Part One You will have two hours and 30 minutes to complete Part One.
1. A client in her 36th week of pregnancy is admitted to the hospital with vaginal bleeding. After undergoing an ultrasonic scan, she's diagnosed with placenta previa. Which assessment finding would best confirm this diagnosis?
A.A rigid abdomen.
B.A soft, nontender uterus.
C.Painful vaginal bleeding.
D.Hypotension.
A B C D
B
A soft, relaxed, nontender uterus accompanied by vaginal bleeding indicates placenta previa. A rigid abdomen indicates abruptio placentae, in which a normally implanted placenta in the upper uterine segment prematurely separates from its implantation site. In placenta previa, the placenta isn't normally implanted, and the client shouldn't feel pain when it begins to break away. Hypotension may indicate many conditions other than placenta previa. Also, bleeding with placenta previa may not be severe enough to cause hypotension.
2. The nurse is providing care for an immobilized client. For this client, the most appropriate and most effective nursing intervention would be
A.getting the client out of bed and into a chair for 30 minutes, twice daily.
B.avoiding repositioning the client if he's comfortable.
C.repositioning the client on alternate sides at least every 2 hours.
D.positioning the client with the greatest pressure at the bony prominence.
A B C D
C
Changing the client's position frequently allows for increased circulation and helps to prevent skin breakdown. The immobilized client receives minimal benefit from sitting upright in a chair for 30 minutes, twice daily. The client shouldn't be left in one position for longer than 2 hours. The greatest pressure shouldn't be placed on bony prominences because these areas can break down from increased pressure.
3. A client hospitalized with pneumonia has thick, tenacious secretions. To help liquefy these secretions, the nurse should
A.turn the client every 2 hours.
B.elevate the head of the bed 30 degrees.
C.encourage increased fluid intake.
D.maintain a cool room temperature.
A B C D
C
Increasing the client's intake of oral or IV fluids helps liquefy thick, tenacious secretions and ensures adequate hydration. Turning the client every 2 hours would decrease pooling of secretions but wouldn't liquefy them. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn't liquefy secretions. Maintaining a cool room temperature would increase the client's comfort but wouldn't liquefy secretions.
4. The nurse is interviewing a 19-year-old female at a clinic. It's her first visit, and she says that she has been exposed to herpes by her boyfriend. Initially, with primary genital or type 2 herpes simplex, the nurse would expect the client to have
A.burning or tingling on the vulva, perineum, or vagina.
B.dysuria and urine retention.
C.perineal ulcers and erosions.
D.bilateral inguinal lymphadenopathy.
A B C D
A
Burning and tingling genital discomfort is the most common initial finding. This symptom will advance to vesicular lesions rupturing into ulcerations, which then dry into a crusty erosion. The client may also experience fever, headache, malaise, myalgia, regional lymphadenopathy, and dysuria.
5. The nurse is caring for a neonate with a myelomeningocele. The priority nursing care of a neonate with a myelomeningocele is primarily directed toward
A.ensuring adequate nutrition.
B.preventing infection.
C.promoting neural tube sac drainage.
D.conserving body heat.
A B C D
B
The nurse needs to provide special care to the neural tube sac to prevent infection. Allowing the sac to dry could result in cracks that allow microorganisms to enter. Pressure on the sac could cause it to rupture, creating a portal of entry for microorganisms. Administering antibiotics and keeping the sac free from urine and stool are other measures to prevent infection. Adequate nutrition is a concern for all neonates, including those with a myelomeningocele. Like all neonates, the neonate with a myelomeningocele must be kept warm, but care must be taken to avoid drying out the neural tube sac with a radiant heater or exerting pressure using a sheet or blanket over the sac.
6. The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. What is a major complication of TPN?
A.Hyperglycemia.
B.Extreme hunger.
C.Hypotension.
D.Hypoglycemia.
A B C D
A
The solution, used as a base for most TPN, consists of a high dextrose concentration and may raise blood glucose levels significantly, resulting in hyperglycemia. Fluid overload may cause hypertension, not hypotension. Extreme hunger occurs with hypoglycemia.
7. The nurse is assessing a neonate. Health history findings indicate that the mother drank 3 oz (88.7mL) or more of alcohol per day throughout her pregnancy. Which characteristic should the nurse expect to find?
A.Prominent nasal bridge.
B.Thick upper lip.
C.Upturned nose.
D.Large for gestational age.
A B C D
C
Neonates born with fetal alcohol syndrome have upturned noses, flattened nasal bridges, and a thin upper lip. They may also be small for gestational age.
8. The nurse has a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when she says that she wants to breast-feed her neonate?
A.Encourage breas-feeding so that she can get her rest and get healthier.
B.Encourage breast-feeding because it's healthier for the neonate.
C.Encourage breast-feeding to facilitate bonding.
D.Discourage breast-feeding because HIV can be transmitted through breast milk.
A B C D
D
Transmission of HIV can occur through breast milk, so breast-feeding should be discouraged in this case.
9. The nurse walks into the room of a client who has had surgery for testicular cancer. The client says that he'll be undesirable to his wife, and he becomes tearful. He expresses that he's spoiled a happy, satisfying sex life with his wife, and says that he thinks it might be best if he would just die. Based on these signs and symptoms, which nursing diagnosis would be most appropriate for planning purposes?
A.Situational low self-esteem.
B.Unilateral neglect.
C.Social isolation.
D.Risk for loneliness.
A B C D
A
The signs and symptoms stated in this case are typical of a client with situational low self-esteem. The diagnosis of unilateral neglect occurs in neurologic illness or trauma when the client shows a lack of awareness of a body part. This client is at risk for social isolation and loneliness, but there's no indication in the case study that these diagnoses are present.
10. The nurse is caring for a client who is in labor. The physician still isn't present. After the neonate's head is delivered, which nursing intervention would be most appropriate?
A.Checking for the umbilical cord around the neonate's neck.
B.Placing antibiotic ointment in the neonate's eyes.
C.Turning the neonate's head to the side, to drain secretions.
D.Assessing the neonate for respirations.
A B C D
A
After the neonate's head is delivered, the nurse should check for the cord around the neonate's neck. If the cord is around the neck, it should be gently lifted over the neonate's head. Antibiotic ointment, to prevent gonorrheal conjunctivitis, is administered to the neonate after birth, not during delivery of the head. The neonate's head isn't turned during delivery. After delivery, the neonate is held with his head lowered to help with drainage of secretions. If a bulb syringe is available, it can be used to gently suction the neonate's mouth. Assessing the neonate's respiratory status should be done immediately after delivery.
11. The nurse is administering sublingual nitroglycerin to a client with chest pain. The nurse should place the medication
A.in the cheek.
B.on the tip of the tongue.
C.under the tongue.
D.under the lower lid of the eye.
A B C D
C
Sublingual medication should be placed under the tongue. Buccal medication should be placed in the cheek. Eyedrops should be instilled in the lower lid in the conjunctival sac. Oral medications should be placed on the tongue and swallowed.
12. The nurse is preparing to remove a previously applied topical medication from a client. The rationale for removing previously applied topical medications before applying new medications is to
A.decrease the possibility of absorption on the nurse's skin.
B.allow distribution of medication.
C.prevent soiling of the client's clothes.
D.avoid administering more than the prescribed dose.
A B C D
D
The nurse should remove previously applied topical medications before applying new medications to prevent accumulation of medication that exceeds the prescribed dose. Wearing gloves will decrease the possibility of absorption on the nurse's skin. Spreading topical medications evenly will allow for distribution of medication. Placing a dressing, if allowable, over the medication will prevent soiling of client's clothes.
13. A client with acute respiratory failure is intubated and placed on mechanical ventilation. Which intervention is most appropriate when suctioning the client?
A.Insert the suction catheter while applying suction.
B.Apply suction until all the secretions have been removed.
C.Use the same catheter to first suction the mouth, then the endotraeheal tube.
D.Preoxygenate with 100% oxygen before suctioning.
A B C D
D
Preoxygenate the client with 100% oxygen before suctioning to prevent the hypoxia that occurs when the client is disconnected from the oxygen source and oxygen is removed from the airway during suctioning. To avoid hypoxia and trauma to the trachea, suction shouldn't be applied when inserting the catheter. To prevent hypoxia, never suction longer than 15 seconds. A suction catheter that has been used to suction the mouth should be considered contaminated and shouldn't be used to suction the endotracheal tube.
14. A nurse in the nursery is preparing to perform phenylketonuria (PKU) testing. Which neonate is ready for the nurse to test?
A.A 3-day-old neonate who has been fed IV since birth.
B.A 2-day-old neonate who has been breast-fed.
C.A 1-day-old neonate receiving formula.
D.A breast-fed neonate being discharged within 24 hours of birth.
A B C D
B
To test for PKU, a neonate must have had a sufficient intake of phenylalanine through the ingestion of either formula or breast milk for at least 2 days. A neonate who has been receiving IV fluids and hasn't yet received breast milk or formula isn't ready to be tested for PKU. A neonate who is discharged within 24 hours of delivery will need to see the physician for PKU testing after receiving formula or breast milk for 48 hours.
15. The nurse is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication?
A.Bone fracture.
B.Loss of estrogen.
C.Negative calcium balance.
D.Dowager's hump.
A B C D
A
Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increases the fragility of bones. Estrogen deficiencies result from menopause--not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, but a negative calcium balance isn't a complication of osteoporosis. Dowager's hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature.
16. Every morning a client with type 1 diabetes receives 15 units of Humulin 70/30. What does this type of insulin contain?
A.70 units of NPH insulin and 30 units of regular insulin.
B.70 units of regular insulin and 30 units of NPH insulin.
C.70% NPH insulin and 30% regular insulin.
D.70% regular insulin and 30% NPH insulin.
A B C D
C
Humulin 70/30 insulin is a combination of 70% NPH insulin and 30% regular insulin.
17. A high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome?
A.The student discusses conflicts over drug use.
B.The student accepts a referral to a substance abuse counselor.
C.The student agrees to inform his parents of the problem.
D.The student reports increased comfort with making choices.
A B C D
B
All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor.
18. A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but that he can control his use if he chooses. Which coping mechanism is he using?
A.Withdrawal.
B.Logical thinking.
C.Repression.
D.Denial.
A B C D
D
Denial is an unconscious defense mechanism in which emotional conflict and anxiety is avoided by refusing to acknowledge feelings, desires, impulses, or external facts that are consciously intolerable. Withdrawal is a common response to stress, characterized by apathy. Logical thinking is the ability to think rationally and make responsible decisions, which would lead the client to admitting the problem and seeking help. Repression is suppressing past events from the consciousness because of guilty association.
19. The nurse is assessing a client with possible osteoarthritis. The most significant risk factor for osteoarthritis is
A.congenital deformity.
B.age.
C.trauma.
D.obesity.
A B C D
B
Age is the most significant risk factor for developing osteoarthritis. Development of primary osteoarthritis is influenced by genetic, metabolic, mechanical, and chemical factors. Secondary osteoarthritis usually has identifiable precipitating events such as trauma.
20. Drugs to treat acute anxiety are prescribed to a client hospitalized for an acute myocardial infarction. The client is reluctant to take anti-anxiety drugs. The nurse suspects that the client is holding the drugs under his tongue and disposing of them after she has left the room. What should the nurse do first?
A.Report her suspicions to the client's physician.
B.Talk to the client about his attitude toward the medications.
C.Search the client's room for evidence of the medications.
D.Tell the client that his behavior must stop for his own well-being.
A B C D
B
Before reporting these concerns to the physician, the nurse should discuss the perceived problem about the medications with the client. The nurse will then have more information about the client's attitude toward anti-anxiety medications when she informs the physician of her suspicions. Searching the client's room for the medications is a violation of the client's right to privacy. The nurse and the physician can talk to the client about the benefits of taking the medication prescribed; however, the client has the right to refuse the medication.
21. Which of the following statements about external otitis is true?
A.External otitis is eharaeterized by pain when the pinna of the ear is pulled.
B.External otitis is usually accompanied by a high fever in children.
C.External otitis is usually related to an upper respiratory infection.
D.External otitis can be prevented by using cotton-tipped applicators to clean the ear.
A B C D
A
External otitis is an infection of the external ear. Pain can be elicited when the pinna of the ear is pulled. Fever and accompanying upper respiratory infection occur more commonly in conjunction with otitis media (infection of the middle ear). Cotton-tipped applicators can actually cause external otitis so their use should be avoided.
22. A client with heart failure develops pink frothy sputum, coarse crackles, and restlessness. Which of the following actions should the nurse take first?
A.Check the client's blood pressure.
B.Place the client in high Fowler's position.
C.Calculate the client's fluid balance.
D.Notify the physician.
A B C D
B
Proper positioning can help reduce venous return to the heart. High Fowler's position also decreases lung congestion. Checking the client's blood pressure is important but doesn't take top priority. Calculating the client's fluid balance wouldn't be an immediate priority in an emergency. Notifying the physician should be done after the client has been repositioned and assessed.
23. The nurse is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to
A.avoid focusing on his weight.
B.increase his activity level.
C.follow a regular diet.
D.continue leading a high-stress lifestyle.
A B C D
B
The client should be encouraged to increase his activity level. Maintaining an ideal weight; following a low-cholesterol, low-sodium diet; and avoiding stress are all important factors in decreasing the risk of atherosclerosis.
24. A client with type 1 diabetes mellitus is pregnant for the second time. Her previous pregnancy ended in spontaneous abortion at 18 weeks' gestation. She's now at 22 weeks' gestation. The nurse is responsible for teaching the client about exercise during her pregnancy. Which of the following statements indicates that the client has an appropriate understanding of her exercise needs?
A."I know I need to walk with a friend or family member. "
B."I know I need to vary the times of day when I exercise. "
C."I know I need to exercise before meals. "
D."I know I need to drink fluids while I walk. "
A B C D
A
A client with type 1 diabetes mellitus may become hypoglycemic while exercising. Someone must accompany her for her safety. She should exercise at the same time each day. She needs to exercise after meals, when blood sugar is high. Fluids aren't necessary, but the client needs to bring a simple carbohydrate with her to treat hypoglycemia.
25. Which of the following positions is most appropriate for a neonate with congenital hip dislocation?
A.Semi-Fowler's with both legs flexed.
B.Legs adducted with head elevated.
C.Swaddled in a baby carrier.
D.Prone position with hips abducted.
A B C D
D
Abduction places the femoral head into the acetabulum for correct alignment. Placing the client in semi-Fowler's position with both legs flexed or with his legs adducted and his head elevated won't help correct the problem. Swaddling the client in a baby carrier would worsen the dislocation.
26. The nurse is admitting a client with a suspected fluid imbalance. The most sensitive indicator of body fluid balance is
A.daily weight.
B.serum sodium levels.
C.measured intake and output.
D.blood pressure.
A B C D
A
Daily weight shows trends and can assist medical management by indicating if interventions and medications are effective. Laboratory data are objective data that indicate whether electrolyte levels are within normal limits for the client with fluid balance problems. However, if a client is dehydrated, some laboratory data can show false elevations. Intake and output is extremely important, but matching the two is difficult because fluid is also lost through breathing, perspiration, stool, and surgical tubes. Vital signs may or may not be helpful because heart rate and blood pressure can be elevated by either depletion or excess of fluids in some situations.
27. The nurse is caring for a client with a fractured hip. The client is combative and confused, and he's trying to get out of bed. The nurse should
A.leave the client and get help.
B.obtain a physician's order to restrain the client.
C.read the facility's policy on restraints.
D.order soft restraints from the storeroom.
A B C D
B
It's mandatory in most settings to have a physician's order before restraining a client. A client should never be left alone while the nurse summons assistance. All staff members require annual instruction on the use of restraints, and the nurse should be familiar with the facility's policy.
28. The nurse is caring for a client with adult respiratory distress syndrome (ARDS). What is the most likely laboratory finding in the early stages of this disease? A. Increased carboxyhemoglobin. B. Decreased partial pressure of arterial oxygen (PaO2). C. Increased partial pressure of arterial carbon dioxide (PaCO2). D. Decreased bicarbonate ().
A B C D
B
Decreased PaO2 indicates hypoxemia, which is a universal finding in ARDS. The PaO2 level is low early in the disease due to hyperventilation and then elevates later in the disease due to fatigue and worsening clinical status. The level may be low in ARDS and is related to reduced tissue oxygenation. The carboxyhemoglobin level will be increased in a client with an inhalation injury, which commonly progresses into ARDS. This isn't a common cause of ARDS.
29. A 78-year-old client with sensorineural hearing loss is admitted to a rehabilitation center after hip replacement surgery. A risk factor for this client would be
A.altered perceptions.
B.toxic levels of pain medication.
C.impaired cognitive function.
D.impaired sense of time.
A B C D
A
This client may be at risk for altered perceptions related to an unfamiliar environment. Nothing in this case relates to pain or medication for pain. Also, no information is given regarding the client's cognitive function. Impaired sense of time would be included in altered perceptions.
30. The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube. The nurse should
A.apply suction to the NG tube every hour.
B.clamp the NG tube if the client complains of nausea.
C.irrigate the NG tube gently with normal saline solution.
D.reposition the NG tube if pulled out.
A B C D
C
The nurse can gently irrigate the tube but must take care not to reposition it. Repositioning can cause bleeding. Suction should be applied continuously--not every hour. The NG tube shouldn't be clamped postoperatively because secretions and gas will accumulate, stressing the suture line.
Part Two You will have one hour and 50 minutes to complete Part Two.
1. A 28-year-old single female arrives at a mental health clinic complaining of depression. She states that she has been feeling numb and empty most of the time and has little energy to perform her usual activities. She has experienced these difficulties since the death of her best friend 6 months ago. Which of the following is the nurse's best response?
A.Tell the client that the physician will prescribe an antidepressant and she will feel better.
B.Encourage the client to get on with her life and stop feeling sorry for herself.
C.Advise the client that it isn't unusual for grieving and loss to continue for quite some time.
D.Suggest that the client return in 3 months if the feelings persist.
A B C D
C
This provides the client with validation and support for her feelings. The other options neither validate the client's bereavement nor allow her to resolve them.
2. A client in the manic phase of bipolar disorder constantly belittles other clients and demands special favors from the nurses. Which nursing intervention would be most appropriate for this client?
A.Ask other clients and staff members to ignore the client's behavior.
B.Set limits with consequences for belittling or demanding behavior.
C.Offer the client an antianxiety drug when belittling or demanding behavior occurs.
D.Offer the client a variety of stimulating activities to distract him from belittling or making demands of others.
A B C D
B
To protect others from a client who exhibits belittling and demanding behaviors, the nurse may need to set limits with consequences for noncompliance. Asking others to ignore the client is likely to increase those behaviors. Offering the client an antianxiety drug or stimulating activities provides no motivation for the client to change problematic behaviors.
3. The nurse is caring for a client with a fractured left femur. What signs indicate potential fat emboli?
A.Increased partial pressure of arterial oxygen (PaO2), reduced sensation in left leg or foot.
B.Left leg pain, dyspnea.
C.Bradycardia, skin bruises.
D.Cyanosis, decreased PaO2.
A B C D
D
Fat emboli may occur with fractures of the long bones and pelvis and may be fatal. Clinical manifestations include cyanosis, dyspnea, tachycardia, chest pain, tachypnea, apprehension, restlessness, confusion, petechiae, and decreased PaO2. Increased PaO2, reduced sensation in left leg or foot, pain in the affected extremity, skin bruises, and bradycardia aren't associated with fat emboli.
4. The nurse is caring for an 85-year-old client. For which important factor directly influencing this client's mental health should the nurse be most aware?
A.The client's attitude toward life circumstances.
B.The client's age, education level, social status, and economic level.
C.The number of children and grandchildren in the family and the client's relationship with them.
D.Grief issues related to loss, role changes, and physical stamina.
A B C D
A
Elderly clients are in the psychosocial stage of continuation of ego integrity and acceptance. The client's attitude toward life circumstances would, therefore, be the most comprehensive. The other choices are valid and important, but option A encompasses all the other answers.
5. A mother brings her 15-month-old male child to the ambulatory care clinic for well-child care. He's crying and pulling at his left ear, which appears erythematous. Which of the following actions should the nurse take first?
A.Ask the mother to leave the room because her anxiety is increasing the child's distress.
B.Examine the ear with the child supine because this aids visualization of the tympanic membrane.
C.Examine the affected ear last in order to minimize distress early in the examination.
D.Examine the left ear first in order to assess what may be physically wrong with the child.
A B C D
C
The suggested sequence of a well-child exam changes when the child is in pain. In this case, it's preferable to examine the affected area last in order to minimize distress early in the examination and to focus on normal, healthy body parts. Parental presence is almost always conducive to a child's cooperation and sense of security. Examination of the ear in an upright position is preferable, especially in a crying child; it's less frightening for the child and decreases the bulging of the tympanic membrane from crying.
6. The nurse is providing preoperative care to a client scheduled for an appendectomy. Which statement regarding pain control is most appropriate?
A."There's no need to ask for pain medication, you'll receive it on a schedule. "
B."Take your pain medication after walking so that you won't feel dizzy. "
C."Take your pain medication before your pain becomes intense. "
D."Use as little pain medication as possible to avoid addiction. "
A B C D
C
When an analgesic is taken before pain becomes severe, less medication is required to control the pain, thus minimizing the risk of adverse effects. Clients shouldn't be told to wait for the nurse to ask about pain or offer an analgesic. Pain medication should be taken before walking or other activities that are expected to cause pain. The client shouldn't be discouraged from using pain medication because of possible addiction. A client with no history of substance abuse has a very minimal risk of addiction when using pain medication for postoperative pain relief.
7. During afternoon rounds, the nurse finds a male client using a pencil to scratch inside his knee-to-toe cast. The client is complaining of severe itching in the ankle area. Which action should the nurse take?
A.Allow him to continue to scratch inside the cast with a pencil.
B.Give him a sterile metal object to use for scratching instead of the pencil.
C.Encourage him to avoid scratching, and obtain an order for diphenhydramine (Benadryl) if severe itching persists.
D.Obtain an order for a sedative, such as diazepam (Valium), to prevent him from scratching.
A B C D
C
Most clients can be discouraged from scratching if given a mild antihistamine, such as diphenhydramine, to relieve itching. Clients shouldn't scratch inside casts because of the risk of skin breakdown and potential damage to the cast. Sedatives aren't usually indicated for itching.
8. While making rounds in a senior citizens' housing complex, the visiting nurse discovers one of her clients sobbing in her darkened apartment. On questioning the client, an 85- year-old widow, the nurse learns that her pet cat of 15 years had been put to sleep the day before. What's the nurse's best response?
A."It shouldn't be hard to find another cat. You'll feel better once you have another pet. "
B."It was only a cat. Why are you allowing yourself to be so upset? It would be different if it were a person. "
C."I'm so sorry that your pet had to be put to sleep. I know how important your cat was to you. "
D."It's probably best for the cat because it was so old and ill. "
A B C D
C
This offers support and empathy and enhances the grieving process. The other options don't address the client's need for support and grieving.
9. The nurse is caring for a client who is on ritodrine therapy to halt premature labor. What condition indicates an adverse reaction to ritodrine therapy?
A.Hypoglycemia.
B.Crackles.
C.Bradycardia.
D.Hyperkalemia.
A B C D
B
Use of ritodrine can lead to pulmonary edema. Therefore, the nurse should assess for crackles and dyspnea. Blood glucose levels may temporarily rise, not fall, with ritodrine. Ritodrine may cause tachycardia, not bradycardia. Ritodrine may also cause hypokalemia, not hyperkalemia.
10. The nurse is planning care for a 10-year-old child in the acute phase of rheumatic fever. Which activity would be most appropriate for the nurse to schedule in the care plan?
A.Playing ping-pong.
B.Reading books.
C.Climbing on play equipment in the playroom.
D.Unrestricted ambulation.
A B C D
B
During the acute phase of rheumatic fever, the child should be placed on bed rest to reduce the heart's workload and prevent heart failure. An appropriate activity for this child would he reading books. The other activities are too strenuous during the acute phase.
11. A nurse is reviewing prenatal care with a client. Which of the following statements by the client best expresses adequate understanding of nutritional needs during pregnancy?
A."I expect to gain a few pounds each month at first. Then I'll really get big and put on 20 pounds or so. "
B."I guess I will get big and gain 20 to 30 pounds and look pregnant."
C."Because I have to eat for two, I should eat whatever I want whenever I feel hungry. "
D."I will need to eat more so that I will gain about 25 pounds, but I want to make sure I don't fill up with junk food. "
A B C D
D
This statement shows an understanding of nutritional needs during pregnancy. Option A accurately portrays weight gain but doesn't express an understanding of nutritional needs. Option B doesn't show an understanding of either nutritional needs or how and when the weight gain will occur. Option C is a common rationalization that can result in excessive weight gain.
12. A 23-year-old primigravida client has a normal vaginal delivery. The next day, the nurse assesses the client's lochia for color, amount, and the presence of clots. Which of the following best describes lochia on the first postpartum day?
A.Dark red (loehia rubra), large amount, with many clots.
B.Pink (lochia serosa), moderate amount, no clots.
C.White (lochia alba), scant amount, no clots.
D.Dark red (lochia rubra), moderate amount, with a few small clots.
A B C D
D
Lochia rubra is usually seen during the first 1 to 3 days. It should be moderate in amount and may include some small clots. Four to eight perineal pads are used daily on average. Heavy bleeding could be from uterine atony or retained placental fragments and therefore requires further investigation. Lochia serosa follows lochia rubra and lasts to about the 10th postpartum day. Lochia alba is seen from approximately the 11th to the 21st postpartum day.
13. Several children in a kindergarten class have been treated for pinworm. To prevent the spread of pinworm, the school nurse meets with the parents and explains that they should
A.tell the children not to bite their fingernails.
B.not let children share hairbrushes.
C.tell the children to cover their mouths and noses when they cough or sneeze.
D.have their children immunized.
A B C D
A
Pinworms come out of the intestine through the anus at night to lay eggs, causing perianal itching. The child wakes up and may begin scratching. Eggs under the fingernails are carried to the mouth if the child chews on his nails, and the pinworm's life cycle continues. In addition to teaching children not to bite their fingernails, parents should keep the nails short and encourage hand washing before food preparation and eating. Sharing hairbrushes contributes to the spread of head lice, not pinworms. Although covering the mouth and nose are hygienic practices to reduce the spread of infections from respiratory droplets, doing so doesn't affect the spread of pinworms. There are no immunizations to protect against pinworms.
14. Immediately after a 1-year-old client returns from a cardiac catheterization, the nurse notes that the pulse distal to the catheter insertion site is weak. The nurse should take which of the following actions?
A.Remove the pressure bandage from the insertion site.
B.Perform passive exercises on the affected extremity.
C.Notify the physician of the assessment.
D.Record the data on the nursing notes and continue to evaluate.
A B C D
D
The pulse distal to the insertion site may be weak for a few hours but should gradually increase in strength. The pressure dressing shouldn't be removed because of the risk of hemorrhage. Passive exercises on the affected extremity wouldn't be performed after a cardiac catheterization. The physician doesn't need to be notified at this time but should be notified if the weak pulse continues for longer than 2 hours.
15. The nurse is caring for a 10-year-old child with rheumatic fever. While obtaining the child's health history from the mother, the nurse should ask if the child recently had which illness?
A.Strep throat.
B.Influenza.
C.Chickenpox.
D.Mononucleosis.
A B C D
A
Rheumatic fever typically follows an infection with group A beta-hemolytic streptococcus, as in strep throat, impetigo, scarlet fever, or pharyngitis. Influenza, chickenpox, and mononucleosis are caused by viruses and don't lead to rheumatic fever.
16. The nurse is developing a teaching plan for a client diagnosed with osteoarthritis. To minimize injury to the osteoarthritic client, the nurse should instruct the client to
A.install safety devices in his home.
B.wear comfortable shoes.
C.get help when lifting objects.
D.wear protective devices when exercising.
A B C D
A
Most accidents occur in the home and safety devices are the most important element in minimizing injury. Shoes should be supportive and not too worn. The client needs to use proper body mechanics when stooping or picking up objects. Protective devices aren't usually necessary for the client to perform exercises.
17. Conjunctivitis may be caused by bacteria, viruses, allergens, or irritants. What signs and symptoms differentiate bacterial conjunctivitis from other types?
A.Subacute onset, severe pain, and preauricular adenopathy.
B.Recurrent onset, no pain, and clear discharge.
C.Acute onset, moderate pain, and purulent discharge.
D.Acute onset, mild pain, and clear discharge.
A B C D
C
Bacterial conjunctivitis has an acute onset, moderate pain, preauricular adenopathy, and a copious and purulent discharge. Viral conjunctivitis has an acute or subacute onset, mild to moderate pain, preauricular adenopathy, and moderate and seropurulent discharge. Allergic conjunctivitis has a recurrent onset, no pain, no preauricular adenopathy, and moderate and clear discharge. Irritant conjunctivitis has an acute onset, mild pain or no pain, rare preauricular adenopathy, and minimal and clear discharge.
18. A first-time mother-to-be is in the labor room, her husband at her bedside. The client states that her contractions began 6 hours ago. Which of the following assessment findings would confirm that the client is in true labor?
A.Discomfort located chiefly in the abdomen.
B.Constant intensity of contractions.
C.Contractions occurring every 10 to 15 minutes and lasting 20 to 30 seconds.
D.Cervix that is 100% effaced and 2 cm dilated.
A B C D
D
In true labor, the cervix becomes effaced and dilated. In false labor, contractions are located chiefly in the abdomen, the intensity of contractions remains the same, and the interval between contractions remains long.
19. A child, age 3, is brought to the emergency department in respiratory distress caused by acute epiglottiditis. Which clinical manifestations should the nurse expect to assess?
A.Severe sore throat, drooling, leaning forward to breathe.
B.Low-grade fever, stridor, barking cough.
C.Pulmonary congestion, productive cough, fever.
D.Sore throat, fever, general malaise.
A B C D
A
A child with acute epiglottiditis appears acutely ill, and clinical manifestations may include drooling (because of difficulty swallowing), severe sore throat, hoarseness, leaning forward with the neck hyperextended, high fever, and severe inspiratory stridor. A low-grade fever, stridor, and barking cough that worsens at night are suggestive of croup. Pulmonary congestion, productive cough, and fever along with nasal flaring, retractions, chest pain, dyspnea, decreased breath sounds, and crackles are indicative of pneumococcal pneumonia. A sore throat, fever, and general malaise point to viral pharyngitis.
20. A client with antisocial personality disorder refuses to take a shower for 3 days. Which response by the nurse is best?
A."It's policy here for all clients to bathe daily. "
B."It's time for your shower. I'll help you with it. "
C."Don't worry about your shower until tomorrow. "
D."Do you want people to make fun of you?"
A B C D
B
This response offers support and sets limits. Option A doesn't offer support. Option C allows the client to continue to break rules. Option D offers neither support nor respect.
21. The nurse is assessing a pregnant woman in the clinic. In the course of the assessment, the nurse learns that this woman smokes one pack of cigarettes per day. The first step the nurse should take to help the woman stop smoking is to
A.assess the client's readiness to stop.
B.suggest that the client reduce the daily number of cigarettes smoked by one-half.
C.provide the client with the telephone number of a formal smoking cessation program.
D.help the client develop a plan to stop.
A B C D
A
Before planning any intervention with a client who smokes, it's essential to determine whether the client is willing or ready to stop smoking. Commonly, a pregnant woman will agree to stop smoking for the duration of the pregnancy. This gives the nurse an opportunity to work with her over time to help with permanent smoking cessation.
22. A child with type 1 diabetes mellitus develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk for this child?
A.Hypercalcemia.
B.Hyperphosphatemia.
C.Hypokalemia.
D.Hypernatremia.
A B C D
C
Insulin administration causes glucose and potassium to move into the cells, causing hypokalemia. Calcium levels aren't directly affected by insulin administration. Hypophosphatemia, not hyperphosphatemia, may occur with insulin administration because phosphorus also enters the cells with insulin and potassium. Sodium levels aren't directly affected by insulin administration.
23. A 2-year-old client returns from surgery after a bowel resection as a result of Hirschsprung's disease. A temporary colostomy is in place. Which immediate postoperative nursing intervention takes priority?
A.Changing the surgical dressing.
B.Suctioning the nasopharynx frequently to remove secretions.
C.Irrigating the colostomy with 100 ml of normal saline solution.
D.Auscultating lung sounds.
A B C D
D
Immediately after surgery, the priority nursing intervention is assessing pulmonary function. The surgical dressing shouldn't require changing right away. Suctioning should be performed only if the client can't maintain a patent airway. Colostomy irrigation isn't warranted.
).
level may be low in ARDS and is related to reduced tissue oxygenation. The carboxyhemoglobin level will be increased in a client with an inhalation injury, which commonly progresses into ARDS. This isn't a common cause of ARDS.
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