NCLEX Review Quiz 2 Saunder's Questions (CH. 16 - 25)

217. The mother of a 3-year-old is concerned because her child still is insisting on a bottle at nap time and at bedtime. Which is the msot appropriate suggestion to the mother? 1. Allow the bottle if it contains juice 2. Allow the bottle if it contains water 3. Do not allow the child to have the bottle 4. Allow the bottle during naps but not at bedtime

2 A toddler should never be allowed to fall asleep with a bottle containing milk, juice, soda, sweetened water or any other sweet liquid because of the risk of nursing (bottle-mouth) caries. If a bottle is allowed at nap time or bedtime, it should contain only water.

206. The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse should make which response? 1. "You need to be concerned" 2. "You need to monitor the child's behavior closely" 3. "At this age, the client is developing his own personality" 4. "You need to provide more praise to the child to stop this behavior

3 According to Erikson, during school-age years (6-12 y/o), the child begins to move toward peers and friends and awat from the parents for support. The child also begins to develop special interests that reflect his/her own developing personality instead of the parents. Therefore, options 1, 2, and 4 are incorrect responses.

193. The registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the accurate measurement of the lentgh of the rube to be inserted, the nurse should take which action? 1. Mark the tube at 10 inches 2. Mark the tube at 32 inches 3. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process 4. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum

3 Measuring the length of a NG tube needed is done by placing the tube at the tip of the client's nose and extending the tube to the earlobe and then down to the xiphoid process. The average length for an adult is about 22 to 26 inches. The remaining options identify incorrect procedures for measuring the length of the tube.

137. The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? 1. Call for help 2. Extinguish the fire 3. Activate the fire alarm 4. Confine the fire by closing the room door

3 The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire then is confined by closing all doors and, finally, the fire is extinguished.

165. The nurse is performing CPR on an adult client. When performing chest compressions, the nurse should depress the sternum by how many inch(es)? 1. 1/4 inch 2. 1 inch 2. 2 inches 3. 3 inches

3 When performing CPR on an adult client, the sternum is depressed 2 inches. The depth for the adult and the child is 2 inches whereas for the infant it is 1 1/2 inches.

135. The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention if noted in the plan indicates the need for revision of the plan? 1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. wearing a lead apron when providing direct care to the client 4. Placing the client in a semiprivate room at the end of the hallway

4 A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent accidental exposure of other clients to radiation. The remaining options identify accurate interventions for a client with an internal radiation implant and protect the nurse from exposure.

210. A 16-year-old is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively? 1. Encourage the child to rest and red 2. Encourage the parents to room in with the child 3. Allow the family to bring in the child's favorite computer games 4. Allow the child to interact with others in his or her same age group

4 Adolescents often are not sure whether they want their parents with them when they are hospitalized. Because of the importance of their peer group, separation from friends is a source of anxiety. Ideally, the members of the peer group will support their ill friend. Options 1, 2, and 3 isolate the child from the peer group.

228. The visiting nurse observe that the older client is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way; my daughter-in-law needs me to stay here." Which is the most important action for the nurse to take? 1. Say to the daughter-in-law, "Confining your father-in-law to his room is inhumane" 2. Suggest to the client and daughter-in-law that they consider a nursing home for the client 3. Say nothing, because it is best for the nurse to remain neutral and wait to be asked for help 4. Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens' center

4 Assisting clients and families to become aware of available community support systems is a role and responsibility of the nurse. Observing that the client has begun to be confined to his room makes if necessary for the nurse to intervene legally and ethically, so option 3 is not appropriate and is passive in terms of advocacy. Option 2 suggests commiting the client to a nursing home and is a premature action on the nurse's part. Although the data provided tell the nurse that this client requires nursing care; the nurse does not know the extent of the nursing care required. Option1 is incorrect and judgmental.

171. The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? 1. Inhale as rapidly as possible 2. Keep a loose seal between the lips and the mouthpiece 3. After maximum inspiration, hold the breath for 24 seconds and exhale 4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees

4 For optimal lung expression with the incentive spirometer, the client should assume the semi-Fowler's on high high-Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.

158. The nurse understands that which is a current guideline for adult cardiopulmonary resuscitation (CPR) for a health care provider? 1. One breath should be given for every five compressions 2. Two breaths should be given for every 15 compressions 3. Initially, two quick breaths should be given as rapidly as possible 4. Each rescue breath should be given over 1 second and should produce a visible chest rise

4 In adult CPR, each rescue breath should be given over 1 second and should produce a visible chest rise. Excessive ventilation (too many breaths per minute or breaths that are too large or forceful) may be harmful ad should not be performed. HCPs should employ a 30-2 compression-to-ventilation ratio for the adult victims.

216. A mother arrives at a clinic with her toddler and tells the nurse that she has a difficult time getting the child to go to bed at night. What measure is most appropriate for the nurse to suggest to the mother? 1. Allow the child to set bedtime limits. 2. Allow the child to have temper tantrums 3. Avoid letting the child nap during the day 4. Inform the child of bedtime a few minutes before it is time for bed

4 Toddlers often resist going to bed. Bedtime protests may be reduced by establishing a consistent before-bedtime routine and enforcing consistent limits regarding the child's bedtime behavior. Informing the child of bedtime a few minutes before it is time for bed is the most appropriate option. Most toddlers take an afternoon nap and, until their second birthday, also may require a morning nap. Firm, consistent limits are needed for temper tantrums or when toddlers try stalling tactics.

195. The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? 1. Exhale slowly 2. Stay very still 3. Inhale and exhale quickly 4. Perform the Valsalva maneuver

4 When the chest tube is removed, the client is asked to perform the Valsalva manueuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an air-tight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.

133. The community health nurse is providing a teaching session about terrorism to members of the community and is discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted by which route(s)? Select all that apply. 1. Bites from ticks or deer flies 2. Inhalation of bacterial spores 3. Through a cut or abrasion in the skin 4. Direct contact with an infected individual 5. Sexual contact with an infected individual 6. Ingestion of contaminated undercooked meat

2, 3, 6 Anthrax is caused by Bacillus anthracis and can be contracted through the digestive system or abrasions in the skin, or inhaled through the lungs. It cannot be spread from person to person or from animal to person, and it is not contracted via bites from ticks and deer flies.

160. The nurse is performing rescue breathing on a 7-year-old child. The nurse delivers one breath per how many seconds to the child? 1. 6-8 2. 8-10 3. 10-12 4. 12-14

1 In a child between the ages of 1 and 8 years, one breath every 6-8 seconds is delivered.

191. The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents and checks the gastric pH. The nurse verifies correct tube placement if which pH value is noted 1. 3.5 2. 7.0 3. 7.35 4. 7.5

1 If the NG tube is in the stomach, the pH of the contents will be acidic. Gastric aspiration have acidic pH values and should be 3.5 or lower. Option 2 indicates a slightly acidic pH. Option 3 indicates a neutral pH. Option 4 indicates an alkaline pH.

202. The maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the mother to take which measure? 1. Allow the newborn infant to signal a need 2. Anticipate all the needs of the newborn infant 3. Attend to the newborn infant immediately when crying 4. Avoid the newborn infant during the first 30 minutes of crying.

1 According to Erikson, the caregiver should not try to anticipate the newborn's needs at all times but must all the newborn infant to signal needs. If a newborn infant is not allowed to signal a need, the newborn will not learn hot to control the enviroment. Erickson believe that a delayed or prolonged response to a newborn infant's signal would inhbit the development of trust and lead to mistrust of others.

203. The mother of a 4-year-old child calls the clinic nurse and expresses concern because the child has been masturbating. Using Freud's psychosexual stages of development, the nurse should make which response? 1. "This is a normal behavior at this age" 2. "Children usually begin this behavior at age 8 years" 3. "The child is very young to begin this behavior and should be brought to the clinic" 4. "This is not normal behavior, and the child should be seen by the health care provider"

1 According to Freud's psychosexual stages of development, between the ages of 3 and 6 the child is in the phallic stage. At this time, the child devotes much energy to examining his/her genitalia, masturbating, and expressing interest in sexual concerns. Therefore options 2, 3, and 4 are incorrect.

209. A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears? 1. Encourage the child's parents to stay with the child 2. Encourage play with other children of the same age 3. Advise the family to visit only during the scheduled visiting hours 4. Provide a private room, allowing the child to bring favorite toys from home

1 Although the preschooler already may be spending some time away from parents at a day care center or preschool, illness adds a stressor that makes separation more difficult. The child may ask repeatedly when parents will be coming for a visit or may constantly want to call the parents. Option 3 and 4 increase stress related to separation anxiety. Option 2 is unrelated to the subject of the question and, in addition may not be appropriate for a child who may be immunocompromised and at risk for infection.

234. The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? 1. Rhythmic respirations with periods of apnea 2. Regular rapid and deep, sustained respirations 3. Totally irregular respiration in rhythm and depth 4. Irregular respirations with pauses at the end of inspiration and expiration

1 Cheyne-Stokes respirations are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular, rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.

180. The nurse is caring for a client following a supraterntorial craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client? 1. semi Fowler 2. Trendelenburg 3. Reverse Trendenlenburg 4. Flat position

1 Clients who has undergone supratentorial surgery should have the head of the bed elevated 30 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion and the head is maintained in a midline neutral position. If a large tumor has been removed, the client should be placed on the nonoperative side to prevent displacement of the cranial contents. A flat position or Trendelenburg's position would increase intracranial pressure. A reverse Trendelenburg's position would not be helpful and may be uncomfortable for the client.

199. The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gently bubbling in the suction control chamber. What action is most appropriate? 1. Do nothing because this is an expected finding 2. Check for an air leak because the bubbling should be intermittent 3. Increase the suction pressure so that the bubbling becomes vigorous 4. Immediately clamp the chest tube and notify the HCP

1 Continuous gentle bubbling should be noted in the suction control chamber. Bubbling should be continuous in the suction control chamber and not intermittent. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so. Chest tubes should only be clamped to check for an air leak or when changing drainage devices.

224. The home care nurse is visiting an older client whose spouse died 6 months ago. Which behavior by the client indicates ineffective coping? 1. Neglecting personal grooming 2. Looking at old snapshots of family 3. Participating in a senior citizens' program 4. Visiting their spouse's grave once a month

1 Coping mechanisms are behaviors used to decrease stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some cases may be harmful to the individual physically or psychologically. The correct option is indicative of a behavior that identifies an ineffective coping behavior in the grieving process.

197. The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? 1. Stridor 2. Occasional pink-tinged sputum 3. Respiratory rate of 24 breaths/min 4. A few basilar lung crackles on the right

1 Following removal of the endotracheal tube the nurse monitors the client for respiratory distress. The nurse reports stridor to the HCP immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client t risk for airway obstruction. Although the findings identified in the remaining options require monitoring, they do not require immediate notification of the health care provider.

184. The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position? 1. Left Sims' position 2. Right Sims' position 3. On the left side of the body, with the head of the bed elevated 45 degrees 4. On the right side of the body, with the head of the bed elevated 45 degrees.

1 For administering an enema, the client is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the Sims' position.

204. The nurse instructor asks a nursing student to present a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. The student plans the conference, knowing that which characteristic relates to this stage of development? 1. This stage is associated with toilet training 2. This stage is characterized by a tapering off of conscious biological and sexual urges 4. This stage is associated with pleasurable and conflicting feelings about the genital organs

1 In general, toilet training occurs during the anal stage. According to Freud, the child gains pleasure from the elimination of feces and from their retention. Option 2 relates to the oral stage. Option 3 relates to the latency period. Option 4 relates to the phallic stage.

205. The nursing instructor asks a nursing student to describe the formal operations stage of Piaget's cognitice developmental theory. The correct response by the nursing student is which statement? 1. "The child has the ability to think abstractly" 2. "The child begins to undestand the environment" 3. "The child is able to classify order, and sort facts" 4. "The child learns to think in terms of past, present, and future

1 In the formal operations stage, the child has the ability to think abstractly and logically. Option 2 identifies the sensorimotor stage. Options 3 identifies the concrete operational stage. Option 4 identifies the preoperational stage.

174. The nurse is monitoring the status of a postoperative client. The nurse would become most concerned with which sign that could indicate an evolving complication? 1. Increasing restlessness 2. A pulse of 96 beats/minute 3. Blood pressure of 110/70 mm Hg 4. Hypoactive bowel sounds in all four quadrants

1 Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mmHg with a pulse of 86 beats/minute is within normal limits. Hypoactive bowel sounds heard in all four quadrants are a normal occurrence.

140. The nurse is caring for a client with meningitis and implements which transmission-based precautions for this client? 1. Private room or cohort client 2. Personal respiratory protection device 3. Private room with negative airflow pressure 4. Mask worn by staff when the client needs to leave the room

1 Meningitis is transmitted by droplet infection. Precautions for this disease include a private room or cohort client and use of a standard precaution mask. Private negative airflow pressure rooms and personal respiratory protection devices are required for clients with airborne disease such as tuberculosis. When appropriate, a mask must be worn by the client and not the staff when the client leaves the room.

167. A postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition? 1. Pneumonia 2. Hypoxemia 3. Fluid imbalance 4. Pulmonary embolism

1 Postoperative respiratory problems are atelectasis pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Hypoxemia is an inadequate concentration of oxygen in arterial blood. Fluid imbalance can be deficit or excess related to fluid loss or overload. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to one or more lobes of the lung; this is usually due to clot formation

178. The nurse is reviewing a health care provider's prescription sheet for a preoperative client that states that the client must be NPO after midnight. The nurse would telephone the HCP to clarify that which medication should be given in the client and not withheld? 1. Prednisone 2. Ferrous sulfate 3. Cyclobenzaprine (Flexeril) 4. Conjugated estrogens (Premarin)

1 Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclebenzaprine (Flexiril) is a skeletal muscle relaxant. Conjugaed estrogen (Premarin) is an estrogen used for hormone replacement therapy in postmenopausal women. These last three medications may be withheld before surgery without undue effects on the client.

177. The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? 1. Assess the patency of the airway 2. Check tubes or drains for patency 3. Check dressing to assess the bleeding 4. Assess the vital signs to compare with preoperative measurements

1 The first action of the nurse is to assess the atency of the airway and resporatory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established.

229. The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin? 1. Crusting 2. Wrinkling 3. Deepening of expression lines 4. Thinning and loss of elasticity in the skin

1 The normal physiological changes that occur in the skin of older adults include thinning of the skin, loss of elastic, deepening of expression lines, and wrinkling. Crusting on the skin would indicate a potential complication

238. The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? 1. After a shower or bath 2. While standing to void 3. After having a bowel movement 4. While lying in bed before arising

1 The nurse needs to teach the client how to perform a testicular self-examination (TSE). The nurse should instruct the client to perform the exam on the same day each month. The nurse should also instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. Palpation is easier and the client will be better able to identify any abnormalities. The client would stand to perform the exam, but it would be difficult to perform the exam while voiding. Having a bowel movement is unrelated to performing the TSE.

215. The 2-year-old child is treated in the emergency department for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safety in the home? 1. "We will be sure not to leave hot liquid unattended" 2. "I guess my children need to understand what the word hot means" 3. "We will be sure that the children stay in the rooms when we work in the kitchen" 4. "We will install a safety gate as soon as we get home so the children cannot get into the kitchen"

1 Toddlers, with their increased mobility and development of motor skills can reach hot water or hot objects palced on counters and stoves and can reach open fires or stove burners above their eye level. The nurse should encourage parents to remain in the kitchen when preparing a meal, use the back burners on the stove, and turn pot handles inward and toward the middle of the stove. Hot liquids should never be left unattended or within the child's reach, and the toddler should always be supervised. The statements in options 2, 3, and 4 do not indicate an understanding of the principles of safety.

219. A mother of a 3-year-old asks a clinic nurse about appropriate and safe toys for the child. The nurse should tell the mother that the most appropriate toy for a 3-year-old is which? 1. A wagon 2. A golf set 3. A farm set 4. A jack set with marbles

1 Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, large trucks, and dolls are some of the appropriate toys. A farm set, a golf set, and jacks with marbles may contain items that the child could swallow.

198. The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 ml. What is the most appropriate action for the nurse to take? 1. Hold the feeding 2. Reinstill the amount and continue with administering the feeding 3. Elevate the client's head at least 45 degrees and administer the feeding 4. Discard the residual amount and proceed with administering the feeding

1 Unless specifically indicated, residual amounts more than 100 ml require holding the feeding. In addition, the feeding is not discarded unless its contents are abnormal in color or characteristics

166. The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? 1. Urinary output of 20 mL/hr 2. Temperature of 37.6 C (99.6 F) 3. Blood pressure of 100/70 mmHg 4. Serous drainage on the surgical dressing

1 Urine output should be maintained at a minimum of 30 mL/hr for an adult. An output of less than 30 mL for each of 2 consecutive hours should be reported to the health care provider. A temperature higher than 37.7 C (100 F) or lower than 36.1 C (97 F) and a falling systolic blood pressure, lower than 90 mmHg are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.

175. A client has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protuding through the incision. Which nursing intervention should the nurse take? Select all that apply. 1. Contact the surgeon 2. Instruct the client to remain quiet 3. Prepare the client for wound closure 4. Document the findings and actions taken 5. Place a sterile saline dressing and ice packs over the wound. 6. Place the client in a supine position without a pillow under the head

1, 2, 3, 4 Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low Fowler's position, and the client is kept quiet, and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.

189. The nurse is preparing to instill medication into a client's nasogastric tube. Which actions should the nurse take before instilling the medication? Select all that apply. 1. Check the residual volume 2. Aspirate the stomach contents 3. Turn off the suction to the nasogastric tube 4. Remove the tube and place it in the other nostril 5. Test the stomach contents for a Ph of less than 3.2

1, 2, 3, 5 By aspirating stomach contents the residual volume can be determine and the pH checked. A pH less than 3.5 verifies gastric placement. The suction should be turned off before the tubing is disconnected to check for residual volume; in addition, suction should remain off for 30 to 60 minutes following medication administration to allow for medication absorption. There is no need to remove the tube and place it in the other nostril in order to administer a feeding; in fact, this is an invasive procedure and is unnecessary.

241. The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. 1. Auscultating lung sounds 2. Obtaining the client's temperature 3. Assessing the strength of peripheral pulses 4. Obtaining information about the client's respirations 5. Performing a musculoskeletal and neurological examination 6. Asking the client about a family history of any illness or disease

1, 2, 4 A focused assessment focuses on a limited or short-term problem, such as the client's complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory systems and the presence of an infection. A complete assessment includes a complete health history and physical examination and forms a baseline database. Assessing the strength of peripheral pulses relates to a vascular assessment, which is not related to this client's complaints. A musculoskeletal and neurological examination also is not related to this client's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete assessment. Likewise, asking the client about a family history of any illness or diease would be included in a complete assessment.

208. A parent of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper trantrums. Using Erikson's psychosocial development theory, which instruction(s) should the nurse provide to the parents? Select all that apply. 1. Set limits on the child's behavior 2. Ignore the child when this behavior occurs 3. Allow the behavior, because this is normal at this age period 4. Provide a simple explanation of why the behavior is unacceptable 5. Punish the child every time the child says "no" to change behavior

1, 4 According to Erikson, the child focuses on gaining some basic control over self and the environment and independence between ages 1-3 years. Gaining independence often means that the child has to rebel against the parents' wishes. Saying things line "no" or "mine" and having temper tantrums are common during this period of development. Being consistent and setting limits on the child's behavior are necessary elements. Providing a simple explanation of why certain behaviors are unacceptable is an appropriate action. Options 2 and 3 do not address the child's behavior. Option 5 is likely to produce a negative response during this normal developmental pattern.

220. Which intervention(s) are appropriate for the care of an infant? Select all that apply. 1. Provide swaddling 2. Talk in a loud voice 3. Provide the infant with a bottle of juice at nap time 4. Hang mobiles with black and white contrast designs 5. Caress the infant while bathing or during diaper changes 6. Allow the infant to cry for at least 10 minutes before responding

1, 4, 5 Holding, caressing, and swaddling provide warmth and tactile stimulation for the infant. To provide auditory stimulation, the nurse should talk to the infant in a soft voice and should instruct the mother to do so also. Additional interventions include playing a music box, radio, or television, or having a ticking clock or metronome nearby. Hanging a bright shiny object in midline within 20-25 cm of the infant's face and hanging mobiles with contrasting colors, such as black and white, provide visual stimulation. Crying is an infant's way of communicating; therefore the nurse would respond to the infant's crying. The mother is taught to do so also. An infant or child should never be allowed to fall asleep with a bottle containing milk, juice, soda pop, sweetened water, or another sweet liquid because of the risk of nursing (bottle-mouth) caries.

183. The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions? 1. "I should not sleep on my left side." 2. "I should not sleep on my right side." 3. "I should not sleep with my head elevated." 4. "I should not wear my glasses at any time."

2 After cataract surgery, the client should not sleep on the side of the body that was operated on to prevent edema formation and intraocular pressure. The client also should be placed in a semi-Fowler's position to assist in minimizing edema and intraocular pressure. During the day, the client may wear glasses or a protective shield; at night, the protective shield alone is sufficient.

211. Which car safety device should be used for a child who is 8 years old and is 4 feet tall? 1. Seat belt 2. Booster seat 3. Rear-facing convertible seat 4. Front-facing convertible seat

2 All children whose weight or height is above the forward-facing limit for their car safety seat should use a belt-positioning booster seat until the vehicle seat belt fits properly, typically when they have reached 4 feet 9 inches in height and are between 8 and 12 years of age. Infants should rise in a car in a semireclined, rear-facing position in an infant-only seat or a convertible seat until they weigh at least 20 pounds and are at least 1 year of age. The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat but is generally at a body weight of 9 kg (20 lbs) and 1 year of age.

186. The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse develops a postoperative plan of care for the client and should include which intervention in the plan? 1. Maintain the client in a prone position 2. Elevate and immobilize the grafted extremity 3. Maintain the grafted extremity in a flat position 4. Keep the grafted extremity covered with a blanket

2 Autografts placed over joints or on lower extremities are elevated and immobilized following surgery for 3 to 7 days, depending on the surgeon's preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering the extremity with a blanket can disrupt the graft site.

214. The nurse is evaluating the developmental level of a 2-year-old. Which does the nurse expect to observe in this child? 1. Uses a fork to eat 2. Uses a cup to drink 3. Pours own milk into a cup 4. Uses a knife for cutting food

2 By age 2 years, the child can use a cup and spoon correctly but with some spilling. By age 3-4, the child begins to use a fork. By the end of the preschool period, the child should be able to pour milk into a cup and begin to use a knife for cutting.

131. The nurse is preparing to initiate an intravenous line containing a high dose of potassium chloride and plans to use an intravenous infusion pump. The nurse brings the pump cord into the bedside, prepares to plug the pump cords into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action? 1. Initiate the intravenous line without the use of a pump 2. Contact the electrical maintenance department for assistance 3. Plug in the pump cord in the available plug above the room sink 4. Use an extension cord from the nurse's lounge for the pump plug

2 Electrical equipment must be maintained in good working order and should be grounded; otherwise it presents a physical hazard. An intravenous line that contains a dose of potassium chloride should be administered by an infusion pump. The nurse needs to use hospital resources for assistance. A regular extension cord should not be used because it poses a risk for fire. Use of electrical appliances near a sink also presents a hazard.

192. The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial nursing action should the nurse take? 1. Call the HCP 2. Place the tube in a bottle of sterile water 3. Immediately replace the chest tube system 4. Place a sterile dressing over the disconnection site

2 If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The HCP may need to be notified. but this is not the initial action. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection

196. While changing the tapes on a tracheostomy tubes, the client coughs and the tube is dislodged. Which is the initial nursing action? 1. Call the health care provider to reinsert the tube 2. Grasp the retention sutures to spread the opening 3. Call the respiratory therapy department to reinsert the tracheostomy 4. Cover the tracheostomy site with a sterile dressing to prevent infection

2 If the tube is dislodged accidentally, the inital nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attemps immediately to replace the tube. Calling ancillary services or the HCP will delay treatment in this emergency situation. Covering the tracheostomy site will block the airway.

139. The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victim will be brought to the emergency department. The nurse should take which initial action? 1. Prepare the triage rooms 2. Activate the emergency response plan 3. Obtain additional supplies from the central supply department 4. Obtain additional nursing staff to assist in treating the casualties

2 In an external disaster (a disaster that occurs outside of the institution or agency), many victims may be brought to the emergency department for treatment. The initial nursing action must be to activate the emergency response plan. Once the emergency response plan is activated, the actions in the other options will occur.

230. The home health nurse is visiting a client for the first time. Which assessing the client's medication history, it is noted that there are 19 prescriptions and several over the counter medications that the client has been taking. Which intervention should the nurse take first? 1. Check for medication interactions 2. Determine whether there are medication duplications 3. Call the prescribing health care provider and report polypharmacy 4. Determine whether a family member supervises medication administration

2 Polypharmacy is a concern in the older client. Duplication of medications needs to be identified before medication interactions can be determined because the nurse needs to know what the client is taking. Asking about medication administration supervision may be part of the assessment, but is not a first action. The phone call to the HCP is the intervention after all other information has been collected.

182. The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client? 1. Side-lying on the operative side 2. On the nonoperative side with the legs abducted 3. Side-lying with the affected leg internally rotated 4. Side-lying with the affected leg externally rotated

2 Positioning following a total hip replacement depends on the surgical techniques used, the method of implantation, the prosthesis, and health care provider's preference. Abduction is maintained when the client is in a supine position or positioned on the nonoperative side. Internal and external rotation, adduction, or side-lying on the operative side (unless specifically prescribed by the HCP) is avoided.

176. A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1. Sodium 141 mEq/L 2. Hemoglobin 8.0 g/dL 3. Plateles 210,000/mm3 4. Serum creatinine 0.8 mg/dL

2 Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon.

173. The nurse assess a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding as the surgical site? 1. Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm, tender skin

2 Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. SIgns and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.

237. The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? 1. Tests the corneal reflexes 2. Tests the six cardinal positions of gaze 3. Tests visual acuity, using Snellen eye chart 4. Tests sensory function by asking the client to close eyes and then lightly touching the forehead, cheeks, and chin

2 Testing the six cardinal positions of gaze is done to assess for muscle weakness in the eye. The client is asked to hold the head steady, and then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the two eyes. A Snellen eye chart assesses visual acuity and cranial nerve II (optic). Testing sensory function by having the client close his/her eyes and then lightly touching areas of the face and testing the corneal reflexes assess cranial nerve V (trigeminal).

213. The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate? 1. Increase oral fluids 2. Document the finding 3. Notify the health care provider 4. elevate the head of the bed to 90 degrees

2 The anterior fontanel is diamond shaped and located on the top of the head. The fontanel should be saft and flat in a normal infant, and it normally closes by 12 to 18 months of age. The nurse would document the finding because it is normal. There is no useful reason to increase oral fluids, notify the HCP, or elevate the head of the bed to 90 degrees.

212. The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/minute. On the basis of this finding, which action is most appropriate? 1. Administer oxygen 2. Document the findings 3. Notify the health care provider 4. Reassess the respiratory rate in 15 minutes.

2 The normal respiratory rate in a 12-month-old infant is 20-40 breaths/min. The normal apical heart rate is 90 to 130 breath/minute, and the average blood pressure is 90/56 mmHg. The nurse would document the finding.

132. The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to applu the safety device to the client. Which observation by the nurse indicates unsafe application of the safety device by the UAP? 1. Placing a safety knot in the safety device straps 2. Safely securing the safety device straps to the side rails 3. Applying safety device straps that do not tighten when force is applied against them 4. Securing so that two fingers can slide easily between the safety device and the client's skin

2 The safety deice straps are secured to the bed frame and never to the side rails to avoid accidental injury in the event that the side rail is released. A half-bow knot should be used for applying a safety device because it does not tighten when force is applied against it and it allows quick and easy removal of the safety device in case of an emergency. The safety device should be secure, and one or two fingers should slide easily between the safety device and the client's skin

179. A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure? 1. Lying in bed on the affected side 2. Lying in bed on the unaffected side 3. Sims' position with the head of the bed flat 4. Prone with the head turned to the side and supported by a pillow

2 To facilitate removal of fluid from the chest, the client is positioned sitting at the edge of the bed leaning over the bedside table, with the feet supported on a stool; or lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees. The prone and Sims' positions are inappropriate positions for this procedure.

207. The nurse educator is preparing to conduct a teaching session for the nursing staff regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information should the nurse include in the session? Select all that apply. 1.Individuals move through all six stages in a sequential fashion 2. Moral development progresses in relationship to cognitive development 3. A person's ability to make moral judgments develops over a period of time 4. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior 5. In stage 1 (punishment-obedience orientation), children are expected to reason as mature members of society 6. In stage 2 (instrumental-relativit orientation), the child conforms to rules to obtain rewards or have favors returned

2, 3, 4, 6 Kohlberg's theory states that individuals move though the six stages of development in a sequential fashion but the not everyone reaches stages 5 and 6 in his or her development of personal morality. The theory provides a framework for undestanding how individuals determine a moral code to quide their behavior. It states that moral development progresses in relationship to cognitive development and that a person's ability to make moral judgements develops over a period of time. IN stage 1, ages 2-3 years (punishment-obedience orientation), children cannot reason as mature members of society. In stage 2, ages 4-7 yrs (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned.

157. The nurse witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway. The nurse opens the airway in this victim by using which method? 1. Flexed position 2. Head tilt-chin lift 3. Jaw thrust maneuver 4. Mdoified head tilt-chin lift

3 If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. The head tilt-chin lift maneuver produces hyperextension of the neck and could cause complications if a neck injury is present. A flexed position is an inappropriate position for opening the airway.

231. The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological change(s) the nurse expects to note? Select all that apply. 1. Increased heart rate 2. Decline in visual acuity 3. Decreased respiratory rate 4. Decline in long-term memory 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset

2, 5, 6 Anatomical changes to the eye affect the individual's visual ability, leading to potential problems with activities of daily living. Light adaptation and visual fields are reduced. Although lung function may decrease, the respiratory rate usually remains unchanged. Heart rate decreases and heart valves thicken. Age-related changes that affect the urinary tract increase an older client's susceptibility to urinary tract infection. Short-term memory may decline with age, but long-term memory is usually maintained. Change in sleep patterns is a increased incidence of awakening after sleep onset.

235. The nurse notes documentation that a client has conductive hearing loss. The nurse understands that this type of hearing loss is caused by which problem? 1. A defect in the cochlea 2. A defect in the 8th cranial nerve 3. A physical obstruction to the transmission of sound waves 4. A defect in the sensory fibers that lead to the cerebral cortex

3 A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in the 8th cranial nerve, or a defect of the sensory fivers that lead to the cerebral cortex.

236. While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. Which describes the sound of a heart murmur? 1. Lub-dub sounds 2. Scratchy, leathery heart noise 3. Gentle blowing or swooshing noise 4. Abrupt, high-pitched snapping noise

3 A heart murmur is an abnormal heart sounds and is described as a gentle, blowing, swooshing sound. Lub-dub sounds are normal and represent the S1 (first) heart sound and S2 (second) heart sound, respectively. A pericardial friction rub is described as a scratchy, leathery heart sound. A click is described as an abrupt, high-pitched snapping sound.

172. The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse determines that the client needs additional teaching if the client makes which statement? 1. "aspirin can cause bleeding after surgery" 2. "Aspirin can cause my ability to clot blood to be abnormal" 3. "I need to continue to take the aspirin until the day of the surgery" 4. "I need to check with my health care provider about the need to stop the aspirin before the scheduled surger"

3 Anticoagulants alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. However, the client should always check with his or her health care provider regarding when to stop taking the aspirin when a surgical procedure is scheduled. Options 1, 2, and 4 are accurate client statements.

240. A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? 1. Stridor 2. Crackles 3. Wheezes 4. Diminished

3 Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions of fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring.

239. The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? 1. The client rigidly extends the arms with pronated forearms and plantar flexion of the feet 2. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended 3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column 4. The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated

3 Brudzinski's sign is tested with the client in the supine position. Te nurse flexes the client's head (gently moves the head to the chest) and there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Kernig's sign alsot tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complans of pain along the vertebral column when the leg is extended. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexes and held tightly to the sides of the body and the legs are extended and internally rotated. Decerebrate posturing is abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, nec extended, and feet plantar-flexed.

188. The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? 1. Right side 2. Low Fowler's 3. High Fowler's 4. Supine with the head flat

3 During insertion of a NG tube, the client is placed in a sitting or high-Fowler's position to facilitate insertion of the tube and reduce the risk of pulmonary aspiration if the client should vomit. The right side and low-Fowler's and supine positions place the client at risk for aspiration; in addition, these positions do not facilitate insertion of the tube.

226. The nurse is providing an education session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify which client as most typically a victim of abuse? 1. A 75-year-old man who has moderate hypertension 2. A 68-year-old man who has newly diagnosed cataracts 3. A 90-year-old woman who has advanced Parkinson's disease 4. A 70 year-old woman who has early diagnosed Lyme disease

3 Elder abuse includes physical, sexual or psychological abuse, misuse of property, and violation of rights. The typical abuse victim is a woman of advanced age with few social contacts and at least one physical or mental impairment that limits her ability to perform activities of daily living. In addition, the client usually lives alone or with the abused and depends on the abuser for care.

170. A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "If it's any help, everyone is nervous before surgery" 2. "I will be happy to explain the entire surgical procedure to you" 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

3 Explanations should begin with the information that the client knows. By providing the client with the individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option 1 does not focus on the client's anxiety. Option 4 avoids the clien'ts anxiety and is focuses on postoperative care.

181. The nurse develops a plan of care for a client with deep vein thrombosis. Which is the best position in which the nurse should place the client? 1. Out-of-bed activities as desired 2. Bed rest with the affected extremity kept flat 3. Bed rest with elevation of the affected extremity 4. Bed rest with the affected extremity in a dependent position

3 For the client with deep vein thrombosis, elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. Bed rest is indicated to prevent pressure fluctuations in the venous system that occur with walking.

190. The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action? 1. Position the client supine to assist in medication absorption 2. Aspirate the nasogastric tube after medication administration to maintain patency 3. Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication 4. Change the suction setting to low intermittent suction for 30 minutes after medication administration

3 If a client has a nasogastric tube connected to suction, the nurse should wait 30 to 60 minutes before reconnecting the tube to the suction apparatus to allow adequate time for medication absorption. The client should not be placed in the supine position because of the risk for aspiration. Aspirating the nasogastric tube will remove the medication just administered. Low intermittent suction also will remove the medication just administered.

163. The nurse witnesses the collapse of a victim in her neighborhood and suspects cardiac arrest. Which action should the nurse take first? 1. Initiate rescue breathing 2. Begin giving chest compressions 3. Activate the emergency response system 4. Obtain an automated external defibrillator

3 If a collapse is witnessed and the nurse suspects cardiac arrest, the nurse should first activate the emergency response systems. Next, the nurse should obtain an automated external defibrillator, followed by initiation of CPR, beginning with chest compressions.

138. A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action? 1. Induce vomiting 2. Call an ambulance 3. Call the Poison Control Center 4. Bring the child to the emergency department

3 If a poisoning occurs, the Poison Control Center should be contacted immediately. Vomiting should not be induced if the victim is unconscious of iif the substance ingested is a strong corrosive or petroleum product. Bringing the child to the emergency department or calling an ambulance would not be the initial action because this would delay treatment. The Poison Control Center may advise the mother to bring the child to the emergency department and, if this is the case, the mother should call an ambulance.

164. The nursing instructor asks a nursing student to describe the procedure for performing abdominal thrusts on an unconscious pregnant woman at 32 weeks' gestation. The student describes a component of the procedure correctly if the student states that he will take which action? 1. Place his hands on the pelvis to perform the thrusts 2. Perform abdominal thrusts until the object is dislodged 3. Perform left lateral abdominal thrusts until the object is dislodged 4. Place a rolled blanket under the right abdominal flank and hip area

3 If an unconscious woman in an advanced gestational stage of pregnancy has a foreign body airay obstruction, the woman is placed on her back. A wedge, such as a pillow or rolled blanket, is placed udbder the right abdominal flank and hip to displace the uterus to the left side of the abdomen. This prevents supine hypotension that can occur if the gravid uterus rests on the vena cava. The rescuer then attemps ventilations, if ventilation is unsuccessful, the rescuer positions the hands as for chest compressions and delivers firm chest thrusts to remove the obstruction. Placing the hands on the pelvis or abdomen and performing left lateral abdominal thrusts are ineffective and could be harmful.

233. The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation? 1. An involuntary rhythmic, rapid, twitching of the eyeballs 2. A dorsiflexion of the ankle and great toe with fanning of the other toes 3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed 4. A lack of normal sense of position when the client is unable to return extended fingers to a point of reference

3 In Romberg's test, the client is asked to stand with the feet together and the arms at the sides, and to close the eyes and hold the position; normally, the client can maintain posture and balance. A positive Romberg's sign is a vestibular neurological sign that is found when a client exhibits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A lack of normal sense of position coupled with an inability to return extended fingers to a point of reference is a finding that indicates a problem with coordination. A positive gaze nystagmus evaluation results in an involuntary rhythmic, rapid, twitching of the eyeballs. A positive Babinski's test results in dorsiflexion of the ankle and great toe with fanning of the other toes; if this occurs in anyone older than 2 years it indicates the presence of central nervous system.

161. The nurse is performing CPR on an infant. When performing chest compressions, the nurse compresses at least how many times? 1. 60 times per minute 2. 80 times per minute 3. 100 times per minute 4. 160 times per minute

3 In an infant, the rate of chest compressions is at least 100 times per minute.

227.The nurse is performing an assessment on an older client who is having difficult sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? 1. "I swim three times a week" 2. "I have stopped smoking cigars" 3. "I drink hot chocolate before bedtime" 4. "I read for 40 minutes before bedtime"

3 Many nonpharmacological sleep aids can be used to influence sleep. However, the client should avoid caffeinated beverages and stimulation such as tea, cola, and chocolate. The client should exercise regularly because exercise promotes sleep by burning off tension that accumulates during the day. A 20-30 minute walk, swim, or bicycle ride three times a week is helpful. The client should sleep on a bed with a firm mattress. Smoking and alcohol should be avoided. The client should avoid large meals, peanuts, beans, fruit, raw vegetables, and other foods that produce gas, and snacks that are high in fat because they are difficult to digest.

225. The nurse is providing instructions to the unlicensed assistive personnel (UAP) regarding care of an older client with hearing loss. Which should the nurse tell the UAP about older clients with hearing loss 1. They are often distracted 2. They have middle ear changes 3. They respond to low-pitched tones 4. They develop moist cerumen production

3 Presbycusis refers to the age-related irreversible degenerative changes of the inner eat that lead to decreased hearing ability. As a result of these changes, the older client has a decreased response to high-frequency sounds. Low-pitched voice tones are heard more easily and can be interpreted by the older client. Option 1, 2, and 4 are not accurate characteristics related to aging.

232. A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take? 1. Have one of the client's family members interpret 2. Have the Spanish-speaking triage receptionist interpret 3. Page an interpreter from the hospital's interpreter services 4. Obtain a Spanish-English dictionary and attempt to triage the client

3 The best action is to have a professional hospital-based interpreter translate for the client. English-speaking family members may not appropriately understands what is asked of them and may paraphrase what the client is actually saying. Also, client confidentiality as well as accurate information may be compromised when a family member or a non-health care provider acts as interpreter.

156. The nurse on the day shift walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. Which is the next nursing action? 1. Open the airway 2. Give the client oxygen 3. Start chest compressions 4. Ventilate with a mouth-to-mask device

3 The next nursing action would be to start chest compressions. Chest compressions are used to keep blood moving through the body and to the vital areas, such as the brain. After 2 minutes of compressions the rescuer opens the victim's airway.

168. The nurse is developing a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of the surgery? 1. Avoid oral hygiene and rinsing with mouthwash 2. Verify that the client has not eaten for the last 24 hours 3. Have the client void immediately before going into surgery 4. Report immediately any slight increase in blood pressure or pulse

3 The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6-8 hours before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.

194. The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. 1. Excessive bubbling in the water seal chamber 2. Vigorous bubbling in the suction control chamber 3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation.

3, 4, 5, 6 The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected fnding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absences of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 ml/hr is considered excessive and requires HCP notification. The chest tube insertion site is covered with an occlusive dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allos gravity to drain the pleural space.

221. The nurse is preparing to care for a dying client and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 1. Discourage reminiscing 2. Make the decisions for the family 3. Encourage expression of feelings, concerns, and fears 4. Explain everything that is happening to all family members 5. Touch and hold the client's or family member's hand if appropriate 6. Be honest and let the client and family know that they will not be abandoned by the nurse

3, 5, 6 The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know that they will not be abandoned. The nurse should touch and hold the client's or family member's hand, if appropriate.

187. The nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral artery. The nurse checks the health care provider's prescription and plans to allow which client position or activity following the procedure? 1. Bed rest in high Fowler's position 2. Bed rest with bathroom privileges only 3. Bed rest with head elevation at 60 degrees 4. Bed rest with head elevation no greater than 30 degrees

4 After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for 4 to 6 hours. The client is maintained on bed rest for 4 to 6 hours (time for bed rest may vary depending on the HCP's preference and on whether a vascular closure device was used) and the client may turn from side to side. The head is elevated no more than 30 degrees (although some HCP's prefer the flat position) until hemostasis is adequately achieved.

223. The nurse is caring for an older client in a long-term care facility. Which action contributes to encouraging autonomy in the client? 1. Planning meals 2. Decorating the room 3. Scheduling hair-cut appointments 4. Allowing the client to choose social activities

4 Autonomy is the personal freedom to direct one's own life as long as it does not impinge on the rights of others. An autonomous person is capable of rational thought. This individual can identify problems, search for alternatives, and select solutions that allow continued personal freedom as long as others and their rights and property are not harmed. Loss of autonomy, and therefore independence, ia a real fear of older clients. The correct option is the only one that allows the client to be a decision maker.

162. The nurse is teaching CPR to a group of nursing students. The nurse asks a student to describe the reason why blind finger sweeps are avoided in infants. The nurse determines that the student understands this reason if the student makes which statement? 1. "The object may have been swallowed" 2. "The infant may bite down on the finger" 3. "The mouth is too small to see the object" 4. "The object may be forced back further into the throat"

4 Blind finger sweeps are not recommended for infants and children because of the risk of forcing the object farther down into the airway. The other options do not identify reasons for avoiding blind finger sweeps.

200. The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate nursing action? 1. Quickly insert the tube 2. Notify the HCP immediately 3. Remove the tube and reinsert when the respiratory distress subsides 4. Pull back on the tube and wait until the respiratory distress subsides

4 During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement and wait until the distress subsides. It is not necessary to notify the health care provider immediately or remove the tube completely. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus.

169. A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? 1. Obtain a court order for the surgery 2. Have the charge nurse sign the informed consent immediately 3. Send the client to surgery without the consent form being signed 4. Obtain a telephone consent from a family member, following agency policy

4 Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by two person who hear the family member's oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but in this case it is not an emergency. Options 1 and 3 are not appropriate in this situation. Also, agency policies regarding informed consent should always be followed.

201. The clinic nurse is preparing to discuss the concepts of Kohlberg's theory of moral development with a parent. What motivates good and bad actions for the child at the preconventional level? 1. Peer pressure 2. Social Pressure 3. Parent's behavior 4. Punishment and reward

4 In the preconventional stage, morals are thought to be motivated by punishment and reward. If the child is obedient and is not punished, then the child is being moral. The child sees actions as good or bad. If the child's actions are good, the child is praised. If the child's actions are bad, the child is punished. Options 1, 2, and 3 are incorrect for this stage of moral development.

218. The nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which is the most appropriate activity for this child? 1. A radio 2. A sports video 3. Large picture books 4. Crayons and a coloring book

4 In the preschooler, play is simple and imaginative, and includes activities such as crayons and coloring books, puppets, felt and magnetic boards, and Play Doh. A radio or sports video are most appropriate for the adolescent. Large picture books are most appropriate for the infant.

136. Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? 1. Gloves and gown 2. Gloves and goggles 3. Gloves, gown, and shoe protectors 4. Gloves, gown, goggles, and faceshield

4 Splashes of body secretions can occur when providing colostomy care. Goggles and a face shield are worn to protect the face and mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, or excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary.

185. A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position? 1. Prone 2. Reverse Trendelenburg's 3. Supine, with the amputated limb flat on the bed 4. Supine, with the amputated limb supported with pillows.

4 The amputated limn is usually supported on pillows for the first 24 hours following surgery to promote venous return and decrease edema. After the first 24 hours, the amputated limb usually is placed flat on the bed to reduce hip contracture. Edema also is controlled by limb-wrapping techniques. In addition, it is important to check health care provider prescriptions regarding positioning following amputation.

134. The nurse is giving a report to an unlicensed assistive personnel (UAP) who will be caring for a client who has hand restraints (safety devices). The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently? 1. Every 2 hours 2. Every 3 hours 3. Every 4 hours 4. Every 30 minutes

4 The nurse should instruct the UAP to check safety devices and skin integrity every 30 minutes. The neurovascular and circulatory status of the extremities should also be checked every 30 minutes. In addition, the safety device should be removed at least every 2 hours to permit muscle exercise and to promote circulation. Agency guidelines regarding the use of safety devices should always be followed.

222. The nurse is providing medication instructions to an older client who is taking digoxin (Lanoxin) daily. The nurse notes that which age-related body change could place the client at risk for digoxin toxcity? 1. Decreased muscle strength and loss of bone density 2. Decreased cough efficiency and decreased vital capacity 3. Decreased salivation and decreased gastrointestinal motility 4. Decreased lean body mass and decreased glomerular filtration rate

4 The older client is at risk for medication toxicity because of decreased lean body mass and an age-associated decreased glomerular filtration rate. Although options 1, 2, and 3 identify age-realted changes that occur in the older client, they are not associated specifically with this risk.

159. The nurse attempts to relieve an airway obstruction in a 3-year-old conscious child. The nurse performs the abdominal thrust maneuver correctly by standing behind the child, placing her arms under the child's axillac and around the child, and positioning her hands to deliver the thrusts between which areas? 1. Groin and the abdomen 2. Umbilicus and the groin 3. Lower abdomen and the chest 4. Umbilicus and the siphoid process

4 To perform abdominal thrusts on a child, the rescuer stands behind the victim and places the arms directly under the victim's axillae and around the victim. The rescuer places the thumb side of one fist against the victim's abdomen in the midline, slightly above the umbilicus and well below the tip of the xyphoid process. The rescuer grasps the fist with the other hand and delivers up to five thrusts. One must take care not to tough the xiphoid process of the lower margins of the rib cage because force applies to these structures may damage internal organs.