NCLEX-PN Test Prep 2(TWO) Questions and Answers with Explanations 1. When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should: A. Attempt to replace the cord B. Place t... he client on her left side C. Elevate the client’s hips D. Cover the cord with a dry, sterile gauze Answer C: The client with a prolapsed cord should be treated by elevating the hips and covering the cord with a moist, sterile saline gauze. The nurse should use her fingers to push up on the presenting part until a Caesarean section can be performed. Do not attempt to replace the cord, as stated in answer A. Answer B is incorrect because turning the client to the left side will not help take pressure off the cord. Answer D is incorrect because the cord should be covered with a moist, sterile gauze, not dry gauze. 2. The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room, a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes? A. The tube will allow for equalization of the lung expansion. B. C. Chest tubes relieve pain associated with a collapsed lung. D. Chest tubes assist with cardiac function by stabilizing lung expansion. Answer B: Chest tubes work to reinflate the lung and drain serous fluid. The tube does not equalize expansion of the lungs, so answer A is incorrect. Pain is associated with collapse of the lung, and insertion of chest tubes is painful, so answer C is incorrect. Answer D is true but is not the primary rationale for performing chest tube insertion. Chest tubes serve as a method of draining blood and serous fluid, and assist in reinflating the lungs. 3. A client who delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aware that successful breastfeeding is most dependent on the: A. Mother’s educational level B. Infant’s birth weight C. Size of the mother’s breast D. Mother’s desire to breastfeed Answer D: Success with breastfeeding depends on many factors, but the most dependable reason for success is desire and willingness to continue the breastfeeding until the infant and mother have time to adapt. The educational level, infant’s birth weight, and size of the mother’s breast have nothing to do with success, so answers A, B, and C are incorrect. 4. The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately? A. The presence of scant bloody discharge B. Frequent urination C. The presence of green-tinged amniotic fluid D. Moderate uterine contractions Answer C: Green-tinged amniotic fluid is indicative of meconium staining. This finding indicates fetal distress. The presence of scant bloody discharge is normal, as are frequent urination and moderate uterine contractions, so answers A, B, and D are incorrect. 5. The nurse is measuring the duration of the client’s contractions. Which statement is true regarding the measurement of the duration of contractions? A. Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction. B. Duration is measured by timing from the end of one contraction to the beginning of the next contraction. C. D. Duration is measured by timing from the peak of one contraction to the end of the same contraction. Duration is measured by timing from the beginning of one contraction to the end of the same contraction. Answer C: Duration is measured from the beginning of one contraction to the end of the same contraction. Answer A is related to frequency. Answer B is incorrect because we do not measure from the end of the contraction to the beginning of the contraction. Duration also is not measured from the peak of the contraction to the end, as stated in answer D. 6. The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for: A. Maternal hypoglycemia B. Fetal bradycardia C. Maternal hyperreflexia D. Fetal movement Answer B: The client receiving Pitocin should be monitored for decelerations. There is no association with Pitocin use and hypoglycemia, maternal hyperreflexia, or fetal movement, so answers A, C, and D are incorrect. 7. A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy? A. Insulin requirements moderate as the pregnancy progresses. B. A decreased need for insulin occurs during the second trimester. C. Elevations in human chorionic gonadotrophin decrease the need for insulin. D. Fetal development depends on adequate insulin regulation. Answer D: During pregnancy, insulin needs increase during the second and third trimesters; they do not decrease, as suggested in answer B. Insulin requirements do not moderate as the pregnancy progresses, so answer A is incorrect. Elevated human chorionic gonadotrophin elevate insulin needs; they do not decrease insulin needs. Thus, answer C is incorrect. Fetal development does depend on adequate nutrition and insulin regulation. 8. A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to: A. Providing a calm environment B. Obtaining a diet history C. Administering an analgesic D. Assessing fetal heart tones Answer A: A calm environment is needed to prevent seizure activity. Any stimulation can precipitate seizures. Assessing the fetal heart tones is important but is not the highest priority in this situation, so answer D is incorrect. Obtaining a diet history should be done later, so answer B is incorrect. Administering an analgesic is not indicated because there is no data in the stem to indicate pain, so answer C is incorrect. 9. A primigravida, age 42, is 6 weeks pregnant. Based on the client’s age, her infant is at risk for: A. Down syndrome B. Respiratory distress syndrome C. Turner’s syndrome D. Pathological jaundice Answer A: The client who is age 42 is at risk for fetal anomalies such as Down syndrome and other chromosomal aberrations. She is not at higher risk for respiratory distress syndrome or pathological jaundice, as stated in answers B and D. Turner’s syndrome, in answer C, is a genetic disorder that is not associated with age factors in pregnancy. 10. A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with: A. Magnesium sulfate B. Calcium gluconate C. Dinoprostone (Prostin E.) D. Bromocrystine (Pardel) Answer C: The client with a missed abortion will have induction of labor. Prostin E. is a form of prostaglandin used to soften the cervix. Magnesium sulfate is used for preterm labor and preeclampsia, not to induce labor, so answer A is incorrect. Calcium gluconate is the antidote for magnesium sulfate and is not used for this client, so answer B is incorrect. Pardel is dopamine receptor stimulant used to treat Parkinson’s disease; it was used at one time to dry up breast milk but is no longer used in obstetrics, so answer D is incorrect. 11. A client with preeclampsia has been receiving an infusion containing magnesium sulfate. Blood pressure is 160/80, deep tendon reflexes are 1 plus, and urinary output for the past hour is 100mL. The nurse should: A. B. Stop the infusion of magnesium sulfate and contact the physician C. Slow the infusion rate and turn the client on her left side D. Administer calcium gluconate and continue to monitor the blood pressure Answer A: The client’s blood pressure is within normal limits. The urinary output is also within normal limits. The only alteration from normal is the decreased deep tendon reflexes. The nurse should continue to monitor the blood pressure and check the magnesium level. The therapeutic level is 4.8– 9.6mg/dL. There is no need to stop the infusion at this time or slow the rate, as stated in answers B and C. Calcium gluconate is the antidote for magnesium sulfate, but there is no data to indicate toxicity, so answer D is incorrect. 12. Which statement describes the inheritance pattern of autosomal recessive disorders? A. An affected newborn has unaffected parents. B. An affected newborn has one affected parent. C. Affected parents have a one in four chance of passing on the defective gene. D. Affected parents have unaffected children who are carriers. Answer C: Autosomal recessive disorders can be passed from the parents to the infant if each parent passes the defective gene. If both parents pass the trait, the child will get two abnormal genes, and the disease results. The parents can also pass the trait to the infant. Answer A is incorrect because, to have an affected newborn, the parents must be carriers. Answer B is incorrect because both parents must be carriers. Answer D is incorrect because the parents can have affected children. Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure 13. A pregnant client, age 32, asks the nurse why her doctor has recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test: A. Because it is a state law B. To detect cardiovascular defects C. Because of her age D. To detect neurological defects Answer D: Alpha fetoprotein is a screening test done to detect neural tube defects such as spina bifida. The test is not mandatory, as stated in answer A; it does not indicate cardiovascular defects, as suggested in answer B; and her age has no bearing on the need for the test, as suggested in answer C. 14. A client with hypothyroidism asks the nurse if she will still need to take thyroid medication during the pregnancy. The nurse’s response is based on the knowledge that: A. There is no need to take thyroid medication because the fetus’s thyroid produces thyroid-stimulating hormones. B. C. It is more difficult to maintain thyroid regulation during pregnancy due to a slowing of metabolism. D. Fetal growth is arrested if thyroid medication is continued during pregnancy. Answer B: During pregnancy, the thyroid gland triples in size. This makes it more difficult to regulate thyroid medication. Answer A is incorrect because there might be a need for thyroid medication during pregnancy. Answer C is incorrect because the thyroid function does not slow. Answer D is incorrect because fetal growth is not arrested if thyroid medication is continued. 15. The nurse is responsible for performing a neonatal assessment on a fullterm infant. At 1 minute, the nurse could expect to find: A. An apical pulse of 100 B. Absence of tonus C. Cyanosis of the feet and hands D. Jaundice of the skin and sclera Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy. Answer C: Cyanosis of the feet and hands is acrocyanosis. This is a normal finding 1 minute after birth. Answers A and B are incorrect because an apical pulse should be 120–160 and the baby should have muscle tone. Jaundice immediately after birth is pathological jaundice and is abnormal, so answer D is incorrect. 16. A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client’s need for: A. Supplemental oxygen B. Fluid restriction C. Blood transfusion D. Delivery by Caesarean section Answer A: Clients with sickle cell crises are treated with heat, hydration, oxygen, and pain relief. Fluids are increased, not decreased, so answer B is incorrect. Answer C is incorrect because blood transfusions are usually not required. Answer D is incorrect because these clients can be delivered vaginally. 17. A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes: A. Increasing fluid intake B. Limiting ambulation C. Administering an enema D. Withholding food for 8 hours Answer A: Before ultrasonography, the client should be taught to drink plenty of fluids and not void. The client may ambulate, so answer B is incorrect. An enema is not needed, and there is no need to withhold food for 8 hours, so answers C and D are incorrect. 18. An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year? A. 14 pounds B. 16 pounds C. 18 pounds D. 24 pounds Answer D: By 1 year of age, the infant is expected to triple his birth weight. Answers A, B, and C are incorrect because these weights are too low. 19. A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test: A. Determines the lung maturity of the fetus B. Measures the activity of the fetus C. Shows the effect of contractions on the fetal heart rate D. Measures the neurological well-being of the fetus Answer B: A nonstress test is done to evaluate periodic movements of the fetus. It is not done to evaluate lung maturity. Answer A is incorrect because a nonstress test does not measure lung maturity. An oxytocin challenge test shows the effect of contractions on fetal heart rate; this makes answer C incorrect. A nonstress test does not measure the neurological well-being of the fetus, so answer D is incorrect. 20. A full-term male has hypospadias. Which statement describes hypospadias? A. The urethral opening is absent. B. The urethra opens on the dorsal side of the penis. C. The penis is shorter than usual. D. The urethra opens on the ventral side of the penis. Answer B: Hypospadia is a condition in which the urethra opens on the dorsal side of the penis. Answer A is incorrect because there is an opening. Answer C is incorrect because the penis is the correct size. Answer D is incorrect because the opening is on the dorsal side, not the ventral side. 21. A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8cm dilated withcomplete effacement. The priority nursing diagnosis at this time is: A. Alteration in coping related to pain B. Potential for injury related to precipitate delivery C. Alteration in elimination related to anesthesia D. Potential for fluid volume deficit related to NPO status Answer A: Transition is the time during labor when the client loses concentration due to intense contractions. Potential for injury related to precipitate delivery has nothing to do with the dilation of the cervix, so answer B is incorrect. There is no data to indicate that the client has had anesthesia or fluid volume deficit, so answers C and D are incorrect. 22. The client with varicella will most likely have an order for which category of medication? A. Antibiotics B. Antipyretics C. Antivirals D. Anticoagulants Answer C: Varicella is chicken pox. This herpes virus is treated with antiviral medications. The client is not treated with antibiotics or anticoagulants, so answers A and D are incorrect. The client might have a fever before the rash appears, but when the rash appears, the temperature is usually gone; thus, answer B is incorrect. . A client is admitted with complaints of chest pain. Which of the following drug orders should the nurse question? A. Nitroglycerin B. Ampicillin C. Propranolol D. Verapamil Answer B: Clients with chest pain can be treated with nitroglycerin, a beta blocker such as propanolol, or Varapamil, so answers A, C, and D are incorrect. There is no indication for an antibiotic such as ampicillin. 24. Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis? A. Avoid exercise because it fatigues the joints. B. Take prescribed anti-inflammatory medications with meals. C. Alternate hot and cold packs to affected joints. D. Avoid weight-bearing activity. Answer B: Clients with rheumatoid arthritis should exercise, but not to the point of pain and not when inflammation is present, so answer A is incorrect. Anti-inflammatory drugs should be taken with meals because they cause stomach upset. Alternating heat and cold is not necessary, so answer C is incorrect. Warm, moist soaks are useful to decrease pain. Weight-bearing activities such as walking are useful, so answer D is incorrect. 25. A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should the nurse question? A. Meperidine B. Mylanta C. Cimetadine D. Morphine Answer D: Morphine is contraindicated in clients with gallbladder disease and pancreatitis because morphine causes spasms of the Sphenter of Oddi. Meperidine, Mylanta, and Cimetadine can be taken by the client with pancreatitis, so answers A, B, and C are incorrect. 26. The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because: A. Hallucinogenic drugs create both stimulant and depressant effects. B. Hallucinogenic drugs induce a state of altered perception. C. Hallucinogenic drugs produce severe respiratory depression. D. Hallucinogenic drugs induce rapid physical dependence. Answer B: Hallucinogenic drugs can cause hallucinations. Continuous observation is ordered to prevent the client from harming himself during withdrawal. Answer A is incorrect because hallucinogenic drugs don’t create both stimulant and depressant effects. Answer C is incorrect because these drugs do not produce severe respiratory depression. Answer D is incorrect because these drugs produce psychological dependence rather than physical dependence. 27. A client with a history of abusing barbiturates abruptly stops drug use. The nurse should give priority to assessing the client for: A. Depression and suicidal ideation B. Tachycardia and diarrhea C. Muscle cramping and abdominal pain D. Tachycardia and euphoric mood Answer B: Barbiturates create a sedative effect. When the client stops taking barbiturates, he will experience tachycardia, diarrhea, and tachpnea. Answer A is incorrect because depression and suicidal ideation go along with barbiturate use. Muscle cramps and abdominal pain are vague symptoms; therefore, answer C is incorrect. Tachycardia is associated with stopping barbiturates, but euphoria is not; thus, answer D is incorrect. 28. During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position? A. Right breech presentation B. Right occipital anterior presentation C. Left sacral anterior presentation D. Left occipital transverse presentation Answer A: The fetal heart tones are heard in the upper abdomen. The positions in answers B, C, and D would lead to the presence of fetal heart tones being detected in the lower abdomen. In answer C, the sacrum is the back. This would lead to fetal heart tones being heard above the umbilicus, but on the right side, not the left. 29. The primary physiological alteration in the development of asthma is: A. Bronchiolar inflammation and dyspnea B. Hypersecretion of abnormally viscous mucus C. Infectious processes causing mucosal edema D. Spasm of bronchiolar smooth muscle Answer D: Asthma is the presence of bronchiolar spasms. This spasm can be brought on by allergies or anxiety. Answer A is incorrect because the primary physiological alteration is not inflammation. Answer B is incorrect because there the production is abnormally viscous mucus, not a primary alteration. Answer C is incorrect because infection is not primary to asthma. 30. A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should: A. Serve high-calorie foods that she can carry with her B. Encourage her appetite by sending out for her favorite foods C. Serve her small, attractively arranged portions D. Allow her in the unit kitchen for extra food whenever she pleases Answer A: The client with mania is seldom sitting long enough to eat and burns many calories for energy. Answer B is incorrect because the client should be treated just as other clients are. Answer C is incorrect because small meals are not correct as an option for this client. Also, in answer D, allowing her into the kitchen gives her privileges that other clients do not have and should not be allowed. 131. To maintain Bryant’s traction, the nurse must make certain that the child’s: A. Hips are resting on the bed with the legs suspended at a right angle to the bed B. C. Hips are elevated above the level of the body on a pillow and the legs suspended parallel to the bed D. Hips and legs are flat on the bed, with the traction positioned at the foot of the bed Answer B: Bryant’s traction is used for fractured femurs and dislocated hips. The hips should be elevated 15° off the bed. Answer A is incorrect because the hips should not be resting on the bed. Answer C is incorrect because the hips should not be above the level of the body. Answer D is incorrect because the hips should not be flat on the bed. Hips are slightly elevated above the bed and the legs suspended at a right angle to the bed 32. Which action by the nurse indicates understanding of herpes zoster? A. The nurse covers the lesions with a sterile dressing. B. The nurse wears gloves when providing care. C. The nurse administers a prescribed antibiotic. D. The nurse administers oxygen. Answer B: Herpes zoster is shingles. Clients with shingles should be placed in contact precautions. Wearing gloves during care will prevent transmission of the virus. Covering the lesions with a sterile gauze is not necessary, so answer A is incorrect. Antibiotics are not prescribed for herpes zoster, so answer C is incorrect. Answer D is incorrect because oxygen is not necessary. 33. The client has an order for a trough to be drawn on the client receiving Vancomycin. The nurse is aware that the nurse should contact the lab in order for them to collect the blood: A. 15 minutes after the infusion B. 30 minutes before the infusion C. 1 hour after the infusion D. 2 hours after the infusion Answer B: A trough level should be drawn 30 minutes before the third or fourth dose. Answers A, C, and D are incorrect times to draw blood levels. . The client using a diaphragm should be instructed to: A. Refrain from keeping the diaphragm in longer than 4 hours B. Keep the diaphragm in a cool location C. Have the diaphragm resized if she gains 5 pounds D. Have the diaphragm resized if she has any surgery Answer B: The client using a diaphragm should keep the diaphragm in a cool location. She should refrain from leaving the diaphragm in longer than 8 hours, not 4, so answer A is incorrect. She should have the diaphragm resized when she gains or loses 10 pounds, so answer C is incorrect. Answer D is incorrect because the client should be resized if she has abdominal surgery. 35. The nurse is providing postpartum teaching for a mother planning to breastfeed her infant. Which of the client’s statements indicates the need for additional teaching? A. “I’m wearing a support bra.” B. “I’m expressing milk from my breast.” C. “I’m drinking four glasses of fluid during a 24-hour period.” D. “While I’m in the shower, I’ll allow the water to run over my breasts.” Answer C: Mothers who plan to breastfeed should drink plenty of liquids. Four glasses in a 24-hour period is not enough. Wearing a support bra is a good practice for the mother who is breastfeeding as well as the mother who plans to bottle feed, so answer A is incorrect. Expressing milk from the breast will stimulate milk production, so answer B is incorrect. Answer D is incorrect because allowing the water to run over the breast will also facilitate “letdown,” when the milk begins to be produced. 36. Damage to the VII cranial nerve results in: A. Facial pain B. Absence of ability to smell C. Absence of eye movement D. Tinnitus Answer A: The facial nerve is cranial nerve VII. If damage occurs, the client will experience facial pain. Answer B is incorrect because the olfactory nerve is responsible for smell. Answer D is incorrect because the auditory nerve is responsible for hearing loss and tinnitus. Answer C is incorrect because eye movement is controlled by the Trochear or C IV. 37. A client is receiving Pyridium (phenazopyridine hydrochloride) for a urinary tract infection. The client should be taught that the medication can: A. Cause diarrhea B. Change the color of her urine C. Cause mental confusion D. Cause changes in taste Answer B: Clients taking Pyridium should be taught that the medication will turn the urine orange or red. Answers A, C, and D are incorrect because this drug does not cause diarrhea, mental confusion, or changes in taste. Pyridium can cause a yellowish color to skin and sclera if taken in large doses. 38. Which of the following test should be performed before beginning a prescription of Accutane? A. Check the calcium level B. Perform a pregnancy test C. Monitor apical pulse D. Obtain a creatinine level Answer B: Accutane is contraindicated for use by pregnant clients because it causes teratogenic effects. Answers A, C, and D are incorrect because calcium levels, apical pulse, and creatinine levels are not necessary. 39. A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir? A. Limiting the client’s activity B. Encouraging a high-carbohydrate diet C. Utilizing an incentive spirometer to improve respiratory function D. Encouraging fluids Answer D: Clients taking Acyclovir should be encouraged to drink plenty of fluids because renal impairment can occur. Answer A is incorrect because there is no need to limit activity. Answer B is incorrect because there is no need to encourage a high-carbohydrate diet. Use of an incentive spirometer is not specific to clients taking Acyclovir, so answer C is incorrect. 40. A client is admitted for an MRI (magnetic resonance imaging). The nurse should question the client regarding: A. Hearing loss B. A titanium hip replacement C. Allergies to antibiotics D. Inability to move his feet Answer A: The client will be asked to remain still during portions of the exam. If the client has difficulty hearing, accommodations for the inability to follow instructions will need to be made. Answer B is incorrect because clients with a titanium joint replacement can have an MRI (magnetic resonance imaging). Answer C is incorrect because the client will not have antibiotics administered in preparation for the exam. Answer D is incorrect because the client will not need to move his feet during the exam. 41. The nurse is caring for the client receiving Amphotericin B. Which of the following indicates that the client has experienced toxicity to this drug? A. Changes in vision B. Nausea C. Urinary frequency D. Changes in skin color Answer D: Clients taking Amphotericin B should be monitored for liver, renal, and bone marrow function because this drug is toxic to the kidneys and liver, and causes bone marrow suppression. Jaundice is a sign of liver toxicity. Answer A is incorrect because changes in vision are not related. Answer B is incorrect because nausea is a side effect, not a sign of toxicity, nor is urinary frequency. Answer C is incorrect because urinary frequency is not a sign of toxicity to Amphotericin B. 42. The nurse should visit which of the following clients first? A. The client with diabetes who has a blood glucose of 95mg/dL B. The client with hypertension being maintained on Lisinopril C. The client with chest pain and a history of angina D. The client with Raynaud’s disease Answer C: The client with chest pain should be seen first because this could indicate a myocardial infarction. The client in answer A has a blood glucose within normal limits. The client in answer B is maintained on blood pressure medication. The client in answer D is in no distress. 43. A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication: A. Once per day in the morning B. Three times per day with meals C. Once per day at bedtime D. Four times per day Answer B: Pancreatic enzymes should be given with meals for optimal effects. These enzymes assist the body to digest needed nutrients. Answers A, C, and D are incorrect methods of administering pancreatic enzymes. 44. Cataracts result in opacity of the crystalline lens. Which of the following best explains the functions of the lens? A. The lens controls stimulation of the retina. B. The lens orchestrates eye movement. C. The lens focuses light rays on the retina. D. The lens magnifies small objects. Answer C: The lens allows light to pass through the pupil and focus light on the retina. The lens does not stimulate the retina (answer A), assist with eye movement (answer B), or magnify small objects (answer D). 45. A client who has glaucoma is to have miotic eyedrops instilled in both eyes. The nurse knows that the purpose of the medication is to: A. Anesthetize the cornea B. Dilate the pupils C. Constrict the pupils D. Paralyze the muscles of accommodation Answer C: Miotic eyedrops constrict the pupil and allow aqueous humor to drain out of the Canal of Schlemm. Answer A is incorrect because miotics do not anesthetize the cornea. Answer B is incorrect because miotics do not dilate the pupil; they constrict the pupil. Answer D is incorrect because miotics do not paralyze the muscles of the eye. 46. A client with a severe corneal ulcer has an order for Gentamycin gtt. q 4 hours and Neomycin 1 gtt q 4 hours. Which of the following schedules should be used when administering the drops? A. Allow 5 minutes between the two medications. B. The medications may be used together. C. The medications should be separated by a cycloplegic drug. D. The medications should not be used in the same client. Answer A: When using eyedrops, allow 5 minutes between medications. Answer B is incorrect because the two medications should not be used simultaneously. Answer C is incorrect because there is no need for the client to also use a cycloplegic. Answer D is incorrect because these drugs can be used by the same client. 47. The client with colorblindness will most likely have problems distinguishing which of the following colors? A. Orange B. Violet C. Red D. White Answer B: Clients with colorblindness will most likely have problems distinguishing violets, blues, and greens. The other colors are less commonly affected, so answers A, C, and D are incorrect. 48. The client with a pacemaker should be taught to: A. Report ankle edema B. Check his blood pressure daily C. Refrain from using a microwave oven D. Monitor his pulse rate Answer D: The client with a pacemaker should be taught to count and record his pulse rate. Answer A is incorrect because ankle edema is a sign of rightsided congestive heart failure, not pacemaker malfunction. Although this is not normal, it is often present in clients with heart disease. If the edema is present in the hands and face, it should be reported. Answer B is incorrect because checking the blood pressure daily is not necessary for these clients. The client with a pacemaker can use a microwave oven, but he should stand about 5 feet from the oven while it is operating; thus, answer C is incorrect. 49. The client with enuresis is being taught regarding bladder retraining. The nurse should advise the client to refrain from drinking after: A. 1900 B. 1200 C. 1000 D. 0700 Answer A: Clients who are being retrained for bladder control should be taught to withhold fluids after about 7 p.m., or 1900. The other hours are too early in the day, so answers B, C, and D are incorrect. 50. Which of the following diet instructions should be given to the client with recurring urinary tract infections? A. Increase intake of meats B. Avoid citrus fruits C. Perform pericare with hydrogen peroxide D. Drink a glass of cranberry juice every day Answer D: Cranberry juice is more alkaline and, when metabolized by the body, is excreted with acidic urine. Bacteria does not grow freely in acidic urine. Answer A, increasing intake of meats, is not associated with urinary tract infections. Answer B is incorrect because the client does not have to avoid citrus fruits. Pericare should be done, but not with hydrogen peroxide, so answer C is incorrect. 51. The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs? A. “I will make sure I eat breakfast within 2 hours of taking my insulin.” B. “I will need to carry candy or some form of sugar with me all the time.” C. “I will eat a snack around three o’clock each afternoon.” D. “I can save my dessert from supper for a bedtime snack.” Answer C: NPH insulin peaks in 8–12 hours, so a snack should be offered at that time. NPH insulin onsets in 90–120 minutes, so answer A is incorrect. Answer B is untrue because NPH insulin is time released and does not usually cause sudden hypoglycemia. Answer D is incorrect, but the client should eat a bedtime snack. 52. A client with rheumatoid arthritis is receiving Methotrexate. After reviewing the client’s chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Methotrexate is to: A. Treat iron-deficiency anemia caused by chemotherapeutic agents B. Create a synergistic effect that shortens treatment time C. Increase the number of circulating neutrophils D. Reverse drug toxicity and prevent tissue damage Answer D: Methotrexate is a folic acid antagonist. Leucovorin is the drug given for toxicity to this drug. Answers A, B, and C are incorrect because the drug is not used to treat iron-deficiency anemia, create a synergistic effect, or increase the number of circulating neutrophils. 53. A client tells the nurse that she is allergic to eggs, dogs, rabbits, and chicken feathers. Which order should the nurse question? A. TB skin test B. Rubella vaccine C. ELISA test D. Chest x-ray Answer B: The client who is allergic to dogs, eggs, rabbits, and chicken feathers is most likely allergic to the rubella vaccine. The client who is allergic to neomycin is also at risk. Answers A, C, and D are incorrect because there is no danger to the client if he has an order for a TB skin test, ELISA test, or chest x-ray. 54. The physician has prescribed rantidine (Zantac) for a client with erosive gastritis. The nurse should administer the medication: A. 30 minutes before meals B. With each meal C. In a single dose at bedtime D. 60 minutes after meals Answer B: Zantac (rantidine) is a histamine blocker. This drug should be given with meals, for optimal effect. It should not be given before meals, so answer A is incorrect. Tagamet (cimetidine) is a histamine blocker that can be given in one dose at bedtime, so answer C is incorrect. These drugs should not be given after meals, so answer D is incorrect. 55. A client is admitted to the hospital following a gunshot wound to the abdomen. A temporary colostomy is performed, and the physician writes an order to irrigate the proximal end of the colostomy. The nurse is aware that the proximal end of a double-barrel colostomy is the end that: A. Is the opening on the client’s left side B. Is the opening on the distal end on the client’s left side C. Is the opening on the client’s right side D. Is the opening on the distal right side Answer C: The proximal end of the double-barrel colostomy is the end toward the small intestines. This end is on the client’s right side. The distal end, in answers A, B, and D, is on the client’s left side. 56. When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to: A. Check the client for bladder distention B. Assess the blood pressure for hypotension C. Determine whether an oxytoxic drug was given D. Check for the expulsion of small clots Answer A: If the nurse checks the fundus and finds it to be displaced to the right or left, this is an indication of a full bladder. Answer B is incorrect because this finding is not associated with hypotension or clots. Oxytoxic drugs (Pitocin) are used to contract the uterus, but the fact that the client did or did not receive Pitocin does not help with the plan of action; therefore, answer C is incorrect. Answer D is incorrect because expulsion of small clots is normal; it has nothing to do with displacement to the right. 57. The physician has ordered a CAT (computerized axial tomography) scan for a client with a possible cerebral aneurysm. Which information is most important to the nurse who is preparing the client for the CAT scan? The client: A. Is having her menstrual period B. Has a history of claustrophobia C. Is allergic to oysters D. Has sensory deafness Answer C: Answer C is correct because a history of allergies to oysters may indicate a potential allergy to the dye used in the contrast medium. Answer A is incorrect because the client can have a CAT scan if she is having her menses. Answer B is incorrect because a history of claustrophobia is not related to having a CAT scan. Answer D is incorrect because a client with sensory hearing loss can have a CAT scan. 58. A 6-month-old client is placed on strict bed rest following a hernia repair. Which toy is best suited to the client? A. Colorful crib mobile B. Hand-held electronic games C. Cars in a plastic container D. 30-piece jigsaw puzzle Answer C: Answer A is incorrect because a 6-month-old is too old for the colorful mobile. Answers B and D are incorrect because he is too young to play with the electronic game or the 30-piece jigsaw puzzle. The best toy for this age is the cars in a plastic container. 59. The nurse is preparing to discharge a client with a long history of polio. The nurse should tell the client that: A. Taking a hot bath will decrease stiffness and spasticity. B. A schedule of strenuous exercise will improve muscle strength. C. Rest periods should be scheduled throughout the day. D. Visual disturbances may be corrected with prescription glasses. Answer C: The client with polio has muscle weakness. Periods of rest throughout the day will conserve the client’s energy. Answer A is incorrect because taking a hot bath can cause burns; however, a warm bath would be helpful. Answer B is incorrect because strenuous exercises are not advisable. Answer D is incorrect because visual disturbances are directly associated with polio; however, there is no guarantee that these visual disturbances can be corrected by glasses. 60. A client on the postpartum unit has a proctoepisiotomy. The nurse should anticipate administering which medication? A. Dulcolax suppository B. Docusate sodium (Colace) C. Methyergonovine maleate (Methergine) D. Methylphenidate (Ritalin) Answer B: The client with a protoepisiotomy will need stool softeners such as docusate sodium. Answer A is incorrect because suppositories are given only with an order from the doctor. Answer C is incorrect because Methergine (methylergonovine) is a drug used to contract the uterus. Answer D is incorrect because Ritalin (methylphenidate) is a drug given for hyperactivity. 61. A client with pancreatic cancer has an infusion of TPN (Total Parenteral Nutrition). The doctor has ordered a sliding scale insulin. The most likely explanation for this order is: A. Total Parenteral Nutrition leads to negative nitrogen balance and elevated glucose levels. B. Total Parenteral Nutrition cannot be managed with oral hypoglycemics. C. D. Total Parenteral Nutrition leads to further pancreatic disease. Answer C: Total Parenteral Nutrition is a high-glucose solution. This therapy often causes the glucose levels to be elevated. Because this is a common complication, insulin might be ordered. Answer A is incorrect because TPN is used to treat negative nitrogen balance; it will not lead to negative nitrogen balance. Answer B is incorrect because Total Parenteral Nutrition can be managed with oral hypoglycemic drugs, but it is difficult. Answer D is incorrect because Total Parenteral Nutrition will not lead to further pancreatic disease. 62. An adolescent primigravida who is 10 weeks pregnant attends the Total Parenteral Nutrition is a high-glucose solution that often elevates the blood glucose levels. antepartal clinic for her first check-up. To develop a teaching plan, the nurse should initially assess: A. The client’s knowledge of the signs of preterm labor B. The client’s feelings about the pregnancy C. Whether the client was using a method of birth control D. The client’s thought about future children Answer B: The client who is 10 weeks pregnant should be assessed to determine how she feels about the pregnancy. Answer A is incorrect because it is too early to discuss preterm labor. Answer C is incorrect because it is too late to discuss whether she was using a method of birth control. Answer D is incorrect because now is not the time to discuss future children; this can be done after the client delivers. 63. The client has an order for Demerol (meperidine) and Phenergan (promethazine) to be given together. The nurse is aware that the purpose of this order is: A. For its synergistic effect B. For its agonist effect C. For its extrapyramidal effects D. For its antagonistic effects Answer A: Demerol and Phenergan are given for their synergistic effect. Synergistic means that one drug increases the effectiveness of the other. Demerol is a narcotic analgesic, and Phenergan is an antianxiety, antiemetic medication. Answer B is incorrect because they are not given for the agonist effect; an agonist is a medication that works with chemicals or substances in the blood, such as hormones. Answer C is incorrect because they are not given together to cause extrapyramidal effects. Answer D is incorrect because antagonists work against one another. 64. The physician has ordered a liver scan with contrast to confirm the diagnosis. Before the procedure, the nurse should: A. Assess the client for allergies B. Bolus the client with fluid C. Tell the client he will be asleep D. Insert a urinary catheter Answer A: A thyroid scan with contrast uses a dye, so the client should be assessed for allergies to iodine. The client will not have a bolus of fluid, will not be asleep, and will not have a urinary catheter inserted, so answers B, C, and D are incorrect. 65. The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse understands that RhoGam is given to: A. Provide immunity against Rh isoenzymes B. Prevent the formation of Rh antibodies C. Eliminate circulating Rh antibodies D. Convert the Rh factor from negative to positive Answer B: RhoGam is used to prevent formation of Rh antibodies. It does not provide immunity to Rh isoenzymes, eliminate circulating Rh antibodies, or convert the Rh factor from negative to positive, so answers A, C, and D are incorrect. 66. The nurse is caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot? A. Application of a short inclusive spica cast B. Stabilization with a plaster-of-Paris cast C. Surgery with Kirschner wire implantation D. No bandages to be used to correct the fractured foot Answer B: A client with a fractured foot often has a short leg cast applied to stabilize the fracture. Answer A is incorrect because a spica cast is used to stabilize a fractured pelvis or vertebral fracture. Answer C is incorrect because Kirschner wires are used to stabilize small bones such as toes. Answer D is incorrect because the client will most likely have a cast application. 67. A nurse is performing the Trendelenburg test for the client with multiple sclerosis. The nurse is aware that this test is used to measure: A. Muscle weakness B. Fluid retention C. Ability to concentrate D. Dexterity Answer A: A Trendelenburg test is done to determine muscle weakness. The Trendelenburg sign is positive if the client cannot stand on one leg without having pelvic weakness. The test is not done to determine fluid volume, as stated in answer B, or to determine the client’s ability to concentrate, as stated in answer C. Answer D is incorrect because the Trendelenburg test does not check for dexterity. 68. Following a heart transplant, a client is started on medication to prevent organ rejection. Which category of medication prevents the formation of antibodies against the new organ? A. Antivirals B. Antibiotics C. Immunosuppressants D. Analgesics Answer C: Immunosuppressants are used to prevent antibody formation. Answer A is incorrect because antivirals are not used in this client. Answer B is not correct because antibiotics do not prevent organ rejection. Answer D is incorrect because analgesics do not prevent rejection. 69. The nurse is preparing a client for cataract surgery. The nurse is aware that the procedure will use: A. Mydriatics to facilitate removal B. Miotic medications such as Timoptic C. A laser to smooth and reshape the lens D. Silicone oil injections into the eyeball Answer A: Before cataract removal, the client will have Mydriatic drops instilled to dilate the pupil. This will facilitate removal of the lens. Answer B is incorrect because miotics constrict the pupil and are not used in cataract clients. Answer C is incorrect because a laser is not used to smooth and reshape the lens. The diseased lens is removed. Answer D is incorrect because a silicone oil is not injected in this client. 70. A client with Alzheimer’s disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most therapeutic for the client? A. Placing mirrors in several locations in the home B. Placing a picture of herself in her bedroom C. D. Alternating healthcare workers to prevent boredom Answer C: Answers A and B are not recommended because placing mirrors and pictures in several locations tends to cause agitation. Answer C is correct because placing simple signs that indicate the location of rooms where the client sleeps, eats, and bathes will help the client be more independent. Answer D is incorrect because alternating healthcare workers also confuses the client and leads to further confusion. 71. A client with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief purpose of the Jackson-Pratt drain is to: A. Prevent the need for dressing changes B. Reduce edema at the incision C. Provide for wound drainage D. Keep the common bile duct open Answer C: A Jackson-Pratt drain is a serum-collection device commonly used in abdominal surgery. Answers A, B, and D are incorrect because a Jackson-Pratt drain will not prevent the need for dressing changes, reduce edema of the incision, or keep the common bile duct open. A t-tube is used to keep the common bile duct open. 72. The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of: A. Mongolian spots B. Scrotal rugae C. Head lag D. Vernix caseosa Placing simple signs to indicate the location of the bedroom, bathroom, and so on Answer C: Head lag is associated with the pre-term newborn and is an expected finding in the newborn less than 36 weeks gestation. Answer A is incorrect because the presence of Mongolian spots are not associated with the pre-term newborn. Answers B and D are findings associated with the fullterm newborn; therefore, they are incorrect. 73. The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately? A. Hematuria B. Muscle spasms C. Dizziness D. Nausea Answer A: Hematuria in a client with a pelvic fracture can indicate trauma to the bladder or impending bleeding disorders. Answers B, C, and D are incorrect because it is not unusual for the client to complain of muscles spasms, dizziness, or nausea following multiple traumas. 74. A client is brought to the emergency room by the police. He is combative and yells, “I have to get out of here; they are trying to kill me.” Which assessment is most likely correct in relation to this statement? A. The client is experiencing an auditory hallucination. B. The client is having a delusion of grandeur. C. The client is experiencing paranoid delusions. D. The client is intoxicated. Answer C: The statement “They are trying to kill me” indicates paranoid delusions. There is no data to indicate that the client is hearing voices, as stated in answer A. Delusions of grandeur are fixed beliefs that the client is superior or perhaps a famous person, so answer B is incorrect. There is no data to indicate that the client is intoxicated, so answer D is incorrect. 75. The nurse is performing tracheostomy care. If the client coughs out the inner cannula, the nurse should: A. Call the doctor B. Replace the inner cannula with a new one C. Hold open the stoma with forceps D. Begin rescue breathing Answer B: Because there is an inner and an outer cannula, the nurse should simply replace the old one with a new, sterile one. Answer A is incorrect because there is no need to call the doctor. Answer C is incorrect because there is no need to hold open the stoma because there is an out cannula. Answer D is incorrect because there is no data to support the lack of respirations in the client. 76. An infant’s Apgar score is 9 at 5 minutes. The nurse is aware that the most likely cause for the deduction of one point is: A. The baby is cold. B. The baby is experiencing bradycardia. C. The baby’s hands and feet are blue. D. The baby is lethargic. Answer C: Infants with a 9 Apgar at 5 minutes most likely have acryocyanosis, a normal physiologic adaptation to birth. Answer A is incorrect because it is most likely not related to the infant being cold. Answer B is incorrect because there is no evidence that the baby has bradycardia. Answer D is incorrect because there is no evidence that the baby is lethargic. 77. The primary reason for rapid continuous rewarming of the area affected by frostbite is to: A. Lessen the amount of cellular damage B. Prevent the formation of blisters C. Promote movement D. Prevent pain and discomfort Answer A: The primary reason for rapid, continuous rewarming of an area affected by frostbite is to lessen cellular damage. Answers B, C, and D are not primary reasons for rapid continuous rewarming, therefore they are incorrect. 78. A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse’s response is based on the knowledge that hemodialysis works by: A. Passing water through the dialyzing membrane B. Eliminating plasma proteins from the blood C. Lowering the pH by removing nonvolatile acids D. Filtering waste through a dialyzing membrane Answer D: Hemodialysis works by using a dialyzing membrane to filter waste that has accumulated in the blood. Answer A is incorrect because it does not pass water through a dialyzing membrane. Answer B is not correct because hemodialysis does not eliminate plasma protein from the blood. Answer C is incorrect because it does not lower the pH. 179. During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate? A. Administering an antibiotic B. Contacting the physician for an order for immune globulin C. Administering an antiviral D. Telling the client that he should remain in isolation for 2 weeks Answer B: The client who is immune-suppressed and exposed to measles should be treated with medications to boost his immunity to the virus. An antibiotic or antiviral will not protect the client, so answers A and C are incorrect. Answer D is incorrect because it is too late to place the client in isolation. 80. A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact? A. The client should be placed in a room with negative pressure. B. Infection requires close contact; therefore, the door may remain open. C. Transmission is highly likely, so the client should wear a mask at all times. D. Infection requires skin-to-skin contact and is prevented by handwashing, gloves, and a gown. Answer D: The client with MRSA should be placed in isolation. Gloves, a gown, and a mask should be used when caring for the client. The door should remain closed, but a negative-pressure room is not necessary, so answers A and B are incorrect. MRSA is spread by contact with blood or body fluid, or by touch to the skin of the client. MRSA is cultured from the nasal passages of the client, so the client should be instructed to cover the nose and mouth when he sneezes or coughs. Answer C is incorrect because it is not necessary for the client to wear the mask at all times. The nurse should wear the mask. 81. A client with an above-the-knee amputation is being taught methods to prevent hip-flexion deformities. Which instruction should be given to the client? A. “Lie supine with the head elevated on two pillows.” B. “Lie prone every 4 hours during the day for 30 minutes.” C. “Lie on your side with your head elevated.” D. “Lie flat during the day.” Answer B: To prevent hip-flexion deformities, the client should be instructed to lie prone every 4 hours for 30 minutes during the day. This will force the leg to extend to 0 and prevent the contracture. Answer A, C, and D are incorrect because lying on his back or side, or flat will not help. 82. A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that, during the Whipple procedure, the doctor will remove the: A. Head of the pancreas B. Proximal third section of the small intestines C. Stomach and duodenum D. Esophagus and jejunum Answer A: During a Whipple procedure, the head of the pancreas, a portion of the stomach, the jejunum, and a portion of the stomach are removed and reanastomosed. Answer B is incorrect because the proximal third of the small intestine is not removed. The entire stomach is not removed, as in answer C, and the esophagus also is not removed, as in answer D. 83. The physician has ordered a minimal bacteria diet for a client with neutropenia. The client should be taught to avoid eating: A. Fruits B. Salt C. Pepper D. Ketchup Answer C: Pepper is not processed and contains bacteria. Answer A is incorrect because fruits can be eaten; they should be cooked or washed and peeled. Answers B and D are allowed. 84. A client is discharged home with a prescription for Coumadin (warfarin sodium). The client should be instructed to: A. Have a Protime done monthly B. Eat more fruits and vegetables C. Drink more liquids D. Avoid crowds Answer A: Coumadin (sodium warfarin) is an anticoagulant. One of the tests for bleeding time is a Protime. This test should be done monthly. Answer B is incorrect because eating more fruits and vegetables is not necessary, and dark-green vegetables contain vitamin K that increases clotting. Answer C is incorrect because drinking more liquids is not necessary. Answer D is not correct because avoiding crowds is also not necessary. 85. The nurse is assisting the physician with removal of a central venous catheter. To facilitate removal, the nurse should instruct the client to: A. Perform the Valsalva maneuver as the catheter is advanced B. Turn his head to the left side and hyperextend the neck C. Take slow, deep breaths as the catheter is removed D. Turn his head to the right while maintaining a sniffing position Answer A: The client having removal of a central venous catheter should be told to hold his breath and bear down. This is known as the Valsalva maneuver. This prevents air from entering the line. Answers B, C, and D are incorrect because they will not facilitate removal. 86. A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for: A. Allergies to pineapples and bananas B. A history of streptococcal infections C. Prior therapy with phenytoin D. A history of alcohol abuse Answer B: Clients with a history of streptococcal infections might have antibodies that render the streptokinase ineffective. Answer A is incorrect because there is no reason to assess the client for allergies to pineapples or bananas. There is no correlation to the use of phenytoin and streptokinase, so answer C is incorrect. A history of alcohol abuse is also not a factor in the order for streptokinase, so answer D is incorrect. 87. The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid: A. Using oil- or cream-based soaps B. Flossing between the teeth C. The intake of salt D. Using an electric razor Answer B: The client who is immune-suppressed and has bone marrow suppression should be taught not to floss his teeth. Answer A is incorrect because using oils and cream-based soaps is allowed. Answer C is incorrect because the client can eat salt. An electric razor is the best way to shave, so answer D is incorrect. 88. The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to: A. Apply the new tie before removing the old one B. Have a helper present C. Hold the tracheotomy with the nondominant hand while removing the old tie D. Ask the doctor to suture the tracheotomy in place Answer A: The best method and safest way to change the ties of a tracheotomy is to apply the new ones before removing the old ones. Answer B is not enough action. Having a helper is good, but the helper might not prevent the client from coughing out the tracheotomy. Answer C is not the best way to prevent the client from coughing out the tracheotomy. Answer D is incorrect because asking the doctor to suture the tracheotomy in place is not appropriate. 89. The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to: A. Turning the client to the left side B. Milking the tube to ensure patency C. Slowing the intravenous infusion D. Notifying the physician Answer D: The output of 300mL is indicative of hemorrhage and should be reported immediately. Answer A is incorrect because turning the client to the left side will not help. Milking the tube is done only with an order and will not help in this situation, so answer B is incorrect. Slowing the intravenous infusion is inappropriate. The infusion should be increased, so answer C is incorrect. 90. The infant is admitted to the unit with tetrology of falot. The nurse would anticipate an order for which medication? A. Digoxin B. Epinephrine C. Aminophyline D. Atropine Answer A: The infant with tetrology of falot has five heart defects. He will be treated with digoxin to slow and strengthen the heart. Epinephrine, aminophyline, and atropine will speed the heart rate and are not used in this client, so answers B, C, and D are incorrect. 91. The nurse is educating the lady’s club in self-breast exam. The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram, which labeled point is the Tail of Spence? A. is the Tail of Spence B. is the Tail of Spence C. is the Tail of Spence D. is the Tail of Spence Answer A: See diagram in Question #191. The Tail of Spence is located in the upper outer quadrant of the breast and extends into the axilla. 92. The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will: A. Tire easily B. Grow normally C. Need more calories D. Be more susceptible to viral infections Answer A: The toddler with a ventricular septal defect will tire easily. Answer B is incorrect because he will be small for his age. He will not need more calories, so answer C is incorrect. He will be susceptible to bacterial infection, but he will be no more susceptible to viral infections than other children, so answer D is incorrect. 93. A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test: A. Determines the lung maturity of the fetus B. Measures the activity of the fetus C. Shows the effect of contractions on fetal heart rate D. Measures the neurological well-being of the fetus Answer B: A nonstress test determines periodic movement of the fetus. It does not determine lung maturity, show contractions, or measure neurological well-being, so answers A, C, and D are incorrect. 94. The nurse is evaluating the client who is dilated 8cm. The following graph is noted on the monitor. Which action should be taken first by the nurse? A. Instructing the client to push B. Performing a vaginal exam C. Turning off the Pitocin infusion D. Placing the client in a semi-Fowler’s position Answer C: The monitor indicates variable decelerations caused by cord compression. If Pitocin is infusing, the nurse should turn off the Pitocin. Instructing the client to push is incorrect because pushing might increase the decelerations and because the client is 8cm dilated. Performing a vaginal exam should be done after turning off the Pitocin. Therefore, answers A, B, and D are incorrect. 95. The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as: A. Atrial flutter B. A sinus rhythm C. Ventricular tachycardia D. Atrial fibrillation Answer C: The graft indicates ventricular tachycardia. The others are not noted on the ECG strip, so answers A, B, and D are incorrect. 196. A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should: A. Be injected into the deltoid muscle B. Be injected in the abdomen C. Aspirate after the injection D. Clear the air from the syringe before injections Answer B: Answer A is incorrect because Lovenox injections should be given in the abdomen. Answers C and D are incorrect because the client should not aspirate after the injection or clear the air from the syringe before injection. 97. The nurse has a pre-op order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to: A. Administer the medications together in one syringe B. Administer the medications separately C. Administer the Valium, wait 5 minutes, and administer the Phenergan D. Question the order because they cannot be given to the same client Answer B: Answer A is incorrect because Valium (diazepam) is not administered with other medications. Both medications can be given to the same client, so answer D is incorrect. Answer C is not necessary and therefore, is incorrect. 98. A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to: A. Douche after intercourse B. Void every 3 hours C. Obtain a urinalysis monthly D. Wipe from back to front after voiding Answer B: Voiding every 3 hours prevents stagnant urine from collecting in the bladder, where bacteria can grow. Answer A is incorrect because douching is not recommended. Answer C is incorrect because obtaining a urinalysis monthly is not necessary. Answer D is incorrect because the client should practice wiping from front to back after voiding and bowel movements. 99. Which task should be assigned to the nursing assistant? A. Placing the client in seclusion B. Emptying the Foley catheter of the preeclamptic client C. Feeding the client with dementia D. Ambulating the client with a fractured hip Answer C: Of these clients, the one who should be assigned to the care of the nursing assistant is the client with dementia. An RN or the physician can place the client in seclusion, so answer A is incorrect. Answer B is incorrect because the nurse should empty the Foley catheter of the preeclamptic client because the client is unstable. Answer D is incorrect because a nurse or physical therapist should ambulate the client with a fractured hip. 100. The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside? A. A tracheotomy set B. A padded tongue blade C. An endotracheal tube D. An airway Answer A: The client who has recently had a thyroidectomy is at risk for tracheal edema. If the client experiences tracheal edema, the endotracheal tube or airway will not correct the problem, so answers C and D will not work. A padded tongue blade is used for seizures and is not used for the client with tracheal edema, so answer D is incorrect. [Show More]
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