NCLEX-PN Test Prep Exam 3(THREE) Questions and Answers with Explanations 1. A papular lesion is noted on the perineum of the laboring client. Which initial action is most appropriate? A. Document t... he finding B. Report the finding to the doctor C. Prepare the client for a C-section D. Continue primary care as prescribed Answer B: Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions. It is not enough to document the finding, so answer A is incorrect. The physician must make the decision to perform a C-section, making answer C incorrect. It is not enough to continue primary care, so answer D is incorrect. 2. A client with a diagnosis of human papillomavirus (HPV) is at risk for which of the following? A. Lymphoma B. Cervical and vaginal cancer C. Leukemia D. Systemic lupus Answer B: The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the other cancers mentioned in answers A, C, and D, so those are incorrect. 3. The client seen in the family planning clinic tells the nurse that she has a painful lesion on the perineum. The nurse is aware that the most likely source of the lesion is: A. Syphilis B. Herpes C. Candidiasis D. Condylomata Answer B: A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer A is incorrect. In answer C, candidiasis is a yeast infection and does not present with a lesion, but it is exhibited by a white, cheesy discharge. Condylomata lesions are painless warts, so answer D is incorrect. 4. A client visiting a family planning clinic is suspected of having an STI. The most diagnostic test for treponema pallidum is: A. Venereal Disease Research Lab (VDRL) B. Rapid plasma reagin (RPR) C. Florescent treponemal antibody (FTA) D. Thayer-Martin culture (TMC) Answer C: FTA is the only answer choice for treponema pallidum. Answers A and B are incorrect because VDRL and RPR are screening tests for syphilis but are not conclusive of the disease; they only indicate exposure to the disease. The Thayer-Martin culture is a test for gonorrhea, so answer D is incorrect. 5. Which laboratory finding is associated with HELLP syndrome in the obstetric client? A. Elevated blood glucose B. Elevated platelet count C. Elevated creatinine clearance D. Elevated hepatic enzymes Answer D: The criteria for HELLP is hemolysis, elevated liver enzymes, and low platelet count. In answer A, an elevated blood glucose level is not associated with HELLP. Platelets are decreased in HELLP syndrome, not elevated, as stated in answer B. The creatinine levels are elevated in renal disease and are not associated with HELLP syndrome, as stated in answer C. 6. The nurse is assessing the deep tendon reflexes of the client with hypomagnesemia. Which method is used to elicit the biceps reflex? A. B. The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow. C. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer. D. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist. Answer A: The answer can only be A because the other methods elicit different reflexes. Answer B elicits the triceps reflex, answer C elicits the patella reflex, and answer D elicits the radial nerve. 7. Which medication should be used with caution in the obstetric client with diabetes? A. Magnesium sulfate B. Brethine C. Stadol D. Ancef Answer B: Brethine is used cautiously because it raises the blood glucose levels. Answers A, C, and D are all medications that are commonly used in the diabetic client, so there is no need to question the order for these medications. 8. A multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1. The nurse’s assessment of this data is: A. The infant is at low risk for congenital anomalies. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer. B. The infant is at high risk for intrauterine growth retardation. C. The infant is at high risk for respiratory distress syndrome. D. The infant is at high risk for birth trauma. Answer C: When the L/S ratio reaches 2:1, the lungs are considered to be mature. The infant will most likely be small for gestational age and will not be at risk for birth trauma, so answer B is incorrect. The L/S ratio does not indicate congenital anomalies, as stated in answer A, and the infant is not at risk for intrauterine growth retardation, as stated in answer D. 9. Which observation in the newborn of a mother who is alcohol dependent would require immediate nursing intervention? A. Crying B. Wakefulness C. Jitteriness D. Yawning Answer C: Jitteriness is a sign of seizure in the neonate. Answers A, B, and D are incorrect because crying, wakefulness, and yawning are expected in the newborn. 10. The nurse caring for a client receiving magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is: A. Decreased urinary output B. Hypersomnolence C. Absence of knee jerk reflex D. Decreased respiratory rate Answer B: The client is expected to become sleepy, have hot flashes, and experience lethargy. A decreasing urinary output, absence of the knee jerk reflex, and decreased respirations are signs of toxicity and are not expected side effects of magnesium sulfate. Therefore, answers A, C, and D are incorrect. 11. The 57-year-old male client has elected to have epidural anesthesia as the anesthetic during a hernia repair. If the client experiences hypotension, the nurse would: A. Place him in the Trendelenburg position B. Obtain an order for Benedryl C. Administer oxygen per nasal cannula D. Speed the IV infusion of normal saline Answer D: If the client experiences hypotension after an injection of epidural anesthetic, the nurse should turn him to the left side if possible, apply oxygen by mask, and speed the IV infusion. Epinephrine, not Benedryl, in answer B, should be kept for emergency administration. A is incorrect because placing the client in Trendelenburg position (head down) will allow the anesthesia to move up above the respiratory center, thereby decreasing the diaphragm’s ability to move up and down, ventilating the client. Answer C is incorrect because the oxygen should be applied by mask, not cannula. 12. A client has cancer of the pancreas. The nurse should be most concerned with which nursing diagnosis? A. Alteration in nutrition B. Alteration in bowel elimination C. Alteration in skin integrity D. Ineffective individual coping Answer A: Cancer of the pancreas frequently leads to severe nausea and vomiting. Answers B, C, and D are incorrect because although they are a concern to the client, they are not the priority nursing diagnosis. 13. The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites? A. Inspection of the abdomen for enlargement B. Bimanual palpation for hepatomegaly C. Daily measurement of abdominal girth D. Assessment for a fluid wave Answer C: Measuring the girth daily with a paper tape measure and marking the area that is measured is the most objective method of estimating ascites. Inspection, in answer A, and checking for fluid waves, in answer D, are more subjective and not correct. Palpation of the liver will not tell the amount of ascites, so answer B is incorrect. 14. The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis? A. Alteration in cerebral tissue perfusion B. Fluid volume deficit C. Ineffective airway clearance D. Alteration in sensory perception Answer B: The vital signs indicate hypovolemic shock, so checking for fluid volume deficit is the appropriate action. Answers A, C, and D do not indicate cerebral tissue perfusion, airway clearance, or sensory perception alterations, and are incorrect. 15. Which information obtained from the visit to a client with hemophilia would cause the most concern? The client: A. Likes to play football B. Drinks several carbonated drinks per day C. Has two sisters with sickle cell tract D. Is taking acetaminophen to control pain Answer A: The client with hemophilia is likely to experience bleeding episodes if he participates in contact sports. Drinking several carbonated drinks per day, as in answer B, has no bearing on the hemophiliac’s condition. Having two sisters with sickle cell, as in answer C, is not information that would cause concern. Taking acetaminophen for pain, as in answer D, is an accepted practice and does not cause concern. 16. The nurse on oncology is caring for a client with a white blood count of 800, a platelet count of 150,000, and a red blood cell count of 250,000. During evening visitation, a visitor is noted to be coughing and sneezing. What action should the nurse take? A. Ask the visitor to wash his hands B. Document the visitor’s condition in the chart C. Ask the visitor to leave and not return until the client’s white blood cell count is 1,000 D. Provide the visitor with a mask and gown Answer D: The client with neutropenia should not have visitors with any type of infection, so the best action by the nurse is to give the visitor a mask and a gown. Asking the visitor to wash his hands is good but will not help prevent the infection from spreading by droplets; therefore, answer A is incorrect. Answer B is incorrect because documenting the visitor’s condition is not enough action for the nurse to take. Answer C is incorrect because asking the visitor to leave and not return until the client’s white blood cell count is 1,000 is an insuffient intervention. The normal WBC is 5,000– 10,000, so a WBC of 1,000 is not high enough to prevent the client from contracting infections. 17. The nurse is caring for the client admitted after trauma to the neck in an automobile accident. The client suddenly becomes unresponsive and pale, with a BP of 60 systolic. The initial nurse’s action should be to: A. Place the client in Trendelenburg position B. Increase the infusion of normal saline C. Administer atropine IM D. Obtain a crash cart Answer B: For some clients with trauma to the neck, the answer would be A; however, in this situation, it is incorrect because lowering the head of the bed could further interfere with the airway. Increasing the infusion and placing the client in supine position is better. If atropine is administered to the client, it should be given IV, not IM, and there is no need for this action at present, as stated in answer C. Answer D is not necessary at this time. 18. Immediately following the removal of a chest tube, the nurse would: A. Order a chest x-ray B. Take the blood pressure C. Cover the insertion site with a Vaseline gauze D. Ask the client to perform the Valsalva maneuver Answer C: When a chest tube is removed, the hole should be immediately covered with a Vaseline gauze to prevent air from rushing into the chest and causing the lung to collapse. The doctor, not the nurse, will order a chest xray; therefore, answer A is incorrect. Taking the BP in answer B is good but is not the priority action. Answer D is incorrect because the Valsalva maneuver is done during removal of the tube, not afterward. 19. A client being treated with sodium warfarin has an INR of 9.0. Which intervention would be most important to include in the nursing care plan? A. Assess for signs of abnormal bleeding B. Anticipate an increase in the dosage C. Instruct the client regarding the drug therapy D. Increase the frequency of neurological assessments Answer A: The normal international normalizing ratio (INR) is 2–3. A 9 might indicate spontaneous bleeding. Answer B is an incorrect action at this time. Answer C is incorrect because just instructing the client regarding his medication is not enough. Answer D is incorrect because increasing the frequency of neurological assessment will not prevent bleeding caused by the prolonged INR. 20. Which snack selection by a client with osteoporosis indicates that the client understands the dietary management of the disease? A. A glass of orange juice B. A blueberry muffin C. A cup of yogurt D. A banana Answer C: The food with the most calcium is the yogurt. The others are good choices, but not as good as the yogurt, which has approximately 400mg of calcium. Therefore, answers A, B, and D are incorrect. 21. The elderly client with hypomagnesemia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates understanding of magnesium sulfate? A. The nurse places a sign over the bed not to check blood pressures in the left arm. B. The nurse places a padded tongue blade at the bedside. C. The nurse measures the urinary output hourly. D. The nurse darkens the room. Answer C: The client receiving magnesium sulfate should have a Foley catheter in place, and the hourly intake and output should be checked because a sign of toxicity to magnesium sulfate is oliguria. There is no need to refrain from checking the blood pressure in the left arm, as stated in answer A. A padded tongue blade should be kept in the room at the bedside, just in case of a seizure, but this is not related to the magnesium sulfate infusion, so this makes answer B incorrect. Answer D is incorrect because just darkening the room will not prevent toxicity, although it might help with the headache associated with preeclampsia. 22. The nurse is caring for a 10-year-old client scheduled for surgery. The client’s mother tells the nurse that her religion forbids blood transfusions. What nursing action is most appropriate? A. Document the mother’s statement in the chart B. Encourage the mother to reconsider C. Explain the consequences of no treatment D. Notify the physician of the mother’s refusal Answer D: If the client’s mother refuses to sign for the child’s treatment, the doctor should be notified. Because the client is a minor, the court might order treatment. Answer A is incorrect because simply documenting the statement is not enough. Answer B is incorrect because it is not the nurse’s responsibility to try to persuade the mother to allow the blood transfusion. Answer C is incorrect because the consequences of the denial of a blood transfusion are not known. 23. A client is admitted to the unit 3 hours after an injury with second-degree burns to the face, neck, and head. The nurse would be most concerned with the client developing which of the following? A. Hypovolemia B. Laryngeal edema C. Hypernatremia D. Hyperkalemia Answer B: The nurse should be most concerned with laryngeal edema because of the area of burn. The next priority should be answer A, hypovolemia. Hypernatremia and hyperkalemia, as stated in answers C and D, are incorrect because the client will most likely experience hyponatremia and hypokalemia. 24. The nurse is evaluating nutritional outcomes for an elderly client with anorexia. Which data best indicates that the plan of care is effective? A. The client selects a balanced diet from the menu. B. The client’s hematocrit improves. C. The client’s tissue turgor improves. D. The client gains weight. Answer D: The client with anorexia shows the most improvement by weight gain. Selecting a balanced diet, as in answer A, is of little use if the client does not eat the diet. The hematocrit in answer B is incorrect because although it might improve by several means, such as blood transfusion, it does not indicate improvement in the anorexic condition. The tissue turgor indicates fluid stasis, not improvement of anorexia; therefore, answer C is incorrect. 25. The client is admitted following repair of a fractured femur with cast application. Which nursing assessment should be reported to the doctor? A. Pain B. Warm toes C. Pedal pulses rapid D. Paresthesia of the toes Answer D: Paresthesia, in answer D, is not normal and might indicate compartment syndrome. At this time, pain beneath the cast is normal, so answer A is incorrect. The client’s toes should be warm to the touch and pulses should be present. Because answers B and C are normal findings, these answers are incorrect. 26. Which would be an expected finding during injection of dye with a cardiac catheterization? A. Cold extremity distant to the injection site B. Warmth in the extremity C. Extreme chest pain D. Itching in the extremities Answer B: It is normal for the client to have a warm sensation when dye is injected. Answer A is incorrect because the client should not have a cold extremity. This indicates peripheral vascular disease. Answer C is incorrect because extreme chest pain can be related to a myocardial infarction. The pain is not normal. Answer D is incorrect because itching is a sign of an allergic reaction. Also, the itching will most likely be on the chest and skin folds. 27. Which action by the healthcare worker indicates a need for further teaching? A. The nursing assistant wears gloves while giving the client a bath. B. The nurse wears goggles while drawing blood from the client. C. The doctor washes his hands before examining the client. D. The nurse wears gloves to take the client’s vital signs. Answer D: It is not necessary to wear gloves to take the vital signs of the client under normal circumstances. If the client has active infection with methicillin-resistant staphylococcus aureus, gloves should be worn. The other answer choices indicate knowledge of infection control by the actions, so answers A, B, and C are incorrect. 28. The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective? A. The client loses consciousness. B. The client vomits. C. The client’s ECG indicates tachycardia. D. The client has a grand mal seizure. Answer D: During ECT, the client will have a grand mal seizure. This indicates completion of the electroconvulsive therapy. Answer A is incorrect because clients are frequently given medication that will cause drowsiness or sleep. Answer B is incorrect because vomiting is not a sign that the ECT has been effective. Answer C is incorrect because tachycardia might be present, but it is not a sign that the ECT has been effective. 29. A 5-year-old is being tested for pinworms. To collect a specimen for assessment of pinworms, the nurse should teach the mother to: A. B. Scrape the skin with a piece of cardboard and bring it to the clinic C. Obtain a stool specimen in the afternoon D. Bring a hair sample to the clinic for evaluation Answer A: Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus, where they lay up to 17,000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. Examine the perianal area with a flashlight 2–3 hours after the child is asleep and to collect any eggs on a clear tape Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. There is no need to scrape the skin, as stated in answer B. Collecting a stool specimen in the afternoon will probably not reveal the eggs because the worms often are not detected during the day; therefore, answer C is incorrect. Answer D is incorrect because eggs are not located in the hair. 30. Which instruction should be given regarding the medication used to treat enterobiasis (pinworms)? A. Treatment is not recommended for children less than 10 years of age. B. The entire family should be treated. C. Medication therapy will continue for 1 year. D. Intravenous antibiotic therapy will be ordered. Answer B: Erterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth (pyrantel pamoate). The entire family should be treated to ensure that no eggs remain. The family should then be tested again in 2 weeks to ensure that no eggs remain. Answer A is incorrect because children less than 10 can be treated with Vermox. Answer C is incorrect because a single treatment is usually sufficient. Answer D is incorrect because there is no need for IV antibiotics for the client with pinworms. 31. Which client should be assigned to the pregnant licensed practical nurse? B. The client with a radium implant for cervical cancer C. The client who has just been administered soluble brachytherapy for thyroid cancer D. The client who has returned from placement of iridium seeds for prostate cancer Answer A: The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy in answer A travels to the radium department for therapy; thus, the radiation stays in the department. The client himself is not radioactive. The client in answer B A. The client who just returned after receiving linear accelerator radiation therapy for lung cancer poses a risk to the pregnant client because the implant stays with the patient. The client in answer C is radioactive in very small doses. For approximately 72 hours, the client should dispose of urine and feces in special containers and use plastic spoons and forks. The client in answer D is also radioactive in small amounts, especially upon return from the procedure. Thus, answers B, C, and D are all incorrect. 32. Which client should be assigned to a private room if only one is available? A. The client with Cushing’s syndrome B. The client with diabetes C. The client with acromegaly D. The client with myxedema Answer A: The client with Cushing’s syndrome has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immune suppressed, and he should not have a roommate because of the possibility of infection. In answer B, the client with diabetes poses no risk to other clients. The client in answer C has an increase in growth hormone and poses no risk to himself or others. The client in answer D has hyperthyroidism or myxedema and so poses no risk to others or himself. 33. The nurse caring for a client on the pediatric unit administers adultstrength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with: A. Negligence B. Tort C. Assault D. Malpractice Answer D: Malpractice is failing to perform or performing an act that causes harm to the client, making answer D correct. In answer A, negligence is failing to perform care for the client. In answer B, a tort is a wrongful act committed to the client or his belongings. Answer C is incorrect because assault is willfully hitting or restraining the client. 34. Which assignment should not be performed by the licensed practical nurse? A. Inserting a Foley catheter B. Discontinuing a nasogastric tube C. Obtaining a sputum specimen D. Initiating a blood transfusion Answer D: The licensed practical nurse should not be assigned to begin a blood transfusion. The licensed practical nurse can insert a Foley catheter, as stated in answer A; discontinue a nasogastric tube, as stated in answer B; and collect sputum specimen, as stated in answer C. Thus, answers A, B, and C are all incorrect. 35. The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority? A. Continuing to monitor the vital signs B. Contacting the physician C. Asking the client how he feels D. Asking the LPN to continue the post-op care Answer B: The vital signs are abnormal and should be reported to the doctor immediately. To continue to monitor the vital signs, as in answer A, could result in deterioration of the client’s condition. Asking the client how he feels in answer C will provide only subjective data. The nurse in answer D is not the best nurse to assign because this client is unstable. 36. Which nurse should be assigned to care for the postpartal client with preeclampsia? The nurse with: A. 2 weeks of experience in postpartum B. 3 years of experience in labor and delivery C. 10 years of experience in surgery D. 1 year of experience in the neonatal intensive care unit Answer B: The nurse in answer B has the most experience in knowing possible complications involving preeclampsia. The nurse in answer A is a new nurse to the unit and so should not be assigned to this client; the nurses in answers C and D have no experience with the postpartum client, so neither should be assigned to this client. 37. Which information should be reported to the state Board of Nursing? A. The facility fails to provide literature in both Spanish and English. B. The narcotic count has been incorrect on the unit for the past 3 days. C. The client fails to receive an itemized account of his bills and services received during his hospital stay. D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath. Answer B: An inaccurate narcotic count on the unit should be reported to the state Board of Nursing because narcotics are controlled substances. Answers A, C, and D are incorrect because they are of little concern to the state board. Although they are important functions, these actions would be resolved within the hospital. 38. The nurse is suspected of charting the administration of a medication that he did not give. After talking to the nurse, the charge nurse should: A. Call the Board of Nursing B. File a formal reprimand C. Terminate the nurse D. Charge the nurse with a tort Answer B: After discussing with the nurse and documenting the incident, filing a formal reprimand is the first action for the charge nurse to take. If the nurse continues following an incorrect procedure that causes, or could cause, harm to the client, termination might be needed. The Joint Commission on Accreditation of Hospitals will probably be interested in the actions in answers A and C, but this is not the immediate action to take. The failure of the nursing assistant to care for the client with hepatitis might result in termination, but this is not of interest to the Joint Commission; therefore, answer D is incorrect. 39. The nurse is making rounds. Which client should be seen first? A. The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension C. The 50-year-old with MRSA (methcillin-resistant staphylococcus aurea) Answer D: The client with multiple sclerosis should receive priority because of the IV cortisone treatment. This client is at highest risk for complications. The clients in answers A and B are more stable and are not the priority. The client with MRSA (methicillin-resistant staphylococcus aureus) is being treated with antibiotics, but there is no data to indicate that the nurse should see this client first, so answer C is incorrect. 40. The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster? A. A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis B. C. A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain Answer B: The two clients who can share a room are the pregnant client and the client with a broken arm and facial lacerations because these clients are stable. The other clients in answers A needs to be placed in separate rooms because the schizophrenic will further upset the client with an ulcerative colitis. Answer C is incorrect because this child is terminal and he should not D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone intravenously The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm be placed in the room with the client with a frontal head injury. Answer D is incorrect because the chest pain may be related to a myocardial infarction. 41. The nurse is caring for a 6-year-old client admitted with the diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following? A. B. The child should be allowed to instill his own eyedrops. C. The mother should be allowed to instill the eyedrops. D. If the eye is clear of any redness or edema, the eyedrops should be held. Answer A: Before instilling eyedrops, the nurse should cleanse the area with water. A 6-year-old child is not developmentally ready to instill his own eyedrops, so answer B is incorrect. Although the mother of the child may instill the eyedrops, the area must be cleansed before administration, so answer C is incorrect. The eye might appear to be clear, but the nurse should instill the eyedrops, as ordered, so answer D is incorrect. 42. The nurse is discussing meal planning with the mother of a 2-year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction? A. “It is okay to give my child white grape juice for breakfast.” B. “My child can have a grilled cheese sandwich for lunch.” C. “We are going on a trip, and I have bought hot dogs to grill for his lunch.” D. “For a snack, my child can have ice cream.” Answer C: The comment of most concern is answer C because hot dogs are commonly the cause of choking in children. There is no reason for concern in the comments in answers A, B, or D; therefore, these are incorrect. 43. A 2-year-old toddler is seen in the pediatrician’s office. During physical assessment, the nurse would anticipate the need for which intervention? A. Ask the parent/guardian to leave the room when assessments are being The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops. performed B. Ask the parent/guardian to remove the child’s toys during examination C. Ask the parent/guardian to stay with the child during the examination D. If the child is screaming, tell him this is inappropriate behavior Answer C: There is no reason to tell the parents to leave because this might cause the child to become more agitated, making answer A incorrect. Removing his toys may also cause him to fret and make the examination more difficult, so answer B is incorrect. Answer D is incorrect because telling him that the behavior is inappropriate will not help because the child is too young to understand. 44. Which instruction should be given to the client who is fitted for a behindthe-ear hearing aid? A. Remove the mold and clean every week B. Store the hearing aid in a cool place C. Clean the lint from the hearing aide with a toothpick D. Change the batteries weekly Answer B: Hearing aids should be stored in a cool place in order to preserve the life of the battery. Answer A is incorrect because the mold should be cleaned daily. Answer C is incorrect because the hearing aid should not be cleaned with a toothpick. Answer D is incorrect because changing the batteries weekly is not necessary. 45. A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is: A. Body image disturbance B. Impaired verbal communication C. Risk for aspiration D. Pain Answer C: A risk for aspiration is the best answer because aspiration of blood can lead to airway obstruction. Answer A does not apply to a child who has undergone a tonsillectomy because there is no alteration in body image. Answer B is incorrect because impaired verbal communication might be true but is not the highest priority. Pain is an issue, but not the highest priority, so answer D is incorrect. 46. A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal? A. High fever B. Nonproductive cough C. Rhinitis D. Vomiting and diarrhea Answer A: If the child has bacterial pneumonia, a high fever is usually present. Bacterial pneumonia usually presents with a productive cough, not a nonproductive cough, so answer B is incorrect. Rhinitis is often seen with viral pneumonia, not bacterial pneumonia, so answer C is incorrect. Vomiting and diarrhea are usually not seen with pneumonia, so answer D is incorrect. 47. The nurse is caring for a client admitted with acute laryngotracheobronchitis (LTB). Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available? A. Intravenous access supplies B. Emergency intubation equipment C. Intravenous fluid administration pump D. Supplemental oxygen Answer B: For a child with LTB and the possibility of complete obstruction of the airway, emergency intubation equipment should always be kept at the bedside. Intravenous supplies and fluid will not treat an obstruction, so answers A and C are incorrect. Answer D is incorrect because although supplemental oxygen is needed, the child will need to be intubated for it to help. 48. The 45-year-old client is seen in the clinic with hyperthyroidism. What would the nurse expect the admitting assessment to reveal? A. Bradycardia B. Decreased appetite C. Exophthalmos D. Weight gain Answer C: Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss, not bradycardia, decreased appetite, or weight gain, so answers A, B, and D are incorrect. 49. The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions? A. Whole-wheat bread B. Spaghetti and meatballs C. Hamburger on white bread with ketchup D. Cheese omelet Answer D: The child with celiac disease should be on a gluten-free diet. Answer D is the only choice of foods that do not contain gluten, so answers A, B, and C are incorrect. 50. The nurse is caring for a 9-year-old child admitted with asthma. During the morning rounds, the nurse finds an O2 sat of 78%. Which of the following actions should the nurse take first? A. Check the arterial blood gases. B. Do nothing; this is a normal O2 sat for this client. C. Apply oxygen. D. Assess the child’s pulse. Answer C: The child with an oxygen saturation level of 78% is hypoxic. He will require oxygen therapy. Checking the arterial blood gases in answer A is good but is not the highest priority and will not correct the problem. If the nurse does nothing, as in answer B, the client’s condition will most likely continue to decline. Answer D is incorrect because assessing the pulse will probably reveal tachycardia, but this is not the highest priority. 51. A gravida II para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse expect to make after the amniotomy? A. Fetal heart tones 160bpm B. A moderate amount of straw-colored fluid C. A small amount of greenish fluid D. A small segment of the umbilical cord Answer B: Normal amniotic fluid is straw colored and odorless. An amniotomy is an artificial rupture of membranes. Fetal heart tones of 160 indicate tachycardia, so answer A is incorrect. Greenish fluid is indicative of meconium, so answer C is incorrect. If the nurse notes the umbilical cord, the client is experiencing a prolapsed cord. This would need to be reported immediately; therefore, answer D is incorrect. 52. The client is admitted to the unit. Vaginal exam reveals that she is 3cm dilated. Which of the following statements would the nurse expect her to make? A. “I can’t decide what to name the baby.” B. “It feels good to push with each contraction.” C. “Don’t touch me. I’m trying to concentrate.” D. “When can I get my epidural?” Answer D: Dilation of 3cm is the end of the latent phase of labor, so a request for an epidural would be expected. Answer A is a vague answer, and answer B would indicate the end of the first stage of labor, or complete dilation. Answer C indicates the transition phase and, thus, is incorrect. 53. The client is having fetal heart rates of 100–110bpm during the contractions. The first action the nurse should take is: A. Reassess the fetal heart tones in 15 minutes B. Turn the client to her left side C. Get the client up and walk her in the hall D. Move the client to the delivery room Answer B: The normal fetal heart rate is 120–160bpm; 100–110bpm is bradycardia. The first action would be to turn the client to the left side and apply oxygen. Answer A is not indicated at this time. Answer C is not the best action for clients experiencing bradycardia. There is no data to indicate the need to move the client to the delivery room at this time, so answer D is incorrect. 54. The nurse is monitoring the client admitted for induction of labor. The nurse knows that Pitocin has been effective when: A. The client has a rapid, painless delivery. B. The client’s cervix is effaced. C. The client has infrequent contractions. D. The client has progressive cervical dilation. Answer D: The expected effect of Pitocin is cervical dilation. Pitocin causes more intense contractions, which can increase the pain, so answer A is incorrect. Cervical effacement is caused by pressure on the presenting part, so answer B is incorrect. Answer C is incorrect because the word infrequent indicates irregular contractions. 55. A vaginal exam reveals a breech presentation. The nurse should take which of the following actions at this time? A. Prepare the client for a Caesarean section B. Apply the fetal heart monitor C. Place the client in Trendelenburg position D. Perform an ultrasound exam Answer B: A breach presentation calls for applying a fetal heart monitor. Answer A is incorrect because there is no need to prepare for a Caesarean section at this time. Answer C is incorrect because placing the client in Trendelenburg position is also not an indicated action. Answer D is incorrect because there is no need for an ultrasound based on the finding. 56. The nurse is caring for a gravida 1 admitted in labor. Which finding would suggest the need for an internal fetal monitor? A. The cervix is dilated 5cm. B. The fetal heart tones are difficult to assess using the external toco monitor. C. The fetus is at station 0. D. Contractions are every 3 minutes. Answer B: There are only a few reasons to apply an internal monitor: if the fetus is in distress or if the fetal heart tones cannot be assessed using the external monitor. Answer A is incorrect because cervical dilation is not a reason to apply an internal monitor. Answer C is incorrect because the fact that the fetus is at 0 station is not a reason to apply an internal monitor. Answer D is also incorrect because noting contractions every 3 minutes is not a reason to apply an internal monitor. It is not necessary for a scalp electrode placement, as long as the membranes are still intact. 57. Which nursing diagnoses is most appropriate for the client as she completes the latent phase of labor? A. Impaired gas exchange related to hyperventilation B. Alteration in oxygen perfusion related to maternal position C. Impaired physical mobility related to fetal-monitoring equipment D. Potential fluid volume deficit related to decreased fluid intake Answer D: Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice chips may be allowed, but this amount of fluid is not sufficient to prevent dehydration. Answer A is incorrect because impaired gas exchange related to hyperventilation is not a risk to the client. Answer B is incorrect because alteration in oxygen perfusion related to maternal position is not a problem encountered by the client at the end of the early phase of labor. Answer C is incorrect because not all clients have fetal monitoring. 58. As the client reaches 8cm dilation, the nurse notes a pattern on the fetal monitor that shows a drop in the fetal heart rate of 30bpm beginning at the peak of the contraction and ending at the end of the contraction. The FHR baseline is 165–175bpm with variability of 0–2bpm. What is the most likely explanation of this pattern? A. The baby is asleep. B. The umbilical cord is compressed. C. There is a vagal response. D. There is uteroplacental insufficiency. Answer D: This information indicates a late deceleration. This type of deceleration is caused by uteroplacental lack of oxygen. Answer A is incorrect because decelerations are not caused by fetal sleep, answer B results in a variable deceleration, and answer C is indicative of an early deceleration. 59. The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to: A. Notify her doctor B. Document the finding C. Reposition the client D. Readjust the monitor Answer C: The initial action by the nurse observing a variable deceleration should be to turn the client to the side, preferably the left side. Administering oxygen is also indicated. Answer A is incorrect because the question asks for the initial action. The initial action should be to turn the client to her side. If this does not resolve the problem, call the doctor. Answers B and D are incorrect because there is no data to indicate that the monitor is applied incorrectly 60. Which of the following is a characteristic of a reassuring fetal heart rate pattern? A. A fetal heart rate of 170–180bpm B. A baseline variability of 25–35bpm C. Ominous periodic changes D. Acceleration of FHR with fetal movements Answer D: Accelerations with movement are normal. Answers A, B, and C indicate ominous findings on the fetal heart monitor. 61. The nurse asks the client with an epidural anesthesia to void every hour during the labor. The rationale for this intervention is: A. The bladder fills more rapidly because of the medication used for the epidural. B. Her level of consciousness is such that she is in a trancelike state. C. The sensation of the bladder filling is diminished or lost. D. She is embarrassed to ask for the bedpan that frequently. Answer C: Epidural anesthesia decreases the urge to void and sensation of a full bladder. A full bladder will decrease the progression of labor. Answer A is incorrect because the bladder does not fill more rapidly in the client with epidural anesthesia. Answer B is incorrect because the client’s level of consciousness is not altered. Answer D is incorrect because there is no data to indicate that the client is embarrassed to ask for the bedpan. 62. A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when: A. Estrogen levels are low. B. Lutenizing hormone is high. C. The endometrial lining is thin. D. The progesterone level is low. Answer B: Lutenizing hormone released by the pituitary is responsible for ovulation. At about day 14, the continued increase in estrogen stimulates the release of lutenizing hormone from the anterior pituitary. The LH surge is responsible for ovulation, or the release of the dominant follicle in reparation from conception, which occurs within the next 10–12 hours after the LH levels peak. Answer A is incorrect because estrogen levels are high at the beginning of ovulation. Answer C is incorrect because the endometrial lining is thick, not thin. Answer D is incorrect because the progesterone levels are high, not low. 63. A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the: A. Age of the client B. Frequency of intercourse C. Regularity of the menses D. Range of the client’s temperature Answer C: The success of the rhythm method of birth control is dependent on the client’s menses being regular. It is not dependent on the age of the client, as stated in answer A; the frequency of intercourse, as stated in answer B; or the range of the client’s temperature, as stated in answer D. 64. A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes? A. Intrauterine device B. Oral contraceptives C. Diaphragm D. Contraceptive sponge Answer C: The best method of birth control for the client with diabetes is the diaphragm. The intrauterine device in answer A prevents implantation by producing an inflammatory response. Clients with diabetes have an increased response to inflammation. Oral contraceptives, in answer B, are not the best method because they tend to elevate blood glucose levels. Contraceptive sponges alone are not best at preventing pregnancy, so answer D is incorrect. 65. The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy? A. Painless vaginal bleeding B. Abdominal cramping C. Throbbing pain in the upper quadrant D. Sudden, stabbing pain in the lower quadrant Answer D: The signs of an ectopic pregnancy are vague until the fallopian tube ruptures. The client will complain of sudden, stabbing pain in the lower quadrant that radiates down the leg or up into the chest. Painless vaginal bleeding is a sign of placenta previa, so answer A is incorrect. Abdominal cramping is a sign of labor, so answer B is incorrect. Throbbing pain in the upper quadrant, in answer C, is nonspecific and is not a sign of an ectopic pregnancy. 66. The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client? A. Hamburger pattie, green beans, French fries, and iced tea B. Roast beef sandwich, potato chips, baked beans, and cola C. Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea D. Fish sandwich, gelatin with fruit, and coffee Answer C: All of the choices are tasty, but the pregnant client needs a diet that is balanced and has increased amounts of calcium, such as is included in answer C: meat, fruit, potato salad, and yogurt, with about 360mg of calcium. Answer A is lacking in fruits and milk. Answer B contains the potato chips, which contain a large amount of sodium. Answer D is not the best diet because it lacks vegetables and milk products. 67. The client with hyperemesis gravidarum is at risk for developing: A. Respiratory alkalosis without dehydration B. Metabolic acidosis with dehydration C. Respiratory acidosis without dehydration D. Metabolic alkalosis with dehydration Answer B: The client with hyperemesis has persistent nausea and vomiting. With vomiting comes dehydration. When the client is dehydrated, she will have metabolic acidosis. Answers A and C are incorrect because they are respiratory in nature, and answer D is incorrect because the client will not be in alkalosis with persistent vomiting. 68. A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is: A. Elevated human chorionic gonadatropin B. The presence of fetal heart tones C. Uterine enlargement D. Breast enlargement and tenderness Answer B: The most definitive diagnosis of pregnancy is the presence of fetal heart tones. The other signs are subjective and can be related to other medical conditions. Answers A and C can be related to a hydatidiform mole. Answer D is very subjective and is often present before menses or with use of oral contraceptives. 69. The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be: A. Hypoglycemic, small for gestational age B. Hyperglycemic, large for gestational age C. Hypoglycemic, large for gestational age D. Hyperglycemic, small for gestational age Answer C: The infant of a diabetic mother is usually large for gestational age. After birth, glucose levels fall rapidly due to the absence of glucose from the mother. Answer A is incorrect because the infant will not be small for gestational age. Answer B is incorrect because the infant will not be hyperglycemic. Answer D is incorrect because the infant will have hypoglycemia and will be large for gestational age. 70. Which of the following instructions should be included in the nurse’s teaching regarding oral contraceptives? A. Weight gain should be reported to the physician. B. An alternate method of birth control is needed when taking antibiotics. C. If the client misses one or more pills, two pills should be taken per day for 1 week. D. Changes in the menstrual flow should be reported to the physician. Answer B: When the client is taking oral contraceptives and begins antibiotics, another method of birth control should be used. Antibiotics decrease the effectiveness of oral contraceptives. Approximately 5–10 pounds of weight gain is not unusual in clients taking oral contraceptives, so answer A is incorrect. If the client misses a birth control pill, she should be instructed to take the pill as soon as she remembers the pill. If she missed two, she should take two; if she missed more than two, she should take the missed pills but use another method of birth control for the remainder of the cycle, so answer C is incorrect. Changes in menstrual flow are expected in clients using oral contraceptive. Often these clients have lighter menses and this need not be reported, so answer D is incorrect. 71. The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with: A. Diabetes B. Positive HIV C. Hypertension D. Thyroid disease Answer B: Clients with HIV should not breastfeed because the infection can be transmitted to the baby through breast milk. The clients mentioned in answers A, C, and D—those with diabetes, hypertension, and thyroid disease —can be allowed to breastfeed. 72. A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to: A. Assess the fetal heart tones B. Check for cervical dilation C. Check for firmness of the uterus D. Obtain a detailed history Answer A: The symptoms of painless vaginal bleeding are consistent with placenta previa, so assessing the fetal heart tones is indicated. Cervical check for dilation is contraindicated because this can increase the bleeding; thus, answer B is incorrect. Checking for firmness of the uterus can be done, but the first action should be to check the fetal heart tones, so answer C is incorrect. A detailed history can be done later, so answer D is incorrect. 73. A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when: A. Her contractions are 2 minutes apart. B. She has back pain and a bloody discharge. C. She experiences abdominal pain and frequent urination. D. Her contractions are 5 minutes apart. Answer D: The client should be advised to come to the labor and delivery unit when the contractions are every 5 minutes and consistent. She should also be told to report to the hospital if she experiences rupture of membranes or extreme bleeding. Answer A is incorrect because she should not wait until the contractions are every 2 minutes. Answer B is incorrect because she should not wait until she has bloody discharge. Answer C is incorrect because this is a vague answer and can be related to a urinary tract infection. 74. The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy? A. Low birth weight B. Large for gestational age C. Preterm birth, but appropriate size for gestation D. Growth retardation in weight and length Answer A: Infants of mothers who smoke are often of low birth weight. Answer B is incorrect because an infant who is large for gestational age is associated with diabetic mothers. Preterm births are associated with smoking but not with appropriate size for gestation, so answer C is incorrect. Growth retardation is associated with smoking, but this does not affect the infant length, making answer D incorrect. 75. The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered: A. Within 72 hours of delivery B. Within 1 week of delivery C. Within 2 weeks of delivery D. Within 1 month of delivery Answer A: To provide protection against antibody production, RhoGam should be given within 72 hours. Answers B, C, and D are incorrect because they would be given too late to provide antibody protection. RhoGam can also be given during pregnancy. 76. After the physician performs an amniotomy, the nurse’s first action should be to assess the: A. Degree of cervical dilation B. Fetal heart tones C. Client’s vital signs D. Client’s level of discomfort Answer B: When the membranes rupture, there is often a transient drop in the fetal heart tones. The heart tones should return to baseline quickly. Any alteration in fetal heart tones, such as bradycardia or tachycardia, should be reported. After the fetal heart tones are assessed, the nurse should evaluate the cervical dilation, as stated in answer A; vital signs, as stated in answer C; and level of discomfort, as stated in answer D. 77. A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix is 5cm dilated with 75% effacement. Based on the nurse’s assessment, the client is in which phase of labor? A. Active B. Latent C. Transition D. Early Answer A: The active phase of labor begins when the client is dilated 4– 7cm. Answer B refers to the latent or early phase of labor, from 1cm to 3cm dilation. Answer C refers to the transition phase of labor, from 8cm to 10cm dilation. Answer D refers to the early phase of labor, from 1cm to 3cm dilation. 78. A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include: A. Teaching the mother to provide tactile stimulation B. Wrapping the newborn snugly in a blanket C. Placing the newborn in the infant seat D. Initiating an early infant-stimulation program Answer B: The infant of a mother with narcotic addiction will undergo withdrawal. Snugly wrapping the infant in a blanket will help prevent the muscle irritability that these babies often experience. Teaching the mother to provide tactile stimulation or provide for early infant stimulation, in answers A and C, is incorrect because he is irritable and needs quiet and little stimulation at this time. Placing the infant in an infant seat is incorrect because this will also cause movement that can increase muscle irritability; thus, answer D is incorrect. 79. A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to: A. Checking for cervical dilation B. Placing the client in a supine position C. Checking the client’s blood pressure D. Obtaining a fetal heart rate Answer C: Following epidural anesthesia, the client should be checked for hypotension and signs of shock every 5 minutes for 15 minutes. The client can be checked for cervical dilation later, after she is stable, so answer A is incorrect. The client should not be positioned supine because the anesthesia can move above the respiratory center and the client can stop breathing, making answer B incorrect. Fetal heart tones should be assessed after the blood pressure is checked, so answer D is incorrect. 80. The nurse is aware that the best way to prevent post-operative wound infection in the surgical client is to: A. Administer a prescribed antibiotic B. Wash her hands for 2 minutes before care C. Wear a mask when providing care D. Ask the client to cover her mouth when she coughs Answer B: The best way to prevent post-operative wound infection is handwashing. Use of prescribed antibiotics will treat infection, not prevent infections, so answer A is incorrect. Wearing a mask and asking the client to cover her mouth are good practices but will not prevent wound infections; thus, answers C and D are incorrect. 81. The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit? A. Pain B. Disalignment C. Cool extremity D. Absence of pedal pulses Answer B: The client with a hip fracture will most likely have disalignment. Answer A is incorrect because all fractures experience pain. Coolness of the extremity and the absence of pulses are indicative of compartment syndrome or peripheral vascular disease, not a fractured hip, so answers C and D are incorrect. 82. The nurse knows that the 60-year-old female client’s susceptibility to osteoporosis is most likely related to: A. Lack of exercise B. Hormonal disturbances C. Lack of calcium D. Genetic predisposition Answer B: After menopause, women lack hormones necessary to absorb and utilize calcium. Doing weight-bearing exercises and taking calcium supplements can help prevent osteoporosis, but these are not the most likely causes, so answers A and C are incorrect. Body types that frequently experience osteoporosis are thin Caucasian females, but they are not most likely to cause osteoporosis, so answer D is incorrect. 83. A 2-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse indicates that the traction is working properly? A. The infant no longer complains of pain. B. The buttocks are 15° off the bed. C. The legs are suspended in the traction. D. The pins are secured within the pulley. Answer B: The infant’s hips should be off the bed approximately 15° in Bryant’s traction. Answers A and C are incorrect because they do not indicate that the traction is working correctly. Answer D is incorrect because Bryant’s traction is skin traction, not skeletal traction. 84. A client with a fractured hip has been placed in traction. Which statement is true regarding balanced skeletal traction? Balanced skeletal traction: A. Utilizes a pin through bones B. Requires that both legs be secured C. Utilizes Kirschner wires D. Is used primarily to heal the fractured hips Answer A: Balanced skeletal traction uses pins and screws. A Steinman pin goes through large bones and is used to stabilize large bones such as the femur. Answer B is incorrect because only the affected leg is in traction. Kirschner wires are used to stabilize small bones, such as fingers and toes, so answer C is incorrect. Answer D is incorrect because this type of traction is not used for fractured hips. 85. The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the client for: A. Hypovolemia B. Pain C. Nutritional status D. Immobilizer Answer A: Bleeding is a common complication of orthopedic surgery. The blood-collection device should be checked frequently to ensure that the client is not hemorrhaging. Answer B is incorrect because the client’s pain should be assessed, but this is not life-threatening. Answer C is incorrect because the nutritional status should be assessed later. An immobilizer is not used, so answer D is incorrect. 86. Which statement made by the family member caring for the client with a percutaneous gastrotomy tube indicates understanding of the nurse’s teaching? A. “I must flush the tube with water after feedings and clamp the tube.” B. “I must check placement four times per day.” C. “I will report to the doctor any signs of indigestion.” D. “If my father is unable to swallow, I will discontinue the feeding and call the clinic.” Answer A: The client’s family member should be taught to flush the tube after each feeding and clamp the tube. The placement should be checked before feedings, so answer B is incorrect. Indigestion can occur with the PEG tube just as it can occur with any client, so there is no need to call the doctor, as suggested in answer C. Medications can be ordered for this, but it is not a reason for alarm. A percutaneous endoscopy gastrotomy tube is used for clients who have experienced difficulty swallowing. The tube is inserted directly into the stomach and does not require swallowing, so answer D is incorrect. 87. The nurse is assessing the client with a total knee replacement 2 hours post-operative. Which information requires notification of the doctor? A. Bleeding on the dressing is 2cm in diameter. B. The client has a low-grade temperature. C. The client’s hemoglobin is 6g/dL. D. The client voids after surgery. Answer C: The client with a total knee replacement should be assessed for anemia. A hemaglobin of 6g/dL is extremely low and might require a blood transfusion (the normal is 14–18g/dL). Bleeding on the dressing of 2cm is not extreme, so answer A is incorrect. Circle the bleeding, write the date and time on the dressing, and chart the finding. If the drainage continues to enlarge, notify the doctor. A low-grade temperature is not unusual after surgery, so answer B is incorrect. Recheck the temperature in 1 hour. If the temperature rises above 101°F, report this finding to the doctor. Tylenol will probably be ordered. Voiding after surgery is not uncommon and is not a sign of immediate danger, so answer D is incorrect. Ensure that the client is well hydrated and monitored. 88. The nurse is caring for the client with a 5-year-old diagnosed with plumbism. Which information in the health history is most likely related to the development of plumbism? A. The client has traveled out of the country in the last 6 months. B. The client’s parents are skilled stained-glass artists. C. The client lives in a house built in 1990. D. The client has several brothers and sisters. Answer B: Plumbism is lead poisoning. If the parents have stained glass as a hobby, there is a danger that the lead used to adhere stained glass can drop in the work area where the child can consume the lead beads. Other factors associated with the consumption of lead are eating from pottery made in Central America or Mexico that is unfired. In answer A, there is no data to suggest that the child is drinking from pottery bought in Central America. Answer C is incorrect because the child in this situation lives in a house built in 1990. Lead was taken out of paint in 1976. Answer D is unrelated to plumbism. 89. A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with prevention of dislocation of the prosthesis? A. An abduction pillow B. A straight chair C. A pair of crutches D. A soft mattress Answer A: An abduction pillow will help to prevent adduction of the hip joint. The client should be taught to avoid crossing the legs. Answer B is incorrect because the client should not flex the hip more than 90°; the straight chair would potentiate the flexion of the hip more than 90°. Answer C is incorrect because the client should use a walker, not crutches, to ambulate. Answer D is incorrect because a hard mattress is best, not a soft one. 90. The client with a joint replacement is scheduled to receive Lovenox (enoxaparin). Which lab value should be reported to the doctor? A. PT of 20 seconds B. PTT of 300 seconds C. Protime of 30 seconds D. INR 3 Answer B: A PTT of 300 is extremely prolonged and can indicate bleeding. Answers A, C, and D are incorrect because there is no need to report a PT of 20, a Protime of 30 seconds, or an INR of 3 because these are within normal findings. 91. An elderly client with abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should: A. Administer oxygen via nasal cannula B. Have Narcan (naloxane) available C. Prepare to administer blood products D. Prepare to do cardioresuscitation Answer B: Narcan is the antidote for narcotic overdose. If hypoxia occurs, the client should have oxygen administered by mask, not cannula, so answer A is incorrect. There is no data to support administering blood products or cardioresuscitation, so answers C and D are incorrect. 92. Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell’s traction? A. 16-year-old female with scoliosis B. 12-year-old male with a fractured femur C. 10-year-old male with sarcoma D. 6-year-old male with osteomyelitis Answer B: The 6-year-old should have a roommate as close to the same age as possible. The client in answer A is 16 and a female. The client in answer C is closest to the client’s age, but the 10-year-old with sarcoma has cancer and will be treated with chemotherapy that makes him immune suppressed. The 6-year-old with osteomylitis is infected, so answer D is incorrect. 93. A client with rheumatoid arthritis has a prescription for hydroxychloroquine (Plaquenil). Which instruction should be included in the discharge teaching? A. Take the medication with milk B. Report joint pain C. Allow 6 weeks for optimal effects D. Have eye exams every six months Answer D: Plaquenil can cause color blindness, and therefore requires that the client’s vision be evaluated every six months. Answer A is incorrect because there is no need to take the medication with milk. Answers B and C are incorrect because these actions are unnecessary. Answer C is incorrect because there is no need to remain upright for 30 minutes after taking the medication. 94. A client with a fractured tibia has a plaster-of-Paris cast applied to immobilize the fracture. Which action by the nurse indicates understanding of a plaster-of-Paris cast? The nurse: A. Handles the cast with the fingertips B. Bivalves the cast C. Dries the cast with a hair dryer D. Allows 24 hours before bearing weight Answer D: A plaster-of-Paris cast takes 24 hours to dry, and the client should not bear weight for 24 hours. The cast should be handled with the palms, not the fingertips, so answer A is incorrect. Answer B is incorrect because bivalving a cast is done for compartment syndrome and is not routine. The client should be told not to dry the cast with a hair dryer because this causes hot spots and could burn the client, so answer C is incorrect. 95. The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best? A. “It will be alright for your friends to autograph the cast.” B. “Because the cast is made of plaster, autographing can weaken the cast.” C. “If they don’t use chalk to autograph, it is okay.” D. “Autographing or writing on the cast in any form will harm the cast.” Answer A: There is no reason that the client’s friends should not be allowed to autograph the cast; it will not harm the cast in any way. This makes answers B, C, and D incorrect. 96. The nurse is assigned to care for the client with a Steinmen pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time? A. Assist the LPN with opening sterile packages and peroxide B. Tell the LPN that clean gloves are allowed C. Tell the LPN that the registered nurse should perform pin care D. Ask the LPN to clean the weights and pulleys with peroxide Answer A: The nurse is performing the pin care correctly when she uses sterile gloves and Q-tips. The nurse can assist her co-worker by opening any packages of sterile dressings that are needed. Answers B, C, and D are incorrect. The nurse should use sterile gloves, not clean gloves, for pin care, a licensed practical nurse can perform pin care, and there is no need to clean the weights. 97. A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken? A. Checking the bowel sounds B. Assessing the blood pressure C. Offering pain medication D. Checking for swelling Answer A: A body cast or spica cast extends from the upper abdomen to the knees or below. Bowel sounds should be checked to ensure that the client is not experiencing a paralytic illeus. Checking the blood pressure is a treatment for any client but is not specific to a spica cast, so answer B is incorrect. Answers C and D are incorrect because they are not concerns associated with a body cast or spica cast. 98. The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge? A. Russell’s traction B. Buck’s traction C. Halo traction D. Crutchfield tong traction Answer C: Halo traction will be ordered for the client with a cervical fracture. Russell’s traction is used for bones of the lower extremities, as is Buck’s traction, so answers A and B are incorrect. Cruchfield tongs are used while in the hospital and the client is immobile, so answer D is incorrect. 99. A client with a total knee replacement has a CPM applied during the postoperative period. Which statement made by the nurse indicates understanding of the CPM machine? A. “Use of the CPM will permit the client to ambulate during the therapy.” B. “The CPM machine controls should be positioned distal to the site.” C. “If the client complains of pain during the therapy, I will turn off the machine and call the doctor. D. “Use of the CPM machine will alleviate the need for physical therapy after the client is discharged.” Answer B: The controller for the continuous passive-motion device should be placed distal to the site to prevent the client from being able to turn off the machine. If the client is allowed to have the control close by, he might be tempted to turn off the machine and stop the passive motion. This treatment is often painful, so the nurse should offer pain medication before the treatment. Answer A is incorrect because the client cannot ambulate during the therapy. Answer C is incorrect because pain is expected and is not a reason to turn off the machine. Answer D is incorrect because the continuous passive-motion machine does not alleviate the need for physical therapy. 100. A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the: A. Palms rest lightly on the handles B. Elbows are flexed 0° C. Client walks to the front of the walker D. Client carries the walker Answer A: The client’s palms should rest lightly on the handles. The elbows should be flexed no more than 30° but should not be extended, so answer B is incorrect. The client should walk to the middle of the walker, not to the front of the walker, so answer C is incorrect. The client should be taught not to carry the walker, so answer D is incorrect. [Show More]
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