Review for the NCLEX-RN Examination

Review for the NCLEX-RN® Examination

Correct Answers & Rationales

1. A 10 year-old client is recovering from a splenectomy following a traumatic injury. The clients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to

Correct Answer: plan nursing care around lengthy rest periods

Rationale:

The initial priority for this client is rest due to the inability of red blood cells to carry oxygen.

2. A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement from the assessment data is likely to explain his noncompliance?

Correct Answer: "I have diminished sexual function."

Rationale:

Inderal, a beta-blocking agent used in hypertension, prohibits the release of epinephrine into the cells; this may result in hypotension which results in decreased libido and impotence.

3. The nurse is caring for a client with a distal tibia fracture. The client has had a closed reduction and application of a toe to groin cast. 36 hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 degrees Fahrenheit. The first assessment the nurse should perform is

Correct Answer: pulse oximetry

Rationale:

Restlessness, confusion, irritability and disorientation may be the first signs of fat embolism syndrome followed by a very high temperature. The nurse needs to confirm hypoxia first.

4. The nurse is caring for a client with a colostomy pouch. During a teaching session, the nurse appropriately recommends that the pouch be emptied

Correct Answer: when it is 1/3 to 1/2 full

Rationale:

If the pouch becomes more than half full it may separate from the flange

5. A client is admitted with infective endocarditis (IE). Which finding would alert the nurse to a complication of this condition?

Correct Answer: heart murmur

Rationale:

Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off, causing emboli and leaving ulcerations on the valve leaflets. These emboli produce findings of cardiac murmur, fever, anorexia, malaise and neurologic sequel' of emboli.

Furthermore, the vegetations may travel to various organs such as spleen, kidney, coronary artery, brain and lungs, and obstruct blood flow.

6. Which blood serum finding in a client with diabetic ketoacidosis alerts the nurse that immediate action is required?

Correct Answer: HCT of 60

Rationale:

This high hematocrit is indicative of severe dehydration which requires priority attention in diabetic ketoacidosis. Without sufficient hydration, all systems of the body are at risk for hypoxia from a lack of or sluggish circulation. In the absence of insulin, which facilitates the transport of glucose into the cell, the body breaks down fats and proteins to supply energy ketones, a by-product of fat

metabolism. These accumulate causing metabolic acidosis (pH <>2 levels are near normal.

7. The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk. The physiological basis for this instruction is that the medication

Correct Answer: stimulates hydrochloric acid production

Rationale:

Decadron increases the production of hydrochloric acid, which may cause gastrointestinal ulcers.

8. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic response to the drug?

Correct Answer: Prothrombin time

Rationale:

Coumadin is ordered daily, based on the client's prothrombin time (PT). This test evaluates the adequacy of the extrinsic system and common pathway in the clotting cascade; Coumadin affects the Vitamin K dependent clotting factors.

9. The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from

Correct Answer: my thigh."

Rationale:

Autografts are done with tissue transplanted from the client's own skin.

10. The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse?

Correct Answer: "Keep in mind that for the age this is a normal response to being in the hospital."

Rationale:

The protest phase of separation anxiety is a normal response for a child this age. In toddlers, ages 1 to 3, separation anxiety is at its peak

11. The nurse is developing a meal plan that would provide the maximum possible amount of iron for a child with anemia. Which dinner menu would be best?

Correct Answer: Ground beef patty, lima beans, wheat roll, raisins, milk

Rationale:

Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, and dried fruits such as raisins. This dinner is the best choice: It is high in iron and is appropriate for a toddler.

12. The nurse planning care for a 12 year-old child with sickle cell disease in a vaso-occlusive crisis of the elbow should include which one of the following as a priority?

Correct Answer: Client controlled analgesia

Rationale:

Management of a sickle cell crisis is directed towards supportive and symptomatic treatment. The priority of care is pain relief. In a 12 year-old child, client controlled analgesia promotes maximum comfort.

13. The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. Which of these instructions should the nurse give the client?

Correct Answer: Begin treatment with acyclovir at the onset of symptoms of recurrence

Rationale:

When the client is aware of early symptoms, such as pain, itching or tingling, treatment is very effective. Medications for herpes simplex do not cure the disease; they simply decrease the level of symptoms.

14. The nurse is teaching parents about accidental poisoning in children. Which point should be emphasized?

Correct Answer: Empty the child's mouth in any case of possible poisoning

Rationale:

Emptying the mouth of poison prevents further ingestion and should be done first to limit damage from the substance. Note that all of the actions are correct, but option B is the priority.

15. The nurse is preparing the teaching plan for a group of parents about risks to toddlers and is including the proper communication in the event of accidental poisoning. The nurse should tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate?

Correct Answer: The affected child's age and weight

Rationale:

All of the above information is important. However, after the substance is identified the age and weight are the priorities. This gives the appropriate health care providers an opportunity to calculate the needed dosage for an antidote while the child is being transported to the emergency department. After this information, the time of the accidental poisoning is next in importance.

16. The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the

following lab reports should the nurse review first?

Correct Answer: Liver enzymes (AST and ALT)

Rationale:

Because acetaminophen is toxic to the liver and causes hepatic cellular necrosis, liver enzymes are released into the blood stream and serum levels of those enzymes rise. Other lab values are reviewed as well.

17. The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance?

Correct Answer: Metabolic alkalosis

Rationale:

Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss of acid and lead to metabolic alkalosis. Findings include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse. Options C and D are correct answers but not the best answers since they are too general.

18. A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is

Correct Answer: assess the child and the extent of the injury

Rationale:

When applying the nursing process, assessment is the first step in providing care. The "5 Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis).

19. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the parent indicates that teaching has been inadequate?

Correct Answer: "I think I remember that my child should not stand until after 72 hours."

Rationale:

Synthetic casts will typically set up in 30 minutes and dry in a few hours. Thus, the client may stand within the initial 24 hours. With plaster casts, the set up and drying time, especially in a long leg cast which is thicker than an arm cast, can take up to 72 hours. Both types of casts give off a lot of heat when drying and it is preferable to keep the cast uncovered for the first 24 hours. Clients may complain of a chill from the wet cast and therefore can simply be covered lightly with a sheet or blanket. Applying ice is a safe method of relieving the itching.

20. The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition?

Correct Answer: Whole milk is difficult for a young infant to digest

Rationale:

Cow's milk is not given to infants younger than 1 year because the tough, hard curd is difficult to digest. In addition, it contains little iron and creates a high renal solute load.

21. The nurse is preparing a handout on infant feeding to be distributed to families visiting the

clinic. Which notation should be included in the teaching materials?

Correct Answer: Solid foods are introduced one at a time beginning with cereal

Rationale:

Solid foods should be added one at a time between 4-6 months. If the infant is able to tolerate the food, another may be added in a week. Iron fortified cereal is the recommended first food.

22. The nurse is planning discharge for a 90 year-old client with musculo-skeletal weakness. Which intervention should be included in the plan that would be most effective for the prevention of falls?

Correct Answer: Place nightlights in the bedroom

Rationale:

Because more falls occur in the bedroom than any other location, begin there. However, work in partnership with the client and family so they are willing to move furniture, lamp cords, and storage areas, add lighting, remove throw rugs, and eliminate other environmental hazards.

23. The nurse is teaching a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to

Correct Answer: keep a regular schedule of meals and snacks

Rationale:

Currently, calorie-controlled diets with strict meal plans are rarely suggested for clients who have diabetes. Try to incorporate schedule or food changes into clients' existing dietary patterns. Help clients learn to read labels and identify specific canned foods, frozen entrees, or other foods which

are acceptable and those which should be avoided.

24. A client enters the emergency department unconscious via ambulance. What document

should be given priority to guide the direction of care for this client?

Correct Answer: A notarized original of advance directives brought in by the partner

Rationale:

This document specifies the client's wishes.

25. The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action?

Correct Answer: Continue to monitor the client to see if the bubbling increases

Rationale:

Bubbling associated with coughing after lung surgery is to be expected as small amounts of air escape the pleural space when pressures inside the chest increase with coughing. Monitoring is the only nursing action required at this time.

26. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would the nurse suspect is relevant to this disease?

Correct Answer: "Strep throat went through all the children at the day care last month."

Rationale:

Evidence supports a strong relationship between infection with Group A streptococci and subsequent rheumatic fever (usually within 2 to 6 weeks). Therefore, the history of playmates recovering from strep throat would indicate that the child most likely also had strep throat.

Sometimes such an infection has no clinical symptoms.

27. The nurse is performing a physical assessment on a toddler. Which of the following actions should be the first?

Correct Answer: Use minimal physical contact

Rationale:

The nurse should approach the toddler slowly and use minimal physical contact initially so as to gain the toddler's cooperation. Be flexible in the sequence of the exam, and give only brief simple explanations just prior to the action.

28. An 8 year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu is the best choice?

Correct Answer: Chicken strips, corn on the cob, milk

Rationale:

This menu is lowest in sodium. Ideally, low fat milk would be available.

29. The nurse provides discharge teaching to the parents of a 15 month-old child with

Kawasaki disease. The child has received immunoglobulin therapy. Which instruction would be appropriate?

Correct Answer: The measles, mumps and rubella vaccine should be delayed

Rationale:

Discharge instructions for a child with Kawasaki disease should include the information that immunoglobulin therapy may interfere with the body's ability to form appropriate amounts of antibodies. Therefore, live immunizations should be delayed.

30. The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority?

Correct Answer: Ineffective airway clearance

Rationale:

The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula at or near the bifurcation. Thus, a priority is maintaining an open airway, preventing aspiration. Other nursing diagnoses are then addressed.

31. A two year-old child is brought to the provider's office with a chief complaint of mild diarrhea for two days. Nutritional counseling by the nurse should include which statement?

Correct Answer: Continue with the regular diet and include oral rehydration fluids

Rationale:

Current recommendations for mild to moderate diarrhea are to maintain a normal diet with fluids to rehydrate.

32. The nurse is teaching parents about the appropriate diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include

Correct Answer: formula or breast milk

Rationale:

The usual diet for a young infant should be followed.

33. The nurse notes that a 2 year-old child recovering from a tonsillectomy has an temperature of 98.2 degrees Fahrenheit at 8:00 AM. At 10:00 AM the child's parent reports that the child "feels very warm" to touch. The first action by the nurse should be to

Correct Answer: reassess the child's temperature

Rationale:

A child's temperature may have rapid fluctuations. The nurse should listen to and show respect for what parents say. Parental caretakers are often quite sensitive to variations in their children's condition that may not be immediately evident to others.

34. The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby's record and expect which immunization to be most associated with the findings the infant is displaying?

Correct Answer: DTaP

Rationale:

The majority of reactions occur with the administration of the DTaP vaccination. Contradictions to giving repeat DTaP immunizations include the occurrence of severe side effects after a previous dose as well as signs of encephalopathy within 7 days of the immunization.

35. The nurse is teaching a class on HIV prevention. Which of the following should be

emphasized as increasing risk?

Correct Answer: Unprotected sex

Rationale:

Because HIV is spread through exposure to bodily fluids, unprotected intercourse and shared drug paraphernalia remain the highest risks for infection.

36. A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?

Correct Answer: Diffuse expiratory wheezing

Rationale:

In asthma, the airways are narrowed, creating difficulty getting air in. A wheezing sound results.

37. An 18 year-old client is admitted to intensive care from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebr'. The nurse's priority assessment should be the client’s

Correct Answer: respiratory function

Rationale:

Spinal injury at the C-2 level results in quadriplegia. While the client will experience all of the problems identified, respiratory assessment is a priority.

38. An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 160/100 to 180/110 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the provider?

Correct Answer: Slurred speech

Rationale:

Changes in speech patterns and level of conscious can be indicators of continued intracranial bleeding or extension of the stroke. Further diagnostic testing may be indicated.

39. A young adult seeks treatment in an outpatient mental health center. The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What is the most therapeutic approach by the nurse?

Correct Answer: Listen quietly without comment

Rationale:

The client's comments demonstrate grandiose ideas. The most therapeutic response is to listen but avoid being incorporated into the client’s delusional system.

40. A depressed client in an assisted living facility tells the nurse that "life isn't worth living anymore." What is the best response to this statement?

Correct Answer: "Have you thought about hurting yourself?"

Rationale:

It is appropriate and necessary to determine if someone who has voiced thoughts about death is considering a suicidal act. This response is most therapeutic in the circumstances. Options A and D deny the validity of the client’s statement, and the purpose of option C is unclear and it lacks client focus.

41. The nurse is observing a client with an obsessive-compulsive disorder in an inpatient

setting. Which behavior is consistent with this diagnosis?

Correct Answer: Repeatedly checking that the door is locked

Rationale:

Behaviors that are repeated are symptomatic of obsessive-compulsive disorders. These behaviors, performed to reduced feelings of anxiety, often interfere with normal function and employment.

42. A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which statement by the client as the most important?

Correct Answer: "I had a blood transfusion 15 years ago."

Rationale:

The client who was transfused prior to blood screening for hepatitis C may show findings many years later. Options B and C are associated with risk of hepatitis B.

43. A 3 year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack?

Correct Answer: Potato chips

Rationale:

Children with celiac disease should eat a gluten free diet. Gluten is found mainly in grains of wheat and rye and in smaller quantities in barley and oats. Corn, rice, soybeans and potatoes are digestible by persons with celiac disease.

44. The nurse is assessing a 17 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate?

Correct Answer: Decreased potassium

Rationale:

In bulimia, loss of electrolytes can occur in addition to other findings of starvation and dehydration.

45. The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to

Correct Answer: assess for abdominal distention

Rationale:

The child is observed for abdominal distention because cerebrospinal fluid may cause peritonitis or a postoperative ileus as a complication of distal catheter placement.

46. The nurse is assessing an 8 month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be most likely to exhibit?

Correct Answer: Irritability

Rationale:

Signs of increased intracranial pressure (IICP) in infants include bulging fontanel, instability, highpitched cry, and cries when held. Vital sign changes include pulse that is variable, e.g., rapid, slow and bounding, or feeble. Respirations are more often slow, deep, and irregular.

47. A practical nurse (PN) is assigned to care for a newborn with a neural tube defect. Which dressing, if applied by the PN, would need no further intervention by the charge nurse?

Correct Answer: Moist sterile nonadherent dressing

Rationale:

Before surgical closure, the sac is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed frequently to keep them moist.

48. A 15 year-old client has been placed in a Milwaukee brace. Which statement from the adolescent indicates the need for additional teaching?

Correct Answer: "I will only have to wear this for 6 months."

Rationale:

The brace must be worn long-term, during periods of growth, usually for 1 to 2 years. It is used to correct curvature of the spine.

49. The nurse is planning care for a 14 year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan?

Correct Answer: Assess movement and sensation of extremities

Rationale:

Following corrective surgery for scoliosis, neurological status requires special attention and assessment, especially that of the extremities.

50. The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion?

Correct Answer: Limit the infusion time of each of the unit to a maximum of 4 hours

Rationale:

Infuse the specified amount of blood within 4 hours. If the infusion will exceed this time, the blood should be divided into appropriately sized quantities.

51. The nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse would emphasize that pancreatic enzymes should be taken

Correct Answer: with each meal or snack

Rationale:

Pancreatic enzymes should be taken with each meal and every snack to allow for digestion of all foods that are eaten.

52. A 14 month-old child ingested half a bottle of aspirin tablets. Which of the following would the nurse expect to see in the child?

Correct Answer: Epistaxis

Rationale:

A large dose of aspirin inhibits prothrombin formation and lowers platelet levels. With an overdose, clotting time is prolonged.

53. The nurse caring for a 9 year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis is a priority at this time?

Correct Answer: Ineffective breathing patterns related to central nervous system depression

Rationale:

Respiratory depression is a life-threatening risk in this overdose.

54. A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report?

Correct Answer: The client’s urine output was 1500 cc in 5 hours

Rationale:

Although all of these may be correct information to include in report, the essential piece would be the urine output.

55. A client has been admitted to the coronary care unit with a myocardial infarction. Which nursing diagnosis should have priority?

Correct Answer: pain related to ischemia

Rationale:

Pain is related to ischemia of the heart muscle, and relief of pain will decrease myocardial oxygen demands, reduce blood pressure and heart rate and relieve anxiety. Pain also stimulates the sympathetic nervous system and increased preload, further increasing myocardial demands.

56. Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment?

Correct Answer: A decrease in lethargy

Rationale:

Lactulose produces an acid environment in the bowel and traps ammonia in the gut; the laxative effect then aids in removing the ammonia from the body. This decreases the effects of hepatic encephalopathy, including lethargy and confusion.

57. A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority?

Correct Answer: Frequent neurovascular assessments of the affected leg

Rationale:

The most important activity for the nurse is to assess neurovascular status. Compartment syndrome is a serious complication of fractures. Prompt recognition of this neurovascular problem and early intervention may prevent permanent limb damage.

58. The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the provider immediately?

Correct Answer: expiratory wheezes that are suddenly absent in 1 lobe

Rationale:

Acute asthma is characterized by expiratory wheezes caused by obstruction of the airways. Wheezes are a high pitched musical sounds produced by air moving through narrowed airways. Clients often associate wheezes with the feeling of tightness in the chest. However, sudden cessation of wheezing is an ominous or bad sign that indicates an emergency -- the small airways are now collapsed.

59. The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse's best recommendation to improve delivery of the medication?

Correct Answer: Adding a spacer device to the MDI canister

Rationale:

If the client is not using the MDI properly, the medication can get trapped in the upper airway, resulting in dry mouth and throat irritation. Using a spacer will allow more drug to be deposited in the lungs and less in the mouth. It is especially useful in the elderly because it allows more time to inhale and requires less eye-hand coordination.

60. A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first?

Correct Answer: Administer the prn dose of albuterol

Rationale:

Peak flow monitoring during exacerbations of asthma is recommended for clients with moderate-tosevere persistent asthma to determine the severity of the exacerbation and to guide the treatment. A peak flow reading of less than 50% of the client's baseline reading is a medical alert condition and a short-acting beta-agonist must be taken immediately.

61. The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is critical for the nurse to include in the plan of care?

Correct Answer: hourly urine output

Rationale:

Clients who have had an episode of decreased glomerular perfusion are at risk for pre-renal failure. This is caused by any abnormal decline in kidney perfusion that reduces glomerular perfusion. Prerenal failure occurs when the effective arterial blood volume falls. Examples of this phenomena include a drop in circulating blood volume as in a cardiac arrest state or in low cardiac perfusion states such as congestive heart failure associated with a cardiomyopathy. Close observation of hourly urinary output is necessary for early detection of this condition.

62. A client is admitted for treatment of a right upper lobe infiltrate and to rule out tuberculosis. Which of these would be the most appropriate self-protective action by the nurse?

Correct Answer: Wear a particulate respirator mask

Rationale:

Tight fitting, high-efficiency masks are required when caring for clients who have a suspected communicable disease of the airborne variety.

63. A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the woman sits in a chair. The mother states "This is not my baby, and I do not want it." After repositioning the child safely, the nurse's best response is

Correct Answer: "You seem upset; tell me what the pregnancy and birth were like for you."

Rationale:

A non-judgmental, open ended response facilitates dialogue between the client and nurse.

64. The nurse is performing a pre-kindergarten physical on a 5 year-old. The last series of vaccines will be administered. What is the preferred site for injection by the nurse?

Correct Answer: vastus lateralis

Rationale:

Vastus lateralis, a large and well developed muscle, is the preferred site, since it is removed from major nerves and blood vessels.

65. The nurse is caring for a 4 year-old two hours after a tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately?

Correct Answer: Increased restlessness

Rationale:

Restlessness and increased respiratory and heart rates are often early signs of hemorrhage.

66. A parent brings her 3 month-old into the clinic, reporting that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment?

Correct Answer: restlessness and increased mucus production

Rationale:

This infant could be experiencing gastroesophageal reflux, or could be allergic to the formula. Restlessness, irritability and increased mucus production can develop if an allergy is present. Soy based formula is often recommended.

67. The nurse manager hears a provider loudly criticize one of the staff nurses within the hearing range of others. The nurse manager's next action should be to

Correct Answer: Request an immediate private meeting with the provider and staff nurse

Rationale:

Assertive communication respects the needs of all parties to express themselves, but not at the expense of others. The nurse manager needs first to protect clients and other staff from this display and come to the assistance of the nurse employee.

68. Which statement best describes time management strategies applied to the role of a nurse manager?

Correct Answer: Set daily goals with a prioritization of the work

Rationale:

Time management strategies include setting goals and prioritization . This is similar to time management of direct care for clients

69. The nurse manager has been using a block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that this method will

Correct Answer: Improve team morale

Rationale:

Nurses are more satisfied when opportunities exist for autonomy and control. The nurse manager becomes the facilitator of scheduling rather than the decision-maker of the schedule when selfscheduling exists.

70. During the initial home visit, a nurse is discussing the care of a client newly diagnosed with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time?

Correct Answer: suggest communication strategies

Rationale:

Alzheimer's disease, a progressive chronic illness, greatly challenges caregivers. The nurse can be of greatest assistance in helping the family to use communication strategies to enhance their ability to relate to the client. By use of select verbal and nonverbal communication strategies the family

can best support the client’s strengths and cope with any aberrant behavior.

71. The nurse is assessing a client with a Stage 2 skin ulcer. Which of the following treatments is most effective to promote healing?

Correct Answer: Applying a hydrocolloid or foam dressing

Rationale:

While the previously accepted treatment was a transparent cover, evidence now indicates that the foam (DuoDerm) dressings work best.

72. When interviewing the parents of a child with asthma, it is most important to assess the child's environment for what factor?

Correct Answer: Household pets

Rationale:

Animal dander is a very common allergen affecting persons with asthma. Other triggers may include pollens, carpeting and household dust.

73. While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is most important for the nurse to teach them about which of the following actions?

Correct Answer: Maintain good oral hygiene and dental care

Rationale:

Swollen and tender gums occur often with use of phenytoin. Good oral hygiene and regular visits to the dentist should be emphasized.

74. A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse?

Correct Answer: the appearance of eyeballs that appear to "pop" out of the client's eye sockets

Rationale:

Exophthalmos or protruding eyeballs is a distinctive characteristic of Graves' Disease. It can result in corneal abrasions with severe eye pain or damage when the eyelid is unable to blink down over the protruding eyeball. Eye drops or ointment may be needed.

75. A client is recovering from a thyroidectomy. While monitoring the client's initial postoperative condition, which of the following should the nurse report immediately?

Correct Answer: Tetany and paresthesia

Rationale:

Because the parathyroid gland may be damaged in this surgery, secondary hypocalcemia may occur. Findings of hypoparathyroidism include tetany, paresthesia, muscle cramps and seizures.

76. As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis?

Correct Answer: "Clothes are becoming tighter across her abdomen."

Rationale:

One of the most common signs of neuroblastoma is increased abdominal girth. The parents' report that clothing is tight is significant, and should be responded to with additional assessments.

77. Parents call the emergency room to report that a toddler has swallowed drain cleaner. The triage nurse instructs them to call for emergency transport to the hospital. The nurse would also suggest that the parents give the toddler sips of _______ while waiting for an ambulance.

Correct Answer: Water

Rationale:

Small amounts of water will dilute the corrosive substance prior to gastric lavage.

78. The nurse is caring for a 4 year-old admitted after receiving burns to more than 50% of his body. Which laboratory data should be reviewed by the nurse as a priority in the first 24

hours?

Correct Answer: Blood urea nitrogen

Rationale:

Glomerular filtration is decreased in the initial response to severe burns, with fluid shift occurring.

Kidney function must be monitored closely, or renal failure may follow in a few days.

79. The mother of a child with a neural tube defect asks the nurse what she can do to decrease

the chances of having another baby with a neural tube defect. What is the best response by

the nurse?

Correct Answer: "Folic acid should be taken before and after conception."

Rationale:

The American Academy of Pediatrics recommends that all childbearing women increase folic acid

from dietary sources and/or supplements. There is evidence that increased amounts of folic acid

prevents neural tube defects.

80. The parents of a 4 year-old hospitalized child tell the nurse, “We are leaving now and will

be back at 6 PM.” A few hours later the child asks the nurse when the parents will come again.

What is the best response by the nurse?

Correct Answer: "They will be back right after supper."

Rationale:

Time is not completely understood by a 4 year-old. Preschoolers interpret time with their own

frame of reference. Thus, it is best to explain time in relationship to a known, common event.

81. During the check up of a 2 month-old infant at a well baby clinic, the mother expresses

concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not

gone away. What is an appropriate response by the nurse?

Correct Answer: "Telangiectatic nevi are normal and will disappear as the baby grows."

Rationale:

Telangiectatic nevi, salmon patch or stork bite birthmarks, are a normal variation and the facial

nevi will generally disappear by ages 1 to 2 years.

82. A nurse admits a premature infant who has respiratory distress syndrome (RDS). In

planning care, nursing actions are based on the fact that the most likely cause of this problem

stems from the infant's inability to

Correct Answer: maintain alveolar surface tension

Rationale:

RDS is primarily a disease related to a developmental delay in lung maturation. Although many

factors may lead to the development of the problem, the central factor is the lack of a normally

functioning surfactant system in the alveolar sac from immaturity in lung development since the

infant is premature.

83. A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds

that the child has deformities of the joints, limbs, and fingers, thinned upper lip, and small

teeth with faulty enamel. The mother states: ”My child seems to have problems in learning to

count and recognizing basic colors.” Based on this data, the nurse suspects that the child is

most likely showing the effects of which problem?

Correct Answer: fetal alcohol syndrome (FAS)

Rationale:

Major features of FAS consist of facial and associated physical features, such as small head circumference and brain size (microcephaly), small eyelid openings, a sunken nasal bridge, an exceptionally thin upper lip, a short, upturned nose and a smooth skin surface between the nose and upper lip. Vision difficulties include nearsightedness (myopia). Other findings are mental retardation, delayed development, abnormal behavior such as short attention span, hyperactivity, poor impulse control, extreme nervousness and anxiety. Many behavioral problems, cognitive impairment and psychosocial deficits are also associated with this syndrome.

84. A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his

bottom and wetting the bed at night." Based on these complaints, the nurse would initially

assess for which problem?

Correct Answer: pinworms

Rationale:

Signs of pinworm infection include intense perianal itching, poor sleep patterns, general irritability, restlessness, bed-wetting, distractibility and short attention span. Scabies is an itchy skin condition caused by a tiny, eight-legged burrowing mite called Sarcoptes scabiei . The presence of the mite

leads to intense itching in the area of its burrows.

85. A nurse is providing a parenting class to individuals living in a community of older homes.

In discussing formula preparation, which of the following is most important to prevent lead

poisoning?

Correct Answer: Let tap water run for 2 minutes before adding to concentrate

Rationale:

Use of lead-contaminated water to prepare formula is a major source of poisoning in infants. Drinking water may be contaminated by lead from old lead pipes or lead solder used in sealing water pipes. Letting tap water run for several minutes will diminish the lead contamination.

86. Which of the following manifestations observed by the school nurse confirms the presence

of pediculosis capitis in students?

Correct Answer: Whitish oval specks sticking to the hair

Rationale:

Diagnosis of pediculosis capitis is made by observation of the white eggs (nits) firmly attached to the hair shafts. Treatment can include application of a medicated shampoo with lindane for children over 2 years of age, and meticulous combing and removal of all nits.

87. A client is scheduled for an intravenous pyelogram (IVP). Which of the following data from

the client’s history indicate a potential hazard for this test?

Correct Answer: Allergy to shellfish

Rationale:

It is important to know if the client has an allergy to iodine or shellfish. If the client does, they may have an allergic reaction to the IVP contrast dye injected during the procedure.

88. A client has returned to the unit following a renal biopsy. Which of the following nursing

interventions is appropriate?

Correct Answer: Monitor vital signs

Rationale:

The potential complication of this procedure is internal hemorrhage. Monitoring vital signs is critical to detect early indications of bleeding.

89. Which statement made by a client indicates to the nurse that the client may have a thought

disorder?

Correct Answer: "I can't find my 'mesmer' shoes. Have you seen them?"

Rationale:

A neologism is a new word self invented by a person and not readily understood by another. Using

neologisms is often associated with a thought disorder.

90. In a psychiatric setting, the nurse limits touch or contact used with clients to handshaking

because

Correct Answer: some clients misconstrue hugs as an invitation to sexual advances

Rationale:

Touch denotes positive feelings for another person. The client may interpret hugging and holding

hands as sexual advances.

91. An important goal in the development of a therapeutic inpatient milieu is to

Correct Answer: provide a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions

Rationale:

A therapeutic milieu is purposeful and planned to provide safety and a testing ground for new

patterns of behavior.

92. Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant

withholding the dose?

Correct Answer: Rash, blood dyscrasias, severe depression

Rationale:

Rash and blood dyscrasias are side effects of anti-psychotic drugs. A history of severe depression is a contraindication to the use of neuroleptics.

93. What finding signifies that children have attained the stage of concrete operations (Piaget)?

Correct Answer: Makes the moral judgment that "stealing is wrong"

Rationale:

The stage of concrete operations is depicted by logical thinking and moral judgments.

94. Which intervention best demonstrates the nurse's sensitivity to a 16 year-old’s appropriate

need for autonomy?

Correct Answer: Provides opportunity to discuss concerns without presence of parents

Rationale:

This intervention provides the teen with the opportunity to have control and encourages decision making.

95. The nurse's primary intervention for a client who is experiencing a panic attack is to

Correct Answer: maintain safety for the client

Rationale:

Clients who display signs of severe anxiety need to be supervised closely until the anxiety is decreased because they may harm themselves or others.

96. When teaching suicide prevention to the parents of a 15 year-old who recently attempted suicide, the nurse describes the following behavioral cue as indicating a need for intervention.

Correct Answer: Giving away valued personal items

Rationale:

Eighty percent of all potential suicide victims give some type of indication that self-destructiveness should be addressed. These clues might lead one to suspect that a client is having suicidal thoughts or is developing a plan.

97. Which of the following times is a depressed client at highest risk for attempting suicide?

Correct Answer: 7 to 14 days after initiation of antidepressant medication and psychotherapy

Rationale:

As the depression lessens, the depressed client acquires energy to follow the plan.

98. A client is admitted to a psychiatric unit with delusions. What findings could the nurse observe that would be consistent with delusional thought patterns?

Correct Answer: Suspiciousness and resistance to therapy

Rationale:

Clinical features of paranoid delusional disorder include extreme suspiciousness, jealousy, distrust,

and a belief that others intend to invoke harm.

99. A client with anorexia is hospitalized on a medical unit due to electrolyte imbalance and cardiac dysrhythmias. Additional assessment findings that the nurse would expect to observe are

Correct Answer: brittle hair, lanugo, amenorrhea

Rationale:

Physical findings associated with anorexia also include reduced metabolic rate and lower vital signs.

100. A client was admitted to the eating disorder unit with bulimia nervosa. The nurse

assessing for a history of complications of this disorder expects

Correct Answer: Dental erosion, parotid gland enlargement

Rationale:

Dental erosion and parotid gland enlargement due to purging are common complications of binge eating followed by self-induced vomiting.

101. A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I have to have my breast removed, my partner will never come near me." The nurse's best response would be which of these statements?

Correct Answer: "Are you worried that the surgery will lead to changes?"

Rationale:

This is a general lead in type of response that encourages further discussion without focusing on an area that the nurse, but possibly not the client, feels is a problem.

102. A client with paranoid delusions stares at the nurse over a period of several days. The

client suddenly walks up to the nurse and shouts "You think you’re so perfect and pure and good." An appropriate response for the nurse is

Correct Answer: "You seem angry right now."

Rationale:

The nurse recognizes the underlying emotion with a matter of fact attitude, but avoids telling the

clients how they feel.

103. A client who is a former actress enters the day room wearing a sheer nightgown, high heels, numerous bracelets, bright red lipstick and heavily rouged cheeks. Which nursing action is the best in response to the client’s attire?

Correct Answer: Directly assist client to her room for appropriate apparel

Rationale:

It assists the client to maintain self-esteem while modifying behavior.

104. A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment finding as what?

Correct Answer: Tardive dyskinesia

Rationale:

Signs of tardive dyskinesia include smacking lips, grinding of teeth and "fly catching" tongue movements. These findings are often described as Parkinsonian.

105. A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse’s action

Correct Answer: may result in charges of unlawful seclusion and restraint

Rationale:

Seclusion should only be used when there is an immediate threat of violence or threatening behavior toward the staff, the other clients, or the client himself.

106. A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states “I demand to be released now!” The appropriate from the nurse is

Correct Answer: "Let’s discuss your decision to leave and then we can prepare you for discharge."

Rationale:

Clients voluntarily admitted to the hospital have a right to demand and obtain release. Discussing

the decision initially allows an opportunity for other interventions.

107. A client recovering from alcoholism asks the nurse, "What can I do when I start recognizing relapse triggers within myself?" How might the nurse best respond?

Correct Answer: "Let’s talk about possible options you have when you recognize relapse triggers

in yourself."

Rationale:

This option encourages the process of self evaluation and problem solving, while avoiding telling the client what to do. Encouraging the client to brainstorm about response options validates the nurse’s belief in the client’s personal competency and reinforces a coping strategy that will be needed when the nurse may not be available to offer solutions.

108. While interviewing a new admission, the nurse notices that the client is shifting positions, wringing her hands, and avoiding eye contact. It is important for the nurse to

Correct Answer: ask the client what she is feeling

Rationale:

The initial step in anxiety intervention is observing, identifying, and assessing anxiety. The nurse should seek client validation of the accuracy of nursing assessments and avoid drawing conclusions based on limited data. In the situation above, the client may simply need to use the restroom but be reluctant to communicate her need!

109. The charge nurse has a health care team that consists of 1 practical nurse (PN), 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager?

Correct Answer: An admission at the change of shifts with atrial fibrillation and heart failure - PN

Rationale:

The care for a new admissions should be performed by an RN. Since the client was admitted at the change of shifts, the stability of the client would not have been established. The charge nurse should take this client. The PN could monitor the IV fluids in option C. Tasks that do not require independent judgment should be delegated. The nurse may delegate the care for a stable client to a UAP.

110. A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?

Correct Answer: Report hourly outputs of less than 30 ml/hr

Rationale:

When directing a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what must be reported. Because the RN is responsible for all care-related decisions, only implementation tasks should be assigned because they do not require independent judgment.

111. The charge nurse is planning assignments on a medical unit. The client with _______should be assigned to the unlicensed assistive personnel (UAP).

Correct Answer: an order of enemas until clear prior to colonoscopy

Rationale:

The UAP can be assigned routine tasks which have predictable outcomes.

112. The charge nurse on the night shift at an urgent care center has to deal with admitting clients of a higher acuity than usual because of a large fire in the area. Which style of leadership and decision-making would be best in this circumstance?

Correct Answer: Assume a decision-making role

Rationale:

Authoritarian leadership assumes that decision-making is the role of the leader with little input by subordinates. This style is best used in emergency situations or as a triage nurse.

113. Which activity can the RN ask an unlicensed assistive personnel (UAP) to perform?

Correct Answer: Check the blood pressure of a 2 hours post operative client

Rationale:

UAPs must be assigned tasks that require no nursing judgment or decision making situations. Vital signs on stable clients are commonly assigned to unlicensed staff.

114. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action?

Correct Answer: Auscultate the lungs

Rationale:

All of the options would be part of the evaluation for the effects of the large amount of fluid in a short period of time. However the worst result is heart failure with lung congestion so the auscultation of the lungs is the priority action. The sequence of actions would be D, A, C, B.

115. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily?

Correct Answer: Watermelon

Rationale:

Watermelon is high in potassium and will replace potassium lost by the diuretic. The other foods are not high in potassium.

116. A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?

Correct Answer: ”That was done correctly. Did you have any problems with the insertion?”

Rationale:

Left side-lying position is the optimal position for the client receiving rectal medications. Due to the position of the descending colon, left side-lying allows the medication to be inserted and move along the natural curve of the intestine and facilitates retention of the medication. After a short time it will not hurt the client to turn in any manner. The suppository should be somewhat melted after 10 to 15 minutes. The other responses are incorrect since no data are in the stem to support such comments.

117. As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do?

Correct Answer: Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.”

Rationale:

This action is a direct threat to the client if the medication enters into the blood stream instead of the muscle. The purpose of aspiration with IM injections is to prevent the injection of the drug directly into the blood stream. Option 4 protects the client and is the most professional.

118. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:

Correct Answer: ensure an open airway

Rationale:

According to the ABCs of CPR the first step in rescuing an unresponsive victim after checking responsiveness and calling for help is to open the victims airway. The airway must be opened appropriately before the need for rescue breaths can be determined. The pulse is assessed, after breathing is evaluated. The need for abdominal thrusts is determined by inability to achieve chest rise when ventilation is attempted.

119. A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to

Correct Answer: Administer epinephrine 1:1000 as ordered

Rationale:

All the answers are correct given the circumstances, but the priority is to administer the epinephrine, then maintain the airway. In the early stages of anaphylaxis, when the patient has not lost consciousness and is normotensive, administering the epinephrine is first, and applying the oxygen, and watching for hypotension and shock, are later responses. The prevention of a severe crisis is maintained by using diphenhydramine.

120. When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse’s best action is to

Correct Answer: notify the admissions office and wait to apply the bracelet

Rationale:

The Admissions Office has the responsibility to verify the client’s identity and keep all the records in the system consistent. Making the changes puts the client at risk for misidentification. Using an incorrect identification bracelet is unsafe.

121. Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take?

Correct Answer: Give information about advance directives

Rationale:

For each admission, nurses should request a copy of the current advance directive. If there is none, the nurse must offer information about what an advance directive implies. It is then the client’s choice to sign it. In option 1 just recording the information is not sufficient. In option 3 the nurse should not assume that the client has been informed of choices for emergency care. In option 4 this represents an inappropriate delegation approach.

122. A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is appropriate to use when performing postmortem care?

Correct Answer: Contact precautions

Rationale:

The resistant bacteria remain alive for up to 3 days after the client dies. Therefore, contact precautions must still be implemented. The body should also be labeled as MRSA-contaminated so that the funeral home staff can protect themselves as well. Gown and gloves are required.

123. A nurse is stuck in the hand by an exposed used hypodermic needle. What immediate action should the nurse take?

Correct Answer: Immediately wash the hands with vigor

Rationale:

The immediate action of vigorously washing will help remove possible contamination. Then the sequence would be options D, A, B.

124. The nurse is having difficulty reading the health care provider's written order that was left just before the shift change. What action should be taken?

Correct Answer: Call the provider for clarification

Rationale:

Relying on anyone else's interpretation is very risky. When in doubt, check it out with the person who wrote the difficult-to-read order. Order entry systems help to minimize this problem.

125. A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

Correct Answer: Glascow Coma Scale 8, respirations regular

Rationale:

The Glascow Coma Scale provides a standard reference for assessing or monitoring level of consciousness. Any score less than 13 indicates a neurological impairment. Using the term comatose provides too much room for interpretation and is not very precise. Avoid using terms such as “appears” or ventilator required.

126. The nurse is reviewing with a client how to collect a clean catch urine specimen. What is the appropriate sequence to teach the client?

Correct Answer: Clean the meatus, begin voiding, then catch urine stream

Rationale:

A clean catch urine is difficult to obtain and requires clear directions. Instructing the client to carefully clean the meatus, then void naturally with a steady stream prevents surface bacteria from contaminating the urine specimen. As starting and stopping flow can be difficult, once the client begins voiding it's best to just slip the container into the stream. Other responses do not reflect correct technique.

127. Following change-of-shift report on an orthopedic unit, which client should the nurse see first?

Correct Answer: 72 year-old recovering from surgery after a hip replacement 2 hours ago

Rationale:

Look for the client who has the most imminent risks and acute vulnerability. The client who returned from surgery 2 hours ago is at risk for life threatening hemorrhage and should be seen first. The 16 year-old should be seen next because it is still the first post-op day. The 75 year-old is potentially vulnerable to age-related physical and cognitive consequences in skin traction should be seen next. The client who can safely be seen last is the 20 year-old who is 2 weeks post-injury.

128. The nurse is offering safety instructions to a parent with a four month-old infant and a four year-old child. Which statement by the parent indicates understanding of appropriate precautions to take with the children?

Correct Answer: "I have the four year-old hold and help feed the four month-old a bottle in the kitchen while I make supper."

Rationale:

The infant seat is to be placed on the rear seat. Small children and infants are not to be left unsupervised. Infants are placed on their "back when they go back" to sleep or are lying in a crib. A four year-old could assist with the care of an infant with proper supervision. This enhances bonding with the infant and the developmental needs of the preschooler to "help" and not feel left out.

129. A couple experienced the loss of a 7 month-old fetus. In planning for discharge, what should the nurse emphasize?

Correct Answer: To discuss feelings with each other and use support persons

Rationale:

To communicate in a therapeutic manner, the nurse's goal is to help the couple begin the grief process by suggesting they talk to each other, seek family, friends and support groups to listen to their feelings.

130. The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time?

Correct Answer: Daily needs and concerns

Rationale:

At 2 days post-MI, the client’s education should be focused on the immediate needs and concerns for the day.

131. An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze first?

Correct Answer: Potassium levels

Rationale:

The most common cause of digitalis toxicity is a low potassium level. Clients must be taught that it is important to have adequate potassium intake especially if taking diuretics that enhance the loss of potassium while they are taking digitalis.

132. A client with a documented pulmonary embolism has the following arterial blood gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 -

87%, HCO3 - 22. Based on these data, what is the first nursing action?

Correct Answer: Administer oxygen

Rationale:

The client has a low PCO2 due to increased respiratory rate from the hypoxemia and signs of respiratory alkalosis. Immediate intervention is indicated.

133. An 8 year-old client is admitted to the hospital for surgery. The child’s parent reports the allergies listed below. Which of these allergies should all health care personnel be aware of?

Correct Answer: Balloons

Rationale:

Allergy to balloons indicates a latex allergy. All personnel in contact with the child will need to be aware of this condition and use non-latex gloves.

134. A 72 year-old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care, what is the most important action by the nurse?

Correct Answer: Assessing the client's ability to participate in self care and/or the reliability of a caregiver

Rationale:

The cognitive ability of the client as well as the availability and reliability of a caregiver must be assessed to determine if home care is a feasible option.

135. A client is admitted to the rehabilitation unit following a cerebral vascular accident (CVA) and mild dysphagia. The most appropriate intervention for this client is to

Correct Answer: position client in upright position while eating

Rationale:

An upright position facilitates proper chewing and swallowing.

136. The provisions of the law for the Americans with Disabilities Act require nurse managers to

Correct Answer: Provide reasonable accommodations for disabled individuals

Rationale:

The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant’s ability to perform the job and not discriminate on the basis of a disability. Employers also must make "reasonable accommodations."

137. A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to

Correct Answer: Improve venous return

Rationale:

Elevating the leg both improves venous return and reduces swelling. Client comfort will be improved as well.

138. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements?

Correct Answer: "In some instances the result is a retarded bone growth."

Rationale:

An epiphyseal (growth) plate fracture in a 7 year-old often results in retarded bone growth. The leg often will be different in length than the uninjured leg.

139. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these?

Correct Answer: Abdominal mass and weakness

Rationale:

Clinical manifestations of neuroblastoma include an irregular abdominal mass that crosses the midline, weakness, pallor, anorexia, weight loss and irritability.

140. A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse?

Correct Answer: Proceed with the triage process in the same manner as any adult client

Rationale:

Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent living or service in the military. Therefore, this married client has the legal capacity of an adult.

141. The nurse is providing instructions for a client with asthma. Which of the following should the client monitor on a daily basis?

Correct Answer: Peak air flow volumes

Rationale:

The peak airflow volume decreases about 24 hours before clinical manifestations of exacerbation of asthma.

142. The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter. The nurse explains that this should be used to

Correct Answer: measure forced expiratory volume

Rationale:

The peak flow meter is used to measure peak expiratory flow volume. It provides useful information about the presence and/or severity of airway obstruction.

143. The nurse is teaching a client newly diagnosed with asthma how to use the metered-dose inhaler (MDI). The client asks when they will know the canister is empty. The best response is

Correct Answer: Drop the canister in water to observe floating

Rationale:

Dropping the canister into a bowl of water assesses the amount of medications remaining in a metereddose inhaler. The client should obtain a refill when the inhaler rises to the surface and begins to tip over. Some of the newer canisters have counters.

144. The nurse is preparing a client with a deep vein thrombosis (DVT) for a Venous Doppler

evaluation. Which of the following would be necessary for preparing the client for this test?

Correct Answer: No special preparation is necessary

Rationale:

This is a non-invasive procedure and does not require preparation other than client education.

145. The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the post-operative period?

Correct Answer: Estrogen replacement therapy

Rationale:

Estrogen increases the hypercoagulability of the blood and increased the risk for development of thrombophlebitis.

146. A 7 month pregnant woman is admitted with complaints of painless vaginal bleeding over several hours. The nurse should prepare the client for an immediate

Correct Answer: Abdominal ultrasound

Rationale:

The standard for diagnosis of placenta previa, which is suggested in the client's history of painless bleeding, is abdominal ultrasound.

147. Therapeutic nurse-client interaction occurs when the nurse

Correct Answer: assists the client to clarify the meaning of what the client has said

Rationale:

Clarification is a facilitating/therapeutic communication strategy. Interpretation, changing the focus/subject, giving approval, and advising are non therapeutic/barriers to communication.

148. Which nursing intervention will be most effective in helping a withdrawn client to develop relationship skills?

Correct Answer: Offer the client frequent opportunities to interact with 1 person

Rationale:

The withdrawn client is uncomfortable in social interaction. The nurse-client relationship is a corrective relationship in which the client learns both tolerance and skills for relationships.

149. A nurse assigned to a manipulative client for 5 days becomes aware of feelings of reluctance to interact with the client. The next action by the nurse should be to

Correct Answer: Discuss the feeling of reluctance with an objective peer or supervisor

Rationale:

The nurse who experiences stress in the therapeutic relationship can gain objectivity through supervision. The nurse must attempt to discover attitudes and feelings in the self that influence the nurse-client relationship.

150. Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category?

Correct Answer: A toddler with severe deep abrasions over 98% of the body

Rationale:

This child has the least chance of survival. Severe deep abrasions should be thought of as second and third degree burns. The child has great risk of both shock and infection combined.