before 20-24 weeks of pregnancy; indications are persistent uterine bleeding and cramp-like pain 4) symptoms are classic signs of abruption

36- The nurse cares for an older client diagnosed with terminal lung cancer. When told about the diagnosis, the client becomes very angry. He curses, throws objects, and hits the nurse tech and LPN/LVN when they attempted provide care for him. It is MOST important for the nurse to take which of the following actions? 1- Inform client that injury or risk of injury to staff is not acceptable. 2- Send the staff out of the room. 3- Administer prescribed antianxiety with full glass of water. 4- Report signs/symptoms to physician immediately.

Q36- Strategy: "FIRST" indicates priority 1) CORRECT— set limits on client's behavior; staff has the right to work in a safe environment 2) gives client the power; speak calmly to client, help to verbalize feelings, use nonthreatening body language 3) nurse should use least restrictive interventions to assist the client to regain control 4) passing the buck; it is the nurse's responsibility to care for the client

37- The nurse, caring for clients in the outpatient clinic, performs a chart review for clients who are receiving medication. The nurse determines that which of the following clients is at risk to develop problems with hearing? 1- A client receiving spironolactone (Aldactone) and cefaclor (Ceclor). 2- A client receiving metformin (Glucophage) and alendronate (Fosamax). 3- A client receiving paroxetine (Paxil) and cholestyramine (Questran). 4- A client receiving furosemide (Lasix) and indomethacin (Indocin).

Q37- Strategy: Think about each answer. 1) Aldactone is a potassium-sparing diuretic and Ceclor is a second- generation cephalosporin; neither drug is ototoxic 2) Glucophage is an oral hypoglycemic and Fosamax is a bone resorption inhibitor; neither is ototoxic 3) Paxil is a selective serotonin reuptake inhibitor (SSRI) and Questran is an antihyperlipidemic agent; neither is ototoxic 4) CORRECT— Lasix is a loop diuretic and is ototoxic, especially when given with other ototoxic drugs; Indocin is a NSAID and is also ototoxic

38- The nurse in the pediatric clinic receives a phone call from the mother of a 3-year-old child. The mother reports that her child has been complaining of a sore throat, has a temperature of 102°F (39°C), and he has suddenly begun drooling. Which of the following suggestions should the nurse make FIRST? 1- "Place a cold water vaporizer in your child's room." 2- "Take your child to the emergency department immediately." 3- "Look into your child's throat and tell me what you see." 4- "Frequently offer your child oral fluids."

Q38- Strategy: "FIRST" indicates priority. 1) appropriate action if the child has croup 2) CORRECT— symptoms indicate acute epiglottitis which can be life threatening; drooling occurs because of difficulty swallowing; child may become apprehensive or anxious; transport to hospital sitting in the parent's lap to reduce stress 3) do not inspect the throat unless immediate intubation can be performed if needed 4) transport to the hospital

39- The nurse cares for a 27-year-old female diagnosed with type 1 diabetes. Two days after admission, the client begins complaining of severe nausea. Which of the following actions should the nurse take FIRST? 1- Determine the client's most recent fasting serum glucose level. 2- Perform a comprehensive client assessment. 3- Ask the client if she is pregnant. 4- Administer an antiemetic.

Q39- Strategy: "FIRST" indicates priority. 1) no relationship between diabetes and nausea; last glucose reading does not give the nurse information about client's current condition 2) CORRECT— nausea not usually associated with diabetes; assess before implementing 3) nurse is making assumptions based on client's age; should perform a comprehensive assessment 4) assess before implementing

4 As a part of discharge teaching, the nurse instructs a client receiving citalopram (Celexa) 20 mg OD. The nurse determines that further teaching is necessary if the client states which of the following?" 1- "This medication helps me with my depression." 2- "I will notify my physician if I show signs of hyperactivity and mania." 3- "I will see improvement in my symptoms in 1 to 4 weeks." 4- "If I experience a fever I will take Tylenol."

Q4- Strategy: "Further teaching is necessary" indicates incorrect information. 1) Celexa is a selective serotonin reuptake inhibitor (SSRI) used to treat depression 2) side effects: mania, hypomania, insomnia, impotence, headache, and dry mouth 3) true statement 4) correct— should notify physician immediately to assess for serotonin syndrome, which is a rare, life threatening event caused by SSRIs; symptoms include abdominal pain, fever, sweating, tachycardia, hypertension, delirium, myoclonus, irritability, and mood changes; may result in death

40- A new registered nurse asks the assigned nurse mentor to check on 4 clients who are receiving oxygen therapy. It is MOST important for the nurse mentor to ask the nurse which of the following questions? 1- "Which client should I see first?" 2- "Have you completed your assessment?" 3- "What are your specific concerns?" 4- "Don't you think you should be able to care for the clients?"

Q40- Strategy: "MOST important" indicates discrimination may be required to answer the question. 1) nurse mentor should find out about the nurse's specific concerns 2) yes/no question; doesn't allow nurse mentor to assess the nurse's needs 3) CORRECT— clarifies the nurse's concerns and will help the new nurse become a safe practitioner 4) yes/no question; nontherapeutic; does not allow nurse mentor to assess new nurse's concerns

41- The nurse cares for a client receiving chlordiazepoxide. It is most important for the nurse to make which assessment? 1- Skeletal muscle spasms and insomnia. 2- Anorexia and dry mouth. 3- Diarrhea and euphoria. 4- Drowsiness and confusion.

Q41- Strategy: Think about each answer. 1) dystonia is side effect of antipsychotics; insomnia caused by SSRIs 2) methylphenidate causes anorexia; dry mouth is side effect of tricyclic antidepressants 3) not caused by chlordiazepoxide 4) CORRECT— antianxiety and sedative/hypnotic used to treat anxiety and alcohol withdrawal; causes drowsiness and sedation; use caution when driving or operating equipmentQ41- Strategy: Think about each answer. 1) dystonia is side effect of antipsychotics; insomnia caused by SSRIs 2) methylphenidate causes anorexia; dry mouth is side effect of tricyclic antidepressants 3) not caused by chlordiazepoxide 4) CORRECT— antianxiety and sedative/hypnotic used to treat anxiety and alcohol withdrawal; causes drowsiness and sedation; use caution when driving or operating equipment

42- Following the administration of morphine sulfate for an adult client, the nurse expects to observe which finding? 1- The client states they feel better. 2- The client is talking with visitors. 3- The client appears to be physically relaxed. 4- The client is no longer crying or moaning.

Q42- Strategy: Think about how each answer relates to pain. 1) client may express pain relief, but in reality may still be experiencing pain 2) client may still be in pain 3) CORRECT— nonverbal cues are the best indication of pain relief 4) not best indication of relief of pain

43- After being admitted for management of a cervical spine injury, a client in a rehabilitation center reports a severe headache. Which of the following actions should the nurse take FIRST? 1- Administer an analgesic medication 2- Ask the client to rank the pain from 1 to 10. 3- Ask the client if he is worried about something. 4- Place the client in a sitting position.

Q43- Strategy: "FIRST" indicates priority. 1) priority is to decrease blood pressure 2) cervical spine injury and severe headache should clue nurse that client is possibly in imminent danger 3) assess for physical causes before psychosocial causes 4) CORRECT— pounding headache and profuse sweating are indications of autonomic hyperreflexia; place in a sitting position immediately to decrease blood pressure and reduce risk of cerebral hemorrhage

44- The nurse receives report on the medical/surgical unit. Which of the following clients should the nurse see FIRST? 1- A client newly diagnosed with type 1 diabetes who had a myocardial infarction 2 days ago. 2- A client diagnosed with right-sided heart failure and glaucoma. 3- A client diagnosed with chronic obstructive pulmonary disease and psoriasis. 4- A client diagnosed with rheumatoid arthritis and malnutrition.

Q44- Strategy: Determine the most unstable client. 1) CORRECT— both diseases are in the dynamic phase and require close monitoring; most unstable client 2) client should be seen second 3) two chronic illnesses 4) client more stable than #1

45- The nurse cares for a 4-year-old on the pediatric unit. The child is unable to go to sleep while in the hospital. It is MOST important for the nurse to take which of the following actions? 1- Turn out the light and close the door. 2- Encourage the child to exercise during the evening. 3- Identify the child's home bedtime ritual. 4- Ask the child's siblings to visit during the evening.

Q45- Strategy: Assess before implementing 1) will increase the child's fears; preschoolers fear injury, mutilation, and punishment 2) will not promote sleep 3) CORRECT— preschoolers require bedtime rituals that should be followed in hospital; nurse should assess before implementing 4) will be comforting to child, but to promote sleep it is more important to determine bedtime routine

46- The nurse prepares an elderly client newly diagnosed with type 1 diabetes for discharge. The client is alert and oriented and lives alone in her home. It is MOST important for the nurse to assess for which of the following? 1- Client's vision and manual dexterity. 2- Client's understanding of diabetes. 3- Client's need for visits from the home care nurse. 4- Client's ability to perform blood glucose monitoring.

Q46- Strategy: "MOST important" indicates discrimination is required to answer the question. 1) CORRECT— client must have the visual acuity and manual dexterity to draw up and administer insulin 2) it is important that the client understands diabetes, but priority is assessing client's ability to manage insulin administration 3) may be necessary 4) important, but first assess the client's vision and manual dexterity

47- The nursing assistive personnel inform the nurse that the elderly client admitted following a hemorrhagic stroke ate half of the food on the tray. The food left on the tray looked as if someone had drawn a straight line down the center of the plate and eaten the food only to one side of the line. Which instruction by the nurse is MOST important? 1- "Rotate the plate so that the food is on the other side." 2- "Offer him a snack later in the day." 3- "Ask the client's family to assist him with the next meal." 4- "Which foods did he omit?"

Q47- Strategy: "MOST important" indicates discrimination is required to answer the question. 1) CORRECT— indicates homonymous hemianopsia (loss of half of the visual field); client neglects one side of body; instruct client to turn head in direction of visual loss 2) food pattern on plate indicates loss of visual field 3) passing the buck 4) situation does not require further assessment

48- The nurse evaluates care for a client who demonstrates manipulative behavior. The nurse should intervene if which of the following is observed? 1- The staff discusses with the client the consequences of his manipulative behavior. 2- The staff establishes limits on the client's manipulative behavior. 3 The staff clarifies the consequences of the client's manipulative behavior. 4 The staff decreases the demands on the client.

Q48- Strategy: "nurse should intervene" indicates something is wrong. 1) appropriate that the staff help to client learn to see the consequences of his behavior 2) appropriate; staff should communicate clearly defined expectations and carry out limit-setting 3) appropriate behavior 4) CORRECT— fosters a sense of entitlement

49- The nurse in the pediatric clinic performs a well-child assessment on a 20-month-old. The child's mother tells the nurse that she is earning extra money by growing houseplants in her home. Which of the following responses by the nurse is MOST appropriate? 1- "How did you get into that business?" 2- "What a great opportunity." 3- "You should not have plants in your home." 4- "Where do you keep the plants?"

Q49- Strategy: "MOST appropriate" indicates discrimination is required to answer the question. 1) encourages the mother to talk about her interests but does not address safety issue of toddler 2) closed response; does not give client opportunity to respond 3) not all plants are toxic; nurse is expressing an opinion without completing the assessment 4) CORRECT— toddlers explore by putting things in their mouth; all potentially toxic agents should be placed out of reach of the toddler; nurse should assess the type of plants in the home and the location of the plants

5 The nurse has just received change-of-shift report. Which client should the nurse see first? 1- A client diagnosed with COPD with a PaO 2 of 70 mm Hg. 2- A client diagnosed with type 1 diabetes and who was just informed the spouse is seriously injured. 3- A client scheduled to leave for the operating room in 30 minutes for a heart valve replacement. 4- A client 10 hours postop after a right mastectomy and reporting wet sheets under her back.

Q5 - Strategy: "First" indicates priority. 1) oxygenation considered "normal to good" for client with COPD; stable client 2) physical needs take priority 3) requires preop injection; all other preparation should be completed; stable client 4) CORRECT— may indicate hemorrhage from operative site; unstable client

50- The nurse performs discharge teaching for a client diagnosed with gastroesophageal reflux disease (GERD). The nurse determines that teaching is successful if the client selects which of the following menus? 1- Pork loin, lettuce and tomato salad with vinegar and oil dressing, jello, and cola. 2- Cheddar cheese omelet, spinach salad, chocolate brownie, and milk. 3- Broiled chicken, cream of broccoli soup, rice pudding, and apple juice. 4- Baked salmon with lemon butter, baked potato, mint chocolate chip ice cream, and lemonade.

Q50- Strategy: "Teaching is successful" indicates correct information. 1) oil dressing high in fat, tomato exacerbates GERD, as do carbonated beverages 2) fatty foods and chocolate exacerbate GERD 3) CORRECT— menu low in fat and contains non-acidic foods 4) lemonade and mint exacerbate GERD

51- The nurse learns that a client with a seizure disorder has a serum phenytoin level of 35 mcg/ml. Which action does the nurse take first? 1- Ask to repeat the serum phenytoin level in morning. 2- Lower the bed and apply foam padding around the bed. 3- Inform the health care provider and expect a change in the phenytoin order. 4- Ensure suction is at the bedside.

Q51- The correct answer is 3 . 1) Repeating the level does not address the current toxic level. 2) Safety measures for seizures do not address the toxic phenytoin level. 3) CORRECT - A serum phenytoin level above 25 mcg/ml is toxic. The priority is to inform the health care provider. 4) A safety measure for a seizure disorder does not address the toxic phenytoin level.

71- The nurse assesses a client recovering from an acute myocardial infarction (MI). Which assessment finding indicates to the nurse that the client is developing cardiogenic shock? 1- Temperature 97.4oF (36.3oC). 2- Heart rate 58 beats/min. 3- Respiratory rate 10 breaths/min. 4- Blood pressure 100/88 mm Hg.

Q71- The correct answer is 4. 1) A lower than normal temperature is associated with neurogenic, not cardiogenic, shock. 2) Bradycardia is associated with neurogenic, not cardiogenic, shock. 3) Bradypnea is a late finding in obstructive, not cardiogenic, shock. 4) CORRECT — Hypotension with a narrow pulse pressure is a clinical manifestation associated with cardiogenic shock.

52- The nurse teaches a group of nursing students about informed consent for medical treatment. The nurse includes teaching about informed consent involving minors. Which statement is correct for the nurse to include in the teaching? 1- Minors with cognitive impairment may consent with a parent. 2- Minors in active military service may consent without a parent. 3- Minors who need emergency surgery may sign the consent. 4- Minors who are orphans cannot sign their informed consent.

Q52- The correct answer is 2. 1) Cognitively impaired persons of any age cannot sign their own consent forms. 2) CORRECT— Minors who are in active military service are considered to be emancipated minors. This legal status allows them to consent to medical treatment on their own accord. 3) In an emergency, consent is not necessary and may not be obtainable quickly enough. 4) Being an orphan does not prevent an emancipated minor from consenting to medical treatment.

53- The nurse provides care for a client experiencing the final stage of chronic kidney disease. Which lab value does the nurse anticipate for this client when providing care? 1- Serum calcium of 9.5 mg/dL (3 mmol/L). 2- Hemoglobin of 15 mg/dL (150 g/L). 3- Serum creatinine of 0.6 mg/dL (53 μmol/L). 4- Phosphate of 5 mg/dL (2 mmol/L).

Q53- The correct answer is 4. 1) The final stage of chronic kidney disease is associated with hypocalcemia, not hypercalcemia. The normal serum calcium range is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L). 2) The final stage of chronic kidney disease is associated with anemia. The normal range 12 to 18 mg/dL (140-175 g/L); therefore, this is not anticipated when providing client care. 3) The final stage of chronic kidney disease is associated with elevated creatinine. The normal creatinine range is 0.5 to 1.2 mg/dL (44 to 106 μmol/L); therefore, this is not anticipated when providing client care. 4) CORRECT— The nurse anticipates hyperphosphatemia for this client, caused by a decreased excretion of phosphate and increased stimulation of parathyroid glands. This causes a release of phosphate from bones. The normal serum phosphate range is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L).

54- A client reports having chest irradiation as a child for non- Hodgkin lymphoma (NHL). On which potential adulthood complication will the nurse focus when assessing this client? 1- Chronic infertility. 2- Asthmatic bronchitis. 3- Hodgkin lymphoma. 4- Lung cancer.

Q54- The correct answer is 4. 1) Radiation to the pituitary gland, ovaries, and testes, and alkylating agents may cause infertility. 2) Asthmatic bronchitis is not associated with radiation. Pneumonitis and pulmonary fibrosis can occur from radiation and alkylating agents. 3) Hodgkin disease may morph into NHL; however, does not occur in reverse. 4) CORRECT— The development of secondary cancers in adults is a long-term complication of childhood cancer treatment. These cancers can be site specific, such as lung cancer or leukemia.

55- The nurse provides care to a client with an internal radiation implant. Which intervention will the nurse include in the plan of care? (Select all that apply.) 1- Donning gloves when emptying the client's bedpan. 2- Placing the client in a semiprivate room at the end of the hallway. 3- Wearing a lead apron when providing direct care to the client. 4- Keeping all linens in the room until the implant is removed. 5- Restricting visitors to family members only.

Q55- The correct answer is 1, 3, 4. 1) CORRECT — Physical barriers are necessary to prevent the accidental exposure of the nurse's skin to radioactive substances. 2) A private room with a private bathroom is essential to prevent the exposure of others to radiation. 3) CORRECT — Protective barriers are required to prevent the accidental exposure of the nurse to radiation. 4) CORRECT — Preventive strategies are necessary to prevent the accidental exposure of others to radiation. 5) No visitors are allowed while the client has the internal radiation implant in place.

56- The nurse prepares a client for a contraction stress test using nipple stimulation. Which measure does the nurse include in the plan of care? 1- Cleanse abdomen with an iodine solution. 2- Place client on an internal fetal monitor. 3- Place client in reclining chair with a slight lateral tilt. 4- Monitor intravenous infusion rate.

Q56- The correct answer is 3. 1) The abdomen does not need to be cleansed for a contraction stress test using nipple stimulation. 2) An internal monitor is not used for a contraction stress test using nipple stimulation. 3) CORRECT— Placing the client in a reclining chair with a slight lateral tilt optimizes uterine perfusion and avoids supine hypotension. 4) Intravenous fluids are not needed for a contraction stress test using nipple stimulation.

57- A client diagnosed with schizophrenia hears voices and tells the nurse that the building is going to explode. Which action will the nurse take first? 1- Escort the client to a quiet room. 2- Engage the client to focus on the nurse. 3- Provide an emergency dose of medication. 4- Call for help since the client is going to run.

Q57-The correct answer is 2. 1) Escorting the client to a quiet room may be necessary if the nurse is unable to orient the client to reality, but this is not the first action to take. 2) CORRECT — The nurse needs to use a one-to-one approach and guide the client to focus on the nurse instead of the hallucination. 3) An emergency dose of medication may be required, but this is not the first action to take. 4) Calling for help may be required if the situation escalates; however, this is not the first action to take.

58- The nurse provides care for a client diagnosed with chronic insomnia. The client reports, "About 1 to 2 hours before bed, I start thinking about whether I will sleep that night and I feel restless." Which intervention should the nurse recommend to this client? (Select all that apply.) 1- Participate in activities that are calming before bed. 2- Avoid negative associations with inability to sleep. 3- If unable to sleep, remain in bed. 4- Keep an alarm clock out of the room. 5- Use essential oils with relaxation properties.

Q58- The correct answer is 1, 2, 5. 1) CORRECT - Distraction and activities that are enjoyable will assist the client in relaxing before bed. 2) CORRECT - Thoughts of lack of sleep eventually become negative association, which impacts the ability to fall asleep. 3) If unable to fall asleep, the client should get out of bed and try a relaxing activity to try and induce relaxation. 4) Not having an alarm clock in the room may increase anxiety, but the alarm clock should not be facing the client. 5) CORRECT - Choosing essential oils such as lavender in a diffuser or placed on the wrist can help induce relaxation.

59- The nurse receives reports on several clients. Which client will the nurse assess first? 1- 9-month-old client with a barking cough, not eating or drinking, with an oxygen saturation of 92% on room air. 2- 14-month-old client with an oral temperature of 1020 F, green nasal drainage, and is pulling at the ears. 3- 6-month-old client with a harsh cough, mild audible wheezes, and retractions noted in the ribs. 4- 2-year-old client with a sore throat, sitting upright, refusing to swallow, and drooling.

Q59- The correct answer is 4. 1) The client's oxygen saturation level is within normal range. This client would not need to be seen first. 2) The client with a possible ear infection is stable and would not need to be seen first. 3) The client's wheezing and retractions are mild. The client would not need to be seen first. 4) CORRECT - The client with a sore throat, sitting upright, refusing to swallow, and drooling could indicate epiglottitis, which causes severe edema in the epiglottis. Epiglottitis can cause loss of airway if the child is stressed, coughs, or cries. This client should be seen first.

6 The nurse instructs a mother of a child diagnosed with a myelomeningocele and who developed an allergy to latex. The nurse determines that teaching is effective if the mother selects which menu for her child? 1- Guacamole with pita bread, lettuce, tomato juice. 2- Poached halibut, brown rice, carrots, peach cobbler. 3- Scrambled eggs, whole wheat toast, nectarine, skim milk. 4- Baked chicken leg, macaroni and cheese, spinach, milkshake.

Q6- Strategy: "Teaching is effective" indicates correct information. 1) if a person has a latex allergy, there is cross-reaction to tomatoes and avocados 2) peach is a cross-reactive food with latex 3) nectarines are cross-reactive with latex 4) CORRECT— this meal does not have any cross-reactive foods with latex; foods to avoid include apple, apricot, avocado, banana, carrot, celery, cherry, chestnut, fig, grape, kiwi, melon, nectarine, passion fruit, papaya, peach, pear, pineapple, plum, potato, and tomato

60- The nurse provides care for a client diagnosed with type 2 diabetes mellitus. The nurse anticipates that the client will be prescribed a second-generation sulfonylurea. Which medication in the hospital formulary belongs to this class of drugs? 1- Metformin. 2- Glipizide. 3- Repaglinide. 4- Miglitol.

Q60- The correct answer is 2 . 1) Metformin, a biguanide, controls blood glucose levels in type 2 diabetes by inhibiting glucose production in the liver and increasing insulin sensitivity in body tissues. 2) CORRECT - Glipizide, a second-generation sulfonylurea, controls blood glucose levels in type 2 diabetes by stimulating pancreatic beta cells to secrete insulin. 3) Repaglinide, a meglitinide, controls blood glucose levels in type 2 diabetes by stimulating pancreatic insulin secretion. 4) Miglitol, an alpha-glucosidase inhibitor, controls blood glucose levels in type 2 diabetes by delaying absorption of complex carbohydrates in the intestine. This delays carbohydrate digestion after meals slowing glucose entry into the systemic circulation.

61- The nurse provides care for a client diagnosed with a duodenal ulcer. The client asks how a stomach infection can cause a duodenal ulcer. Which response by the nurse is best? 1- "Bacteria in the duodenum deteriorate the area, causing an ulceration." 2- "The bacteria enters the lining of the intestines and changes the protective layer." 3- "There is no explanation for how this occurs in a vast majority of people." 4- "Medication for the stomach infection causes the duodenal lining to break down."

Q61- The correct answer is 2 1) A duodenal ulcer is not caused by bacteria that is found in the duodenum. It is caused by gastric bacteria. 2) CORRECT- With Helicobacter pylori (H. pylori), the bacteria penetrate the intestinal mucosa, altering the function and consistency leading to ulcerations. 3) An H. pylori infection causes different manifestations, such as chronic atrophic gastritis, stomach cancer, acute gastritis, or duodenal ulcers. 4) Antibiotic therapy to treat H. pylori does not cause duodenal ulcer development.

62- The nurse provides care for a post-operative client. Which conditions does early ambulation after surgery help prevent? (Select all that apply.) 1- Dehiscence. 2- Thromboembolism. 3- Atelectasis. 4- Paralytic ileus. 5- Pressure decubiti.

Q62- The correct answer is 2, 3, 4, 5 1) There is no evidence that ambulation reduces the risk of wound separation. 2) CORRECT - Ambulation reduces the risk of thromboembolism by increasing venous blood flow. 3) CORRECT - Ambulation reduces the risk of atelectasis by increasing the mobilization and expectoration of mucus. 4) CORRECT - Ambulation reduces the risk of paralytic ileus and promotes peristalsis. 5) CORRECT - Ambulation reduces the risk of pressure decubiti by reducing the time in bed and relieving pressure on bony prominences.

63- The nurse prepares for the admission of a child diagnosed with rubeola. Which isolation precaution does the nurse plan for the child? 1- Enteric. 2- Contact. 3- Protective. 4- Respiratory.

Q63- The correct answer is 4 1) Enteric isolation is not indicated based on the method of transmission of the rubeola infection. 2) Contact isolation is not indicated based on the method of transmission of the rubeola infection. 3) Protective isolation is not appropriate for this disease process. This is appropriate for a client with neutropenia. 4) CORRECT - Rubeola is transmitted by airborne particles or direct contact with infectious droplets, so respiratory isolation is required.

64- The nurse provides care for a client diagnosed with a pressure injury wound on the sacrum. Which client care activity is appropriate to delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1- Set up supplies for use in the dressing change. 2- Choose the right dressing for wound treatment. 3- Measure the wound size and depth and notify nurse. 4- Reposition the client at least every 2 hours. 5- Assist the client with adequate food and fluid intake.

Q64- The correct answer is 1, 4, 5. 1) CORRECT — Setting up supplies is within the scope of practice of NAPs. 2) Selecting the right dressing is done by the nurse, based on assessment of the wound. 3) Measuring the wound is an assessment that the nurse does. 4) CORRECT — Repositioning the client independently as directed by the nurse is within the scope of practice of NAPs. 5) CORRECT — Assisting clients with food and fluid intake is within the scope of practice of NAPs.

65- The nurse notes the presence of purulent drainage at the insertion site of a client's intravenous catheter. Which action will the nurse take after discontinuing the catheter? 1- Apply heat to the affected site. 2- Save the catheter to send to the laboratory. 3- Apply a pressure dressing. 4- Insert a new intravenous catheter on the opposite extremity.

Q65- The correct answer is 2. 1) Although treatment eventually will occur, this is not the next step for the nurse to take. 2) CORRECT — A culture of the catheter tip will identify the organism causing the infection at the insertion site. 3) A pressure dressing is not required. 4) Inserting a new catheter eventually will occur but is not the next step for the nurse to take.Q65- The correct answer is 2. 1) Although treatment eventually will occur, this is not the next step for the nurse to take. 2) CORRECT — A culture of the catheter tip will identify the organism causing the infection at the insertion site. 3) A pressure dressing is not required. 4) Inserting a new catheter eventually will occur but is not the next step for the nurse to take.

66- The nurse creates a care plan for a client who has a stage 3 pressure injury. Which nursing diagnosis should the nurse assign as the highest priority for this client? 1- Risk for infection. 2- Imbalanced nutrition, less than body requires. 3- Altered health maintenance. 4- Impaired skin integrity.

Q66- The correct answer is 4. 1) Risk for infection would not be the highest priority because it is a risk diagnosis. The client does not show any signs or symptoms of infection. 2) Imbalanced nutrition, less than body requires is not the highest priority because there is not supporting data in the scenario to indicate the client is malnourished. 3) Altered health maintenance is not the highest priority. Impaired skin integrity will be a higher priority than altered health maintenance. 4) CORRECT - The scenario states the client has a stage 3 pressure injury. The interventions surrounding care for the wound will be the highest priority.

67- The nurse provides care for a newborn in the delivery room. Which nursing intervention will the nurse use to prevent the newborn from experiencing conductive heat loss? 1- Drying the newborn's skin immediately after birth. 2- Putting the unclothed newborn against the mother's skin. 3- Keeping the incubator away from windows and outside walls. 4- Placing the newborn under a radiant warmer.

Q67- The correct answer is 2. 1) Drying the newborn's skin immediately after birth helps prevent convective heat loss. 2) CORRECT - Placing the unclothed newborn against the mother's helps prevent conductive heat loss. 3) Keeping the incubator away from windows helps prevent radiant heat loss. 4) Placing the newborn under a radiant warmer can increase heat loss from evaporation.

68- The nurse develops a brochure on informed consent. Which information is appropriate for the nurse to include in the brochure? (Select all that apply.) 1- An informed consent should not be obtained until the client has discussed the exact details of the surgery or procedure. 2- Witnessing an informed consent means that the nurse verifies that the client is mentally competent. 3- The nurse needs to explain the benefits and risks of the procedures that require an informed consent. 4- Even if a client has signed a general admission consent, an informed consent is required for the client to have a chest X-ray. 5- Acting as a client advocate, the nurse is responsible for ensuring that the client has received adequate information regarding the proposed procedure.

Q68- The correct answer is 1, 2, 5. 1) CORRECT — Informed consent is permission granted by a client after discussing the exact details of the treatment with the health care provider who will perform the surgery or procedure. 2) CORRECT — By witnessing a client's signing of an informed consent, the nurse verifies that the client is mentally competent and that the signature is that of the client. 3) It is not the nurse's responsibility to explain the benefits and risk of the procedures that require an informed consent. The health care provider needs to do that. 4) General consent forms giving permission for treatment in a hospital are signed by a client before being admitted. An informed consent would not be required for a chest X-ray. 5) CORRECT — The nurse, as a client advocate, is responsible for ensuring that the client has received adequate information regarding the proposed procedure.

69- The family sits at the bedside of a client nearing the end-of-life. Which action is appropriate for the nurse to implement? (Select all that apply.) 1- Teach family members about physical signs of impending death. 2- Encourage the management of adverse signs and symptoms. 3- Assess family coping mechanisms to handle impending loss. 4- Avoid spirituality as nurse's beliefs may not be congruent with the client's. 5- Leave the family alone as there is no more need for direct nursing care.

Q69- The correct answer is 1, 2, 3. 1) CORRECT — Teaching about physical signs of impending death will help allay the family's fears and anxiety. 2) CORRECT — Managing adverse signs and symptoms allows maximum comfort of the client. 3) CORRECT — Assessing family coping mechanisms allows the provision of client and family-centered care. 4) Spirituality/spiritual practices may bring comfort to the client and family. 5) Abandoning the family is not appropriate. They are a part of end-of- life care.

7 The nurse cares for children in the outpatient pediatric clinic. It is MOST important for the nurse to perform tuberculosis screening on which of the following children? 1- A child just returned from a 2-week trip to Europe. 2- A child recently moved to an apartment because the family lost their home. 3- A child with a new nanny who just emigrated from Latin America. 4- A child who weighed 4 lb, 10 oz at birth.

Q7- Strategy: All answers are assessments. Determine how they relate to risk factors for tuberculosis. 1) tuberculosis is endemic to Asia, Middle East, Africa, Latin America, and Caribbean; consider screening if child has traveled to an endemic region 2) the homeless and impoverished are at risk for developing tuberculosis 3) CORRECT— children traveling to endemic areas or who have prolonged, close contact with indigenous persons should undergo immediate skin testing 4) no reasons to undergo immediate screening

70- A client experiencing insomnia asks if there are any dietary modifications that can help improve sleep. Which response by the nurse is best? 1- Eat small portions throughout the day. 2- Limit alcohol in the late afternoon and evenings. 3- Restrict fluid intake to five liters per day. 4- Reduce daily intake of salt and sugar.

Q70- The correct answer is 2. 1) There is no scientific evidence that eating small portions can improve sleep. 2) CORRECT - The diuretic effect of alcohol can cause the client to awaken from sleep to void. Limiting alcohol intake can improve sleep. 3) Fluid restriction does not improve sleep quality. 4) Salt and sugar reduction is part of general wellness. They are not associated with improved sleep.

72- Which statement is appropriate for the professional development educator to include in a discussion of medical asepsis with a group of new clinical employees? (Select all that apply.) 1- "It is necessary to keep the door closed when caring for a client on airborne precautions." 2- "I need to wear gloves when taking the blood pressure of a client on contact precautions." 3- "I should put on a mask when taking the temperature of a client on contact precautions." 4- "It is necessary to use disposable dishes and utensils for a client on droplet precautions." 5- "A surgical mask is required when working within 3 feet of client on droplet precautions."

Q72- The correct answer is 1, 2, 5. 1) CORRECT — This is an appropriate statement for the professional development educator to include when teaching new clinical staff in regard to medical asepsis. It is necessary to keep the door closed when caring for a client on airborne precautions. 2) CORRECT — This is an appropriate statement for the professional development educator to include when teaching new clinical staff in regard to medical asepsis. Gloves are required when taking the blood pressure of a client on contact precautions. 3) A mask is not needed when taking the temperature of a client on contact precautions. 4) Disposable dishes and utensils are not needed for a client on droplet precautions. 5) CORRECT — This is an appropriate statement for the professional development educator to include when teaching new clinical staff in regard to medical asepsis. A surgical mask is required when working within 3 feet of client on droplet precautions.

73- The nurse provides care for a client diagnosed with multiple myeloma. The client's new pain management regimen includes timed- release oxycodone and immediate-release oxycodone. The client asks the nurse how to schedule these new medications. Which response by the nurse is best? 1 "Take the timed-release medication every morning and evening." 2 "Take the immediate-release medication any time that you are hurting." 3 "Schedule the medication close to bedtime in case it makes you sleepy." 4 "Schedule both medications so that your pain is relieved all day."

Q73- The correct answer is 4. 1) This response does not address the schedule for the immediate- release narcotic. 2) This response does not address the schedule for the extended- release narcotic. 3) This response is inaccurate. Extended-release medications do not have immediate effects like sleepiness, but immediate-release medications might, and this leaves the client without pain relief all day. 4) CORRECT — The client needs to schedule the medications so that around the clock stable analgesic control is achieved.

74- The nurse provides care for a client diagnosed with diabetic ketoacidosis (DKA). Which intervention does the nurse expect the health care provider to prescribe? (Select all that apply.) 1 Short acting intravenous (IV) insulin. 2 Isotonic intravenous (IV) fluids. 3 Total parenteral nutrition (TPN). 4 Hourly intake and output. 5 Finger blood glucose every four hours.

Q74- The correct answer is 1, 2, 4. 1) CORRECT—Regular insulin administered intravenously will lower blood glucose. 2) CORRECT—Isotonic IV fluids replace fluid and electrolytes losses that often occur with DKA. 3) A prescription for TPN is not indicated for this client. 4) CORRECT—Hourly intake and output to monitor hydration status is necessary. 5) Hourly blood glucose check is indicated. Four hours is too long an interval.

75- The nurse provides care to clients on a progressive care unit. Which client does the nurse see first? 1 The client with abdominal incision dehiscence and foul-odor to the wound. 2 The client with a new tracheostomy with a speaking valve caused by respiratory arrest after a heroin overdose. 3 The client with a blood pressure of 86/44 mm Hg receiving intravenous antibiotics for urosepsis. 4 The client with a blood glucose of 215 mg/dL receiving treatment for diabetic ketoacidosis.

Q75- The correct answer is 3. 1) The client with a foul-smelling wound and dehiscence needs wound cultures and antibiotics. This client is in no acute distress. 2) The client with a new tracheostomy is in no acute distress. 3) CORRECT - The client with urosepsis has low blood pressure, which could indicate poor organ perfusion. This client should be seen first by the nurse. 4) The client with diabetic ketoacidosis has a blood glucose level that is not causing distress. This client can be seen later.

8 The nurse plans care for a patient in hemorrhagic shock from injuries sustained in a fall. It is MOST important for the nurse to take which of the following actions? 1- Obtain vital signs. 2- Identify the source of the bleeding. 3- Elevate the head of the bed 30°. 4- Administer 0.9% NaCl IV.

Q8- Strategy: Assess before implementing. 1) assessment; more important to determine the source of bleeding 2) CORRECT— assessment first step; initial priority to identify and then apply direct pressure and elevate affected area if possible 3) intervention; elevate the extremities 4) intervention; 1-2 liter bolus of isotonic fluids (lactated Ringer or 0.9% NaCl) will be given

9 During the change-of-shift report, the charge nurse overhears two nurses exchanging loud, rude remarks about one nurse's excessive use of overtime. Which of the following statements by the charge nurse is MOST appropriate? 1- "I want to see both of you in my office right away." 2- "Would you please lower your voices and finish the report." 3- "I want the two of you to stop yelling and work this problem out." 4- "Both of you are good nurses and are under a lot of stress right now."

Q9- Strategy: Determine the outcome of each response. Is it appropriate? 1) confrontation is not the appropriate conflict management approach when emotions are high 2) CORRECT— forcing is the most appropriate conflict management technique; enables nurses to exchange information; client care takes priority over interpersonal conflict 3). need cooling-off period before issues can be discussed; communicating about patient care takes priority 4) "don't worry" response; may make the nurses feel better but does not address the immediate task of completing the report