NCLEX (Single Test) Review

1. The nurse supervises the transfer of an elderly client with left-sided weakness from the bed to the chair. After assisting the client to a sitting position, which of the following actions should the nurse take NEXT? 1 Place nonskid shoes on the client's feet. 2 Instruct the client that she will be moving toward her left side. 3 Ask the client to pivot on her right foot. 4 Support the left leg with the nurse's knee.

Q1. 1) CORRECT— instruct client to wear shoes when transferring, nonskid soles decrease the chance of falls 2) if client has weaker side, transfer toward the stronger side; nurse should assess if a transfer belt is required; place chair at 45° angle to the bed 3) appropriate action; first put shoes on client; instruct client to use armrests on chair for support 4) appropriate action to provide stability to weak leg so that client can stand during transfer

3. The nurse cares for clients in the prenatal clinic. A client comes to the clinic for a prenatal visit on June 6. Her last menstrual period was December 10. The nurse expects the client's fundal height to measure 1 24 cm. 2 26 cm. 3 28 cm. 4 30 cm.

Q3. 1) incorrect, determine EDC based on N ä gele's rule-date LMP Dec. 10; EDB- Sept. 17; client is 26 weeks pregnant; from 24-34 weeks, fundal height correlates well with weeks of gestation; 24 cm is approximately 24 weeks' gestation 2) CORRECT— client is 26 weeks pregnant; fundal height should correlate with weeks of pregnancy 3) fundus is too high 4) fundus is too high

75. The nurse assists in the delivery and receives a newborn infant. Which are the nurse's priority actions in the first 10 minutes of the newborn's life? Select all that apply. 1 Assign the Apgar scores. 2 Take all vital signs except blood pressure. 3 Administer the Hepatitis B injection. 4 Place a cap/hat on the newborn's head. 5 Place identification band on the mother and infant. 6 Bathe the infant.

Q75. 1) CORRECT— Stabilizing the newborn and promoting thermoregulation of the newborn from intrauterine to extrauterine life is the priority of the nurse in the first minutes after an infant is born. Apgar performed at 1 and 5 min of life to assess infant's transition to extrauterine life; cardiac rate, respirations, muscle tone, reflexes, and color are given 0 to 2 points each; score of 0 to 3 considered poor, 4 to 6 fair, 7 to 10 excellent. 2) CORRECT— Part of newborn assessment. 3) Administering the Hepatitis B is done to stimulate immunity but is not completed in the first 10 minutes after birth. 4) CORRECT— Cap will prevent heat loss. 5) CORRECT— Priority action to ensure identify of the newborn. 6) Newborn is not bathed until the newborn's temperature is stable.

10. The home care nurse visits a client diagnosed with progressive systemic sclerosis. The client complains that she is having more trouble swallowing and moving her right hand. Which of the following responses by the nurse is MOST important? 1 "This must be a difficult time for you." 2 "You should schedule an appointment with your health care provider." 3 "Can you tolerate pressure on your hand?" 4 "Tell me more about the problems you are having swallowing."

Q10. 1) it is important to allow client to verbalize feelings, but physical needs take priority 2) may be required, but nurse should complete assessment 3) appropriate assessment for Raynaud phenomenon; eating problems take priority 4) CORRECT— progressive systemic sclerosis is a connective tissue disease that causes dysphagia and esophageal reflux because of decreased motility; nurse should assess before determining the appropriate imp

11. A terminally ill client with excruciating pain episodes complains the pain medication given at night does not relieve the pain as well as it does during the day. A chart review reveals that clients report pain medication being less effective, and the clients receive more medication when a particular nurse is working. Which of the following actions should the nurse take FIRST? 1 Set up a hidden camera in the medication room. 2 Ask physician to consider increasing the dosage of medication at night. 3 Determine how long the client has been receiving the medication. 4 Temporarily assign another nurse to give all of the PRN medications.

Q11. 1) priority is caring for the client in pain 2) clients complaining of pain is an indication that there may be a problem with one of the nurses 3) assumes that client is experiencing a tolerance to the medication 4) CORRECT— primary focus is client comfort; validation of the nurse having a substance abuse problem does not override quality client care

12. The nurse cares for a patient hospitalized for a head injury. The client is receiving 0.9% sodium chloride at 100 cc/h and has an indwelling Foley catheter in place. The nurse notes the patient's urinary output is 1,000 cc in 3 hours. Which of the following actions by the nurse is MOST appropriate? 1 Contact the physician. 2 Decrease the amount of fluids the patient is receiving. 3 Assess the client's mucous membranes. 4 Measure the urine specific gravity.

Q12. 1) complete the assessment before contacting the physician; symptoms of diabetes insipidus include excessive urine output, severe dehydration, excessive thirst, anorexia, weight loss 2) ADH deficiency causes the excretion of large volumes of dilute urine; if deprived of fluids, may cause shock 3) may see signs of dehydration, such as poor skin turgor and dry or cracked mucous membranes 4) CORRECT— low specific gravity (1.001 and 1.005) is characteristic of diabetes insipidus; head injury causes interference with production or release of ADH; record I and O, urine specific gravity, and daily weight; ensure client's intake of fluid and administer DDAVP

13. The nurse cares for a patient with chest tubes. Two days after insertion, the chest tube is accidentally pulled out of the pleural space. Which of the following actions should the nurse take FIRST? 1 Don sterile gloves and replace the tube. 2 Apply pressure with a dressing that is tented on one side. 3 Instruct the client to cough and deep-breathe. 4 Auscultate the lung.

Q13. 1) inserting the tube is a medical procedure 2) CORRECT— decreases chance that atmospheric air will enter pleural space and allows for escape of pleural air 3) increases the amount of atmospheric air that enters the pleural space 4) priority is covering the opening; listen to lungs after emergency measure instituted

14. A tornado roared through a populated area, causing multiple casualties. Which of the following patients should the nurse see FIRST? 1 A patient with a small penetrating abdominal wound caused by flying debris. 2 A patient with blunt trauma to the abdomen that caused bruising. 3 A patient complaining of chest pain with asymmetrical chest movement noted. 4 A patient who is confused and restless with no visible injuries.

Q14. 1) may cause bleeding; injury does not appear to be life-threatening 2) second patient that should be seen; observe for ecchymosis, which indicates retroperitoneal bleeding into the abdominal wall 3) CORRECT— indicates flail; monitor for shock, give humidified oxygen, manage pain, monitor ABGs 4) appears most stable

15. A man hospitalized for alcohol abuse comes to the nurses' station and asks the nurse if he can go to the cafeteria to get something to eat. When told that his privileges do not include visiting the cafeteria, the patient becomes verbally abusive. Which of the following actions by the nurse is MOST appropriate? 1 Tell the patient to lower his voice. 2 Ask the patient what he wants from the cafeteria. 3 Calmly but firmly escort the patient to his room. 4 Assign a nursing attendant to accompany the patient to the cafeteria.

Q15. 1) do not argue; carry out limit-setting 2) reinforces inappropriate behavior 3) CORRECT— limit-setting, ensures safety; patient with substance abuse needs consistent, undivided staff approach, clearly defined expectations, as well as limit-setting; avoid threats and promises 4) reinforces abusive behavior

16. The nurse prepares a client for a skin biopsy. Which of the following statements, if made by the client, should the nurse report to the physician? 1 "I have been taking aspirin for my aching joints." 2 "I applied lotion to my skin after my shower last night." 3 "I laid out in the sun yesterday." 4 "I had coffee and a sweet roll for breakfast this morning."

Q16. 1) CORRECT— aspirin can increase the risk for bleeding and should be reported 2) does not affect the biopsy 3) not a good health habit, but it does not affect the biopsy 4) a punch or shave biopsy is usually performed on the skin and does not require NPO; clean biopsy site once a day with tap water or saline; leave site open

17. The nurse counsels a client diagnosed with degenerative joint disease. It is MOST important for the nurse to include which of the following instructions? 1 "Place your joints in the position of comfort." 2 "Place your joints in a flexed position." 3 "Place your joints in full extension." 4 "Place your joints in their functional position."

Q17. 1) may lead to limitations in movement; place in functional position 2) would cause flexion contractures that limit mobility; only use a small pillow under the head or neck; do not use large pillows under the knees; to reduce back discomfort, elevate legs 8-10 inches 3) should be placed in correct functional position to maintain mobility of joint 4) CORRECT— maintains mobility of joints

18. The nurse is making staff assignments on the medical/surgical unit. The nurse should assign a nursing assistant to care for which of the following clients? 1 A client diagnosed with a CVA 2 weeks ago requiring assistance ambulating. 2 A client diagnosed with COPD who is in acute distress requiring assistance bathing. 3 A client receiving total parenteral nutrition through a PICC line requiring a dressing change. 4 A client diagnosed with type 1 diabetes on mechanical ventilation requiring a bath.

Q18. 1) CORRECT— stable patient requiring a standard, unchanging procedure; instruct nursing assistant about the how far to walk the client and any untoward occurrences to report 2) client requires assessment; not appropriate for the nursing assistant 3) requires skill of the RN 4) requires skill of the RN

19. The home care nurse visits a client receiving warfarin (Coumadin) 5 mg PO daily for DVT. The nurse learns the client operates a horse ranch. It is MOST important for the nurse to include which of the following instructions? 1 Ride with a companion and wear an identification bracelet. 2 Carry a cell phone and dressings and tape. 3 Provide significant others with a written itinerary for the day. 4 Temporarily change to activities that are safer for client.

Q19. 1) riding with a companion is helpful but does not specifically reduce the risks; should wear an Medic Alert bracelet 2) CORRECT— because of occupation and prescribed anticoagulant, client is at risk for tissue damage; in case of injury, apply pressure to wound and summon help 3) others knowing potential location is relevant but does not reduce risks 4) taking the medication is long-term; nurse should help client integrate appropriate interventions into lifestyle

27. The nurse administers meperidine (Demerol) 75 mg IM to a postoperative patient. Thirty minutes later, it is MOST important for the nurse to take which of the following actions? 1 Reposition the patient. 2 Elevate the patient's head and place a pillow under the shoulders. 3 Observe the patient for restlessness and distress. 4 Ambulate the patient.

Q27. 1) will promote comfort; other interventions include cool, well-ventilated, quiet room and a back rub 2) will promote comfort 3) CORRECT— nurse should evaluate the actual outcomes; if medication ineffective, will also see inability to concentrate and apprehension 4) more important to allow client to rest

2. A 16-year-old girl is brought to the emergency room by her parents for evaluation of an eating disorder. When the nurse approaches the client to draw a blood sample, the client cries out, "I hate having my blood drawn. Go away!" Which of the following responses by the nurse is BEST? 1 "What's the matter? Are you afraid of what we are going to find?" 2 "What is it about having your blood drawn that upsets you?" 3 "Take a deep breath. It will be over before you know it." 4 "I'll be back in 15 minutes so we can discuss your concern."

Q2. 1) yes/no question; nurse is making an assumption 2) CORRECT— open-ended; relates to client's verbal and nonverbal communication and responds to the client's feelings 3) "don't worry" response; nontherapeutic 4) do not leave the client alone

20. The nurse cares for clients in the outpatient clinic. A client with a pacemaker calls to report that he just had an episode of dizziness and shortness of breath. Which of the following responses by the nurse is MOST important? 1 "What is your pulse?" 2 "What were you doing before the episode?" 3 "Have you experienced this before?" 4 "Is the area over the pacemaker painful or red?"

Q20. 1) CORRECT— may indicate pacemaker malfunction; nurse should assess client's current status 2) assess if client was close to electromagnetic field that might interfere with function of pacemaker; more important to assess current status 3) should be asked later in conversation 4) may indicate infection; more important to assess cardiac functioning

21. The nurse cares for the pregnant client diagnosed with sickle-cell crisis. Which action should the nurse take first? 1 Administer oxygen. 2 Turn client to right side. 3 Begin an IV with normal saline. 4 Administer antibiotics.

Q21. 1) second action; crisis caused by extensive extracellular sickling 2) no reason to turn to right side; do not keep knees and hips in a flexed position 3) CORRECT— dehydration perpetuates cell sickling; intake should be at least 200 mL/hour 4) more susceptible to blood-borne pathogens; frequent handwashing; avoid people diagnosed with URI

22. The nurse cares for a laboring patient. The patient requests something for pain and says to the nurse, "I'm really scared of shots." Which of the following responses by the nurse is BEST? 1 "A shot is your only option, because labor slows the GI tract." 2 "I can give you a pill now, but it will not last as long as an injection." 3 "What was your previous experience with shots?" 4 "What are you afraid of?"

Q22. 1) is an accurate response but does not allow the client to express her feelings 2) oral medication is not recommended in labor because of the decrease in GI motility 3) CORRECT— an assessment to assist the nurse in gathering information toward achieving pain relief and to this particular client's psychological state; assess before intervening 4) judgmental and nontherapeutic

23. The nurse on the medical/surgical unit admits an elderly client after the patient has undergone a below-the-knee amputation. The nurse obtains vitals signs and assesses that the client is able to be aroused but is sleepy. When the client awakens and realizes that the amputation was performed, the client begins to scream. Which of the following statements by the nurse is MOST appropriate? 1 "The physician informed you that the amputation was required." 2 "I'll get you some medication so that you can rest." 3 "Your family is waiting in the lobby to come see you." 4 "Since you seem upset, I'll stay with you."

Q23. 1) first step of readjustment of changed body image is psychological shock; client will not be receptive to receiving information 2) more important for the nurse to stay with the client 3) passing the buck; nurse should care for client 4) CORRECT— acknowledges client's feelings; nurse should stay with patient, focus on here and now, and deal with client's immediate problems

24. The nurse determines that which of the following clients is MOST at risk to develop gastroesophageal reflux disease (GERD)? 1 A 16-year-old African American male who had an NG tube for 3 days after surgery for a ruptured appendix. 2 A 30-year-old Hispanic female with a diagnosis of cholelithiasis and a t-tube in place. 3 A 52-year-old Caucasian female who is 5'5" tall and weighs 185 pounds. 4 A 65-year-old Caucasian male with a laryngectomy for laryngeal cancer.

Q24. 1) NG tube is a risk factor; NG tube compromises esophageal sphincter function and permits acidic stomach contents to enter the esophagus 2) being female is a risk factor for GERD 3) CORRECT— GERD is gastrointestinal contents flowing backward into the esophagus; risk factors include female, over the age of 45, and obesity; GERD appears more often in Caucasians 4) risk factors include age and ethnicity; smoking is also a risk factor for GERD

25. The nurse cares for clients in the emergency department after an earthquake. Which of the following clients should the nurse see FIRST? 1 A client at 7 months' gestation complaining of cramping and blood-streaked discharge. 2 A client with a displaced fracture of the right radius with blood seeping from the wound. 3 A client complaining of lightheadedness; nurse notes client is clammy, pulse 112, respirations 28. 4 A client with type 1 diabetes who took insulin immediately before the earthquake and is complaining of lightheadedness.

Q25. 1) may be in early labor, stable patient 2) illnesses that can wait up to 2 hours are considered urgent 3) CORRECT— client appears to be developing shock; most unstable client 4) lightheadedness probably due to hypoglycemia; more stable than client in shock

26. The nurse on the medical unit is called to the room of an elderly client. The nurse finds the client sitting up in bed reporting pressure in the chest and jaw. Vital signs are: BP 160/94, P 112, R 20, T 99.5°F (38°C). The client has a history of hypertension and is receiving IV antibiotics for a diagnosis of pneumonia. Which action should the nurse take first? 1 Administer oxygen at 4 L/min via nasal canula. 2 Place the client on a cardiac monitor and obtain a 12-lead ECG. 3 Obtain blood for CK-MB, troponin, and myoglobin levels. 4 Assess patency of the client's IV line.

Q26. 1) CORRECT— implementation; ABCs take priority; exhibiting signs of acute coronary syndrome (ACS) which may be unstable angina, myocardial ischemia or infarction 2) assessment; should be completed after oxygen administration; provides data for health care provider to determine required treatment 3) assessment; third action, elevations are indicative of MI; do not wait for lab results before beginning treatment 4) assessment; ensure route for IV medication such as nitroglycerin, morphine, fibrinolytic, and heparin

28. The nurse admits a patient to the cardiac unit with a diagnosis of heart failure. It is MOST important for the nurse to clarify which of the following orders by the physician? 1 Furosemide (Lasix) 20 mg IV every 12 hours. 2 2 g/day sodium diet 3 Normal saline at 125 ml/hour IV. 4 Oxygen at 2 L per nasal cannula.

Q28. 1) appropriate order; loop diuretic that promotes the excretion of excess water; decreases blood volume and pressure in the left ventricle 2) appropriate order; because extracellular fluid is primarily regulated by sodium, a low-sodium diet may decrease excess water 3) CORRECT— because the patient may have excess fluid volume, may be on fluid volume restriction; weigh daily and measure I and O 4) appropriate order; may have impaired gas exchange and develop hypoxemia depending on the severity of heart failure

29. The nurse performs an assessment for a client diagnosed with bilateral cataracts. To determine the amount of visual impairment experienced by the client, which of the following questions by the nurse is BEST? 1 "Would you please identify what you can see clearly?" 2 "How have your visual abilities changed?" 3 "When did you first notice that your vision had changed?" 4 "Would you please tell me what you have difficulty seeing?"

Q29. 1) cataracts are partial or total opacity of the normally transparent crystalline lens and cause objects to appear distorted and blurred; nurse unable to estimate loss of vision with this question 2) question is too broad and difficult to understand 3) does not determine the client's current vision 4) CORRECT— this question helps the nurse determine client's current loss of vision

30. The nurse performs dietary teaching with a client who has hepatitis B. Which of the following menus, if selected by the client, is BEST? 1 Hamburger, french fries, a dill pickle, and malted milk. 2 Lean roast beef, baked potato, green beans, and coffee. 3 Bacon, eggs, toast with butter, and milk. 4 Biscuits with sausage, gravy, and buttered grits, and orange juice.

Q30. 1) high-fat foods; encourage fruits, vegetables, cereals, lean meat 2) CORRECT— high-carbohydrate, low-fat 3) high-fat foods; not allowed: marbled meats, avocados, milk, bacon, egg yolks, and butter 4) high-fat foods

31. The nurse assesses a client diagnosed with paranoid schizophrenia. Which of the following assessments indicates to the nurse that the client may need assistance with self-care activities? 1 The client speaks in a low monotone voice. 2 The client had suicidal ideation on two previous admissions. 3 The client is fearful that poison is being placed in his food. 4 The client is unable to maintain eye contact with the nurse.

Q31. 1) may appear guarded, intense, and reserved; may adopt a superior, hostile, and sarcastic attitude; will have no bearing on self-care activities 2) may indicate depression 3) CORRECT— paranoia is an irrational suspicion; cannot be changed by experience or reality; may prevent client from eating; provide food in closed containers to prevent the suspicion of tampering 4) indicates a negative symptom of schizophrenia and contributes to poor social functioning but does not help client needs with self-care activities

32. The charge nurse on the night shift receives a call from one of the nurses who is to report the next morning. The day-shift nurse reports that she has been diagnosed with strep throat and placed on antibiotics. Which of the following responses by the charge nurse is MOST appropriate? 1 "How long have you had the sore throat?" 2 "How long have you been on antibiotics?" 3 "Do you have an elevated temperature?" 4 "Do you have a doctor's release to work?"

Q32. 1) duration of sore throat is not relevant to being able to work 2) CORRECT— after 24 hours of antibiotic therapy, strep throat is no longer contagious and a health care provider can resume responsibilities 3) fever is the body's reaction to disease as a defense mechanism; being afebrile is often a condition for being able to work but duration of antibiotic therapy is the best indicator 4) nurse does not need a physician's release in the case of strep throat

33. The nurse cares for a client receiving cholestyramine (Questran) 4 g BID. The nurse would be MOST concerned if the client makes which of the following statements? 1 "I have a hard bowel movement every 2 or 3 days." 2 "I sprinkle the powder on my orange juice at breakfast." 3 "I have increased my intake of milk and green leafy vegetables." 4 "I take digoxin (Lanoxin) at lunch every day."

Q33. 1) CORRECT— constipation is a side effect of medication; encourage diet high in fiber and fluids 2) sprinkle on liquid, let stand for a few minutes, and stir thoroughly; after drinking, add a small amount of liquid to same glass, mix, and drink to ensure intake of entire dose 3) medication depletes fat-soluble vitamins; milk contains vitamins A and D; green leafy vegetables contain vitamins E and K 4) take other medication one hour before or 4 to 6 hours after taking Questran

34. The nurse teaches a client receiving alendronate 10 mg PO daily. Which statement by the client causes the nurse to determine that the teaching is effective? 1 "I will take the medication at lunch." 2 "I'm glad that I don't have to participate in a regular exercise program." 3 "If I forget a dose, I should take it when I remember it." 4 "I should wear sunscreen when I go outside."

Q34. 1) take medication first thing in the morning, at least half an hour before ingesting other medication, food, or drink 2) used for treatment and prevention of osteoporosis; client should participate in regular weight-bearing exercise to increase bone density 3) only take the medication first thing in the morning; if client misses a dose, should skip the dose and resume the next morning 4) CORRECT — causes photosensitivity; wear sunscreen and protective clothing when outdoors

35. The nurse admits a client to the medical unit with a diagnosis of heart failure and pneumonia. The client's wife states that the client has recently experienced a significant decline in his hearing and is extremely depressed. Which of the following actions by the nurse is MOST appropriate? 1 Provide the client an opportunity to express his feelings about the hearing loss. 2 Assign the client to a nurse who has a hearing impairment. 3 Encourage the client to use the incentive spirometer every hour while awake. 4 Contact a support group for the hearing impaired.

Q35. 1) according to Maslow, physical needs take priority over psychosocial needs 2) intervention aimed at the hearing loss and depression; nurse needs to deal with physical needs first 3) CORRECT— pneumonia causes impaired gas exchange; incentive spirometry prevents or reverses atelectasis 4) initial interventions aimed at the pneumonia

36. The home care nurse visits an elderly client 1 day following a colonoscopy. The daughter states that her mother has been confused since coming home from the procedure. Which of the following actions should the nurse take FIRST? 1 Instruct the client to increase her intake of fluids. 2 Obtain the client's vital signs. 3 Determine how many times the client has voided. 4 Ask the client if she has experienced abdominal cramping.

Q36. 1) confusion may be sign of hypovolemic shock; client may be dehydrated because of bowel prep, nurse should first assess 2) CORRECT— hypovolemia can occur from bowel prep and altered mental status may be an early indication; assess for decreased blood pressure, increased pulse, light-headedness and dizziness 3) if client dehydrated, will void smaller amounts of concentrated urine; priority is to assess vital signs 4) may experience abdominal cramping caused by insufflation of air

37. The nurse in the outpatient clinic assesses an elderly client. The client states that the spouse had a stroke 7 months ago, and the client cared for the spouse for 3 months. Four months ago, the client had to place the spouse in a long-term care facility because of being no longer able to provide care. Since that time the client reports having lost 40 pounds, it is fearful to live alone, and the spouse is sorely missed. The nurse notices that the client is extremely hard of hearing. Which suggestion should the nurse make first? 1 "I think you should move to the nursing home with your spouse." 2 "Have you considered installing a security system in your home?" 3 "I'm going to refer you to Meals on Wheels." 4 "Perhaps you should find a hobby or join a club for seniors."

Q37. 1) assumes client is a candidate for a nursing home; loneliness is not a reason to move to a long-term care facility 2) addresses client's concern about safety and security; priority is making sure that the client eats 3) CORRECT— according to Maslow, take care of basic needs first 4) client's nutrition and safety take priority over psychosocial needs

38. The nurse cares for a client diagnosed with chronic obstructive pulmonary disease (COPD) receiving oxygen per nasal canula at 2 L/min. The nurse observes that the client has shortness of breath and chest pain. The nurse notifies the assigned physician, and the physician makes no changes in the amount of oxygen the client is receiving. Which of the following responses by the nurse is MOST appropriate? 1 Report concerns to the supervisor. 2 Contact the physician a second time. 3 Inform the family members that the physician has not changed the client's orders. 4 Continue to monitor the respiratory status of the client.

Q38. 1) client has symptoms of oxygen toxicity; hypoxemia is a greater threat than oxygen toxicity 2) hypoxemia is greater threat than oxygen toxicity 3) inappropriate action 4) CORRECT— nurse should continue to assess client's condition and report changes to the physician; hypoxemia is greater threat than oxygen toxicity

39. The community health nurse visits the home of a client with four school- aged children. The client is diagnosed with severely disabling migraine headaches. Which of the following instructions by the nurse is MOST appropriate? 1 "Hire someone to help with your children." 2 "Report excessive menstrual flow." 3 "Avoid stressful situations." 4 "Go to bed at the same time every night."

Q39. 1) may or may not be feasible for client; requires further assessment before making this suggestion 2) fluctuating estrogen levels have been related to migraine headaches, but the amount of flow does not appear to be related 3) triggers include eating chocolate or cheese, drinking coffee, and going for long periods of time between meals 4) CORRECT— fatigue is a trigger

4. Recently several staff members on the unit have complained of back strain. The nurse determines that the staff is not consistently using correct body mechanics when transferring patients. Which of the following suggestions should the nurse make FIRST? 1 "Encourage your patients to assist as much as possible." 2 "Use your arms and legs when moving a client." 3 "Determine if help is required to transfer a patient." 4 "Position yourself close to the patient."

Q4. 1) decreases the nurse's workload and promotes client strength and independence 2) appropriate action; use the larger muscles of the body and not the back; don't twist spine 3) CORRECT— first step is to assess; determine the weight to be transferred and if help (other staff members, mechanical devices) is required and available 4) minimizes the force felt by the nurse; always keep weight to be lifted close to the body

40. In early October, a home health nurse makes a home visit to an older client diagnosed with cataracts who is scheduled to have cataract removal with a lens implant in mid-November. Which of the following recommendations by the nurse is MOST important? 1 "Notify a trusted neighbor that you will be gone overnight." 2 "Get a flu shot as soon as possible" 3 "Read this information about surgical removal of cataracts." 4 "Check with your insurance company regarding co-payment and services."

Q40. 1) usually performed on an outpatient basis, with discharge usually 2 hours after surgery 2) CORRECT— flu can cause client to sneeze, cough, or blow nose, which would increase intraocular pressure; flu shot helps prevent occurrence of flu 3) promoting wellness takes priority 4) is important; but client's physical well-being takes priority

41. A patient is to be discharged after a right total hip replacement. Which of the following statements, if made by the patient to the nurse, indicates that teaching has been effective? 1 "I can't sit in my favorite recliner with my legs up." 2 "I should ask my wife to put on my socks and shoes." 3 "I should clean the incision with a mixture of hydrogen peroxide and water before applying a sterile dressing." 4 "I don't need to continue to do the leg exercises I learned in the hospital."

Q41. 1) can sit in recliner as long as hip flexion is less than 45 to 60°; avoid stooping; do not sleep on operative side until directed to do so 2) CORRECT— this self-care activity would cause hip flexion greater than 40 to 60°, might cause dislocation of hip; maintain abduction; do not cross legs 3) not needed, should use soap and water 4) should continue to do exercises

5. A client is receiving packed red blood cells. Several minutes after the infusion is started, the client complains of nausea and low back pain. It is MOST important for the nurse to take which of the following actions? 1 Obtain a urine specimen. 2 Start an IV of D 5 W. 3 Discard the blood container in a biohazard container. 4 Decrease the rate of the transfusion.

Q5. 1) CORRECT— should be sent to lab for hemoglobin determination; symptoms of hemolytic reaction include nausea, vomiting, pain in lower back, hypotension, increase in pulse rate, decrease in urinary output, hematuria 2) should restart normal saline; stop the blood, supportive care: oxygen, Benadryl, airway management 3) container should be returned to lab 4) should be discontinued due to hemolytic reaction; draw blood sample for plasma, hemoglobin culture, and retyping

42. The mother of an 8-month-old boy is concerned because her son has started to scream and refuses to eat when left with the child-care provider. Which of the following statements by the nurse is BEST? 1 "Start looking for a different child-care provider." 2 "Check your son for bruises and other injuries." 3 "Remember that this is just a phase your son is going through." 4 "Hand your child his blanket as you say goodbye."

Q42. 1) separation anxiety indicates normal development; fear of strangers begins at 7 months, peaks at 8 months 2) no indication of abuse; normal development 3) is normal growth and development, question asks for best response; phases- protests, cries/screams for parents and is inconsolable by others; despair, cry ends but is less active, not interested in food or play; denial, appears adjusted, appears interested in environment, ignores parents when they return 4) CORRECT— exhibiting separation anxiety; reassure child by offering favorite blanket or toy, talk to infant when leaving the room, and allow infant to hear parent's voice on telephone

43. The mother of a 4-year-old tells the nurse she is worried because her daughter has begun to stutter. The mother asks the nurse what actions can be taken to stop the stuttering. Which of the following responses by the nurse is BEST? 1 "What has been happening in your child's life?" 2 "Reward your child when she speaks fluently." 3 "Instruct your child to start over and speak more slowly." 4 "Slow down your own speech and talk to your daughter calmly."

Q43. 1) implies that something is wrong; broken fluency is a normal occurrence in preschoolers 2) because it is normal behavior, there is no reason to offer reward 3) will make child conscious of speech and increase the stuttering 4) CORRECT— does not call attention to the child's speech pattern and does gives the child time and space to respond; secondary stuttering is a normal phase of language development

44. While sitting at the front desk completing an assessment sheet, a new graduate nurse asks the nursing assistant to perform a finger stick blood sugar for the assigned client. The nursing assistant responds, "Why can't you do it?" Which of the following responses by the nurse is BEST? 1 "Please page me when you have completed the task." 2 "It is important that the blood sugar be completed now." 3 "Why did you ask that?" 4 "If you don't have time, I will ask someone else to do it."

Q44. 1) CORRECT— performing a finger stick is within the scope of practice of the nursing assistant and the task should be carried out as delegated 2) nurse not required to explain assignment 3) nontherapeutic; leads to further discussion, which is not appropriate 4) example of reverse delegation, lower person on hierarchy delegates to person higher on the hierarchy

45. The nurse cares for clients on the neurological unit. After receiving report, which of the following clients should the nurse see FIRST? 1 A client who is non-responsive with intermittent limb movement. 2 A client whose muscle tone of all four limbs is flaccid. 3 The client who is non-responsive but follows the staff with his eyes. 4 The client who immediately withdrawals from painful stimuli.

Q45. 1) limb movement indicates brain injury is not severe 2) CORRECT— flaccidity most indicative of serious irreversible impairment 3) tracking with the eyes indicates client less impaired than client with flaccid muscles 4) indicates a higher level of consciousness, according to Glasgow Coma Scale

46. The home care nurse visits a client receiving levothyroxine (Synthroid) 75 mcg OD. The client tells the nurse that he has been experiencing insomnia the last couple of weeks. Which of the following responses by the nurse is MOST appropriate? 1 "The physician may have to decrease the dose of medication." 2 "Tell me about your bedtime routine." 3 "When do you take the medication?" 4 "Take a warm bath before going to bed."

Q46. 1) should assess before implementing 2) assessment; more important to determine when client is taking the medication 3) CORRECT— should take medication before breakfast to prevent insomnia 4) assumes that medication is not the cause of the insomnia

47. The nurse cares for a client diagnosed with hypertension and type 1 diabetes mellitus. The client complains to the nurse that the physician wants the client to discontinue taking verapamil (Calan) 80 mg PO tid and begin taking captopril (Capoten) 50 mg PO tid. The client states, "It took a long time to find a medication that controls my blood pressure with minimal side effects, and I do not want to go through that again." Which of the following responses by the nurse is BEST? 1 "How many different antihypertensives did you try?" 2 "Captopril is the best drug for preventing or slowing down the destruction of your kidneys." 3 "Your physician is a specialist in this area and feels you need to change." 4 "Why not give it a try?"

Q47. 1) focus on the here and now; not relevant how many different drugs the client tried 2) CORRECT— Capoten dilates the efferent arterioles, resulting in lowering the glomerular pressure; verapamil dilates the afferent arterioles, increasing the pressure 3) does not give the client a reason why the physician wants to change the medication 4) answer does not give the client any information

48. The nurse cares for the client diagnosed in stage I chronic kidney disease. During the nursing assessment, the nurse expects the client to make which statement? 1 "I don't seem to urinate as much as I used to." 2 "I seem to have more swelling in my feet and ankles." 3 "I urinate more at night." 4 "The health care provider told me I need dialysis."

Q48. 1) oliguria occurs during stage II (kidney damage) 2) occurs during stage II 3) CORRECT— stage I is diminished kidney reserve; kidney function is reduced but healthier kidney is able to compensate; since kidney not as able to concentrate urine, client has polyuria and nocturia 4) required in stage V (end-stage kidney disease)

49. The nurse in the pediatric clinic performs a well-child assessment on a 15- month-old. The child's mother tells the nurse that she is very excited because her mother is visiting. The grandmother rarely visits, and the child's mother is pleased that grandmother and grandchild will spend time together. Which of the following responses by the nurse is MOST important? 1 "Your toddler may be fearful when left alone with her grandmother." 2 "How long is your mother staying?" 3 "Does your mother take any medication?" 4 "I'm sure your mother will enjoy her grandchild."

Q49. 1) toddlers display less fear of strangers as long as parents are present; when left alone, the toddler may be fearful or anxious; appropriate information for the nurse to relate to the mother; psychosocial need 2) not the most important question 3) CORRECT— because toddlers explore by putting things in their mouths, parents should be aware of all potentially toxic substances in the home; parents should be aware if visitors in the home are taking medication, which should not be left in purses or suitcases lying around 4) safety takes priority

50. The nurse notes that a patient is positive for the hepatitis B surface antigen. Which questions should the nurse include in the patient's assessment to help determine the source of the infection? 1 "Have you been anywhere where the water may have been contaminated?" 2 "Have you eaten any food in areas where the workers may not have had access to hand washing?" 3 "Have you had unprotected sex with anyone who has hepatitis B?" 4 "Have you eaten any raw shellfish lately?" 5 "Have you had a recent blood transfusion?" 6 "Do you share needles with anyone?"

Q50. 1) hepatitis A is spread through the fecal-oral route by ingestion of fecal contaminants 2) hepatitis A is spread through the fecal-oral route by ingestion of fecal contaminants 3) CORRECT - hepatitis B is shed in the body fluid of infected individuals; a mode of transmission of hepatitis B is from unprotected sex with someone who is infected 4) refers to transmission hepatitis A 5) CORRECT - hepatitis B is shed in the body fluid of infected individuals; a mode of transmission of hepatitis B is from blood transfusions 6) CORRECT - hepatitis B is shed in the body fluid of infected individuals; a mode of transmission of hepatitis B is needle sharing

51. The nurse provides care for a newly delivered infant with a temperature of 97.2 °F (36.2°C). Which actions will the nurse take when caring for this newborn? Select all that apply. 1 Place the newborn skin-to-skin on the mother's chest. 2 Double wrap the newborn in blankets from the clean linen cart. 3 Place a hat/cap on the newborn's head. 4 Place the dry and diapered newborn under a radiant warmer. 5 Bathe the newborn in warm water while protecting the umbilical stump.

Q51. 1) CORRECT- Infant needs to be warmed. Skin-to-skin maternal-infant contact can help raise the infant's temperature. 2) Cover the couplet with a warmed blanket. Blankets for newborns with a low temperature need to be pre-warmed; blankets from the linen cart are not pre- warmed. 3) CORRECT - Covering the newborn's head with a hat/cap, or swaddling in a blanket with its head covered, will help prevent heat loss from the head. 4) CORRECT - Newborns need to wear only a diaper under a radiant warmer; this action increases the surface area to absorb the radiant heat. 5) Newborns need to be thermodynamically stable prior to the first bath. The newborn will lose heat due to evaporation during the bath.

52. The client was recently admitted from the emergency department. The nurse prepares the client's prescribed medications. Which steps does the nurse take to ensure the client receives the correct medication? Select all that apply 1 Asks another nurse to verify the medications after retrieving the medications from the medication system. 2 Documents the administration of the medications before delivering them to the client. 3 Calls the client by name only to make sure the correct client is receiving the correct medication. 4 Focuses only on the delivery of the medication for the client. 5 Questions the prescriber of a medication if the dose seems too large. 6 Verifies the medication label with the medication administration record three times.

Q52. 1) double verification is only required for specific medications, such as insulin; double-verifying all medications is impractical; some calculated dosages should be double-checked 2) documentation of medication administration is completed immediately after the delivery, not before 3) use at least two client identifiers when administering medications 4) CORRECT — prepare medications for only one client at a time in an uninterrupted environment 5) CORRECT — medication needs to be verified if the dose seems too large or too small 6) CORRECT — labels need to be read at least 3 times and verified with the medication record

53. The nurse administers medication. While documenting the administration, the nurse realizes an error in administration. Which actions must the nurse take? Select all that apply 1 Evaluate the effect of the medication. 2 Notify the patient's health care provider. 3 Call the hospital's Risk Manager. 4 Notify the patient of the error. 5 Notify the nurse's attorney. 6 Complete an occurrence report.

Q53. 1) CORRECT - One of the nurse's role is evaluation of therapeutic modalities, even if the patient receives an incorrect treatment. 2) CORRECT - The nurse needs to notify the health care provider, the patient, and the charge nurse/nurse manager all need to be informed of the error. 3) Risk Management will be informed via the occurrence/incident report. The department does not need to be informed separately. If the error is significant, e.g. resulted in a death, then the nurse manager will need to contact the Risk Manager. 4) CORRECT - Appropriate action. 5) An attorney needs to be involved only if the patient is harmed. There is no information indicating harm, and harm is not automatically assumed in the event of an erroneous medication administration. 6) CORRECT - The nurse needs to complete an occurrence/incident report .

54. The nurse prepares a dose of enoxaparin (Lovenox) for the patient after a hip replacement. Which supplies will the nurse need to best deliver the prescribed medication from a multi-dose vial? Select all that apply. 1 A 3 mL syringe. 2 A 28 gauge needle. 3 A medication cup. 4 Alcohol swabs. 5 A medication label.

Q54. 1) Lovenox is only administered subcutaneously (SQ). A routine dose of Lovenox is less than 1 mL and is most safely administered from a 1 mL syringe. 2) CORRECT - A smaller gauge needle is appropriate because the medication is delivered subcutaneously. 3) A medication cup is not necessary because the medication is delivered SQ. 4) CORRECT - Alcohol swabs are needed to prepare the skin prior to administration. 5) CORRECT - For safety reasons, the medication must be labeled after it is drawn.

55. An 88-year-old client has two units of packed blood cells ordered for transfusion. The client does not have an IV. Which supplies does the nurse gather when preparing to administer the blood? Select all that apply. 1 Secondary solution of 5% dextrose solution. 2 Filtered piggyback tubing. 3 20 gauge IV cannula. 4 Blood pressure cuff. 5 Thermometer. 6 Glucometer.

Q55. 1) when administering blood, the secondary solution is normal saline, which reduces the risk of hemolysis of the red cells 2) CORRECT — blood is administered with a 20-micron in-line filter 3) CORRECT — age consideration for this client is the administration of blood through a smaller-bore cannula (20 or 22 gauge); nursing care will require a slower administration of the blood 4) CORRECT — frequent vital signs are required when administering blood 5) CORRECT — obtain temperature to assess for reactions 6) glucometer is not necessary when administering blood; blood glucose levels are not affected by blood administration

56. The nurse prepares 0900 medications for a 90-year-old client who was recently transferred from an assisted care facility. The nurse will use which actions to identify the client to ensure the correct client receives the medication? Select all that apply. 1 Ask the client to state the client's name. 2 Ask the roommate to identify the client. 3 Check the name on the client's identification band. 4 Compare the client to a photo of the client in the chart. 5 Check the client's room number against the admission record. 6 Scan the bar code on the client's ID bracelet.

Q56. 1) CORRECT— Two client identifiers must be determined before administering any medication. Calling the client by name is an acceptable identifier. 2) Two client identifiers must be determined before administering any medication. Asking the roommate to identify the client is not appropriate. 3) CORRECT— Two client identifiers must be determined before administering any medication. Checking the name on the client's identification band is an appropriate action. 4) CORRECT— Two client identifiers must be determined before administering any medication. Comparing the client to a photo is an appropriate identifier. Clients transferred from a residential facility frequently have photos in their client records because identification bands are not often worn in these types of facilities. 5) The client could have been moved to a different room since admission. 6) CORRECT— Two client identifiers must be determined before administering any medication. Using a bar code system is an appropriate action.

57. The patient is admitted to the ambulatory care unit for cataract removal and lens replacement. The nurse marks the patient's left eye after verifying the consent with the patient. During the immediate pre-operative period, the nurse calls for a "time out." Which actions will be included in the "time out"? Select all that apply. 1 The surgeon will indicate the left eye is the operative eye. 2 The anesthesiologist will verify the consent has been signed. 3 The scrub nurse will only use instruments indicated for the left eye. 4 The patient will indicate cataract removal of the left eye. 5 The circulating nurse will identify the patient by name and date of birth. 6 The circulating nurse and the surgeon will agree that the left eye is the operative eye.

Q57. 1) CORRECT— A "time out" is called before the initiation of any surgical procedure. Cataract surgery is conducted with a local anesthetic and sedation. Before sedation, the patient can be involved in the "time out" procedure. The goals of the "time out" are to correctly identify the patient, correctly identify the operative site and side, and verify that the OR team is in agreement on the procedure to be performed. 2) Verification of the consent is performed before arrival in the OR. 3) Instruments are not identified as right- and left-sided. 4) CORRECT— Part of the time out procedure. 5) CORRECT— Part of the time out procedure. 6) CORRECT—The goals of the "time out" are to correctly identify the patient, correctly identify the operative site and side, and verify that the OR team is in agreement on the procedure to be performed.

58. The nurse manager of the newborn nursery notes an increase in the number of newborns readmitted to the hospital. The infants are diagnosed with infections acquired during their initial stays in the newborn nursery. The nurse manager decides to review medical asepsis with the nursery staff. Which actions should be included in the review? Select all that apply. 1 Use of betadine on the prepuce of the penis before circumcision. 2 Three-minute hand scrub before entering the nursery. 3 Consistent use of hand sanitizer between caring for different newborns. 4 Use of sterile gloves when providing newborn care before the newborn's bath. 5 Changing the linen in the crib once a day.

Q58. 1) Medical asepsis is known as clean technique; uses techniques that inhibit growth and spread of pathogens. Using betadine prior to circumcision applies the principles of surgical asepsis. 2) CORRECT— A 3-minute scrub is particular to the newborn nursery area and included in medical asepsis. 3) CORRECT— Hand hygiene is included in medical asepsis. 4) Non-sterile gloves are used. 5) CORRECT— Changing linen is included in medical asepsis.

59. The facility-wide nursing management team is concerned about the rise in the number of hospital acquired infections identified during the past year. The team decides to review the hospital policies that include sterile technique. Which policies will the team review? Select all that apply. 1 Preparation of fresh fruits and vegetables for consumption. 2 Foley catheter insertion. 3 Flash (quick) instrument sterilization. 4 Hand washing. 5 Operative site preparation. 6 Placement of a central venous catheter.

Q59. 1) Sterile technique includes the process and procedures that destroy all microorganisms. Food preparation is considered a clean technique and requires the preparers to wash their hands before food preparation. 2) CORRECT— Catheter insertion for clients in the hospital require sterile technique. 3) CORRECT— Sterile technique includes the process and procedures that destroy all microorganisms. 4) Hand washing applies the principles of medical asepsis and therefore is a clean technique. 5) CORRECT—Operative site preparation requires sterile technique. 6) CORRECT — Inserting a central venous catheter requires sterile technique.

6. An elderly client is brought to the outpatient clinic by the spouse. The nurse notes that the client has a 10-year history of chronic kidney disease and has been taking cimetidine for two weeks. It is most important for the nurse to investigate which statement made by the client's spouse? 1 My spouse has been reporting bowel movements that are hard to pass. 2 My spouse takes the cimetidine just before eating meals. 3 My spouse seems to be having more trouble with memory lately. 4 My spouse sometimes has a headache after reading the newspaper.

Q6. 1) cimetidine decreases gastric secretion by inhibiting the actions of histamine at the H 2 -receptor site; constipation is a common side effect of this medication; should increase fiber in diet; not most important 2) cimetidine should be taken with meals and at bedtime 3) CORRECT— elderly clients and clients with kidney disease are most susceptible to CNS side effects (confusion, dizziness) of the medication; dosage may need to be reduced 4) headache may be side effect of medication, or may be caused by need to change glasses; not most important

60. The nurse provides care to an 87-year-old client who was just transferred from a long-term residential care facility. Recently, the client became agitated and increasingly confused. The initial nursing assessment reveals a foul smelling discharge in the perineal area. Which nursing actions are necessary upon the patient's admission to an acute care facility? Select all that apply. 1 Place an indwelling Foley catheter. 2 Contact the healthcare provider. 3 Take pictures of the affected area. 4 Scrub the perineal area with a bacteriostatic solution. 5 Document the condition of the perineal area.

Q60. 1) Indwelling catheters increase the risk for infection. 2) CORRECT— The healthcare provider needs to be informed. Cultures need to be ordered so the non-hospital acquired infection may be documented and treated accordingly. An infection is the likely cause for the agitation and confusion. 3) Pictures of the peri area are not included in the standard of care. 4) A bacteriostatic solution kills the microorganisms before an appropriate treatment plan can be determined. 5) CORRECT—Appropriate action.

61. The charge nurse reviews a list of patients admitted to an inpatient acute care unit. During the hand-off report, the nurse plans to alert the staff to the patients who are at highest risk for developing methicillin- resistant Staphylococcus aureus (MRSA). Which patients will the nurse include in the alert? Select all that apply. 1 The patient who has had an indwelling Foley catheter in place for 48 hours. 2 The patient who is receiving vincristine (Oncovin) through an indwelling port. 3 The patient admitted with elevated troponin levels. 4 The patient with a CD4 (T-cell) count of 200. 5 The patient who is recovering from a closed fractured femur. 6 The patient with a temperature of 100° F (37.7° C).

Q61. 1) CORRECT— MRSA is spread by direct contact and invades patients who have an existing portal of entry, such as a Foley catheter, a vascular access devise, and an endotracheal tube. 2) CORRECT— MRSA is spread by direct contact and invades patients who have an existing portal of entry, such as a Foley catheter, a vascular access devise, and an endotracheal tube. 3) The patient with the elevated troponin level has had a myocardial infarction and has no additional risk for MRSA. 4) CORRECT— Immunocompromised people are at risk for MRSA. T-cell counts are generally between 500-1000; if below 400, the patient is immunocompromised. 5) There is no additional information about the patient with the fractured femur to indicate additional risk of MRSA. 6) There is no additional information about the patient with the fever to indicate additional risk of MRSA.

62. The 78-year-old client is transferred from an acute care facility to long-term care with the diagnosis of a stroke. The client has become increasingly confused over the past 2 days. Multiple laboratory tests are prescribed. Which findings cause the nurse to contact the healthcare provider? Select all that apply. 1 Heart rate of 86 beats per minute. 2 Blood glucose level of 96 mg/dL (5.33 mmol/L). 3 Urinalysis positive for nitrites. 4 Potassium of 3.8 mEq/L. 5 Temperature of 101.30 F (38.50 C). 6 White blood cell count of 18,000/mm3.

Q62. 1) the heart rate is within normal limits 2) blood glucose is within normal limits 3) CORRECT— positive nitrite in the urine is an indication of a urinary tract infection 4) potassium level is within normal limits 5) CORRECT— confusion in an elderly client is common when the client has a urinary tract infection; elevated temperature and WBC are indications of an infection 6) CORRECT— elevated temperature and WBC are indications of an infection; this client has a urinary tract infection that needs to be treated before urosepsis develops; promptly reporting outstanding values is the registered nurse's responsibility

63. The nurse prepares the oral medications for the client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) does the nurse put on before entering the client's room? Select all that apply. 1 Gown. 2 Gloves. 3 Mask. 4 Eyewear. 5 Foot covers. 6 Hair cover.

Q63. 1) CORRECT — MRSA is spread by direct contact and requires contact precautions; wear gown when entering room if clothing will have contact with client or environmental surfaces or if client is incontinent, has diarrhea, has an ileostomy, a colostomy, or wound drainage; remove PPE before leaving room 2) CORRECT — nurse should wear clean, nonsterile gloves for client contact or contact with potentially contaminated areas; remove PPE before leaving room 3) wearing mask is part of standard precautions; wear mask, eye protection, face shield if there is danger of splashes or sprays of blood, bodily fluids, or excretions; does not apply when administering oral medication 4) wearing eyewear is part of standard precautions; wear mask, eye protection, face shield if there is danger of splashes or sprays of blood, bodily fluids, or excretions; does not apply when administering oral medication 5) foot covers not required 6) hair cover not required

64. The client recently diagnosed with chronic obstructive pulmonary disease (COPD) prepares for discharge. The nurse coordinates the client's discharge with the case manager. Which items will the nurse request so the client's home care needs are met? Select all that apply. 1 An apnea alarm. 2 An incentive spirometer (IS). 3 Oxygen therapy. 4 Nebulizer equipment. 5 A medical alert bracelet. 6 A smoke alarm.

Q64. 1) Apnea is not a problem with COPD. Therefore, an alarm is not necessary. 2) An incentive spirometer is used to increase inspiratory lung volume. COPD is a restrictive disease. Incentive spirometry is sustanined maximal inspiration used postoperatively to prevent or treat atelectasis. 3) CORRECT— Oxygen therapy necessary for the client to help improve oxygenation. 4) CORRECT— Nebulizer necessary for the client to help improve oxygenation. 5) CORRECT— A medical alert bracelet is necessary for notification of the patient's condition. 6) Home care nurse should assess for presence of smoke alarm. This is not the responsibility of the staff nurse.

65. The nurse instructs the parents of a child recently diagnosed with cystic fibrosis (CF) about how to perform percussion and postural drainage. The nurse determines teaching is appropriate if the parents state which of the following? Select all that apply. 1 "I shall position my child in a side lying position with the right side of the chest elevated on pillows." 2 "I shall place my child in a prone with thorax and abdomen elevated." 3 "I shall place my child supine with head elevated 20 degrees." 4 "I shall place my child in a knee-chest position and place pillows under the chest." 5 "I shall place my child in an upright position."

Q65. 1) CORRECT— The goal of postural drainage is to facilitate the movement of the thick secretions from the lungs that are prevalent in cystic fibrosis. Head is in dependent position which facilitates the movement of secretions. 2) CORRECT — Head in dependent position which facilitates the movement of secretions. 3) Head not in dependent position. 4) CORRECT— Head in dependent position which will facilitate the movement of secretions from the lungs. 5) Client sitting upright, head not in dependent position.

66. The emergency department nurse admits the client reporting a severe headache. The nurse notes right-sided weakness and the client is hypertensive. Which nursing actions must the nurse implement in the first hour of care? Select all that apply. 1 Offer the client a semi-soft diet. 2 Contact physical therapy for consultation. 3 Draw labs for complete blood count, including platelets. 4 Complete the order for a computed tomography (CT) scan. 5 Teach the patient about what to expect during a lumbar puncture. 6 Initiate an IV of LR at 50 mL/hour.

Q66. 1) Client admitted with indicates of a stroke. The patient will remain NPO until the diagnostic studies are complete. 2) Physical therapy may be involved because the patient has right-sided weakness. However, the consultation will not occur within the first hour because the patient is not yet stable. 3) CORRECT — A complete blood count will be ordered to evaluate for any internal hemorrhaging and use of clotting factors during the initial phase of a stroke. 4) CORRECT — A CT scan can detect for differences between and ischemic and hemorrhagic stroke, as well as the size and location of the stroke. 5) CORRECT— A lumbar puncture may be ordered for detection of blood in the cerebral spinal fluid. 6) CORRECT— An IV is necessary at a slow rate so medications can be delivered intravenously if needed. Fluid overload needs to be avoided in patients diagnosed with stroke, so the rate of fluid infusion will be very low at first.

67. The patient presents to the emergency department reporting chest pain and heaviness in the chest. Which of the following will the nurse include in the patient's focused assessment for reports of chest pain? Select all that apply. 1 Overall skin tone and color. 2 Subcutaneous emphysema. 3 Neck vein distention. 4 Edema to the lower extremities. 5 Capillary refill to the fingers and toes. 6 Aphasia.

Q67. 1) CORRECT— Skin tone and color indicates overall circulatory patterns. 2) Subcutaneous emphysema occurs with the rupture of alveoli and is seen with or before the development of a pneumothorax. The patient would display severe shortness of breath with a pneumothorax. 3) CORRECT— Right-sided heart failure can cause neck vein distention when the patient changes from a supine to upright position. 4) CORRECT— Edema to the lower extremities is a sign of right-sided failure. 5) CORRECT— Peripheral perfusion is assessed with capillary refill. 6) Aphasia is the loss of the ability to speak and is not associated with chest pain.

68. The emergency department nurse reviews discharge instructions for the client diagnosed with angina. The nurse instructs the client about the difference between chest pain caused by angina and myocardial infarction. The nurse determines teaching is effective if the client makes which statement? Select all that apply. 1 "Pain caused by angina causes an intense stabbing pain." 2 "Exertion may cause angina pain." 3 "Pain caused by angina is relieved by sitting upright." 4 "Pain caused by angina often occurs early in the morning." 5 "Anginal pain is relieved with the administration of nitroglycerine (NTG)."

Q68. 1) Angina pain is characterized as a squeezing or viselike pain. Intense stabbing pain is more closely associated with a myocardial infarction (MI). 2) CORRECT— Exertion, emotion, and/or extremes in temperature are precipitating factors in angina pain. 3) Pericarditis is often relived by sitting upright, whereas angina pain is relieved with rest. 4) MI pain more closely correlates with the morning hours. 5) CORRECT— NTG often relieves angina pain.

69. The nurse plans to teach about the benefits of probiotic therapy to the members of a local garden club. The nurse states that people diagnosed with which disorders benefit most from probiotic therapy? Select all that apply. 1 Antibiotic-associated diarrhea. 2 Coronary artery disease. 3 Transient ischemic attacks. 4 Irritable bowel syndrome. 5 Lactose intolerance. 6 Asthma.

Q69. 1) CORRECT— probiotics are live microorganisms similar to those found in the gastrointestinal (GI) track; when colonized, they enhance the immune response and stabilize the mucosal barrier in the digestive track 2) clients diagnosed with cardiac disorders do not benefit from probiotic therapy 3) clients diagnosed with vascular disorders do not benefit from probiotic therapy 4) CORRECT— irritable bowel syndrome manifested by changes in intestinal motility; indications are alterations in bowel pattern, pain, bloating, and abdominal distention; client may benefit from probiotic therapy 5) CORRECT— lactose intolerance is a condition of malabsorption due to deficiency of intestinal lactase; client may benefit from probiotic therapy 6) clients diagnosed with respiratory disorders do not benefit from probiotic therapy

7. The nurse cares for an older woman with frequent bladder incontinence following a cerebrovascular accident (CVA). Which of the following actions by the nurse is MOST appropriate? 1 Perform intermittent catheterizations using sterile technique 2 Teach the patient how to perform Valsalva maneuver. 3 Instruct the patient how to perform the Cred é maneuver. 4 Toilet the patient when she awakens in the morning and before and after meals.

Q7. 1) only used for problems with retention 2) straining and bearing down on the abdominal muscles alters the heart rate; will not prevent incontinence 3) used to initiate urination when there is retention; place a cupped hand over the bladder and push inward and downward 4) CORRECT— will establish a regular toileting routine

70. The nurse plans a healthy-living session for a group of seniors at an independent living center. Which advice, founded on evidence-based practice, does the nurse include in the teaching session? Select all that apply. 1 Include at least five servings of fruits and vegetables and six servings of whole grains. 2 Socialize only with people living in the independent living center. 3 Sit outside in the sun for 10-15 minutes two to three times per week to facilitate production of vitamin D. 4 Get a tetanus booster and a pneumonia immunization shot every 5 years. 5 Decrease calcium intake to 500 mg daily.

Q70. 1) CORRECT — complex carbohydrates and fiber are needed for a healthy digestive system 2) isolation is a problem among the elderly, and they need to be encouraged to socialize in healthy and safe environments, such as a local senior center; clients should not socialize exclusively with one group 3) CORRECT — vitamin D is necessary for calcium absorption; the easiest way to facilitate production of vitamin D is through limited exposure to the sun 4) the tetanus booster is needed every 10 years; an influenza vaccination is needed annually; the pneumococcal vaccination is administered to high-risk groups younger than 65 years and to others at 65 years and every 5 years thereafter 5) calcium intake should be 1000-1500 mg daily

71. The nurse cares for the client reporting generalized fatigue despite getting 7 to 8 hours of sleep a night. The client's lab values are as follows: albumin 4.2 g/dL, sodium 142 mEq/L, hematocrit is 31%, and hemoglobin is 9.6 g/dL. Based on these lab values, the nurse should encourage the client to increase intake of which foods? Select all that apply. 1 Chicken breast. 2 Instant oatmeal. 3 Steamed clams. 4 Steamed green beans. 5 Corn on the cob. 6 Tuna.

Q71. 1) Client has indications of anemia which is decrease in red cells or hemoglobin content or altered hemoglobin function; caused by decreased red cell production, blood loss, or increased destruction of red cells. Tissue hypoxia causes fatigue, pallor of the skin and mucous membranes, increased respiratory rate and depth, dizziness, difficulty concentrating, cold intolerance. Organ meats are high in iron. Should encourage chicken giblets rather than the chicken breast. 2) CORRECT— Fortified cereals good source of iron. 3) CORRECT— Oysters, clams, and scallops (mollusks) are a top-ten source of iron. 4) Dark, leafy vegetables such as spinach and collards are good sources of iron. 5) Corn-on-the-cob is a carbohydrate food and not a good source of iron. 6) Mollusks, red meat, egg yolks, and poultry giblets are good sources of iron.

72. The clinic nurse instructs the client schedule for a hip replacement about the necessary devices needed at home after the procedure. The nurse determines teaching is successful if the client makes which statements? Select all that apply. 1 "I will use an elevated toilet seat." 2 "I will borrow a wheel chair from my neighbor." 3 "I will have a hand brake installed on my car." 4 "I will use a shower chair and a hand-held shower." 5 "I have practiced using a grabber." 6 "I will obtain a glucometer."

Q72. 1) CORRECT— After a hip replacement, it is important that the client prevent hip flexion and promote stability. Using an elevated toilet seat prevents hip flexion 2) Client may require a walker, but under usual circumstances a wheelchair is not necessary. 3) By the time the postoperative client can drive a car, a hand brake is not be necessary. 4) CORRECT— Provides for safety and stability. Instruct client to avoiding bending to prevent hip flexion. 5) CORRECT— Using a grabber prevents the client from flexing the hip while picking up items in low areas or having to climb to reach items over the head. 6) No relationship between glucometer and hip replacement.

73. The nurse cares for geriatric clients. Which actions does the nurse take to reduce the possibility of hip fracture within the geriatric population? Select all that apply. 1 Instructs the clients to eat four servings of dairy products each day. 2 Asks the clients about exposure to the sun. 3 Determines the type of flooring in the clients' home. 4 Instructs the clients how to use a walker when ambulating. 5 Contacts an occupational therapist to have a ramp installed at home. 6 Reviews leg-strengthening exercises.

Q73. 1) CORRECT — adequate sources of calcium and vitamin D are necessary to support bone strength 2) CORRECT — fifteen to twenty minutes of exposure to the sun three to four times per week facilitates vitamin D necessary for calcium absorption 3) CORRECT — slick waxed floors and scatter rugs are trip hazards 4) there is no indication in the question that any of the clients are in need of a walker, as many elderly people are ambulatory without assistance 5) there is no indication in the question that any of the clients are in need of a ramp, as many elderly people are ambulatory without assistance 6) CORRECT — leg-strengthening exercises can promote muscle growth and improve coordination, therefore decreasing the risk of hip fracture

74. The client at 39 weeks gestation is in active labor assisted by oxytocin (Pitocin). The nurse notes the development of late decelerations on the fetal monitor strip. Which actions must the nurse take in the next 60 seconds? Select all that apply. 1 Reduce the infusion of pitocin from 10 mL/h to 6 mL/h. 2 Position the client on her left side. 3 Increase the IV infusion of Lactated Ringers. 4 Notify the client's support person. 5 Apply a re-breather mask with oxygen flowing at 10 L/minute. 6 Call the scrub tech and set up the operating room for a cesarean section.

Q74. 1) Late deceleration are caused by uteroplacental insufficiency, cord compression, and/or maternal supine hypotensive syndrome; fetal hypoxia and acidosis usually result. The goal of the nursing actions is to increase oxygenation to the fetus. The infusion of Pitocin must be turned off to decrease the frequency of contractions. 2) CORRECT— Positioning the client on her left side decreases the weight of the uterus on the vena cava and increases oxygen flow to the placenta. 3) CORRECT— Increasing the infusion of LR is called a fluid resuscitation and decreases the viscosity of the blood. The end effect is increasing oxygenation. 4) The support person needs to understand what is happening, but this is not a priority in the first minute. 5) CORRECT— Applying a re-breather mask will increase oxygenation. 6) There is no immediate indication for a cesarean section.

8. An older man is returned to his hospital room three hours after a transurethral resection of the prostate (TURP). The patient has a continuous bladder irrigation (CBI). Which of the following observations, if made by the nurse, requires an intervention? 1 The patient is in bed with his legs drawn up to his abdomen. 2 There is 500 cc fluid in the urinary drainage bag. 3 There is 350 cc of reddish urine in the drainage bag. 4 The head of the patient's bed is elevated 45 degrees.

Q8. 1) CORRECT— indicates pain; also, catheter is taped to thigh, and leg should be kept straight to maintain traction on the catheter 2) expected due to the CBI; assess for shock and hemorrhage; check dressing and drainage; urine may be bright red for 12 h; monitor vital signs 3) expected drainage soon after surgery; CBI contains isotonic fluid used to keep the catheter patent 4) no restriction on positioning as long as leg that has catheter taped to it is straight

9. The nurse on the medical/surgical floor receives four new admissions. Which of the following clients should be placed in a private room? 1 A client with a draining abdominal abscess covered with a dressing. 2 A client diagnosed with influenza. 3 A client diagnosed with cancer who appears septic. 4 A client with diverticulitis complaining of abdominal pain.

Q9. 1) standard precautions required as long as the abscess is covered with a dressing and the dressing contains the drainage 2) CORRECT— requires droplet precautions; place in private room or with patients with the same infection; maintain spatial separation of at least 3 feet; door can remain open 3) microorganisms have entered the bloodstream due to impaired immune function; standard precautions; assess for s/s shock 4) standard precautions