MED SURG 206 Comprehensive Foundation NCLEX Questions And Answers( All Answers Are Correct)

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Comprehensive Foundation NCLEX Question 1 100 / 100 pts The client with cellulitis of the lower leg has had cultures done on the affected area. The nurse reviewing the results of the culture repor... t interprets that which of the following organisms is not part of the normal flora of the skin? Staphylococcus epidermidis Correct! Escherichia coli Candida albicans Staphylococcus aureus Rationale: E. coli is normally found in the intestines and is a common source of infection of wounds and the urinary system. C. albicans, S. aureus, and S. epidermis are part of the normal flora of the skin. Test-Taking Strategy: To answer this question correctly, you must be familiar with the normal microorganisms that inhabit the skin. Note that the question asks for the organism that is not part of normal flora. Remember that E. coli is normally found in the intestines. Review basic skin structures if you had difficulty with this question. Question 2 100 / 100 pts The client has been diagnosed with paronychia. The nurse understands that this is a disorder of the: Pilosebaceous glands Correct! Nails Hair follicles Epithelial layer of skin Rationale: Paronychia is a fungal infection that is most often caused by Candida albicans. This results in inflammation of the nail fold, with separation of the fold from the nail plate. The area is generally tender to touch, with purulent drainage. Disorders of the hair follicles include folliculitis, furuncles, and carbuncles. Disorders of the pilosebaceous glands include acne vulgaris and seborrheic dermatitis. There are a variety of disorders involving the epithelial skin. Test-Taking Strategy: To answer this question accurately, you must be familiar with a variety of skin disorders and their causes. Remember that paronychia is a nail disorder. If this question was difficult, review the characteristics of paronychia. Question 3 100 / 100 pts The nurse is assigned to the care of a client scheduled for surgery for a right colon tumor. Which of the following is the most characteristic manifestation of cancer at this site? Correct! Dull abdominal pain exacerbated by walking Flat, ribbon-like stools Crampy gas pains Frequent diarrhea Rationale: Characteristic symptoms of right colon tumors include vague, dull, abdominal pain exacerbated by walking, and dark red- or mahogany-colored blood mixed in the stool. The symptoms described in the other options are associated with left colon tumors. Test-Taking Strategy: Knowledge regarding the signs of right and left colon tumors is required to answer this question. Note, however, that “crampy gas pains” and “dull abdominal pain exacerbated by walking” describe different patterns of pain. This may suggest to you that one of the two is correct. If you are not familiar with the differences between right and left colon tumors, review this content. Question 4 100 / 100 pts The client with an endocrine disorder complains of weight loss and diarrhea, and says that he can “feel his heart beating in his chest.” The nurse interprets that which of the following glands is most likely responsible for these symptoms? Parathyroid Pituitary Correct! Thyroid Adrenal cortex Rationale: The thyroid gland is responsible for a number of metabolic functions in the body, including metabolism of nutrients (such as fats and carbohydrates). Increased metabolic function places a demand on the cardiovascular system for a higher cardiac output. Thus, a client with increased activity of the thyroid gland exhibits weight loss from higher metabolic rate and increased pulse rate. Test-Taking Strategy: Use knowledge of the function of the thyroid gland to answer this question. Remember that the thyroid gland is responsible for metabolic function. This will assist in directing you to “thyroid.” If you had difficulty answering this question, review the function of the thyroid gland. Question 5 100 / 100 pts The client with diabetes mellitus is being tested to determine long-term diabetic control. Which of the following results would the nurse expect to see if the client’s long-term control is within acceptable limits? Fasting blood glucose level of 150 mg/dL Correct! Glycosylated hemoglobin of 6% Presence of albumin in the urine Presence of ketones in the urine Rationale: This measurement of glycosylated hemoglobin (Hb A1c) detects glucose binding on the red blood cell (RBC) membrane and is expressed as a percentage. It measures glucose for the life of the RBC, which is 120 days. The fasting blood glucose level should be lower than 130 mg/dL. The urine should be free of both ketones and urine. Test-Taking Strategy: Specific knowledge of the effects of an increased blood glucose level in the body is necessary to answer this question. Noting the words “long-term” will direct you to “glycosylated hemoglobin of 6%.” Review the alterations in normal physiology that occur with diabetes mellitus if you had difficulty with this question. Question 6 100 / 100 pts Discharge teaching for a client recovering from an attack of chronic pancreatitis should include which of the following instructions? Diet should be high in carbohydrates, fats, and proteins. Frothy fatty stools indicate that enzyme replacement is working. Alcohol should be consumed in moderation. Correct! Avoid caffeine, because it may aggravate symptoms. Rationale: Knowing that caffeinated beverages, such as coffee, tea, and soda, will worsen symptoms, such as pain, will direct you to select “Avoid caffeine, because it may aggravate symptoms.” Alcohol can precipitate an attack of chronic pancreatitis and needs to be avoided. The recommended diet is moderate carbohydrates, low fat, and high protein. Frothy fatty stools indicate that the replacement enzyme dose needs to be increased. Test-Taking Strategy: “Alcohol should be consumed in moderation” can be immediately eliminated because alcohol can precipitate another attack and needs to be avoided. “Diet should be high in carbohydrates, fats, and proteins” can be eliminated because the recommended diet is moderate carbohydrates, low fat, and high protein. Finally, frothy fatty stools indicate that the enzyme dose needs to be increased, so “frothy fatty stools indicate that enzyme replacement is working” can be eliminated. Review home care instructions for the client with chronic pancreatitis if you had difficulty answering this question. Question 7 100 / 100 pts A client returns to the nursing unit after undergoing an esophagogastroduodenoscopy (EGD). Which of the following reflects appropriate intervention by the nurse? Correct! Withhold oral fluids until the client’s gag reflex has returned. Tell the client to report a sore throat immediately, because it is a serious complication. Allow the client unassisted bathroom privileges. Keep the client lying flat in bed in the supine position. Rationale: In preparation for the passage of the endoscope, an anesthetic is sprayed to inactivate the gag reflex and thus facilitate passage of the tube. It may take 1 to 2 hours for the anesthetic spray to wear off and for the gag reflex to return. “Allow the client unassisted bathroom privileges,” “keep the client lying flat in bed in the supine position,” and “tell the client to report a sore throat immediately, because it is a serious complication” are incorrect. Test-Taking Strategy: Apply knowledge of endoscopic procedures of the upper gastrointestinal tract to assist you with selecting the correct option. Because the client will receive conscious sedation for the procedure and anesthetic spray to the throat, postprocedure safety precautions must be maintained. This includes assistance to the bathroom and head of the bed elevation to prevent aspiration of oral secretions. A sore throat is common postprocedure and may persist for a few days but is not a cause for alarm. Review these postprocedural instructions if you had difficulty with this question. Question 8 100 / 100 pts A client presents to the urgent care center with complaints of abdominal pain and vomits bright red blood. Which of the following is the priority action taken by the nurse? Perform a complete abdominal assessment. Obtain a thorough history of the recent health status. Prepare to insert a nasogastric tube and test pH and occult blood. Correct! Take the client’s vital signs. Rationale: The nurse should take the client’s vital signs first to determine whether the client is hypovolemic or in shock from blood loss; this also provides a baseline blood pressure and pulse by which to gauge the effectiveness of treatment. Signs and symptoms of shock include low blood pressure, rapid weak pulse, increased thirst, cold clammy skin, and restlessness. Test-Taking Strategy: The strategic word in the question is “priority.” This tells you that more than one or all of the options may be partially or totally correct. Although all the options may be applicable to the care of this client, use principles of priority setting to answer the question. A client with an acute upper gastrointestinal (GI) bleed is at risk for shock. From the options provided, taking the client’s vital signs is the nursing action that will provide information about the status of the client’s circulating volume status. Review care to the client with a GI bleed if you had difficulty with this question. Question 9 100 / 100 pts The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse would monitor the status of breath sounds in that area by placing the stethoscope: In the fifth intercostal space Near the lateral 12th rib Posteriorly, under the left-sided scapula Correct! Just under the left-sided clavicle Rationale: For the client with a left apical pneumothorax, the nurse would place the stethoscope just under the left clavicle. The apex of the lung is the rounded uppermost part of the lung. All the other options are incorrect. Test-Taking Strategy: Knowledge of anatomical landmarks is needed to answer this basic question. Noting the client’s diagnosis and the strategic words “left apical” will direct you to “just under the left-sided clavicle.” If needed, review assessment of the client with a left apical pneumothorax. Question 10 100 / 100 pts A client’s total cholesterol level is 344 mg/dL, low-density lipoprotein cholesterol (LDL-C) level is 164 mg/dL, and high-density lipoprotein cholesterol (HDL-C) level is 30 mg/dL. Based on analysis of the data, how should the nurse direct client teaching? Correct! The client is at high risk for cardiovascular disease, and measures to modify all identified risk factors should be taught. The client should maintain the current dietary regimen but increase activity levels. Results are inconclusive unless the triglyceride level is also screened, so teaching is not indicated at this time. The client is at low risk for cardiovascular disease, so the client should be encouraged to continue to follow the current regimen. Rationale: In the absence of documented cardiovascular disease, the desired goal is to have the total cholesterol level lower than 200 mg/dL. A desired LDL-C level for all individuals is lower than 100 mg/dL, and a desirable HDL-C level is higher than 40 mg/dL. Because the client’s levels are outside the range for all three values to a significant degree, the client is at high risk for developing cardiovascular disease and requires teaching on risk factor reduction. Test-Taking Strategy: Use knowledge of normal values for serum cholesterol and lipoprotein levels to answer this question. The question does not indicate that the client has documented heart disease, so the standard recommended values apply. Knowing that the total cholesterol should be lower than 200 mg/dL helps you choose your answer correctly. Review the risk factors for cardiovascular disease if you had difficulty answering this question. Question 11 100 / 100 pts The nurse identifies that a client is having occasional premature ventricular contractions (PVCs) on the cardiac monitor. The nurse reviews the client’s laboratory results and determines that which of the following results would be consistent with the observation? Serum chloride level of 95 mEq/L Correct! Serum potassium level of 2.8 mEq/L Serum sodium level of 150 mEq/L Serum calcium level of 11.5 mg/dL Rationale: The nurse assesses the client’s serum laboratory study results for hypokalemia. The client may experience PVCs in the presence of hypokalemia, because this electrolyte imbalance increases the electrical instability of the heart. The electrolyte imbalances mentioned in the other options do not have this effect. Test-Taking Strategy: Focus on the data in the question. Recalling that a low potassium level causes cardiac irritability will direct you to “serum potassium level of 2.8 mEq/L.” If this question was difficult, review the effects of electrolyte imbalances on the cardiac system. Question 12 0 / 100 pts The client is admitted to the hospital with a tentative diagnosis of bladder cancer. The nurse expects the client history to reveal which of the following earliest manifestations of the disease? Pyuria and palpable abdominal mass You Answered Painful urination and hematuria Proteinuria and dysuria Correct Answer Hematuria with no pain Rationale: The earliest signs and symptoms of bladder cancer are hematuria that is not accompanied by pain. The hematuria is intermittent at first. Later symptoms include hematuria with dysuria and frequency because of bladder irritation. Pyuria and proteinuria are not part of the clinical picture. A mass is usually not palpable. Test-Taking Strategy: The strategic word in the question is “earliest.” Begin to answer this question by eliminating “pyuria and palpable abdominal mass” first, because pyuria would be caused by infection. Knowing that pain and discomfort are later signs helps you eliminate “proteinuria and dysuria” and “painful urination and hematuria” next. This leaves “hematuria with no pain” as correct. The client usually presents with intermittent painless hematuria. Review the early manifestations of bladder cancer if you had difficulty with this question. Question 13 100 / 100 pts The nurse is attempting to inspect the lacrimal apparatus of the client’s eye. Because of its anatomical location, the nurse should do which of the following? Retract the lower eyelid, and ask the client to look up. Correct! Retract the upper eyelid, and ask the client to look down. Retract the upper eyelid, and ask the client to look up. Retract the lower eyelid, and ask the client to look down. Rationale: The lacrimal apparatus consists of the lacrimal gland (in the upper lid over the outer canthus) and the secretory ducts, which direct tears to the lacrimal sac in the inner canthus. The nurse examines part of this apparatus by retracting the upper eyelid and asking the client to look down. Abnormal findings would include edema and tenderness. The other statements are incorrect. Test-Taking Strategy: Recall the normal anatomy of the eye and visualize the procedure for checking the lacrimal apparatus. This will direct you to “retract the upper eyelid, and ask the client to look down.” If this question was difficult, review this assessment procedure. Question 14 100 / 100 pts The nurse who is assessing the client’s eyes notes that the pupil gets larger when looking at an object in the distance and gets smaller when looking at a near object. The nurse documents this finding as: Correct! Accommodation Myopia Hyperopia Photophobia Rationale: Accommodation is the expected change in pupil size when changing gaze from a near object to a far one, and back again. The pupils dilate when looking at the far object and constrict when looking at the near one. Photophobia is an abnormal sensitivity to light. Myopia (nearsightedness) and hyperopia (farsightedness) are disturbances in visual acuity. Test-Taking Strategy: Focus on the data in the question, and note the relationship between the data and the definition of accommodation. If this question was difficult, review the definition of accommodation. Question 15 100 / 100 pts The nurse suspects the client may be experiencing dysfunction in the area of the semicircular canals of the ear if the client experiences: Conduction hearing loss Sensorineural hearing loss Tinnitus Correct! Disturbance in balance Rationale: The semicircular canals function to aid the client’s sense of balance. These canals do not relate to hearing function or the presence of tinnitus. Test-Taking Strategy: Eliminate “conduction hearing loss” and “sensorineural hearing loss” first because they are comparable or alike. For the remaining options, it is necessary to know that the semicircular canals function to aid the client’s sense of balance. Review the function of the semicircular canals if you had difficulty with this question. Question 16 100 / 100 pts The nurse is caring for a client who is scheduled to have electroencephalography. The nurse determines that the client is ready for the procedure after noting which of the following? The morning dose of an anticonvulsant has been administered. Correct! The client’s hair has been shampooed. The client has had two cups of coffee with breakfast. The client has not had any breakfast. Rationale: Preprocedure care for electroencephalography involves client teaching about the procedure, shampooing the client’s hair, and providing a light meal and fluids to prevent hypoglycemia (which could alter electroencephalographic results). Medications, such as antidepressants, tranquilizers, and anticonvulsants, are withheld for 24 to 48 hours before the procedure, as determined by the physician. Stimulants, such as coffee, tea, cola, alcohol, and cigarettes, are also withheld for 12 hours prior to the test. Test-Taking Strategy: Focus on the name of the test and think about the procedure involved in performing this test. This will direct you to “the client’s hair has been shampooed.” Review this neurological test if you had difficulty with this question. Question 17 100 / 100 pts The nurse should ask the client to do which of the following when testing the function of the spinal accessory nerve (CN XI)? Open the mouth and say “ah.” Vocalize the sounds “la-la,” “mi-mi,” and “kuh-kuh.” Swallow a sip of water. Correct! Elevate the shoulders. Rationale: The spinal accessory nerve has only a motor component. This cranial nerve is assessed by asking the client to elevate the shoulders, which may be done with or without resistance. It can also be assessed by asking the client to turn the head from one side to the other, resist attempts to pull the chin toward midline, and push the head forward against resistance. The incorrect options are assessed as part of glossopharyngeal nerve (CN IX) and vagus nerve (CN X) testing, which are done together. Test-Taking Strategy: Focus on the subject, the spinal accessory nerve. Recalling the function of this nerve and that it has only a motor component will direct you to “elevate the shoulders.” Review the cranial nerves and neurological assessment if you had difficulty with this question. Question 18 100 / 100 pts The nurse is assisting in performing a physical assessment of a right-handed client’s musculoskeletal system. Which of the following would be an abnormal finding? Symmetrical movements bilaterally Correct! Presence of fasciculations Muscle strength of normal power Hypertrophy of right upper arm of 1 cm Rationale: Fasciculations are fine muscle twitches that are not normally present. Hypertrophy, or increased muscle size, on the client’s dominant side of up to 1 cm is considered normal. Muscle strength is graded from (paralysis) to (normal power). Symmetrical muscle movement is a normal finding. Test-Taking Strategy: “Muscle strength of normal power” and “symmetrical movements bilaterally” should be eliminated first because they are normal findings. To choose correctly between the remaining two options, you must know that slight hypertrophy is normal on the dominant side, whereas fasciculations are not. Review basic physical assessment findings of the musculoskeletal system if you had difficulty with this question. Question 19 0 / 100 pts Which of the following teaching points is the priority when the nurse is teaching the client about caring for a plaster cast? The cast gives off heat as it dries. You Answered A stockinette and soft padding are put over the leg area before casting. Correct Answer Immediately report any increase in drainage or interruption in cast integrity. The client can bear weight on the cast in 1 hour. Rationale: Increases in drainage or interruption in cast integrity will affect healing and could lead to osteomyelitis. To apply a cast, the skin is washed and dried well. A stockinette is placed smoothly and evenly over the area to be casted, followed by a roll of padding. The plaster is then rolled onto the padding, and the edges are trimmed or smoothed if needed. A plaster cast gives off heat as it dries. A plaster cast can tolerate weight-bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast. Test-Taking Strategy: Note the strategic word “priority.” Recalling that drainage is a sign of infection will direct you to “immediately report any increase in drainage or interruption in cast integrity.” Review the principles of cast care and the client teaching points if you had difficulty with his question. Question 20 100 / 100 pts The nurse caring for a client who has undergone kidney transplantation is monitoring the client for organ rejection. The nurse understands that in cases in which the recipient rejects transplanted organs, the cells of the transplanted organs are seen by the body as a(n): T cell Correct! Foreign antigen B cell Antibody Rationale: In cases in which transplanted organs are rejected by the recipient, the transplanted organs are seen by the body as foreign antigens. Antibodies are produced to act against a specific antigen. B and T lymphocytes are responsible for cellular and humoral immunity. Test-Taking Strategy: Knowledge regarding the action and purpose of each of the items listed in the options is required to answer this question. Noting that the subject of the question is rejection of a transplanted organ will assist in directing you to “a foreign antigen.” If you had difficulty with this question, review the types of immune responses. Question 21 100 / 100 pts The nursing student understands that the primary purpose of neutrophils in the inflammatory response is to: Dilate the blood vessels. Correct! Phagocytize any potentially harmful agents. Produce permeability of the blood vessels. Increase fluids at the site of injury. Rationale: In the inflammatory response, neutrophils appear in the area of injury in 30 to 60 minutes. Their primary purpose is to phagocytize (ingest and destroy) any potentially harmful agents, such as microorganisms. “Dilate the blood vessels,” “increase fluids at the site of injury,” and “produce permeability of the blood vessels” are incorrect. Test-Taking Strategy: Knowledge regarding the inflammatory response and physiological process that occurs is required to answer this question. Remember that neutrophils phagocytize. If you are unfamiliar with the inflammatory response, review this content. Question 22 100 / 100 pts The nurse is receiving a client from the postanesthesia care unit following left aboveknee amputation. The priority nursing action at this time is which of the following? Correct! Elevate the foot of the bed. Put the bed in a reverse Trendelenburg’s position. Position the stump flat on the bed. Keep the stump flat, with the client lying on his or her operative side. Rationale: Edema of the stump is controlled by elevating the foot of the bed for the first 24 hours after surgery. After the first 24 hours, the stump is placed flat on the bed to reduce hip contracture. Edema is also controlled by stump wrapping techniques. Test-Taking Strategy: The subject of the question is correct positioning of the stump immediately following surgery. Use principles of gravity and edema control to answer this question. If you had difficulty with this question, review postoperative positioning following amputation. Question 23 100 / 100 pts The nurse caring for a client following craniotomy who has a supratentorial incision understands that the client should most likely be maintained in which of the following positions? Dorsal recumbent position Supine position Correct! Semi-Fowler’s position Prone position Rationale: In supratentorial surgery (surgery above the brain’s tentorium), the client’s head is usually elevated 30 degrees to promote venous outflow through the jugular veins. The client’s head or the head of the bed is not lowered in the acute phase of care after supratentorial surgery. An exception to this position is the client who has undergone evacuation of a chronic subdural hematoma, but a physician’s prescription is required for positions other than those involving head elevation. Additionally, the physician’s prescription regarding positioning is always checked and agency procedures are always followed. Test-Taking Strategy: Knowledge regarding supratentorial surgery and craniotomy is required to answer this question. Remember that with supratentorial surgery the head should be kept up. If you had difficulty with this question, review positioning following craniotomy surgery. Question 24 0 / 100 pts The physician is about to remove a chest tube from a client. After the dressing is removed and the sutures have been cut, the nurse assisting the physician asks the client to: Exhale immediately. Correct Answer Perform the Valsalva maneuver. You Answered Take a deep breath. Breathe in and out quickly. Rationale: When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is then quickly withdrawn, and an airtight dressing is taped in place. The pleura seals itself off, and the wound heals in less than 1 week. Test-Taking Strategy: Knowledge of correct procedure for chest tube removal is required to answer this question. Visualize the procedure as you read each option. This will direct you to “perform the Valsalva maneuver.” If you had difficulty with this question, review the procedure for removing a chest tube. Question 25 100 / 100 pts A client with liver cancer who is receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter. The nurse would try to limit which of the following foods that are most likely to have this taste for the client? Potatoes Cantaloupe Correct! Pork Custard Rationale: Chemotherapy may cause distortion of taste. Frequently, beef and pork are reported to taste bitter or rancid. The nurse can promote client nutrition by helping the client choose alternative sources of protein in the diet, such as mild-tasting fish, cold chicken, turkey, eggs, or cheese. “Custard,” “potatoes,” and “cantaloupe” are not likely to cause distortion of taste. Test-Taking Strategy: The subject of the question is optimal management of a change in taste sensation. To answer this question accurately, you must be able to identify the most troublesome foods. Remember that meats can cause a distortion in taste. If you had difficulty with this question, review interventions related to nutrition in the client receiving chemotherapy. Question 26 100 / 100 pts The client has been diagnosed with gout. In developing a teaching plan for this client, the nurse should include a list that identifies which of the following foods to be avoided? Carrots Chocolate Correct! Chicken liver Tapioca Rationale: Liver and other organ meats should be omitted from the diet of a client who has gout because of their high purine content. Purines are a form of protein. The food items identified in the other options contain negligible amounts of purines and may be consumed freely by the client with gout. Test-Taking Strategy: Focus on the pathophysiology of the client’s diagnosis and the subject, foods high in purine. Remember that organ meats are high in purines. Review foods high in purine if you had difficulty with this question. Question 27 0 / 100 pts The nurse is caring for the client with cirrhosis. As part of dietary teaching to minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase intake of which of the following? Correct Answer Pork Chicken Broccoli You Answered Milk Rationale: Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in the vitamin. Other good sources include peanuts, asparagus, and whole grain and enriched cereals. Test-Taking Strategy: Note the strategic words “best understanding” in the question. This may indicate that more than one option may be a food that contains thiamine. Knowledge regarding food items high in thiamine is required to answer this question. If you are unfamiliar with these foods, review these food items. Question 28 100 / 100 pts The nurse reviews the plan of care for a child with Reye’s syndrome. The nurse prioritizes the nursing interventions included in the plan and prepares to monitor for: Correct! Signs of increased intracranial pressure The presence of protein in the urine Signs of hyperglycemia Signs of a bacterial infection Rationale: Intracranial pressure and encephalopathy are major symptoms of Reye’s syndrome. Protein is not present in the urine. Reye’s syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this disease. Test-Taking Strategy: This question asks you to select a priority nursing intervention for the child with Reye’s syndrome. Recalling that Reye’s syndrome is related to a history of viral infection and that hypoglycemia is associated with this syndrome will assist in eliminating “signs of hyperglycemia” and “signs of increased intracranial pressure.” Use prioritizing skills to select “signs of increased intracranial pressure” over “the presence of protein in the urine.” If you had difficulty with this question, review care of the child with Reye’s syndrome. Question 29 100 / 100 pts The pediatric nurse in the ambulatory surgery unit is caring for a child following a tonsillectomy. The child is complaining of a dry throat. Which of the following items would the nurse offer to the child? A glass of milk Cola with ice Correct! Green gelatin Cool cherry-flavored drink Rationale: Following tonsillectomy, cool clear liquids should be administered. Citrusflavored, carbonated, and extremely hot or cold liquids should be avoided because they may irritate the throat. Red liquids are avoided because they give the appearance of blood if the child vomits. Milk and milk products, including pudding, are avoided because they coat the throat and cause the child to clear his or her throat, thus increasing the risk of bleeding. Test-Taking Strategy: Knowledge of foods and fluids to avoid following tonsillectomy is required to answer this question. First, eliminate foods and fluids that may irritate or cause bleeding, which are “cola with ice” and “a glass of milk.” The strategic word “cherry” in “cool cherry-flavored drink” should be the clue that this is not an appropriate food item. Review dietary measures following tonsillectomy if you had difficulty with this question. Question 30 100 / 100 pts The ambulatory care nurse makes a follow-up telephone call to the mother of a child who underwent a myringotomy with insertion of tympanostomy tubes on the previous day. The mother of the child tells the nurse that the child is complaining of discomfort. The nurse would instruct the mother to: Call the local pharmacist regarding a stronger over-the-counter analgesic. Correct! Give the child acetaminophen (Tylenol) for the discomfort. Call the physician immediately. Give the child children’s aspirin, and call the physician if it does not help. Rationale: Following myringotomy with insertion of tympanostomy tubes, the child may experience some discomfort. It is not necessary to notify the physician, and additionally, this response to the mother may alarm her. Aspirin should not be given to the child. Tylenol can be given to relieve the discomfort. “Call the local pharmacist regarding a stronger over-the-counter analgesic” is inappropriate. Test-Taking Strategy: “Call the physician immediately” and “call the local pharmacist regarding a stronger over-the-counter analgesic” can easily be eliminated. It is not necessary to call the physician immediately and it is inappropriate for the pharmacist to prescribe a stronger medication. It seems reasonable that the child may have some discomfort following this surgical procedure. Recalling that aspirin should not be given to a child will assist in eliminating “call the local pharmacist regarding a stronger overthe-counter analgesic.” If you had difficulty with this question, review postoperative care following myringotomy. Question 31 100 / 100 pts A nursing student is preparing a clinical conference. The topic of the discussion is caring for the child with cystic fibrosis (CF). Which of the following comments by the student would indicate that the student needs further review of information about cystic fibrosis? Correct! It is a disease that causes dilation of the passageways of many organs. It is a disease that causes mucus that is formed to be abnormally thick. It is transmitted as an autosomal recessive trait. It is a chronic multisystem disorder affecting the exocrine glands. Rationale: CF is a chronic multisystem disorder affecting the exocrine gland. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait. Test-Taking Strategy: Note the strategic words “needs further review” in the question. These words indicate a negative event query and the need to select the incorrect statement. Knowledge regarding the physiology associated with CF is required to answer this question. Recalling that obstruction of the small passageways of organs occurs, and careful reading of “it is a disease that causes dilation of the passageways of many organs,” will easily direct you to this option. If you are unfamiliar with the pathophysiology associated with CF, review this content. Question 32 100 / 100 pts A sweat test is performed on an infant with a suspected diagnosis of cystic fibrosis (CF). The nurse reviews the results of the test and notes that the chloride level is 40 mEq/L. The nurse interprets that this finding is indicative of: A negative test An unrelated finding A positive test Correct! Suggestive of CF and requires a repeat test Rationale: In a sweat test, sweating on the infant’s forearm is stimulated with pilocarpine, the sample is collected on absorbent material, and the amount of sweat chloride is measured. A chloride level higher than 60 mEq/L is considered to be a positive test result. A sweat chloride level lower than 40 mEq/L is considered normal. A sweat chloride level higher than or equal to 40 mEq/L is suggestive of CF and requires a repeat test. “A negative test,” “a positive test,” and “an unrelated finding” are incorrect interpretations of the test results. Test-Taking Strategy: Knowledge about diagnostic results related to the sweat test is required to answer this question. Remember a level of 40 mEq/L is suggestive of CF. If you had difficulty with this question or are unfamiliar with this test, review this content. Question 33 0 / 100 pts The nursing student is caring for an infant with a respiratory infection and is monitoring for signs of dehydration. The nursing instructor asks the student to identify the most reliable method of determining fluid loss. The instructor determines that the student understands this method when the student states that the plan is to: Obtain a temperature every 2 hours. Correct Answer Monitor body weight. You Answered Assess the mucous membranes. Monitor output. Rationale: Body weight is the most reliable method of measuring body fluid loss or gain. One kilogram of weight change represents 1 L of fluid loss or gain. “Monitor output,” “assess the mucous membranes,” and “obtain a temperature every 2 hours” are also appropriate measures to assess for dehydration, but the most reliable method is to monitor body weight. Test-Taking Strategy: Note the strategic words “most reliable” in the question to assist in eliminating “assess the mucous membranes” and “obtain a temperature every 2 hours” first. From the remaining options, recall that it would be very difficult to obtain an accurate measurement of output on an infant. This should direct you to “monitor body weight.” Review assessment techniques for determining dehydration if you had difficulty with this question. Question 34 100 / 100 pts The nurse is developing a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse includes to monitor the child for signs of: Failure to thrive Bleeding Decreased tolerance to stimulation Correct! Congestive heart failure (CHF) Rationale: Nursing care initially centers on observing for signs of CHF. The nurse monitors for increased respiratory rate, increased heart rate, dyspnea, crackles, and abdominal distention. “Bleeding,” “failure to thrive,” and “decreased tolerance to stimulation” are not findings directly associated with this disorder. Test-Taking Strategy: Knowledge that Kawasaki disease is a cause of acquired heart disease in children will assist in directing you to “congestive heart failure (CHF).” If you are unfamiliar with the characteristics of Kawasaki disease, review this content. Question 35 100 / 100 pts The nurse is reviewing the health record of an infant with a diagnosis of congenital heart disease. The nurse notes documentation in the record that the infant has clubbing of the fingers. The nurse understands that this finding is caused by: Correct! Poor oxygenation Poor sucking ability Consistent sucking on the fingers Chronic fatigue Rationale: The child with congenital heart disease may develop clubbing of the fingers. Clubbing of the fingers is thought to be caused by anoxia or poor oxygenation. “Chronic fatigue,” “poor sucking ability,” and “consistent sucking on the fingers” are unrelated to this occurrence. Test-Taking Strategy: Knowledge regarding the cause of clubbing of the fingers is required to answer this question. Focusing on the diagnosis identified in the question will assist in directing you to “poor oxygenation.” Review this clinical manifestation noted in congenital heart disease if you had difficulty with this question. Question 36 100 / 100 pts The nurse is caring for a child who was brought to the clinic complaining of severe abdominal pain and is suspected of having acute appendicitis. The child is lying on the examining table, with the knees pulled up toward the chest. The nurse assists the physician with further assessment of the progression of the child’s pain, knowing that the physician will palpate the abdomen: Correct! Midway between the right anterior superior iliac crest and the umbilicus Midway between the left iliac crest and the umbilicus Midway between the left inguinal area and the acetabulum Midway between the liver and the gallbladder Rationale: McBurney’s point is usually the location of greatest pain in the child with appendicitis. McBurney’s point is midway between the right anterior superior iliac crest and the umbilicus. “Midway between the liver and the gallbladder,” “midway between the left iliac crest and the umbilicus,” and “midway between the left inguinal area and the acetabulum” will not appropriately assess the progression of pain in the child with appendicitis. Test-Taking Strategy: Knowledge that the appendix is located in the right side of the abdomen will assist in eliminating “midway between the left iliac crest and the umbilicus” and “midway between the left inguinal area and the acetabulum.” Additionally, recalling that the appendix is located in the lower abdominal area will assist in eliminating “midway between the liver and the gallbladder.” Review the location of McBurney’s point if you had difficulty with this question. Question 37 100 / 100 pts The nurse is developing a plan of care for an infant being admitted with hypertrophic pyloric stenosis who is scheduled for pyloromyotomy. In the preoperative period, the nurse suggests to document in the plan of care to position the child: Correct! Prone with the head of the bed elevated In an infant seat placed in the crib Supine with the head of the bed at a 30-degree angle Supine with the head at a 90-degree angle Rationale: In the preoperative period, the infant is positioned prone with the head of the bed elevated to reduce the risk of aspiration. “In an infant seat placed in the crib,” “supine with the head at a 90-degree angle,” and “supine with the head of the bed at a 30-degree angle” are inappropriate positions for preventing this risk. Test-Taking Strategy: Visualize each of the positions to select the correct option. Keeping in mind that aspiration is the concern will easily direct you to “prone with the head of the bed elevated.” Review preoperative care for pyloromyotomy if you had difficulty with this question. Question 38 100 / 100 pts A female adolescent with type 1 diabetes mellitus has been chosen for her school’s cheerleading squad. She visits the school nurse to obtain information regarding adjustments needed in her treatment plan for diabetes. The school nurse instructs the student to: Take the prescribed insulin 1 hour prior to practice or game time rather than in the morning. Correct! Eat six graham crackers or drink a cup of orange juice prior to practice or game time. Eat half the amount of food normally eaten. Take two times the amount of prescribed insulin on practice and game days. Rationale: An extra snack of 15 to 30 g of carbohydrate eaten before activities, such as cheerleader practice, will prevent hypoglycemia. Six graham crackers or a cup of orange juice will provide 15 to 30 g of carbohydrate. The adolescent should not be instructed to adjust the amount or time of insulin administration. Meal amounts should not be decreased. Test-Taking Strategy: “Take two times the amount of prescribed insulin on practice and game days” and “take the prescribed insulin 1 hour prior to practice or game time rather than in the morning” can be eliminated first, because insulin dosages and times should not be adjusted in this situation. From the remaining options, recalling the manifestations and treatment associated with hypoglycemia will direct you to “eat six graham crackers or drink a cup of orange juice prior to practice or game time.” Review treatment to prevent hypoglycemia if you had difficulty with this question. Question 39 0 / 100 pts The nurse has been caring for an adolescent newly diagnosed with type 1 diabetes mellitus. The nurse provides instructions to the adolescent regarding the administration of insulin. The nurse tells the adolescent to: You Answered Rotate each insulin injection site on a daily basis. Use the same site for injections for 1 month before rotating to another site. Use only the stomach and thighs for injections. Correct Answer Use one major site for the morning injection and another site for the evening injection for 2 to 3 weeks before changing major sites. Rationale: To help decrease variations in absorption from day to day, the child should use one location within a major site for the morning injection, rotating to another site for the evening injection, and a third site for the bedtime injection if needed. This pattern should be continued for a period of 2 to 3 weeks before changing major sites. “Use only the stomach and thighs for injections,” “rotate each insulin injection site on a daily basis,” and “use the same site for injections for 1 month before rotating to another site” are incorrect instructions to the adolescent. Test-Taking Strategy: Eliminate “use only the stomach and thighs for injections” first because of the close-ended word “only.” From the remaining options, knowledge of the physiology associated with absorption of insulin will easily direct you to “Use one major site for the morning injection and another site for the evening injection for 2 to 3 weeks before changing major sites.” If you had difficulty with this question, review insulin administration. Question 40 100 / 100 pts The nurse is talking to the parents of a child newly diagnosed with diabetes mellitus. The nurse determines that the parents have a proper understanding of preventing and managing hypoglycemia if the parents state that they will: Administer glucagon immediately if shakiness is felt. Correct! Carry a glucose source when leaving home in case a hypoglycemic reaction occurs. Give the child 8 oz of diet cola at the first sign of weakness. Report to the emergency department if the blood glucose level is 65 mg/dL. Rationale: The child or parents should carry a source of glucose so it is readily available in the event of a hypoglycemic reaction. LifeSavers or hard candies will provide a source of glucose. A diet carbonated beverage does not meet this need. If the blood glucose level is 65 mg/dL, a source of glucose may be needed, but it is unnecessary to report to the emergency department. Glucagon is used for an unconscious client or if a client experiencing a hypoglycemic reaction is unable to swallow. Test-Taking Strategy: Recalling the description and pathophysiology of hypoglycemia will assist in answering this question. Use the process of elimination and knowledge of hypoglycemia to assist in directing you to “carry a glucose source when leaving home in case a hypoglycemic reaction occurs.” Review the treatment for hypoglycemia if you had difficulty with this question. Question 41 100 / 100 pts A nursing student caring for a 6-month-old infant is asked to collect a sample for urinalysis from the infant. The student collects the specimen by: Catheterizing the infant using the smallest available Foley catheter Obtaining the specimen from the diaper by squeezing the diaper after the infant voids Noting the time of the next expected voiding and preparing to collect the specimen into a cup when the infant voids Correct! Attaching a urinary collection device to the infant’s perineum for collection Rationale: Although many methods have been used to collect urine from an infant, the most reliable method is the urine collection device. This device is a plastic bag that has an opening lined with adhesive so that it may be attached to the perineum. Urine for certain tests, such as specific gravity, may be obtained from a diaper by collection of the urine with a syringe. Urinary catheterization is not to be done unless specifically prescribed because of the risk of infection. It is not reasonable to try to identify the time of the next voiding to attempt to collect the specimen. Test-Taking Strategy: Use the process of elimination to answer the question. Eliminate “noting the time of the next expected voiding and preparing to collect the specimen into a cup when the infant voids” because this is unrealistic. Eliminate “catheterizing the infant using the smallest available Foley catheter” because catheterization is not prescribed, and the risk of infection exists with this procedure. Eliminate “obtaining the specimen from the diaper by squeezing the diaper after the infant voids” because only certain tests can be done on the urine obtained from the diaper. If you had difficulty with this question, review the procedure for collecting urine specimens from an infant and an incontinent child. Question 42 0 / 100 pts A 2-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering over 40% of the body. The burns are both partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies, anticipating that which of the following will be prescribed initially? Application of an antimicrobial agent to the burns You Answered Insertion of a nasogastric tube Correct Answer Insertion of a Foley catheter Administration of an anesthetic agent for sedation Rationale: A Foley catheter is inserted into the child’s bladder so that urine output can be accurately measured on an hourly basis. Although pain medication may be required, the child would not receive an anesthetic agent and should not be sedated. The burn wounds would be cleansed after assessment, but this would not be the initial action. IV fluids are administered at a rate sufficient to keep the child’s urine output at 1 to 2 mL/kg of body weight per hour for children weighing less than 30 kg, thus reflecting adequate tissue perfusion. A nasogastric tube may or may not be required but would not be the priority intervention. Test-Taking Strategy: Note the strategic word “initially” in the question. “Administration of an anesthetic agent for sedation” can be eliminated first because the child should not be sedated and an anesthetic agent would not be administered. Eliminate “insertion of a nasogastric tube” next, knowing that a nasogastric tube may or may not be required. From the remaining options, knowledge that fluid resuscitation and determining the adequacy of the amounts of fluid are essential will direct you to “insertion of a Foley catheter.” Review the treatment of burns if you had difficulty with this question. Question 43 100 / 100 pts The nurse is implementing a teaching plan for a 4-month-old child who has been diagnosed with developmental dysplasia of the hip (DDH). The child will be placed in the Pavlik harness. Which of the following statements by the family would indicate that they understand the care of their child while placed in the Pavlik harness? “I realize that I will also need to put two diapers on my child so that the harness does not get soiled.” “I know that the harness must be worn continuously.” Correct! “I will watch for any redness or skin irritation where the straps are applied and call the doctor if there is any irritation.” “I will bring my child back to the orthopedic office in a month so the straps can be checked.” Rationale: If stabilization of the hip is required, a cast is initially applied. This is kept in place for 3 to 6 months until the hip is stabilized. After this is completed, and if further treatment is required, a Pavlik harness is the treatment of choice next. A Pavlik harness is a removable abduction brace. This is a procedure that requires the brace be checked every 1 to 2 weeks for adjustment of the straps. The use of double diapering is not recommended for DDH because of the possibility of hip extension. Because there are straps applied to the child’s skin, it is important to check the skin of the child frequently. Test-Taking Strategy: Knowledge regarding care of the child in a Pavlik harness is required to answer this question. Use of the process of elimination and knowing that the child must return to the orthopedic office in 1 to 2 weeks for strap adjustment will allow you to eliminate “I will bring my child back to the orthopedic office in a month so the straps can be checked.” Also, knowing that the Pavlik harness is removable will allow you to eliminate “I know that the harness must be worn continuously.” because this states that the harness should be worn continuously. It is also not recommended that double diapering be done with children who are diagnosed with DDH, so this will eliminate “I realize that I will also need to put two diapers on my child so that the harness does not get soiled.” This will lead you to the correct response, as stated in “I will watch for any redness or skin irritation where the straps are applied and call the doctor if there is any irritation.” If you had difficulty with this question, review teaching components for caregivers of children who are placed in a Pavlik harness. Question 44 100 / 100 pts The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse monitors for the most serious complication associated with this type of traction by assessing for a(n): Correct! Elevated temperature Increase in the blood pressure Decrease in the urinary output Lack of appetite Rationale: The most serious complication associated with skeletal traction is osteomyelitis, an infection involving the bone. Organisms gain access to the bone systemically or through the opening created by the metal pins or wires used with the traction. Osteomyelitis may occur with any open fracture. Clinical manifestations include complaints of localized pain, swelling, warmth, tenderness, an unusual odor from the fracture site, and an elevated temperature. “A lack of appetite,” “a decrease in the urinary output,” and “an increase in the blood pressure” are not specifically associated with osteomyelitis. Test-Taking Strategy: Note that the question addresses skeletal traction. Recalling that skeletal traction involves an invasive procedure will direct you to “an elevated temperature.” Review the complications associated with skeletal traction if you had difficulty with this question. Question 45 100 / 100 pts A nursing student is assigned to care for a child with sickle cell disease (SCD). The nursing instructor asks the student to describe the causative factors related to this disease. Which of the following statements, if made by the student, indicates a need for further research? Correct! If each parent carries the trait, the children will inherit the trait. Children with the HbS (sickle cell hemoglobin) trait are not symptomatic. SCD is an autosomal recessive disease. If one parent has the HbS trait and the other parent is normal, there is a 50% chance that each offspring will inherit the trait. Rationale: SCD is an autosomal recessive disease. Children with the HbS trait are not symptomatic. If one parent has the HbS trait and the other parent is normal, there is a 50% chance that each offspring will inherit the trait. If each parent carries the trait, there is a 25% chance that their child will be normal, a 50% chance that the child will carry the trait, and a 25% chance that each child will have the disease. Test-Taking Strategy: Note the strategic words “need for further research.” These words indicate a negative event query and the need to select the incorrect option. Knowledge of the causative factors related to SCD is necessary to answer this question. If you had difficulty with this question, review this content. Question 46 100 / 100 pts The nurse has reviewed the physician’s prescriptions for a child suspected of a diagnosis of neuroblastoma and is preparing to implement diagnostic procedures that will confirm the diagnosis. The nurse most appropriately prepares to: Correct! Collect a 24-hour urine sample. Send the child to the radiology department for a chest x-ray. Assist with a bone marrow aspiration. Perform a neurological assessment. Rationale: Neuroblastoma is a solid tumor found only in children. It arises from neural crest cells that develop into the sympathetic nervous system and the adrenal medulla. Typically, the tumor infringes on adjacent normal tissue and organs. Neuroblastoma cells may excrete catecholamines and their metabolites. Urine samples will indicate elevated vanillylmandelic acid (VMA) levels. A bone marrow aspiration will assist in determining marrow involvement. A neurological examination and a chest x-ray may be performed but will not confirm the diagnosis. Test-Taking Strategy: Use the process of elimination in answering this question. Focus on the strategic word “confirm” and the pathophysiology associated with this diagnosis. “Perform a neurological assessment” and “send the child to the radiology department for a chest x-ray” can be eliminated easily, because they will not confirm the diagnosis. Focusing on the origin of the tumor location will assist in eliminating “assist with a bone marrow aspiration.” If you are unfamiliar with this type of tumor, review this content. Question 47 100 / 100 pts The nurse is reviewing the record of a 10-year-old child suspected of having Hodgkin’s disease. The nurse anticipates noting which of the following characteristic manifestations documented in the assessment notes? Correct! Painless and movable lymph nodes in the cervical area Painful lymph nodes in the supraclavicular area Malaise Fever Rationale: Clinical manifestations specifically associated with Hodgkin’s disease include painless, firm, and movable adenopathy in the cervical and supraclavicular area. Hepatosplenomegaly is also noted. Although anorexia, weight loss, fever, and malaise are associated with Hodgkin’s disease, these manifestations are vague and can be seen in many disorders. Test-Taking Strategy: Note the strategic words “characteristic manifestations” in the question. Eliminate “fever” and “malaise” first because these symptoms are general and vague. Next, think about the pathophysiology associated with Hodgkin’s disease. Recalling that painless adenopathy is associated with Hodgkin’s disease will direct you to “painless and movable lymph nodes in the cervical area.” Review the clinical manifestations related to Hodgkin’s disease if you had difficulty with this question. Question 48 100 / 100 pts The nurse is providing instructions to the mother of a child with human immunodeficiency virus (HIV) infection regarding immunizations. Which of the following statements, if made by the mother, indicates an understanding of the immunization schedule? Correct! “Family members in the household need to receive the influenza vaccine.” “My child will receive all the vaccines like any other child.” “The hepatitis B vaccine is not to be given to my child.” “Blood tests need to be evaluated before any immunizations are given to my child.” Rationale: A child with HIV infection will receive the same immunizations as other children except for live vaccines. All household members receive the influenza vaccine. “Blood tests need to be evaluated before any immunizations are given to my child.” is not necessary and is inaccurate. Test-Taking Strategy: “Blood tests need to be evaluated before any immunizations are given to my child.” can be easily eliminated. From the remaining options, recalling that inactivated vaccines need to be administered to the child with HIV infection and siblings will assist in eliminating “My child will receive all the vaccines like any other child.” Careful reading of the remaining options will easily direct you to “Family members in the household need to receive the influenza vaccine.” Review immunizations for the immunodeficient child if you had difficulty with this question. Question 49 100 / 100 pts The nurse is preparing to administer an MMR (measles, mumps, and rubella) vaccine to a 15-month-old child. Prior to administering the vaccine, which of the following questions would the nurse ask the mother of the child? “Has the child had any sore throats?” Correct! “Is the child allergic to any antibiotics?” “Has the child been exposed to any infections?” “Has the child been eating properly?” Rationale: Prior to the administration of MMR vaccine, a thorough health history needs to be obtained. MMR is used with caution in a child with a history of an allergy to gelatin, eggs, or neomycin, because the live measles vaccine is produced by chick embryo cell culture and MMR also contains a small amount of the antibiotic neomycin. “Has the child had any sore throats?” “Has the child been eating properly?” and “Has the child been exposed to any infections?” are not contraindications to administering immunizations. Test-Taking Strategy: Knowledge regarding the contraindications related to administering the MMR vaccine is required to answer this question. When thinking about contraindications to this vaccine, think about allergic reactions. Remember that MMR is used with caution in a child with a history of an allergy to gelatin, eggs, or neomycin. If you had difficulty with this question, review the nursing implications related to the administration of MMR. Question 50 100 / 100 pts An adolescent is seen in the health care clinic with complaints of chronic fatigue. On physical examination, the nurse notes that the adolescent has swollen lymph nodes. Laboratory test results indicate the presence of Epstein-Barr virus (mononucleosis). The nurse informs the mother of the test results and provides instruction regarding care of the adolescent. Which of the following statements, if made by the mother, indicates an understanding of care measures? “I need to isolate my child so that the respiratory infection is not spread to others.” “I will call the physician if my child is still feeling tired in 1 week.” Correct! “I need to call the physician if my child complains of abdominal pain or left shoulder pain.” “I need to keep my child on bed rest for 3 weeks.” Rationale: The mother needs to be instructed to notify the physician if abdominal pain, especially in the left upper quadrant, or left shoulder pain occurs, because this may indicate splenic rupture. Children with enlarged spleens are also instructed to avoid contact sports until splenomegaly resolves. Bed rest is not necessary, and children usually self-limit their activity. No isolation precautions are required, although transmission can occur via saliva, close intimate contact, or contact with infected blood. The child may still feel tired in 1 week as a result of the virus. Test-Taking Strategy: Knowledge regarding the organs affected in mononucleosis will assist in answering this question. “I need to keep my child on bed rest for 3 weeks.” and “I need to isolate my child so that the respiratory infection is not spread to others.” can be eliminated first because they are unnecessary interventions in this disease. From the remaining two options, knowledge that splenic rupture is a concern will direct you to “I need to call the physician if my child complains of abdominal pain or left shoulder pain.” Review care to the child with this infection if you had difficulty with this question. Question 51 100 / 100 pts A child is seen in a health care clinic, and a diagnosis of chickenpox is confirmed. The mother expresses concern for two other children at home. She asks the nurse if the child is infectious to the other children. The most appropriate response by the nurse is: “The infectious period occurs after the lesions begin.” “The infectious period is not known, and it is possible that the children may develop the chickenpox.” Correct! “The infectious period begins 1 to 2 days before the onset of the rash to about 5 days after the onset of the lesions and crusting of the lesions.” “The infectious period begins when the lesions begin to crust.” Rationale: The infectious period of chickenpox is 1 to 2 days before the onset of the rash to about 5 days after the onset of the lesions and the crusting of the lesions. “The infectious period occurs after the lesions begin.” “The infectious period begins when the lesions begin to crust.” and “The infectious period is not known, and it is possible that the children may develop the chickenpox.” are inaccurate. Test-Taking Strategy: Knowledge about the infectious period associated with chickenpox is required to answer this question. Option “The infectious period is not known, and it is possible that the children may develop the chickenpox.” can easily be eliminated first because of the words “not known.” For the remaining options, select “The infectious period begins 1 to 2 days before the onset of the rash to about 5 days after the onset of the lesions and crusting of the lesions.” because it is the umbrella option. If you had difficulty with this question, review the infectious period associated with chickenpox. Question 52 100 / 100 pts A client who was receiving enteral feedings in the hospital has been started on a regular diet and is almost ready for discharge. The client will be self-administering supplemental tube feedings between meals for a short time after discharge. When the client expresses concern about his or her ability to perform this procedure at home, the nurse would best respond with which of the following? “Maybe a friend will do the feeding for you.” “Do you want to stay in the hospital a few more days?” “Have you discussed your feelings with your family and doctor?” Correct! “Tell me more about your concerns about going home.” Rationale: A client often has fears about leaving the secure environment of a health care facility. This client has a specific fear about not being able to handle tube feedings at home. An open communication statement such as “Tell me more about...” often leads to valuable information about the client and his or her concerns. “Maybe a friend will do the feeding for you.” and “Have you discussed your feelings with your family and doctor?” are nontherapeutic responses because they place the client’s issues on hold. “Do you want to stay in the hospital a few more days?” is beyond the scope of practice for the nurse to implement and may not be necessary. Test-Taking Strategy: Use therapeutic communication techniques to answer the question. “Tell me more about your concerns about going home.” focuses on the client’s feelings. Remember to address the client’s feelings first. Review therapeutic communication techniques if you had difficulty with this question. Question 53 100 / 100 pts The client with pancreatitis is being weaned from parenteral nutrition (PN). The client asks the nurse why the PN cannot just be stopped. The nurse includes in a response to the client that which of the following complications could occur with sudden termination of PN formula? Hypokalemia Dehydration Correct! Rebound hypoglycemia Hypernatremia Rationale: Clients receiving PN are receiving high concentrations of glucose. To give the pancreas time to adjust to decreasing glucose loads, the infusion rates are tapered down. Prior to discontinuing the PN, the body must adjust to the lowered glucose level. If the PN were suddenly withdrawn, the client could have rebound hypoglycemia. Although the other options are potential complications, they are not risks associated with discontinuing PN abruptly. Test-Taking Strategy: Use the process of elimination to answer the question. Recall that PN solutions contain high concentrations of glucose; this will easily direct you to “rebound hypoglycemia.” Review the components of a PN solution and the considerations related to weaning if you had difficulty with this question. Question 54 0 / 100 pts The nurse is providing care to a client with continuous tube feedings through a nasogastric (NG) tube. The nurse should avoid doing which of the following, which is not part of the standard care for a client receiving enteral nutrition? You Answered Check for placement every 4 hours. Check for placement prior to administering medications through the tube. Check the residual every 4 hours. Correct Answer Hang a new feeding bag every 72 hours. Rationale: A feeding bag and tubing should be changed every 24 hours (or per agency protocol) to reduce risk of bacterial contamination. Placement and residual should be checked at least every 4 hours during administration of continuous tube feedings and prior to giving medications through the tube. Test-Taking Strategy: Note the strategic words “avoid” and “not” in the question. These words indicate a negative event query and the need to select the incorrect action. Visualize the procedure to assist in answering the question. Eliminate each of the incorrect options because they are comparable or alike. If you had difficulty with this question, review the nursing care associated with continuous tube feedings. Question 55 0 / 100 pts The nurse is monitoring the nutritional status of the client receiving enteral nutrition. The nurse monitors which of the following to determine the effectiveness of the tube feedings for this client? Calorie count Correct Answer Daily weight Serum protein level You Answered Daily intake and output Rationale: The most accurate measurement of the effectiveness of nutritional management of the client is through the use of daily weighing. These should be done every day at the same time (preferably early morning), in the same clothes, and using the same scale. “Calorie count,” “serum protein level,” and “daily intake and output” assist in measuring nutrition and hydration status. However, the effectiveness of the diet is measured by maintenance of body weight. Test-Taking Strategy: The strategic word in the question is “effectiveness.” This tells you that the correct option is an outcome rather than a tool to measure the outcome. With this in mind, eliminate “calorie count,” and “daily intake and output” first because these are tools that the nurse uses to measure nutritional and fluid status. Eliminate “serum protein level” next, because it reflects only one component of the diet, namely, protein. If you had difficulty with this question, review the methods of monitoring the effectiveness of the tube feedings. Question 56 100 / 100 pts The nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client has experienced: Correct! Phlebitis of the vein Hypersensitivity to the IV solution Infiltration of the IV line Allergic reaction to the IV catheter material Rationale: Phlebitis at an IV site can be distinguished by client discomfort at the site, as well as by redness, warmth, and swelling proximal to the catheter. The IV line should be discontinued, and a new line should be inserted at a different site. The remaining options are incorrect. Test-Taking Strategy: Remember that options that are comparable or alike are not likely to be correct. In this case, “hypersensitivity to the IV solution” and “allergic reaction to the IV catheter material” are comparable or alike and therefore are eliminated. Focus on the data in the question to select “phlebitis of the vein” over “infiltration of the IV line.” Also recalling the signs of common IV complications will assist in answering correctly. Review the signs and symptoms of phlebitis if you had difficulty with this question. Question 57 100 / 100 pts The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse prepares to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the medication cart. Which of the following is the appropriate action by the nurse? Wipe the tubing port with Betadine. Correct! Change the IV tubing. Scrub the needleless device with an alcohol swab. Attach a new needleless device. Rationale: The nurse should change the IV tubing because it has become contaminated and could cause systemic infection to the client. Wiping the port with Betadine is insufficient and would be contraindicated in any case, because the tubing will be attached directly to an angiocatheter in the client’s vein. The needleless device has not been contaminated and does not need replacement or cleansing. Test-Taking Strategy: Focus on the subject, contamination of the tubing. Note the relationship between the subject and “change the IV tubing.” Review aseptic technique if you had difficulty with this question. Question 58 100 / 100 pts The nurse is providing discharge instructions to an Asian-American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. Which of the following nursing actions is most appropriate? Correct! Continue with the instructions verifying client understanding. Identify the importance of the instructions for the maintenance of health care. Walk around to the client so that you continuously face the client. Give the client a dietary booklet, and return later to continue with the instructions. Rationale: Most Asian-American individuals maintain a formal distance with each other, which is a form of respect. Many are uncomfortable with face-to-face communications, especially when there is direct eye contact. If the client turns away from the nurse during a conversation, the best action is to continue with the conversation. Walking around to the client so that the nurse faces the client is in direct conflict with cultural practices. Identifying the importance of the instructions for the maintenance of health care may be viewed as degrading. Returning later to continue with the explanation may be viewed as a rude gesture. Test-Taking Strategy: Understanding the characteristics of this cultural group will assist in answering the question. Eliminate “identify the importance of the instructions for the maintenance of health care” and “give the client a dietary booklet, and return later to continue with the instructions” first, because these are nontherapeutic actions. From the remaining two options, “continue with the instructions verifying client understanding” is the most therapeutic. If you had difficulty with this question, review the communication practices of this cultural group. Question 59 100 / 100 pts The nurse is preparing to assist a Jewish-American client with eating lunch. A kosher meal is delivered to the client. Which of the following nursing actions is most appropriate in assisting the client with the meal? Replace the plastic utensils with metal eating utensils. Carefully place the food from the paper plates to glass plates. Unwrap the eating utensils for the client. Correct! Ask the client to unwrap the eating utensils, and allow the client to prepare the meal for eating. Rationale: Kosher meals arrive on paper plates and with plastic utensils sealed. Health care providers should not unwrap the utensils or place the food on another serving dish. Although the nurse may want to be helpful in assisting the client with the meal, the only appropriate option for this client is “ask the client to unwrap the eating utensils, and allow the client to prepare the meal for eating.” Test-Taking Strategy: Knowledge regarding the rituals associated with kosher meals is required to answer this question. “Replace the plastic utensils with metal eating utensils” and “carefully place the food from the paper plates to glass plates” are comparable or alike and can be eliminated first. For the remaining options, it is necessary to be familiar with kosher rituals to direct you to “ask the client to unwrap the eating utensils, and allow the client to prepare the meal for eating.” If you had difficulty with this question, review these cultural characteristics. Question 60 100 / 100 pts The nurse plans to do dietary teaching with an African-American client. The nurse understands that foods preferred by individuals of this culture are which of the following? Rice Red meat Fruits Correct! Fried foods Rationale: African-American food preferences include pork, greens, rice, and fried foods. Asian-American food preferences include raw fish, rice, and soy sauce. Hispanic Americans prefer beans, fried foods, spicy foods, chilies, and carbonated beverages. European Americans prefer carbohydrates and red meat. Test-Taking Strategy: Knowledge regarding the food practices and preferences related to the various cultures is required to answer the question. Correlate fried foods with African Americans. This may assist when answering other questions similar to this one. If you had difficulty with this question, review the food preferences associated with the African-American culture. Question 61 100 / 100 pts A registered nurse (RN) who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. The most appropriate initial action by the RN is which of the following? Call the police. Correct! Call the nursing supervisor. Call security. Lock the co-worker in the medication room until help is obtained. Rationale: The nurse practice act requires reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This incident needs to be reported to the nursing supervisor, who will then report to the board of nursing and other authorities as required. “Lock the co-worker in the medication room until help is obtained” is an inappropriate and unsafe action. Security may be called if a disturbance occurs, but there are no data in the question to support this. Therefore, this is not the initial action. Test-Taking Strategy: Use the principles of prioritizing when answering this question. Note the strategic word “initial” in the question. Eliminate “lock the co-worker in the medication room until help is obtained” first because this is an inappropriate and unsafe action. Recall the lines of organizational structure to assist in directing you to “call the nursing supervisor.” If you had difficulty with this question, review the nurse’s responsibilities when substance abuse is suspected or occurs. Question 62 100 / 100 pts A hospitalized client tells the registered nurse (RN) that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the RN for assistance in obtaining a witness to the will. The most appropriate response to the client is which of the following? Correct! “I will call the nursing supervisor to seek assistance regarding your request.” “Whoever is available at the time will sign as a witness for you.” “I will sign as a witness to your signature.” “You will need to find a witness on your own.” Rationale: Living wills are required to be in writing and signed by the client. The client’s signature must be either witnessed by specified individuals or notarized. Many states prohibit any employee, including a nurse of a facility where the declaring is receiving care, from being a witness. “You will need to find a witness on your own.” is nontherapeutic and not a helpful response. The RN should seek the assistance of the nursing supervisor. Test-Taking Strategy: Note the strategic words “most appropriate.” “I will sign as a witness to your signature.” and “Whoever is available at the time will sign as a witness for you.” are comparable or alike and should be eliminated first. “You will need to find a witness on your own.” is eliminated because it is a nontherapeutic response. Review legal implications associated with wills if you had difficulty with this question. Question 63 100 / 100 pts The nurse caring for a newly admitted client is reviewing the medication prescription sheet in preparation for administering medications to the client. The nurse notes that the physician has prescribed a medication dose that is twice the amount that the client has reported taking prior to admission. The most appropriate nursing action is to: Correct! Contact the physician directly. Question the client regarding the accuracy of the reported dosage. Ask the physician about the prescription the next time the physician makes rounds. Administer the medication as prescribed. Rationale: If the nurse determines that a physician’s prescription is unclear or if the nurse has a question about a prescription, the nurse should contact the physician prior to implementing it. Under no circumstances should the nurse carry out the prescription unless the prescription is clarified. Questioning the client regarding the accuracy of the dosage of the medication may seem like a viable option, but this action may also cause the client to become upset. The nurse would not administer the medication nor would the nurse administer an altered dosage. Waiting until the physician makes rounds delays treatment. Test-Taking Strategy: Use the process of elimination to answer the question. Eliminate “administer the medication as prescribed” and “ask the physician about the prescription the next time the physician makes rounds” first by applying general principles related to medication administration and safety. From the remaining options, select “contact the physician directly” over “question the client regarding the accuracy of the reported dosage” because this is the action that will clarify the prescription and ensure a safe environment for the client. Review medication administration principles and guidelines related to physician’s prescriptions if you had difficulty with this question. Question 64 100 / 100 pts The registered nurse (RN) hears a client calling out for help. The RN hurries down the hallway to the client’s room and finds the client lying on the floor. The RN performs a thorough assessment and assists the client back to bed. The physician is notified of the incident, and the nurse completes an incident report. Which of the following would the RN document on the incident report? The client fell out of bed. The client became restless and tried to get out of bed. Correct! The client was found lying on the floor. The client climbed over the side rails. Rationale: The incident report should contain the client’s name, age, and diagnosis. It should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation. “The client was found lying on the floor” is the only option that describes the facts as observed by the nurse. “The client fell out of bed,” “the client climbed over the side rails,” and “the client became restless and tried to get out of bed” are interpretations of the situation and are not factual data as observed by the nurse. Test-Taking Strategy: Use the process of elimination and read the information as contained in the question to select the correct option. Remember to focus on factual information when documenting and to avoid including interpretations. This should easily direct you to “the client was found lying on the floor.” Review documentation principles related to incident reports if you had difficulty with this question. Question 65 0 / 100 pts An adult client is brought to the emergency department by emergency medical services after being hit by a car. The name of the client is not known. The client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. In regard to informed consent for the surgical procedure, which of the following is the best initial action? Call the police to identify the client and locate the family. Correct Answer Transport the victim to the operating room for surgery. You Answered Obtain a court order for the surgical procedure. Ask the emergency medical services team to sign the informed consent. Rationale: Generally, there are only two situations in which the informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. “Obtain a court order for the surgical procedure” is unnecessary, and “ask the emergency medical services team to sign the informed consent” is inappropriate. Although “call the police to identify the client and locate the family” may be pursued, it is not the best initial action. Test-Taking Strategy: Use the process of elimination to answer the question. Recall that when an emergency is present delaying treatment for the purpose of obtaining informed consent could result in injury or death. This will easily direct you to “transport the victim to the operating room for surgery.” Review the issues surrounding informed consent if you had difficulty with this question. Question 66 100 / 100 pts The nurse is caring for a client whose physician prescribes airborne precautions. The nurse notes that the client is scheduled for magnetic resonance imaging (MRI). Which of the following nursing actions is most appropriate in preparing the client for the test? Delay the test until airborne precautions are discontinued. Correct! Place a surgical mask on the client for transport and for contact with other individuals. Place the client in gown, gloves, and mask. Request that the MRI technicians wear masks. Rationale: If the client is on airborne precautions, client movement and transport should be limited if possible. If transport or movement is necessary, client dispersal of droplet nuclei can be minimized by placing a surgical mask on the client. “Place the client in gown, gloves, and mask” and “request that the MRI technicians wear masks” are not necessary. “Delay the test until airborne precautions are discontinued” might place the client at risk for complications. This leaves “place a surgical mask on the client for transport and for contact with other individuals,” which is appropriate protection for the staff. Test-Taking Strategy: Use the process of elimination, and focus on the subject of the question, airborne precautions. Eliminate “place the client in gown, gloves, and mask” and “request that the MRI technicians wear masks” because these actions are not necessary. For the remaining options, note that “delay the test until airborne precautions are discontinued” places the client at risk. This should easily direct you to “place a surgical mask on the client for transport and for contact with other individuals.” Review airborne precautions if you had difficulty with this question. Question 67 100 / 100 pts The nurse is assigned to care for a chemically dependent client who has the potential for violent episodes. In planning to care for the client, which of the following actions is the priority? The nurse: Speaks slowly to the client Correct! Projects an attitude of calmness when caring for the client Bargains with the client to prevent the violent episodes Moves slowly when approaching the client Rationale: If a client has the potential for episodes of violence, the nurse would avoid bargaining or making promises to the client. Additionally, the nurse should not judge or criticize the client. “Speaks slowly to the client” and “Moves slowly when approaching the client” identify appropriate nursing actions in the care of the client who has the potential for violence; however, “projects an attitude of calmness when caring for the client” is the priority and encompasses “speaks slowly to the client” and “moves slowly when approaching the client.” Test-Taking Strategy: Read each option carefully, noting that “speaks slowly to the client” and “moves slowly when approaching the client” are comparable or alike types of actions and that “projects an attitude of calmness when caring for the client” is the umbrella option. Nurses should avoid bargaining techniques with any client, but especially those that have the potential for violence. Review nursing actions that minimize violence if you had difficulty with this question. Question 68 100 / 100 pts A nurse is conducting a basic life support (BLS) recertification class and is discussing automated external defibrillation (AED) when a member of the class asks the nurse to identify the correct location for the placement of conductive gel pads to treat ventricular fibrillation. The nurse correctly responds with: Bilaterally, under the right-sided and left-sided clavicles Correct! Under the right-sided clavicle and to the left of the nipple in the midaxillary line Centered on the upper and lower halves of the sternum Parallel, between the umbilicus and the left-sided nipple Rationale: In defibrillation, one gel pad is placed on the upper right-sided chest below the clavicle and the other gel pad is placed to the left of the nipple with the center in the midaxillary line. The electrode paddles are placed over the pads for defibrillation with firm pressure. “Bilaterally, under the right-sided and left-sided clavicles,” “parallel, between the umbilicus and the left-sided nipple,” and “parallel, between the umbilicus and the left-sided nipple” are incorrect because effective defibrillation will not occur with the gel pads in these locations. Test-Taking Strategy: Use knowledge of anatomy of the heart to answer the question. Knowing that the paddles must be placed so that energy is conducted through the heart allows you to eliminate each of the incorrect options. If you had difficulty with this question, review the correct placement of pads for defibrillation. Question 69 100 / 100 pts The nurse notes that a 5-year-old child is choking but is awake and alert at this time. As the nurse rushes to aid the child, the nurse plans to place the hands between which of the following landmarks to do the abdominal thrust maneuver? The lower abdomen and chest The groin and the xiphoid process Correct! The umbilicus and xiphoid process The umbilicus and the groin Rationale: To perform the abdominal thrust maneuver, the rescuer stands behind the victim and places the arms directly under the victim’s axillae and then around the victim. The thumb side of one fist is placed against the victim’s abdomen in the midline slightly above the umbilicus and well below the tip of the xiphoid process. The xiphoid process and ribs are avoided to prevent damage to internal organs. The fist is grasped with the other hand, and upward thrusts are delivered. Test-Taking Strategy: Use the process of elimination. Eliminate “the lower abdomen and chest” first because it is vague. “The umbilicus and the groin” is eliminated next because the anatomical location is too low. Use the same principle to select between the remaining two options. If you had difficulty with this question, review the correct hand placement for the abdominal thrust maneuver. Question 70 100 / 100 pts A nurse is undergoing annual recertification in basic life support (BLS). The BLS instructor asks the nurse to identify the most appropriate pulse point to use when determining pulselessness on an infant. The nurse undergoing recertification replies that the correct pulse point is: Radial Popliteal Correct! Brachial Carotid Rationale: When assessing a pulse in an infant (younger than 1 year), the pulse should be checked at the brachial artery. This is because the relatively short, fat neck of an infant makes palpation of the carotid artery difficult. The pulses in “radial,” “carotid,” and “popliteal” are difficult to locate and palpate. Test-Taking Strategy: Specific knowledge about circulatory assessment in an infant is required to answer this question. Use knowledge of infant anatomy to select the correct option. “Radial,” “carotid,” and “popliteal” should be eliminated because they are difficult to locate and palpate. Review cardiac assessment and BLS in an infant if you had difficulty with this question. Question 71 100 / 100 pts The nurse is assigned to assist in caring for a client who recently returned from the operating room (OR). On data collection, the nurse notes that the client’s vital signs are blood pressure (BP), 118/70 mm Hg; pulse, 91 beats/min; and respirations, 16 breaths/min. Preoperative vital signs were BP, 132/88 mm Hg; pulse, 74 beats/min; and respirations, 20 breaths/min. Which of the following actions should the nurse plan to take first? Correct! Recheck the vital signs in 15 minutes. Cover the client with a warm blanket. Shake the client gently to arouse. Call the surgeon immediately. Rationale: A drop in blood pressure slightly below a client’s preoperative baseline reading is common after surgery. The nurse should recheck the vital signs. Warm blankets are applied to maintain the client’s body temperature. Level of consciousness can be assessed by the evaluation of the client’s response to light touch and verbal stimuli. It is not necessary to contact the surgeon immediately. Test-Taking Strategy: Use principles of priority setting and the ABCs—airway, breathing, and circulation—to answer this question. Note that the strategic word in the question is “first.” The assessment of vital signs takes priority over warming the client and arousing the client. The vital signs are within normal limits following a surgical procedure; therefore, the surgeon does not need to be notified immediately. Review postoperative assessment if you had difficulty with this question. Question 72 100 / 100 pts The nurse is reviewing the physician’s prescription sheet for the preoperative client, which states that the client must be NPO after midnight. The nurse should clarify which of the following medications should be given to the client and not withheld? Correct! Atenolol (Tenormin) Ferrous sulfate Conjugated estrogen (Premarin) Cyclobenzaprine (Flexeril) Rationale: Atenolol is a beta blocker. Beta blockers should not be stopped abruptly, and the physician should be contacted about the administration of this medication prior to surgery. If a beta blocker is stopped abruptly, the myocardial need for oxygen is increased. Cyclobenzaprine (Flexeril) is a skeletal muscle relaxant. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Conjugated estrogen (Premarin) is an estrogen used for hormone replacement therapy in postmenopausal women. The other three medications may be withheld before surgery without undue effects on the client. Test-Taking Strategy: Knowledge about medications that may have special implications for the surgical client is required to answer this question. Noting that atenolol is a cardiac medication will direct you to “atenolol (Tenormin).” Review preoperative procedures related to medications if you had difficulty with this question. Question 73 100 / 100 pts The client who underwent preadmission testing prior to a surgical procedure had serum laboratory studies drawn, including complete blood count, electrolytes, coagulation studies, and creatinine. Which of the following laboratory results should be reported to the surgeon immediately? Serum creatinine level, 0.8 mg/dL Correct! Hemoglobin (Hgb) level, 8.9 g/dL Platelet count, 210,000/mm3 Serum sodium (Na) level, 141 mEq/L Rationale: Routine screening tests include a complete blood count, coagulation studies, and serum electrolyte and creatinine levels. The complete blood count includes the hemoglobin analysis. All these values are within normal range except the hemoglobin. If a client has a low hemoglobin level, the surgery could likely be postponed by the surgeon. Test-Taking Strategy: To answer this question accurately, recall the normal values for the various laboratory studies identified in this question. Note that the hemoglobin value is the only abnormal value. Review these laboratory values if you had difficulty answering this question. Question 74 100 / 100 pts The client has a prescription for administering an enema. After preparing the equipment and solution, the nurse assists the client into which of the following positions? Left side-lying, with the head of the bed elevated 45 degrees Correct! Left-sided lateral Sims position Right side-lying, with the head of the bed elevated 45 degrees Right-sided lateral Sims position Rationale: When administering an enema, the client is placed in a left-sided Sims position so that the enema solution can flow by gravity in the natural direction of the colon. The client is lying on his or her side, with the body turned approximately 45 degrees. The lower leg is extended, with the upper leg flexed at the hip and knee to a 45- to 90-degree angle. “Right-sided lateral Sims position,” “left side-lying, with the head of the bed elevated 45 degrees,” and “right side-lying, with the head of the bed elevated 45 degrees” are incorrect. Test-Taking Strategy: Use knowledge of bowel anatomy to answer this question. Eliminate “left side-lying, with the head of the bed elevated 45 degrees,” and “right sidelying, with the head of the bed elevated 45 degrees” first, because the head of bed should be flat. Use anatomy concepts to choose “left-sided lateral Sims position” over “right-sided lateral Sims position.” Review the procedure for administering an enema if you had difficulty with this question. Question 75 100 / 100 pts The nurse is caring for a client with a chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse takes which immediate action? Places the client in a prone position Places a sterile dressing over the end of the chest tube Correct! Immerses the end of the tube in sterile saline Has the client hold a breath Rationale: If the drainage system is broken or interrupted or the tube disconnects, the end of the tube should be placed in a bottle of sterile saline held below the level of the chest. A new drainage system is then immediately obtained and set up. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. Placing the client in the prone position and asking the client to hold his or her breath are incorrect and may cause respiratory difficulty. The nurse should perform an assessment on the client and contact the physician. Test-Taking Strategy: Reason that the correct option will prevent a complication caused by the disconnection. Eliminate “places the client in a prone position” and “places a sterile dressing over the end of the chest tube” because these actions do not immediately treat the problem. Knowing the complications that can occur from a disconnection will easily direct you to “immerses the end of the tube in sterile saline.” Review interventions related to chest tube complications if you had difficulty with this question. Question 76 100 / 100 pts The newly appointed vice president for nursing operations has announced that the authority for decision making will be decentralized and distributed throughout the organization. The nurse managers anticipate that the channel of communication and authority will be characterized by an organizational chart that is: Vertical Circular Horizontal Correct! Flat Rationale: In “flat” organizations, authority and responsibility are delegated to the lowest operational level possible. “Vertical” is incorrect because a vertical chart indicates a formal line of authority and communications. Traditionally, vertical charts indicate decision making at the upper levels of management. “Circular” indicates a concentric or circular chart, with the chief executive in the center and successive layers of authority. “Horizontal” refers to a horizontal, or left-to-right, chart that depicts the chief executive at the left, with lower layers of the authority to the right. Test-Taking Strategy: Note the strategic words “decentralized and distributed throughout the organization.” Organizational charts are drawings that show how the parts of an organization are linked. Vertical charts indicate hierarchy for decision making, and flat charts indicate authority and responsibility for decision making at the lowest possible level. Review these organizational concepts and structures as they relate to health care facilities if you had difficulty with this question. Question 77 100 / 100 pts The graduate nurse is interviewed by the manager of a unit that has three vacancies and is told that the manager’s leadership style is one of letting the staff nurses make the decisions about the unit’s operations. When the interviewee meets with the day nursing staff, the graduate nurse hears examples of unit issues indicating that the manager’s approach is laissez-faire. Which of the following questions should the graduate nurse ask to confirm her suspicions? “Does the manager facilitate decision making by the group?” “Does the manager maintain control and make all decisions?” “Does the manager change style according to the needs of the group?” Correct! “Does the manager assume a passive, nondirective approach?” Rationale: A laissez-faire leader assumes a passive, nondirective approach. “Does the manager facilitate decision making by the group?” describes a democratic leader. This type of leader is a “talk with the members” type of leader to gain input and facilitate decision making by the group. “Does the manager maintain control and make all decisions?” describes an autocratic leader; this type of leader would make the decisions. “Does the manager change style according to the needs of the group?” describes a situational leader; this is seen when a manager indicates that for some situations, the manager decides, but for other situations, the staff nurses decide. Test-Taking Strategy: Note the strategic words “letting the staff nurses make the decisions” in the question. When a graduate nurse interviews for positions, it is important for the graduate to validate impressions. The graduate nurse needs to formulate questions that allow substantiation of impressions. Focusing on the strategic words will direct you to the correct option. Review each leadership style and identify how decisions under each style of leadership are made if you had difficulty with this question. Question 78 100 / 100 pts A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement, if made by the client, indicates a need for further education? “I need to be aware of any infections and report signs of infection immediately to my health care provider.” “I will perform glucose monitoring at home.” Correct! “I need to avoid exercise because of the negative effects on insulin production.” “I need to stay on the diabetic diet.” Rationale: Exercise is safe for the client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many women are taught to perform blood glucose monitoring. If the woman is not performing the blood glucose monitoring at home, then it will be performed at the clinic or health care provider’s office. Signs of infection need to be reported to the health care provider. Test-Taking Strategy: Use the process of elimination, noting the strategic words “need for further education.” These words indicate a negative event query and the need to select the incorrect option. Noting these strategic words, including the word “avoid,” in the correct option will assist in answering the question. If you had difficulty with this question, review the teaching points for a client with gestational diabetes mellitus. Question 79 100 / 100 pts The nurse is caring for a pregnant client who has herpes genitalis. The nurse provides instructions to the client about treatment modalities that may be necessary for treatment of this condition. Which of the following statements, if made by the client, indicates an understanding of these treatment measures? Correct! “It may be necessary to have a cesarean section for delivery.” “I do not need to abstain from sexual intercourse.” “I need to use vaginal creams after I douche every day.” “I need to douche and perform a sitz bath three times a day.” Rationale: If a client has an active lesion, either recurrent or primary at the time of labor, delivery should be by cesarean. Clients are advised to abstain from sexual contact while the lesions are present. If it is an initial infection, the client should continue to abstain from sexual intercourse until the cultures are negative because prolonged viral shedding may occur. Douches are contraindicated, and the genital area should be kept clean and dry to promote healing. Test-Taking Strategy: Use the process of elimination to assist in directing you to “It may be necessary to have a cesarean section for delivery.” The options “I need to use vaginal creams after I douche every day.” and “I need to douche and perform a sitz bath three times a day.” can be eliminated first because they are comparable or alike. Next, eliminate the option “I do not need to abstain from sexual intercourse.” because of the strategic words “do not.” If you are unfamiliar with the treatment measures associated with this infection, review this content. Question 80 100 / 100 pts A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Which of the following nursing actions would be appropriate? Call the maternity unit and inform them that the client will be admitted in a prelabor condition. Correct! Instruct the client that these are common and may occur throughout the pregnancy. Contact the physician. Instruct the client to maintain bed rest for the remainder of the pregnancy. Rationale: Braxton Hicks contractions are irregular painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, the other options are unnecessary and inaccurate. Test-Taking Strategy: Knowledge regarding the assessment findings in Braxton Hicks contractions and their significance is required to answer this question. The options “Contact the physician” and “Call the maternity unit and inform them that the client will be admitted in a prelabor condition” are comparable or alike and can be eliminated first. For the remaining options, knowing that Braxton Hicks contractions can occur throughout pregnancy will assist in directing you to “Instruct the client that these are common and may occur throughout the pregnancy”. If you had difficulty with this question, review the physiology associated with Braxton Hicks contractions. Question 81 100 / 100 pts The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The physician has documented the presence of Goodell’s sign. The nurse determines that this sign is indicative of: The presence of fetal movement The presence of human chorionic gonadotropin (hCG) in the urine Correct! A softening of the cervix A soft blowing sound that corresponds to the maternal pulse while auscultating the uterus Rationale: In the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, causing Goodell’s sign. Cervical softening is noted by the examiner during pelvic examination. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and is caused by blood circulation through the placenta. The presence of hCG is noted in the maternal urine in a urine pregnancy test. Goodell’s sign does not indicate the presence of fetal movement. Test-Taking Strategy: Use the process of elimination. Remember that Goodell’s sign is a softening of the cervix. If you had difficulty with this question, review the changes in the cervix that occur during pregnancy. Question 82 100 / 100 pts The nursing instructor is reviewing a plan of care formulated by a nursing student who is preparing to instruct a pregnant client in performing Kegel exercises. The nursing instructor asks the student the purpose of the Kegel exercises. Which of the following responses, made by the student, indicates an understanding of the purpose of these types of exercises? “The exercises will help prevent ankle edema.” “The exercises will help reduce backaches.” Correct! “The exercises will help strengthen the pelvic floor in preparation for delivery.” “The exercises will help prevent urinary tract infections.” Rationale: Kegel exercises will assist in strengthening the pelvic floor. Pelvic tilt exercises will help reduce backaches. Instructing a client to drink 8 oz of fluids six times a day will help prevent urinary tract infections. Leg elevation will assist in preventing ankle edema. Test-Taking Strategy: Focus on the subject of the question, and use the process of elimination to answer the question. Knowing that Kegel exercises will help strengthen the perineal floor muscles will assist in directing you to the correct option. If you had difficulty with this question, review the purpose of the Kegel exercises. Question 83 100 / 100 pts A nonstress test is prescribed for a pregnant client, and the client asks the nurse about the procedure. Which of the following information will the nurse provide to the client? “The test will take about 2 hours and will require close monitoring for 2 hours after the procedure is completed.” “The test is an invasive procedure and requires that you sign an informed consent.” “The fetus is challenged by uterine contractions to obtain the necessary information.” Correct! “An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly.” Rationale: The nonstress test takes about 30 to 40 minutes. The test is termed nonstress because it consists of monitoring only; the fetus is not challenged or stressed by uterine contractions to obtain the necessary data. It is a noninvasive test, and an ultrasound transducer that records fetal heart activity is secured over the maternal abdomen where the fetal heart is heard most clearly. A tocotransducer that detects uterine activity and fetal movement is then secured to the maternal abdomen. Fetal heart activity and movements are recorded. Test-Taking Strategy: Focus on the subject, the nonstress test. Knowing that the test is noninvasive will assist in eliminating the incorrect options. If you are unfamiliar with this test, review its procedure. Question 84 100 / 100 pts The pregnant client calls the clinic and tells the nurse that she is experiencing leg cramps and is awakened by the cramps at night. The nurse would tell the client to _____ the knee when the cramps occur. Plantar flex the foot while flexing Correct! Dorsiflex the foot while extending Dorsiflex the foot while flexing Plantar flex the foot while extending Rationale: Leg cramps occur when the pregnant client stretches the leg and plantar flexes the foot. Dorsiflexing the foot while extending the knee stretches the affected muscle, prevents the muscle from contracting, and stops the cramping. Test-Taking Strategy: Knowledge about the actions that will alleviate muscle cramps will assist in answering this question. Visualize each description in the options to assist in directing you to the correct option. If you had difficulty with this question, review measures that will assist in reducing muscle cramps in the client. Question 85 100 / 100 pts A nurse is collecting data on a pregnant client in the first trimester of pregnancy whose medical record indicates the presence of iron deficiency anemia. The nurse would monitor the client to detect which of the following signs indicating that this problem has not yet resolved? Correct! Complaints of daily headaches and fatigue Pink mucous membranes Increased vaginal secretions Complaints of increased frequency of voiding Rationale: Anemia is one of the most common problems in pregnancy, and iron deficiency anemia and folic acid deficiency anemia are two of the most common types. It is estimated that between 20% and 60% of all women are anemic at some point during pregnancy (hemoglobin concentration lower than 10.5 to 11.0 g/dL). Complaints of daily headaches and fatigue are abnormal findings and may reflect complications caused by decreased O2 supply to vital organs, thus supporting laboratory findings. The incorrect options are expected findings in the first trimester of pregnancy. Test-Taking Strategy: Note the strategic words “first trimester of pregnancy and has not yet resolved in the question.” Use the process of elimination and knowledge of abnormal and normal findings to assist in directing you to the correct option. Knowing that the other options are normal findings during the first trimester of pregnancy helps you eliminate each of them. “Complaints of daily headaches and fatigue” is abnormal and may reflect decreased O2 supply to vital organs, thus supporting laboratory findings. Review the clinical manifestations associated with anemia if you had difficulty with this question. Question 86 100 / 100 pts A nurse has just received the intershift report. After reviewing the client assignment and the appropriate medical records, the nurse determines that which of the following clients is most at risk for developing postdelivery endometritis? A client experiencing an elective cesarean delivery at 38 weeks’ gestation A gravida II who delivered vaginally following an 18-hour labor A primigravida with a normal spontaneous vaginal delivery Correct! An adolescent experiencing an emergency cesarean delivery for fetal distress Rationale: Endometritis is an acute infection of the uterine mucous lining immediately after delivery and is still a leading cause of mortality for childbearing women in the United States. Cesarean delivery is the primary risk factor for uterine infection, especially after emergency procedures. Other risk factors include prolonged rupture of membranes, multiple vaginal examinations, and an excessive length of labor. The other options do not describe the client most at risk to develop endometritis following delivery. Test-Taking Strategy: Note the strategic words “most at risk” in the question. Use the process of elimination and knowledge about the cause of endometritis to assist in answering the question. Noting the strategic words “fetal distress” in the correct option will assist in directing you to this option. If you had difficulty with this question or are unfamiliar with the cause associated with this condition, review this content. Question 87 100 / 100 pts The nurse has provided instructions to a pregnant client who is preparing to take iron supplements. The nurse determines that the client understands the instructions if the client states that she will take the supplements with which of the following? Tea Milk Coffee Correct! Orange juice Rationale: Foods containing ascorbic acid will increase the absorption of iron. Calcium and phosphorus in milk and tannin in tea decrease iron absorption. Coffee binds iron and prevents it from being fully absorbed. Orange juice is the only item that contains ascorbic acid and will increase the absorption of iron supplements. Test-Taking Strategy: Use the process of elimination to answer the question. Recalling that ascorbic acid increases the absorption of iron and knowledge of the food items that contain ascorbic acid will easily direct you to the correct option. Review client teaching points related to the administration of iron if you had difficulty with this question. Question 88 0 / 100 pts The nurse is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal patterns show a late deceleration on the monitor strip. Based on this finding, the nurse prepares for which most appropriate nursing actions? Placing the mother in a supine position Correct Answer Administering oxygen via face mask Increasing the rate of the intravenous (IV) oxytocin infusion You Answered Documenting the findings and continuing to monitor the fetal patterns Rationale: Late decelerations are caused by uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore, oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An IV oxytocin infusion is discontinued when a late deceleration is noted; otherwise, the oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency caused by stimulation of contractions caused by the oxytocin. “Documenting the findings and continuing to monitor the fetal patterns” would delay necessary treatment. Test-Taking Strategy: Knowledge related to the significance of a late deceleration is required to answer this question. Use the ABCs—airway, breathing, and circulation—to assist in answering the question. Review content related to late decelerations if you had difficulty with this question. Question 89 100 / 100 pts The nurse is assisting the nurse midwife in preparing to perform Leopold’s maneuver on a pregnant client. The nurse instructs the client about the procedure and then: Asks the client to drink 8 oz of water Correct! Asks the client to urinate Locates the fetal heart tones with a fetoscope Warms the sonogram gel before placing it on the client’s abdomen Rationale: An empty bladder contributes to a woman’s comfort during this examination. Drinking water to fill the bladder and warming sonogram gel may be performed prior to a sonography (ultrasound). Often, Leopold’s maneuver is performed to aid the examiner in locating the fetal heart tones. Test-Taking Strategy: Focus on the subject of the question, Leopold’s maneuver. Use knowledge regarding this maneuver to assist in answering the question. Recalling that it is often used to help locate fetal heart tones will assist in eliminating “Locates the fetal heart tones with a fetoscope”. Eliminate “asks the client to drink 8 oz of water” and “warms the sonogram gel before placing it on the client’s abdomen” next because they both relate to a sonogram. Review the procedure and purpose of Leopold’s maneuver if you had difficulty with this question. Question 90 100 / 100 pts The nurse assists in the vaginal delivery of a newborn. Following the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of: Hematoma Correct! Placental separation Placenta previa Uterine atony Rationale: As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. The other options are incorrect. Test-Taking Strategy: The options “hematoma,” “placenta previa,” and “uterine atony” are comparable or alike in that they identify complications of pregnancy. The option “placental separation” indicates a normal finding following vaginal delivery of the newborn and is the correct option. Review this stage of labor if you had difficulty with this question. Question 91 100 / 100 pts The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan. The nurse prioritizes the plan and selects which of the following nursing interventions as the highest priority? Providing comfort measures Keeping the significant other informed of the progress of the labor Changing the client’s position frequently Correct! Monitoring fetal status Rationale: The priority in the plan of care would include the intervention that addresses the physiological integrity of the fetus. Although providing comfort measures, changing the client’s position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, fetal status is the priority. Test-Taking Strategy: Note the strategic words “highest priority.” Use Maslow’s Hierarchy of Needs theory and the ABCs—airway, breathing, and circulation—to assist in answering the question. Remember that physiological integrity is the priority. Review priority nursing interventions for the client with dystocia if you had difficulty with this question. Question 92 100 / 100 pts The nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which of the following findings would alert the nurse to a compromise? Coordinated uterine contractions Maternal fatigue Progressive changes in the cervix Correct! The passage of meconium Rationale: Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged but does not indicate fetal or maternal compromise. Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor. Test-Taking Strategy: Focus on the subject of the question, signs of fetal or maternal compromise. Use the process of elimination, noting that the options “maternal fatigue,” “coordinated uterine contractions”, and “progressive changes in the cervix” are normal expectations during labor. Review the findings that indicate fetal or maternal compromise if you had difficulty with this question. Question 93 100 / 100 pts The postpartum client who had a vaginal delivery of a healthy newborn has a prescription for a sitz bath. The nurse who is assisting the client tells the client that the sitz bath will: Stimulate a bowel movement. Correct! Promote healing and provide comfort. Reduce the edema and swelling. Numb the tissue. Rationale: Warm, moist heat is used after the first 24 hours following tissue trauma from a vaginal birth to provide comfort, promote healing, and reduce the incidence of infection. This is done with a sitz bath. Ice is used in the first 24 hours to reduce edema and to numb the tissue. Promoting a bowel movement is best achieved by ambulation. Test-Taking Strategy: Focus on the subject of the question, the purpose for a sitz bath. Use the process of elimination to assist in directing you to the correct option. If you had difficulty with this question, review the purpose of a sitz bath following vaginal delivery. Question 94 0 / 100 pts When participating in the planning of care of a postpartum client who plans to breastfeed her infant, the nurse realizes the importance of including which of the following in the teaching plan to prevent the development of mastitis? Express and discard milk from the affected breast at the first signs of mastitis. Correct Answer Massage distended areas as the infant nurses. Offer only one breast at each feeding. You Answered Cleanse nipples with a mild antibacterial soap before and after infant feedings. Rationale: Massaging the distended areas as the infant nurses will encourage complete emptying of the breast and prevent milk stasis. Soap should not be used on the nipples because of the risk of drying or cracking. Each breast should be offered at each feeding to prevent milk stasis and to ensure adequate milk supply. If early signs of mastitis occur, the client usually will be instructed to nurse the infant more frequently, because infant sucking is thought to empty the breast more completely. Test-Taking Strategy: Note the strategic words “breast-feed” and “importance.” Also think about the pathophysiology associated with mastitis and use knowledge regarding the prevention of mastitis to direct you to the correct option. Review the early signs of mastitis if you had difficulty with this question. Question 95 100 / 100 pts The nurse is checking the reflexes of a neonate. In eliciting the Moro reflex, the nurse would do which of the following? Stimulate the perioral cavity with a finger. Stimulate the ball of the infant’s foot with firm pressure. Correct! Clap hands, or slap the mattress. Stimulate the pads of the infant’s hands with firm pressure. Rationale: The Moro reflex is elicited by a loud noise, such as a hand clap or a slap on the mattress. The neonate should respond (in sequence) with extension and abduction of the limbs, followed by flexion and abduction of the limbs and then by flexion and adduction of the limbs. This reflex disappears at 6 months of age. The rooting reflex is elicited by stimulating the perioral area with the finger. The palmar grasp reflex is elicited by stimulating the palm of the hand with firm pressure, and the plantar grasp reflex is elicited by stimulating the ball of the foot with firm pressure. Test-Taking Strategy: Use the process of elimination to assist in answering the question. The options “stimulate the ball of the infant’s foot with firm pressure” and “stimulate the pads of the infant’s hands with firm pressure” are comparable or alike and should be eliminated first. Focusing on the subject of the question, Moro reflex, and thinking about the procedure for testing this reflex will assist in directing you to the correct option. Review assessment of neonatal reflexes if you had difficulty with this question. Question 96 100 / 100 pts The nurse is preparing to assist in administering neonatal resuscitation with a ventilation bag and mask because the newborn is apneic, is gasping, and has a heart rate below 100 beats/min. The nurse understands that the number of ventilations per minute that will be delivered to this neonate is _____ breaths/min. 70 to 80 80 to 100 20 to 40 Correct! 40 to 60 Rationale: If the infant is apneic or has gasping respirations after stimulation, or the heart rate is below 100 beats/min, positive pressure ventilation by bag and mask can be given. The anesthesia bag used for neonatal resuscitation should have a pressure gauge. Ventilations should be given at a rate of 40 to 60 breaths/min at pressures of 15 to 20 cm H2O. Test-Taking Strategy: Focus on the subject, administering neonatal resuscitation. Remember that the normal respiratory ventilation breaths delivered to a neonate who is apneic or gasping is 40 to 60 breaths/min. Also remembering that the normal respiratory rate varies from 30 to 60 breaths/min when the infant is not crying will assist in answering correctly. If you had difficulty with this question, review the technique for resuscitating a newborn. Question 97 100 / 100 pts The nurse has provided instructions to a client on how to bathe her newborn. The nurse demonstrates the procedure to the client and on the following day asks the client to perform the procedure. Which of the following observations, if made by the nurse, indicates that the client is performing the procedure correctly? The client cleans the newborn’s ears and then moves to the eyes and the face. The client washes the arms, chest, and back, followed by the neck, arms, and face. The client washes the entire newborn’s body and then washes the eyes, face, and scalp. Correct! The client begins to wash the newborn by starting with the eyes and face. Rationale: Bathing should start at the eyes and face and with the cleanest area first. Next, the external ears and behind the ears are cleaned. The newborn’s neck should be washed because formula, lint, or breast milk will often accumulate in the folds. Hands and arms are next, then the legs, with the diaper area washed last. Test-Taking Strategy: Remember the basic techniques of bathing a client to assist in answering this question. Always start with the cleanest area of the body first and proceed to the dirtiest area. Use techniques related to washing an adult to assist in answering this question. If you had difficulty with this question, review home care measures related to the care of the newborn. Question 98 100 / 100 pts The nurse is checking a newborn’s 1-minute Apgar score based on the following assessment. The heart rate is 160 beats/min; he has positive respiratory effort with a vigorous cry; his muscle tone is active and well-flexed; he has a strong gag reflex and cries with stimulus to the soles of his feet; his body is pink, with his hands and feet cyanotic. What is the newborn’s 1-minute Apgar score? 10 7 Correct! 9 8 Rationale: The newborn has a score of 9 because his heart rate, respiratory effort, muscle tone, and reflex irritability all have a score of 2, with color having a score of 1 because of the acrocyanosis. Test-Taking Strategy: Focus on the subject, a 1-minute Apgar score. Recalling the procedure for determining the Apgar score will direct you to the correct option. Review this scoring procedure if you had difficulty with this question. Question 99 100 / 100 pts The nurse has been caring for a client with a diagnosis of depression. The client says to the nurse, “I wish you would just be my friend.” The appropriate response by the nurse is: “You have plenty of friends. You don’t need me to be your friend, too.” “I am your friend.” “I can’t be your friend. I’m the nurse, and you’re the client.” Correct! “Our relationship is a therapeutic and helping one.” Rationale: Nurses may struggle with requests by clients to “be my friend.” When this occurs, the nurse should make it clear that the relationship is a therapeutic and helping one. This does not mean that the nurse is not friendly toward the client at times. It does mean, however, that the nurse follows the stated guidelines regarding a therapeutic relationship. “I am your friend.” “I can’t be your friend. I’m the nurse, and you’re the client.” and “You have plenty of friends. You don’t need me to be your friend, too.” are inappropriate. Test-Taking Strategy: Use the process of elimination to answer the question. Focus on the subject of a therapeutic nurse-client relationship, and use therapeutic communication techniques to assist in answering the question. This should easily direct you to “Our relationship is a therapeutic and helping one.” If you had difficulty with this question, review therapeutic nurse-client relationships. Question 100 100 / 100 pts A mental health nurse who has been meeting with a client with a diagnosis of posttraumatic stress disorder is in the termination phase of the nurse-client relationship. The nurse notes that the client has been quiet and withdrawn and interprets the client’s behavior as: An indication of the need for antidepressants An inability of the client to terminate from the nurse Correct! A normal behavior that can occur during termination An indication of the need for additional therapy sessions Rationale: In the termination phase of a relationship, it is normal for a client to demonstrate a number of regressive behaviors. Typical behaviors include the return of symptoms, anger, withdrawal, and minimizing the relationship. The behavior that the client is experiencing is normal during the termination phase and does not necessarily indicate the need for hospitalization, additional sessions, or antidepressants. Test-Taking Strategy: Note the strategic words “termination phase.” This alone may assist in directing you to “a normal behavior that can occur during termination.” Additionally, note that “an indication of the need for antidepressants,” “an inability of the client to terminate from the nurse,” and “an indication of the need for additional therapy sessions” are comparable or alike. These options address the need for further supervised treatment. If you are unfamiliar with the client behaviors associated with the termination phase, review this content. Question 101 100 / 100 pts The nurse is conducting a group therapy session when a female client, who has shared with the group at a previous session that she isolates herself when she feels depressed, suddenly gets up to leave. The appropriate nursing action is which of the following? Tell the client that it is not safe to leave. Correct! Encourage the client to stay, and ask the client what she is feeling. Tell the client that if she leaves she cannot return to this therapy group. Lock the door so that the client cannot leave at this potentially vulnerable time. Rationale: If a client attempts to leave a group session, ask the client what the client is feeling and try to connect the behavior with a feeling. The client should be encouraged to stay. The door should not be locked. If the client still leaves, follow up with the client after the group session and find out more about the client’s thoughts and feelings. “Lock the door so that the client cannot leave at this potentially vulnerable time” is inappropriate and is a violation of the client’s rights. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques to assist in directing you to “encourage the client to stay, and ask the client what she is feeling.” Remember, it is best to focus on the client’s feelings. If you had difficulty with this question, review therapeutic communication techniques. Question 102 100 / 100 pts A nursing student is conducting a clinical conference and is describing the characteristics associated with milieu therapy. Which of the following statements, if made by the student, indicates an understanding of the focus of this form of therapy? Correct! “A living, learning, or working environment is the focus of milieu therapy.” “A behavioral approach to changing behavior is the focus of milieu therapy.” “Milieu therapy provides a cognitive approach to changing behavior.” “Milieu therapy provides a behavior modification approach type of therapy.” Rationale: Milieu therapy, or “therapeutic community,” has as its focus a living, learning, or working environment. Such therapy may be based on any number of therapeutic modalities, from structured behavioral therapy to spontaneous, humanistically oriented approaches. Although milieu therapy may include behavioral approaches, its primary focus is described in the correct option. Test-Taking Strategy: Knowledge about the components of milieu therapy is required to answer this question. Note that “Milieu therapy provides a cognitive approach to changing behavior.” “Milieu therapy provides a behavior modification approach type of therapy.” and “A behavioral approach to changing behavior is the focus of milieu therapy.” are comparable or alike and that “A living, learning, or working environment is the focus of milieu therapy.” identifies an umbrella description. Review this form of therapy if you had difficulty with this question. Question 103 100 / 100 pts \The nurse is developing a plan of care for a client admitted to the psychiatric unit at high risk for suicide. The focus of the plan is to promote a safe and therapeutic environment. Which of the following interventions would the nurse include in the plan of care? Maintain a distance of 10 inches at all times. Place the client in a private room. Assign a leadership task to the client. Correct! Establish a therapeutic relationship. Rationale: A therapeutic relationship will increase feelings of acceptance in the suicidal client. Placing the client in a private room would intensify the client’s feeling of worthlessness. Placing the client in a leadership role can overwhelm the client, lead to failure, and reinforce the feelings of worthlessness. Distances of 18 inches or less constitute intimate space, and invasion of this space may increase the client’s tension and feelings of helplessness. Test-Taking Strategy: Use the process of elimination to answer the question. Focus on the strategic words “safe and therapeutic.” Eliminate “place the client in a private room” because isolation is not a safe intervention. Eliminate “assign a leadership task to the client” because a leadership role can lead to feelings of worthlessness. A distance of 10 inches is restrictive. Additionally, noting the strategic word “therapeutic” in “establish a therapeutic relationship” will assist in directing you to the correct option. If you had difficulty with this question, review the interventions for a suicidal client. Question 104 100 / 100 pts A mental health nurse is assigned to care for a client with a diagnosis of undifferentiated schizophrenia. The nurse uses which of the following approaches when planning care for this client? Correct! Provide assistance with grooming and nutrition until the client's thinking has cleared. Repeatedly point out inconsistencies in the client's communication during initial treatment. Allow the client to set the goals for the plan of care. Let the client act out initially, and use the quiet room and restraints as needed. Rationale: In the acute phase, the nurse must assume responsibility for planning for the client's basic human needs, such as nutrition, hygiene, sleep, and activities of daily living (ADLs). As the nurse plans care for the schizophrenic client, it is important to understand the client's developmental stage and ability to accept the disease. The client lacks insight and may not be aware of the illness because of the severe decompensation in thinking. “Allow the client to set the goals for the plan of care” and “let the client act out initially, and use the quiet room and restraints as needed” are incorrect because these actions do not provide a structured routine. “Repeatedly point out inconsistencies in the client's communication during initial treatment” is a nontherapeutic communication technique. Test-Taking Strategy: Knowing that clients with schizophrenia require a structured routine, eliminate “allow the client to set the goals for the plan of care” first. Eliminate “repeatedly point out inconsistencies in the client's communication during initial treatment” next because this is not consistent with therapeutic communication techniques. Choose between the remaining two options knowing that the client requires structure and assistance during this phase of illness. Review care of the client with schizophrenia if you had difficulty with this question. Question 105 100 / 100 pts The client tentatively diagnosed with a borderline personality is admitted to the psychiatric unit for control of symptoms. Based on a thorough understanding of personality disorders, the nurse would select which nursing diagnosis as the priority? Correct! Risk for self-mutilation Ineffective coping Social isolation Chronic low self-esteem Rationale: Clients with borderline personality disorder are most often hospitalized because of impulsive attempts at self-mutilation or suicide. The nursing intervention of constant close observation is usually initiated to protect the client from impulsive behavior. Therefore, “risk for self-mutilation” is the priority. Test-Taking Strategy: The strategic word in the question is “priority.” Safety takes priority, especially in the situation when, based on the client’s diagnosis, the client is at risk of harming himself or herself. Maslow’s Hierarchy of Needs theory can be used to help you focus on “risk for self-mutilation,” the nursing diagnosis that focuses on safety. Review care to the client with a personality disorder if you had difficulty with this question. Question 106 100 / 100 pts A client admitted to the inpatient unit is being considered for electroconvulsive therapy (ECT). The client is calm, but the client’s daughter is hypervigilant and anxious. The daughter says to the nurse, “My mother’s brain will be shocked with electricity. How can the doctor even think about doing this to her?” Which of the following responses by the nurse would be therapeutic? “I think you need to speak directly to the psychiatrist.” “Your mother has decided to have this treatment. You should support her.” “Maybe you’ll feel better if you see the ECT room and speak to the staff.” Correct! “It sounds as though you are very concerned about the procedure. Let’s discuss the procedure.” Rationale: The most effective responses to a client or family member who is visibly anxious and upset are those that use therapeutic communication techniques. Therapeutic communication includes active collaboration that facilitates problem solving, change, learning, and growth. The correct option addresses the daughter’s concerns while upholding the dignity of the client. When these concerns are verbalized, the nurse can then give information that may help allay fears. “I think you need to speak directly to the psychiatrist.” “Maybe you’ll feel better if you see the ECT room and speak to the staff.” and “Your mother has decided to have this treatment. You should support her.” are nontherapeutic responses. Test-Taking Strategy: The subject of the question is knowledge of therapeutic techniques. In “I think you need to speak directly to the psychiatrist.” and “Maybe you’ll feel better if you see the ECT room and speak to the staff.” the nurse avoids dealing with the client’s and family’s concerns, and these are therefore incorrect. “Your mother has decided to have this treatment. You should support her.” puts distance between the nurse and the daughter and is punitive in nature. If you had difficulty with this question, review these basic communication techniques. Question 107 100 / 100 pts The nurse is assigned to a client who is psychotic, pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines that the priority of care at this time is which of the following? Providing the other clients on the unit with a sense of comfort and safety by isolating the client Offering the client a less stimulated area in which to calm down and gain control Correct! Providing safety for the client and other clients on the unit Assisting in caring for the client in a controlled environment, such as a quiet room Rationale: Safety for the client and other clients is the priority. “Providing safety for the client and other clients on the unit” is the only option that addresses the client’s and other clients’ safety needs. “Offering the client a less stimulated area in which to calm down and gain control” and “assisting in caring for the client in a controlled environment, such as a quiet room” address only the client’s needs. “Providing the other clients on the unit with a sense of comfort and safety by isolating the client” addresses only the needs of the other clients on the unit. Test-Taking Strategy: Remember that options that are comparable or alike are not likely to be correct. With this in mind, eliminate each of the incorrect options because they isolate the client from others. The correct option is also the umbrella option and encompasses both the client’s safety needs and the safety needs of others on the unit. Review care to the psychotic client if you had difficulty with this question. Question 108 100 / 100 pts A client who has sustained severe injuries in a motorcycle accident was diagnosed with intensive care unit (ICU) psychosis. The nurse would be most likely to conclude that the client’s status is improving if the client: Appears to be delirious but has stopped trying to pull out the nasogastric tube Keeps his eyes fixed on the nurses while they are working in the room but has stable vital signs Correct! Increases the number of hours slept at one time and is increasingly alert Tells his wife, "I feel better, but the doctors want to give me a lethal injection." Rationale: The foreign environment of a hospital’s critical care unit, the loss of a normal sleep-wake cycle, effects of injuries, and succumbing to placement of invasive lines, tubes, and possibly restraints can lead to delirium and feelings of powerlessness. The symptoms of psychosis are more likely to resolve when the client resumes a more normal sleep cycle and is physiologically stable. Improvement from ICU psychosis is evidenced by decreased hallucinations, anxiety, and aggressive behavior, along with increased sleep and absence of injuries. Test-Taking Strategy: The subject of the question is knowledge of ICU psychosis. Eliminate “Appears to be delirious but has stopped trying to pull out the nasogastric tube,” “tells his wife, ‘I feel better, but the doctors want to give me a lethal injection,’" and “keeps his eyes fixed on the nurses while they are working in the room but has stable vital signs” because of the strategic words “delirious,” “lethal,” and “fixed on the nurses” in these options. Review care to the client with ICU psychosis if you had difficulty with this question. Question 109 100 / 100 pts A nurse caring for a client recently admitted to the hospital for anorexia nervosa enters the client’s room and finds her in the middle of performing rapid exercises. Which action would be the priority? Allow the client to complete her exercise program. Ignore the behavior, and return when the client is finished. Tell the client that she is not allowed to exercise rigorously. Correct! Interrupt the client, and offer to take her for a walk. Rationale: When working with a client diagnosed with anorexia nervosa, the nurse must limit the amount of rigorous exercise that the client performs while providing for appropriate types and amounts of exercise. Clients with anorexia nervosa are frequently preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake, which causes further deterioration of their physical state. “Allow the client to complete her exercise program,” “ignore the behavior, and return when the client is finished,” and “tell the client that she is not allowed to exercise rigorously” are inappropriate priority actions. Test-Taking Strategy: The strategic word in the question is “priority.” Use knowledge of this disorder to eliminate “allow the client to complete her exercise program.” Eliminate “ignore the behavior, and return when the client is finished” because ignoring behavior is nontherapeutic. Eliminate “tell the client that she is not allowed to exercise rigorously” because of the strategic words “not allowed.” If you had difficulty with this question, review interventions for the client with anorexia nervosa. Question 110 100 / 100 pts The postsurgical client with a history of heavy alcohol intake is at risk for delirium tremens (DTs), which would be manifested by: Hypotension, stupor, agitation, headache, and auditory hallucinations Hypotension, ataxia, muscular rigidity, and tactile hallucinations Coarse hand tremor, agitation, hallucinations, and hypotension Correct! Fever, hypertension, changes in level of consciousness, and hallucinations Rationale: The symptoms associated with DTs typically are anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations, changes in level of consciousness, agitation, fever, and delusions. “Hypotension, ataxia, muscular rigidity, and tactile hallucinations,” “coarse hand tremor, agitation, hallucinations, and hypotension,” and “hypotension, stupor, agitation, headache, and auditory hallucinations” are incorrect. Test-Taking Strategy: To answer this question correctly, you must be familiar with the manifestations of DTs. Recalling that hypertension occurs may assist in directing you to the correct option. Review the symptoms of DTs if you had difficulty with this question. Question 111 100 / 100 pts A hospitalized client with a history of alcohol abuse tells the nurse, “I am leaving now. I don’t want help. I have other things to attend to that are more important.” The nurse attempts to discuss the client’s concerns, but the client dresses and begins to walk out of the hospital room. The nurse should take which of the following actions at this time? Restrain the client, and call the physician. Call security to block the exits to the nursing unit. Tell the client that readmission is not possible after leaving against medical advice (AMA). Correct! Call the nursing supervisor. Rationale: The nurse should call the nursing supervisor. When clients leave against medical advice (AMA), most health care facilities have documents relating to the client’s responsibilities, which the client is asked to sign before leaving. The nurse should request that the client speak to the physician before leaving, but if the client refuses, the nurse cannot hold the client against his or her will. Any client has a right to health care and cannot be told otherwise (“tell the client that readmission is not possible after leaving against medical advice (AMA)”). A nurse can be charged with false imprisonment if a client is made to wrongfully believe that he or she cannot leave the hospital (“restrain the client, and call the physician” and “call security to block the exits to the nursing unit”). Test-Taking Strategy: Options that are comparable or alike are not likely to be correct. With this in mind, eliminate “restrain the client, and call the physician” and “call security to block the exits to the nursing unit” because they are both forms of false imprisonment. Choose correctly between the remaining options, using legal principles as they relate to nursing practice. Review the points related to false imprisonment if you had difficulty with this question. Question 112 100 / 100 pts A client who has attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. Which of the following is the priority nursing action at this time? Suggest placing the client in a seclusion room where all potentially dangerous articles have been removed. Request that a friend of the client remain with the client at all times. Correct! Stay with the client at all times. Have the client put on a hospital gown, and remove the client’s clothing from the room. Rationale: The plan of care for a client with a serious suicide attempt must reflect action that will promote the client’s safety. Constant observation status (one on one by the nurse) and never being less than an arm’s length away are the best intervention. “Have the client put on a hospital gown, and remove the client’s clothing from the room” and “suggest placing the client in a seclusion room where all potentially dangerous articles have been removed” do not provide constant surveillance of the client. “Request that a friend of the client remain with the client at all times” places an unfair burden on the friend of the client, which is inappropriate. Test-Taking Strategy: Begin to answer this question by eliminating “have the client put on a hospital gown, and remove the client’s clothing from the room” and “suggest placing the client in a seclusion room where all potentially dangerous articles have been removed,” because they do not provide safe care to the client. Choose “stay with the client at all times” over “request that a friend of the client remain with the client at all times” because it does not allow the client to be unattended and does not place a burden on the friend. Review nursing interventions for the client at risk for suicide if you had difficulty with this question. Question 113 100 / 100 pts A client who attempted suicide by hanging is brought to the emergency department by emergency medical services. The immediate nursing action is which of the following? Correct! Assess the client’s respiratory status and for the presence of neck injuries. Take the client’s vital signs. Call the mental health crisis team and notify them that a client who attempted suicide is being admitted to the hospital. Perform a focused assessment, paying particular attention to the client’s neurological status. Rationale: The immediate nursing action for a client who attempted suicide is to assess physiological status. Airway is always the priority. Therefore, assessing the client’s respiratory status and for the presence of neck injuries is the immediate action that the nurse takes. Although “take the client’s vital signs,” “call the mental health crisis team and notify them that a client who attempted suicide is being admitted to the hospital,” and “perform a focused assessment, paying particular attention to the client’s neurological status” identify appropriate nursing actions, they are not the priority. Test-Taking Strategy: Note the strategic words “immediate” and “suicide by hanging.” Use the ABCs of airway, breathing, and circulation to direct you to “assess the client’s respiratory status and for the presence of neck injuries.” This option addresses the airway. Review the immediate nursing actions for a client who attempted suicide if you had difficulty with this question. Question 114 100 / 100 pts The nurse is caring for a client who overdosed on acetylsalicylic acid (aspirin) 24 hours ago. The nurse expects to note which of the following findings associated with an anticipated acid-base disturbance? Tachypnea, dizziness, and paresthesias Decreased respiratory rate and depth, cardiac irregularities Disorientation and dyspnea Correct! Drowsiness, headache, and tachypnea Rationale: The client who ingests a large amount of acetylsalicylic acid (aspirin) is at risk for developing metabolic acidosis 24 hours later. If metabolic acidosis occurs, the client is likely to exhibit drowsiness, headache, and tachypnea. In the very early hours following aspirin overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism. However, by 24 hours postoverdose, the compensatory mechanism fails and the client reverts to metabolic acidosis. The client with metabolic alkalosis (“decreased respiratory rate and depth, cardiac irregularities”) is likely to experience cardiac irregularities and a compensatory decreased respiratory rate and depth. “Disorientation and dyspnea” and “tachypnea, dizziness, and paresthesias” indicate respiratory acidosis and alkalosis, respectively. Test-Taking Strategy: Note that the strategic words in the question are “24 hours ago.” Recalling that the client is at risk for metabolic acidosis will direct you to “drowsiness, headache, and tachypnea.” If this question was difficult, review the effects of aspirin overdose and the manifestations of metabolic acidosis. Question 115 100 / 100 pts The nurse overhears the physician stating that the client who is in hypovolemic shock requires plasma expansion. The nurse anticipates that the physician will write a prescription to transfuse which of the following blood products to this client? Packed red blood cells Cryoprecipitate Correct! Albumin Platelets Rationale: Albumin may be used as a plasma expander in hypovolemia with or without shock. Cryoprecipitate is useful in treating bleeding from hemophilia or disseminated intravascular coagulopathy because it is rich in clotting factors. Packed red blood cells replace erythrocytes and are not a plasma expander. Platelets are used when the client’s platelet count is low, typically below 20,000/mm3 . Test-Taking Strategy: Specific knowledge of the benefits and uses of various blood products is needed to answer this question. The strategic words are “requires plasma expansion.” These words will assist in directing you to “albumin.” Review the various blood component therapies if you had difficulty with this question. Question 116 100 / 100 pts The nurse is caring for a group of clients on the clinical nursing unit. Which of the following clients should the nurse plan to monitor for signs of fluid volume deficit? Client with controlled hypertension Client in acute renal failure Client in congestive heart failure Correct! Client with an ileostomy Rationale: The client with an ileostomy is at risk for fluid volume deficit caused by increased gastrointestinal (GI) tract losses. Other causes of fluid volume deficit include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. Clients who have heart failure or renal failure are at risk for fluid volume excess. Hypertension is unrelated to the subject of the question. Test-Taking Strategy: Focus on the strategic words “fluid volume deficit.” Read each option, considering the fluid imbalance that can occur in each. Eliminate “client in acute renal failure” and “client in congestive heart failure” first because these clients would be more likely to retain fluid than to lose it. Choose correctly between the remaining two options, keeping in mind the liquid nature of ileostomy drainage. If you had difficulty with this question, review the causes of fluid volume deficit. Question 117 0 / 100 pts The nurse is administering a dose of a prescribed diuretic to an assigned client. The nurse should monitor the client for hypokalemia as a side effect of therapy if the client has been receiving which of the following medications? Triamterene (Dyrenium) You Answered Spironolactone (Aldactone) Correct Answer Bumetanide (Bumex) Amiloride HCl (Midamor) Rationale: Bumetanide (Bumex) is a loop diuretic that places the client at risk for hypokalemia. The nurse would monitor this client carefully for signs of hypokalemia, monitor serum potassium levels, and encourage intake of high-potassium foods. The other medications listed are potassium-sparing diuretics. Test-Taking Strategy: Recall the classifications of the various diuretics outlined in the options to answer this question. Remember that bumetanide is a loop diuretic. Review the risks of these medications and those medications that are potassium-sparing if you had difficulty with this question. Question 118 100 / 100 pts The nurse is obtaining the intershift report for a group of assigned clients. Which of the following assigned clients should the nurse monitor closely for signs of hyperkalemia? A client with ulcerative colitis A client who has a history of long-term laxative abuse Correct! A client admitted 6 hours ago with a 40% burn injury A client with Cushing’s syndrome Rationale: Hyperkalemia is likely to occur in clients who experience cellular shifting of potassium caused by early massive cell destruction, such as in trauma or burns. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis (with the exception of diabetic acidosis). Clients with Cushing’s syndrome, ulcerative colitis, or those using laxatives excessively are at risk for hypokalemia. Test-Taking Strategy: Remember that options that are comparable or alike are not likely to be correct. With this in mind, eliminate “a client with ulcerative colitis” and “a client who has a history of long-term laxative abuse” first because they reflect gastrointestinal losses. Remember that cell destruction causes potassium shifts, which will direct you to the correct option. Also remember that Cushing’s syndrome presents a risk for hypokalemia and Addison’s disease presents a risk for hyperkalemia. If you had difficulty with this question, review the risk factors associated with hyperkalemia. Question 119 100 / 100 pts The nurse is caring for a client with a nasogastric tube (NGT) who has a prescription for NGT irrigation once every 8 hours. The nurse plans to irrigate the NGT with which of the following solutions to maintain homeostasis? Sterile water Tap water 0.45% sodium chloride Correct! 0.9% sodium chloride Rationale: Homeostasis is maintained by irrigating with an isotonic solution, such as 0.9% sodium chloride. Tap water, sterile water, and sodium chloride are hypotonic solutions. Test-Taking Strategy: Use the process of elimination to answer the question. Knowing that options that are comparable or alike are not likely to be correct, eliminate “tap water” and “sterile water” because they include water. Irrigating with solutions that contain water increases the risk for fluid and electrolyte imbalance. Select between the last two options, knowing that an isotonic irrigating solution helps maintain homeostasis; thus, “0.45% sodium chloride” can be eliminated. Review the tonicity of these solutions if you had difficulty with these questions. Question 120 100 / 100 pts The client with a history of seizure disorder is having a routine serum phenytoin level drawn. The nurse who receives a telephone report of the results notes that the client’s blood level of the medication is within the therapeutic range if the value reported is which of the following? 35 mcg/mL 28 mcg/mL 6 mcg/mL Correct! 15 mcg/mL Rationale: The therapeutic range for serum phenytoin (Dilantin) level is 10 to 20 mcg/mL. If the level is below the therapeutic range, the client could experience seizure activity. If the level is too high, the client is at risk for phenytoin toxicity. Test-Taking Strategy: To answer this question accurately, you must be familiar with the therapeutic reference range for this laboratory test. Remember that the normal range is 10 to 20 mcg/mL. Review the therapeutic phenytoin level if you had difficulty with this question. Question 121 100 / 100 pts The adult client has had serum electrolyte levels drawn. The nurse receiving the results by telephone from the laboratory would be most concerned with which of the following results? Sodium level, 142 mEq/L Correct! Potassium level, 5.4 mEq/L Bicarbonate level, 24 mEq/L Chloride level, 103 mEq/L Rationale: The normal adult ranges of serum electrolyte levels are sodium, 136 to 145 mEq/L; potassium, 3.5 to 5.1 mEq/L; chloride, 98 to 106 mEq/L; and bicarbonate (venous), 22 to 30 mEq/L. The only abnormal value identified above is the serum potassium level, which would be the one of most concern to the nurse because of potential cardiac arrhythmias. Test-Taking Strategy: To answer this question accurately, you must be familiar with normal serum electrolyte levels. Remember that the normal potassium level is 3.5 to 5.1 mEq/L. If this question was difficult, review these laboratory values. Question 122 0 / 100 pts A client with preeclampsia is receiving magnesium sulfate. The nurse assesses the client closely for which sign of magnesium toxicity? Correct Answer Respiratory rate of 10 breaths/min Hyperactive deep tendon reflexes Proteinuria You Answered Serum magnesium level of 5 mEq/L Rationale: Magnesium toxicity is a risk associated with magnesium sulfate therapy. Signs of magnesium toxicity relate to central nervous system (CNS) depression and include respiratory depression, loss of deep tendon reflexes, and sudden drop in fetal heart rate and/or maternal heart rate and blood pressure. Magnesium is excreted through the kidneys. If renal impairment is present, magnesium toxicity can develop very quickly. Therapeutic serum levels of magnesium are 4 to 7 mEq/L. Test-Taking Strategy: To answer this question accurately, you must recall that magnesium sulfate is a CNS depressant. Begin to answer this question by eliminating “proteinuria” and “hyperactive deep tendon reflexes,” which are signs of preeclampsia. Select between the last two options using medication knowledge and recalling that the therapeutic serum levels of magnesium are 4 to 7 mEq/L. Review this medication and the normal magnesium level if this question was difficult. Question 123 100 / 100 pts The nurse is told that the result of a serum carbamazepine (Tegretol) level for a child who is receiving the medication for the control of seizures is 10 mcg/mL. Based on this laboratory result, the nurse anticipates that the physician will prescribe: Correct! Continuation of the presently prescribed dosage Discontinuation of the medication A decrease of the dosage of the medication An increase of the dosage of the medication Rationale: When carbamazepine is administered, blood levels need to be monitored periodically to check for the child’s absorption of the medication. The amount of the medication prescribed is based on the blood level achieved. The therapeutic serum range of carbamazepine is 4 to 12 mcg/mL. The nurse would anticipate that the physician will continue the presently prescribed dosage. Test-Taking Strategy: Knowing the therapeutic serum drug level of carbamazepine will direct you to the correct option. Remember that the therapeutic serum range is 4 to 12 mcg/mL. If you had difficulty with this question, learn the therapeutic serum drug level of carbamazepine. Question 124 0 / 100 pts Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. The nurse is providing instructions to the client and spouse regarding wound treatment. Which of the following should the nurse include in the instructions? Apply twice a day, and leave it open to the air. You Answered Apply twice a day, and cover it with a sterile dressing. Apply once a day, and leave it open to the air. Correct Answer Apply once a day, and cover it with a sterile dressing. Rationale: Collagenase is used in the treatment of dermal lesions and severe burns. Its action is to débride the affected area. It is applied once daily and covered with a sterile dressing. “Apply twice a day, and leave it open to the air,” “apply once a day, and leave it open to the air,” and “apply twice a day, and cover it with a sterile dressing” are incorrect application procedures. Test-Taking Strategy: Knowledge regarding the use of this medication is required to answer this question. Remember that this medication is applied daily and covered with a sterile dressing. Review the procedure for applying collagenase if you had difficulty with this question. Question 125 100 / 100 pts The client with a burn injury is applying mafenide (Sulfamylon) to the wound. The client calls the physician’s office and tells the nurse that the medication is uncomfortable and is causing a burning sensation. The nurse instructs the client to: Correct! Continue with the treatment, as this is expected. Apply a thinner film than prescribed to the burn site. Come to the office to see the physician immediately. Discontinue the medication. Rationale: Mafenide is used to treat partial- and full-thickness burns. It is bacteriostatic for both gram-negative and gram-positive organisms present in avascular tissues. The client should be warned that the medication will cause local discomfort and burning. The nurse does not instruct a client to alter a medication prescription (“discontinue the medication” and “apply a thinner film than prescribed to the burn site”). It is not necessary that the client see the physician immediately at this time. Test-Taking Strategy: Eliminate “discontinue the medication” and “apply a thinner film than prescribed to the burn site” because they represent, in effect, a change in medication prescription, which is outside the realm of legal nursing practice. To choose correctly between the last two options, you must be familiar with this medication and its expected effects. Remember that this medication will cause local discomfort and burning. If you had difficulty with this question, review this medication now. Question 126 100 / 100 pts An adolescent client with severe cystic acne has been prescribed isotretinoin (Accutane). Which statement by the client would suggest the need for further teaching? Correct! “I need to take my vitamin A supplement so that the treatment will work.” “If my lips begin to burn, it is probably because of the medication.” “My eyes may become dry and burn as a result of the medication.” “I will return to the clinic for blood tests.” Rationale: Isotretinoin (Accutane) is used to inhibit inflammation in the client with severe cystic acne. Adverse effects include elevated triglyceride levels, skin dryness, and eye discomfort, such as dryness and burning. Lip inflammation, called cheilitis, can also occur. Vitamin A supplements are stopped during this treatment because of their additive effects. Test-Taking Strategy: Use the process of elimination and note the strategic words “need for further teaching.” These words indicate a negative event query and the need to select the incorrect option. Remember that vitamin A supplements are stopped during treatment. This will also assist in answering questions similar to this one. If you are unfamiliar with this medication and the client teaching points involved, review this content. Question 127 0 / 100 pts The client with cancer has received a course of chemotherapy and received fluorouracil (Adrucil). The nurse should plan to tell the client to report which of the following immediately? Alopecia Headache You Answered Changes in color vision Correct Answer Stomatitis and diarrhea Rationale: Fluorouracil (Adrucil) should be discontinued as soon as reactions (stomatitis, diarrhea) occur. Dosage can also be limited by palmar-plantar erythrodysesthesia syndrome (also called hand-foot syndrome), characterized by tingling, burning, redness, flaking, swelling, and blistering of the palms and soles. Alopecia is common and would not require immediate reporting. Headache and vision changes are not associated with fluorouracil. Test-Taking Strategy: General knowledge of the adverse effects associated with the administration of antineoplastic medications is required to answer this question. Remember that stomatitis and diarrhea is a concern with fluorouracil (Adrucil). Review the adverse effects of this medication if you had difficulty with this question. Question 128 100 / 100 pts The nurse reviewing a medical record notes that high concentrations of methotrexate followed by leucovorin (citrovorum factor, folic acid) are being given to the client with cancer. The nurse correctly interprets that the reason for therapy with leucovorin is to: Hasten the effect of the methotrexate. Promote medication excretion. Promote protein synthesis. Correct! Preserve normal cells. Rationale: The administration of leucovorin with methotrexate is known as leucovorin rescue. High concentrations of methotrexate cause harm and damage to normal cells. Leucovorin bypasses the metabolic block caused by methotrexate, thereby permitting normal cells to synthesize. Leucovorin rescue is potentially hazardous, because failure to administer leucovorin in the right dose at the right time can be fatal. Test-Taking Strategy: To answer this question accurately, it is necessary to understand the action of leucovorin and the reason for administering it with methotrexate. Eliminate “hasten the effect of the methotrexate” first, because increased fluids and diuretics normally are prescribed and administered to hasten the effect of methotrexate. To select from the remaining options, you must be familiar with this medication. If you had difficulty with this question, review leucovorin rescue. Question 129 0 / 100 pts The client who has been diagnosed with cancer is to receive chemotherapy with both cisplatin (Platinol-AQ) and vincristine (Oncovin). The client asks the nurse why both medications must be given together. The nurse's response is based on the understanding that the purpose of using both medications is to: You Answered Decrease the risk of the alopecia and stomatitis. Prevent the destruction of normal cells. Increase the likelihood of erythrocyte and leukocyte recovery. Correct Answer Increase the destruction of tumor cells. Rationale: Cisplatin (Platinol-AQ) is an alkylating-like medication, and vincristine (Oncovin) is a vinca alkaloid. Alkylating medications are cell cycle phase–nonspecific. Vinca alkaloids are cell cycle phase–specific and act on the M phase. Single-agent medication therapy seldom is used. Combinations of medications are used to increase the destruction of tumor cells. Test-Taking Strategy: Knowledge of the rationale for combination medication therapy is required to answer the question. Read each option carefully and remember that combinations of medications are used to increase the destruction of tumor cells. If this question was difficult, review the purpose of combination chemotherapy. Question 130 100 / 100 pts The client with breast cancer has been given a prescription for cyclophosphamide (Cytoxan). The nurse determines that the client understands the proper use of the medication if the client states that he or she will: Take the medication with large meals. Increase dietary intake of potassium. Decrease dietary intake of magnesium. Correct! Increase fluid intake to 2 to 3 L/day. Rationale: A toxic effect of cyclophosphamide (Cytoxan) is hemorrhagic cystitis. The client should drink large amounts of fluid during the administration of this medication. Clients also should observe for hematuria. The medication should be taken on an empty stomach, unless gastrointestinal upset occurs. Hyperkalemia can result from the use of the medication; therefore, the client would not be encouraged to increase potassium intake. The client would not be instructed to alter magnesium intake. Test-Taking Strategy: Knowledge of the toxic effects of cyclophosphamide will assist you to answer this question correctly. If you correlated cyclophosphamide with hemorrhagic cystitis, by the process of elimination, “increase fluid intake to 2 to 3 L/day” would then be selected. If you had difficulty with this question, review the toxic effects associated with this medication. Question 131 100 / 100 pts The client in the preoperative holding area has been given a dose of scopolamine. The nurse assesses the client for which of the following side effects of the medication? Excessive urination Diaphoresis Correct! Dry mouth Pupillary constriction Rationale: Scopolamine is an anticholinergic medication that can be used preoperatively. It causes frequent side effects, such as dry mouth, urinary retention, decreased sweating, and dilation of the pupils. The other options are incorrect. Test-Taking Strategy: To answer this question accurately, you must be familiar with this medication and its uses and/or the fact that it is an anticholinergic medication. Focusing on the strategic word “preoperative” and recalling the purpose of administering medications in the preoperative period will assist in directing you to the correct option. If the medication is unfamiliar to you, review its side effects. Question 132 100 / 100 pts The physician prescribes cromolyn (Intal) for the client with asthma. The nurse identifies that the client correctly understands the purpose of this medication when the client states that the medication will: Correct! Suppress an allergic response. Eliminate the need for a rescue inhaler. Promote bronchodilation. Decrease the risk of infection. Rationale:. Cromolyn is a first-line therapy for prophylactic treatment of asthma; it is a mast-cell stabilizer, antiasthmatic, and antiallergic. It does not decrease the risk of infection. It is not a bronchodilator. The medication acts in part by stabilizing the cytoplasmic membrane of mast cells, thereby preventing release of histamine and other mediators. It does not eliminate the need for the rescue inhaler. Test-Taking Strategy: Specific knowledge about this medication is needed to answer this question. Focus on the name of the medication and remember that cromolyn is a mast-cell stabilizer, antiasthmatic, and antiallergic. Review this medication, its actions, and uses if you had difficulty with this question. Question 133 0 / 100 pts A client with heart disease is taking digoxin (Lanoxin) and complains of having no appetite, diarrhea, and blurry vision. The nurse notes that the client’s serum potassium (K) level is 3.0 ng/mL. Based on analysis of the data, what might the nurse anticipate assessing when reviewing the digoxin level results? Correct Answer Digoxin level higher than 2 ng/mL You Answered Digoxin level lower than 0.5 ng/mL Digoxin level of 1.8 ng/mL Digoxin level of 0 ng/mL because of diarrhea Rationale: When the client is taking digoxin, digoxin toxicity is a concern. The therapeutic digoxin level is 0.5 to 2 ng/mL. Anorexia, diarrhea, and visual disturbances are symptoms of digoxin toxicity. In addition, a low serum potassium level potentiates the risk for digoxin toxicity. This client’s potassium level is low at 3.0 ng/mL. The client’s complaints are indicative of digoxin toxicity. Therefore the only correct option is “digoxin level higher than 2 ng/mL.” Test-Taking Strategy: Focus on the data in the question and use knowledge about digoxin toxicity and the therapeutic digoxin level. This will direct you to “digoxin level higher than 2 ng/mL” because the results in this option exceed the therapeutic range. Also recalling the relationship between digoxin toxicity and a low potassium level will direct you to “digoxin level higher than 2 ng/mL.” If you had difficulty with this question, review digoxin and the indications of digoxin toxicity. Question 134 100 / 100 pts The nurse is providing medication information to a client who is beginning medication therapy with enalapril (Vasotec). The nurse reminds the client that which of the following is an anticipated, although unpleasant, side effect of this medication? Increased blood pressure Metallic taste in the mouth Correct! Persistent dry cough Rapid pulse Rationale: The principal adverse effects of enalapril, an angiotensin-converting enzyme (ACE) inhibitor, are persistent cough, first-dose hypotension, and hyperkalemia. The medication is used to treat hypertension. A rapid pulse and metallic taste in the mouth are not side effects. Test-Taking Strategy: Focus on the name of the medication and recall that most ACE inhibitors medication names end with the letters -pril. Next remember that ACE inhibitors cause a persistent cough. Review the side effects of this medication if you had difficulty with this question. Question 135 100 / 100 pts A client having a myocardial infarction is receiving alteplase (Activase) therapy. Which of the following actions should be carried out by the nurse to monitor for the most frequent adverse effect? Monitor for signs and symptoms of infection. Correct! Monitor for bleeding. Assess for allergic reaction. Evaluate the client for muscle weakness. Rationale: Alteplase is a thrombolytic medication, which means that it breaks down or dissolves clots; therefore, bleeding is a concern. Local or systemic infection could occur with poor aseptic technique during medication administration, but it is rare. Allergic reaction is not a frequent response. Muscle weakness is not an adverse effect of this medication. Test-Taking Strategy: Recalling that this medication is a thrombolytic will direct you to “monitor for bleeding.” Also, remember that medication names that end in the letters -ase are enzymes that break down components of the target system, in this case, breaking down blood clots, thus the adverse effect is bleeding. Review the adverse effects of this medication if you had difficulty with this question. Question 136 100 / 100 pts The nurse has a prescription to give a first dose of hydrochlorothiazide (HydroDIURIL) to an assigned client. The nurse would question the prescription if the client has a history of allergy to which of the following? Penicillin Iodine Shellfish Correct! Sulfa drugs Rationale: Thiazide diuretics, such as hydrochlorothiazide, are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. A sulfa allergy must be communicated to the pharmacist, physician, nurse, and other health care providers. The other options are not contraindications for administering the medication. Test-Taking Strategy: Use the process of elimination to answer the question. Remember that options that are comparable or alike are not likely to be correct. With this in mind, eliminate “iodine” and “shellfish.” To select from the remaining options recall the chemical composition of thiazide diuretics contain a sulfa ring. This will easily direct you to “sulfa drugs.” Review this medication if you had difficulty with this question. Question 137 0 / 100 pts The nurse has a prescription to give a client a scheduled dose of digoxin (Lanoxin). Prior to administering the medication, the nurse assesses for which of the following manifestations that could indicate digoxin toxicity? Dyspnea, edema, and palpitations Correct Answer Double vision, loss of appetite, and nausea Constipation, dry mouth, and sleep disorder You Answered Chest pain, hypotension, and paresthesias Rationale: Double vision, loss of appetite, and nausea are signs of digoxin toxicity. Other signs of digoxin toxicity include bradycardia, visual alterations (such as green and yellow vision, or seeing spots or halos), confusion, vomiting, diarrhea, decreased libido, and impotence. The other options are incorrect because they do not identify manifestations of digoxin toxicity. Test-Taking Strategy: Knowledge about the signs of digoxin toxicity is required to answer the question. Remember that gastrointestinal and visual disturbances are the most common signs with gastrointestinal disturbances occurring early. If you had difficulty with this question, review digoxin toxicity. Question 138 100 / 100 pts The nurse is working with a client receiving an intravenous heparin sodium drip. The nurse should review which of the following laboratory studies to determine the therapeutic effect of heparin for the client? Bleeding time Correct! Partial thromboplastin time (PTT) Thrombin time Prothrombin time (PT) Rationale: The PTT will assess the therapeutic effect of heparin, and the PT is one test that will assess for the therapeutic effect of warfarin (Coumadin). Thrombin time and bleeding time are hematological studies that may be prescribed for clients with coagulopathy or other disorders. Test-Taking Strategy: Focus on the medication and recall that it is an anticoagulant. Eliminate “bleeding time” and “thrombin time” because they are not commonly prescribed during anticoagulant therapy. Choose between the remaining two options, knowing the differences between the value measured for heparin and the one measured for warfarin. If you had difficulty with this question, review care to the client receiving heparin. Question 139 100 / 100 pts The nurse teaching a mother how to administer ear drops to an infant tells the mother to pull the child’s ear: Up and back and direct the solution onto the eardrum Correct! Down and back and direct the solution toward the wall of the canal Up and back and direct the solution toward the wall of the canal Down and back and direct the solution onto the eardrum Rationale: The ear is pulled down and straight back in a child younger than 3 years. The infant is turned onto the side, with the affected ear uppermost. The nurse pulls down and back on the earlobe with the nondominant hand while resting the wrist of the dominant hand on the infant’s head. The medication is directed toward the wall of the canal rather than onto the eardrum. The infant should lie with the affected ear uppermost for 10 to 15 minutes to retain the solution. In an adult or a child older than 3 years, the ear is pulled up and back to straighten the auditory canal. Test-Taking Strategy: Eliminate “up and back and direct the solution onto the eardrum” and “down and back and direct the solution onto the eardrum” because they are potentially harmful. You would not direct ear solution directly onto the eardrum. Remember that in a child younger than 3 years, pulling the ear down and straight back is the correct method for administering ear medications. Review the procedure for administering eye drops to an infant if you had difficulty with this question. Question 140 100 / 100 pts The nurse is describing medication side effects to a client who is taking a benzodiazepine. The nurse tells the client to take the medication only as prescribed because of the most serious risk of: Headache Skin rashes Correct! Dependence Gastrointestinal side effects Rationale: A benzodiazepine carries with it a high risk for abuse and physical and psychological dependence. For this reason, limited amounts of these medications are given to a client at one time. The other symptoms may be side effects of some benzodiazepines but are not as serious as the risk of dependence. Test-Taking Strategy: Read the question carefully. The strategic words in the question are “most serious risk.” Evaluate each of the options according to that parameter and note that the question addresses a benzodiazepine. This will help you eliminate each of the incorrect options. If this question was difficult, review the risks related to the use of benzodiazepines. Question 141 100 / 100 pts The nurse would question the physician if which of the following medications was prescribed for a client with glaucoma? Carteolol hydrochloride (Ocupress) Pilocarpine nitrate Pilocarpine HCl (Pilocar) Correct! Atropine sulfate (Isopto Atropine) Rationale: Pilocarpine and carteolol are examples of miotic agents used in the treatment of glaucoma. Atropine sulfate is a mydriatic and cycloplegic medication that is contraindicated for use in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye. Test-Taking Strategy: Knowledge regarding the classifications of the medications identified in the options will assist you in answering the question. You can easily eliminate “pilocarpine HCl (Pilocar)” and “pilocarpine nitrate” because they are comparable or alike. Next remember that atropine sulfate is contraindicated in glaucoma. If you had difficulty with this question, review these medication classifications and the contraindications for their use. Question 142 100 / 100 pts The client reports frequent use of acetaminophen (Tylenol) for relief of frequent headaches and other discomforts. The nurse should evaluate which of the diagnostic data to determine if the client is at risk for toxicity? Correct! The liver function studies The electrocardiogram The chest x-ray The upper gastrointestinal x-ray results Rationale: In adults, overdose of acetaminophen causes liver damage. In addition, clients with liver disorders are at higher risk of experiencing hepatotoxicity with chronic acetaminophen use. “The chest x-ray,” “the upper gastrointestinal x-ray results,” and “the electrocardiogram” are not associated with acetaminophen overdose. Test-Taking Strategy: Focus on the name of the medication. Recalling that acetaminophen causes liver damage will direct you to “the liver function studies.” Review the adverse effects of acetaminophen if this question was difficult. Question 143 100 / 100 pts The nurse is assisting in the care of a client with myasthenia gravis who is receiving pyridostigmine (Mestinon). Which of the following medications should the nurse plan to have readily available should the client develop cholinergic crisis because of excessive medication dosage? Correct! Atropine sulfate Vitamin K Acetylcysteine (Mucomyst) Protamine sulfate Rationale: If the client is in cholinergic crisis, the antidote for the medication would be a medication that is an anticholinergic. Thus, the antidote for cholinergic crisis is atropine sulfate. Vitamin K is the antidote for warfarin (Coumadin). Protamine sulfate is the antidote for heparin, and acetylcysteine (Mucomyst) is the antidote for acetaminophen (Tylenol). Test-Taking Strategy: To answer this question, you must know that atropine sulfate is an anticholinergic medication. This allows you to reason that this is the medication that would reverse the effects of pyridostigmine. Knowing the clinical manifestations of cholinergic crisis will also help direct you to the medication (“atropine sulfate”) that reverses these manifestations. Familiarity with the other antidotes will also help you to answer this question and eliminate “vitamin K,” “protamine sulfate,” and “acetylcysteine (Mucomyst).” Review antidotes if you had difficulty with this question. Question 144 100 / 100 pts The client with a new medication prescription for allopurinol (Zyloprim) asks the nurse, “I know this is for gout, but how does it work?” In formulating a response, the nurse understands that allopurinol: Prevents influx of calcium ions during cell depolarization Lowers the risk of sulfa crystal formation in the urine Correct! Decreases uric acid production Reduces the production of fibrinogen Rationale: Allopurinol (Zyloprim) is classified as an antigout medication. It decreases uric acid production by inhibiting the xanthine oxidase enzyme and reduces uric acid concentrations in both serum and urine. The other options are incorrect. Test-Taking Strategy: Use the process of elimination to answer the question. Eliminate “reduces the production of fibrinogen” and “prevents influx of calcium ions during cell depolarization” first, because they address hematological and cardiac events. Knowledge about the pathophysiology of gout will help you choose correctly between the remaining two options. If you had difficulty with this question, review the action of allopurinol. Question 145 100 / 100 pts Baclofen (Lioresal) is prescribed for the client with multiple sclerosis. The nurse determines that the medication is having the intended effect if which of the following is noted in the client? Decreased local pain and tenderness Correct! Decreased muscle spasms Increased range of motion Increased muscle tone Rationale: Baclofen is a skeletal muscle relaxant and acts at the spinal cord level to decrease the frequency and degree of muscle spasms in clients with multiple sclerosis, spinal cord injury, or other diseases. The other options are incorrect. Test-Taking Strategy: Knowledge that this medication is a skeletal muscle relaxant will direct you to “decreased muscle spasms.” Also focusing on the client’s diagnosis will assist in answering correctly. Review this medication if you had difficulty with this question. Question 146 100 / 100 pts The nurse is reviewing the medical record of a newly assigned client and notes that the client is receiving cyclobenzaprine hydrochloride (Flexeril) for the treatment of muscle spasms. The nurse questions the prescription if which of the following disorders is noted in the admission history? Recurrent pneumonia Correct! Angle-closure glaucoma Chronic bronchitis Hypothyroidism Rationale: Because cyclobenzaprine has anticholinergic effects, it should be used cautiously in clients with a history of urinary retention, angle-closure glaucoma, and increased intraocular pressure. It is intended for short-term (2- to 3-week) therapy. “Hypothyroidism,” “chronic bronchitis,” and “recurrent pneumonia” are incorrect. Test-Taking Strategy: Remember that options that are comparable or alike are not likely to be correct. With this in mind, eliminate “chronic bronchitis” and “recurrent pneumonia” because they both relate to a respiratory disorder. Knowledge that this medication has anticholinergic effects will easily assist in directing you to “angle-closure glaucoma.” If you are unfamiliar with this medication and the contraindications associated with its administration, review this content. Question 147 100 / 100 pts Blood work has been drawn on a client who has been taking cyclosporine (Sandimmune) following allogenic liver transplantation. The nurse checks the results of which of the following tests to determine the presence of an adverse effect related to this medication? Cholesterol level Hematocrit level Hemoglobin level Correct! Blood urea nitrogen (BUN) level Rationale: Nephrotoxicity is one of the most common adverse effects of cyclosporine. Nephrotoxicity is evaluated by monitoring the BUN and creatinine levels. “Hematocrit level,” “hemoglobin level,” and “cholesterol level” are unrelated to the adverse effects associated with the administration of this medication. Test-Taking Strategy: Eliminate “hematocrit level” and “hemoglobin level” first because they are comparable or alike. For the remaining options, it is necessary to know that nephrotoxicity is an adverse effect and that nephrotoxicity is evaluated by monitoring the BUN level and the creatinine level. Review the adverse effects of this medication if you had difficulty with this question. Question 148 100 / 100 pts The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome (AIDS) who is receiving foscarnet (Foscavir). The nurse reviews the physician’s prescriptions, expecting to note a prescription for which of the following laboratory tests while this client is taking the medication? Lymphocyte count CD4+ cell count Correct! Serum creatinine level Serum albumin level Rationale: Foscavir is very toxic to the kidneys. Serum creatinine is monitored prior to therapy, 2 to 3 times weekly during induction therapy, and at least once weekly during maintenance therapy. It also may cause decreased levels of calcium, magnesium, phosphorus, and potassium in the bloodstream. Thus, these levels also are measured with the same frequency. The laboratory tests in “CD4+ cell count,” “serum albumin level,” and “lymphocyte count” are not specific to the medication. Test-Taking Strategy: It is necessary to know the toxicities and important side effects of this medication to select the correct option. Remember that foscarnet is very toxic to the kidneys. This will assist in answering questions about the medication that are similar to this one. If needed, review this medication. Question 149 100 / 100 pts The nurse is discussing the past week’s activities with a client receiving amitriptyline hydrochloride. The nurse determines that the medication is most effective for this client if the client reports which of the following? Having difficulty concentrating on an activity Sleeping 14 to 16 hours each day A decrease in appetite Correct! Ability to get to work on time each day Rationale: Depressed individuals will sleep for extended periods, have a change in appetite, be unable to go to work, and have difficulty concentrating. They may also experience fatigue, feelings of guilt or worthlessness, loss of interest in activities, and possible suicidal tendencies. After they have had some therapeutic effect from their medication, they will report resolution of many of these complaints and demonstrate an improvement in their appearance. Test-Taking Strategy: Use the process of elimination to answer the question. Note the strategic words “most effective.” The symptoms stated in “a decrease in appetite,” “sleeping 14 to 16 hours each day,” and “having difficulty concentrating on an activity” are all symptoms of depression. The ability to report to work indicates a therapeutic response to the medication, thus indicating compliance with the medication regimen. Review the intended effect of this medication if you had difficulty with this question. Question 150 100 / 100 pts The nurse employed in the mental health clinic is interviewing a female client who has had clomipramine hydrochloride (Anafranil) prescribed. The nurse interprets that the client is noncompliant with taking the medication as prescribed if the client exhibits which of the following behaviors? Correct! Frequently checking her purse for her keys Complaints of hunger and fatigue Slight dizziness when standing up quickly Tired, fatigued appearance Rationale: Clomipramine (Anafranil) is commonly used in the treatment of obsessivecompulsive disorder. Frequent checking for keys is a nonproductive repetitive activity that is characteristic of this disorder. Reappearance of symptoms may indicate noncompliance with medication therapy. The incorrect options are common side effects of the medication. Test-Taking Strategy: Knowledge regarding the purpose of this medication is required to answer the question. Recalling that the medication is used in the treatment of obsessive-compulsive disorder will easily direct you to the correct option. Review the purpose and action of this medication if you had difficulty with this question. Quiz Score: 13,100 out of 15,000 Previous Next Submission Details: [Show More]

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