Part One You will have two hours and 30 minutes to complete Part One.
1. In teaching a female client who is HIV-positive about pregnancy, the nurse would know more teaching is necessary when the client says,
A."The baby can get the virus from my placenta. "
B."I'm planning on starting on birth control pills. "
C."Not everyone who has the virus gives birth to a baby who has the virus. "
D."I'll need to have a C-section if I become pregnant and have a baby. "
A B C D
D
The human immunodeficiency virus (HIV) is transmitted from mother to child via the transplacental route, but a Cesarean section delivery isn't necessary when the mother is HIV-positive. The use of birth control will prevent the conception of a child who might have HIV. It's true that a mother who is HIV-positive can give birth to a baby who is HIV-negative.
2. After a client receives an IM injection, he complains of burning pain in the injection site. Which nursing action would be the best to take at this time?
A.Apply a cold compress to decrease swelling.
B.Apply a warm compress to dilate the blood vessels.
C.Massage the area to promote absorption of the drug.
D.Instruct the client to tighten his gluteal muscles to promote better absorption.
A B C D
B
Applying heat increases blood flow to the area, which, in turn, increases the absorption of the medication. Cold decreases the pain but allows the medication to stay in the muscle longer. Massage is a good intervention but applying a warm compress is better. Tightening the gluteal muscles may cause additional burning if the drug irritates muscular tissues.
3. A client with a pneumothorax receives a chest tube attached to a Pleur-evac. The nurse notices that the fluid of the second chamber of the Pleur-evac isn't bubbling. Which nursing assumption would be most invalid?
A.The tubing from the client to the chamber is blocked.
B.There is a leak somewhere in the tubing system.
C.The client's affected lung has reexpanded.
D.The tubing needs to be cleared of fluid.
A B C D
B
Bubbling in the second chamber of a Pleur-evac system signifies that air is moving from the collection chamber to the water seal chamber. It's normal for bubbling to occur during inspiration, but continuous bubbling signifies a leak in the closed system. Absence of bubbling in the second chamber signifies a block in the system. It can also mean that the affected lung has reexpanded.
4. The nurse assesses a client with urticaria. The nurse understands that urticaria is another name for
A.hives.
B.a toxin.
C.a tubercle.
D.a virus.
A B C D
A
Hives and urticaria are two names for the same skin lesion. A toxin is a poison. A tubercle is a tiny round nodule produced by the tuberculosis bacillus. A virus is an infectious parasite.
5. A client reveals to the nurse that he's sexually impotent. Which statement best expresses what the nurse should understand her client to mean?
A.He's disinterested in sexual intimacy.
B.He's unable to attain or retain an erection.
C.His ejaculate is void of sperm.
D.His semen isn't potent enough to impregnate.
A B C D
B
Impotence is defined as the inability to achieve penile erection. It also involves being unable to maintain an erection to the point of ejaculation. Disinterest in sexual intimacy can be labeled with a number of terms, including celibacy and asexuality. Infertility is the term used when a man's semen is incapable of impregnating a woman.
6. The nurse is teaching the mother of an infant with tetralogy of Fallot. The mother asks what to do when her infant becomes very blue and has trouble breathing after crying. The nurse should tell the mother,
A."Leave the infant alone until the crying stops. "
B."Put the infant in the knee-chest position. "
C."Offer the infant a bottle of formula. "
D."Take the infant for a ride in the car. "
A B C D
B
The infant is having a "tet" or blue spell, which is an acute spell of hypoxia and cyanosis. This occurs when the infant's oxygen requirements are greater than what is supplied in the blood. Treatment involves placing the infant in the knee-chest position to reduce venous return from the extremities because that blood is desaturated. It also increases systemic vascular resistance, which causes more blood to be shunted to the pulmonary artery. Leaving the infant alone until the crying stops will cause an increase in cyanosis. An infant who is crying and having trouble breathing shouldn't be offered a bottle because of the danger of aspiration. A ride in the car may quiet some infants, but it would be inappropriate in this situation.
7. Two middle-aged sisters have been diagnosed with Huntington's disease. The children of these clients want to know what their chances are of developing this genetic disorder. The nurse's best response would be.
A."Only women become symptomatic. "
B."This disorder is an autosomal dominant disorder, so each child has a 50% chance of inheriting it. "
C."This disorder is an autosomal recessive disorder, so each child has a 25% chance of inheriting it. "
D."Women are symptomatic and men are carriers of this disorder. "
A B C D
B
Huntington's disease is an autosomal dominant disorder; therefore, each child has a 50% chance of inheriting it. Men and women are equally affected.
8. Because antianxiety agents such as chlordiazepoxide (Librium) can potentiate the effects of other drugs, the nurse should incorporate which of the following instructions in her teaching plan?
A.Avoid mixing antianxiety agents with alcohol or other central nervous system (CNS) depressants.
B.Avoid taking antianxiety agents at bedtime.
C.Avoid taking antianxiety agents on an empty stomach.
D.Avoid consuming aged cheese when taking antianxiety agents.
A B C D
A
Potentiating effect refers to a drug's ability to increase the potency of another drug if taken together. Therefore, the client should be instructed to avoid alcohol while taking Librium because it potentiates the drug's CNS depressant effect. Taken at bedtime, this drug will induce sleep. Librium comes in capsule form and usually can be taken with water. Aged cheese is restricted with monoamine oxidase inhibitors, not Librium.
9. A 26-year-old male is admitted to an inpatient psychiatric hospital after having been picked up by the local police while walking around the neighborhood at night without shoes in the snow. He appears confused and disoriented. Which of the following is the most immediate nursing action?
A.Assess and stabilize the client's medical needs.
B.Assess and stabilize the client's psychological needs.
C.Attempt to locate the nearest family member to get an accurate history.
D.Arrange a transfer to the nearest medical facility.
A B C D
A
The possibility of frostbite must be evaluated before the other interventions. Options B, C, and D don't address the client's immediate medical needs.
10. Before administering a tube feeding to a toddler, which of the following methods should the nurse use to check the placement of a nasogastric (NG) tube?
A.Abdominal X-rays.
B.Injection of a small amount of air while listening with a stethoscope over the abdominal area.
C.A check of the pH of fluid aspirated from the tube.
D.Visualization of the measurement mark on the tube made at the time of insertion.
A B C D
C
Intestinal, gastric, and respiratory fluids have different pH values. Therefore, checking the pH of fluid aspirated from the tube is the most reliable technique for checking proper NG tube placement without taking X-rays before each feeding. X-rays can't be performed multiple times every day. Because auscultation of air can be heard when the tube is in the esophagus as well as in the stomach, this isn't the best test for checking placement. Observing the insertion measurement mark isn't a good check either because the mark may remain the same even though the tube has migrated up or down into the esophagus, lungs, or intestines.
11. The nurse caring for a 3-day-old neonate notices that he looks slightly jaundiced. Although not a normal finding, it's an expected finding of physiologic jaundice and is caused by which of the following?
A.Poor clotting mechanism.
B.High hemoglobin (Hb) levels between 14 and 20 g/dL per 100 mL of blood.
C.Persistent fetal circulation.
D.Large, immature liver.
A B C D
D
The primary cause of neonate jaundice is the immaturity of the liver and its inability to break down red cells effectively. Poor clotting mechanisms, elevated Hb, and persistent fetal circulation contribute to the jaundice but aren't causes of it.
12. When caring for children who are sick, who have sustained traumas, or who are suffering from nutritional inadequacies, the nurse should know the correct hemoglobin (Hb) values for children. Which of the following ranges would be inaccurate?
A.Neonates. 10.6 to 16.5.
B.3 months. 10.6 to 16.5.
C.3 years. 9.4 to 15.5.
D.10 years. 10.7 to 15.5.
A B C D
A
To sustain them until active erythropoiesis begins, neonates have Hb concentrations higher than those of older children. The normal value of Hb for neonates is 18 to 27g/dL. Disease as well as such nonpathologic conditions as age, sex, altitude, and the degree of fluid retention or dehydration can affect Hb values. The values for a 3-month-old, a 3-year-old, and a 10-year-old are correct as stated above.
13. During a client's chemotherapy regimen for breast cancer, which is important for the nurse to include in her plan of care?
A.Instruct the client to consume plenty of raw fruits and vegetables.
B.Take rectal temperatures for greater accuracy.
C.Tell the client to avoid crowds and infected individuals.
D.Ask friends and relatives not to visit during the course of chemotherapy.
A B C D
C
The client receiving chemotherapy is susceptible to infection from bone marrow suppression and granulocytopenia. Clients should be instructed to avoid malls, movie theaters, and infected individuals. Raw fruits and vegetables may be contaminated by pathogens and should be avoided during severe neutropenia or washed in hot soapy water. Although rectal temperatures may be more accurate, they aren't appropriate for the neutropenic client. Taking temperatures rectally increases the risk of rectal abscess due to rectal trauma. Meticulous hand washing by staff and visitors will prevent the spread of infection; there is no need for sterile garb and no need to avoid visiting-the client will need emotional support from family at this time.
14. After taking glipizide (Glucotrol) for 9 months, a client experiences secondary failure. Which of the following would the nurse expect the physician to do?
A.Initiate insulin therapy.
B.Switch the client to a different oral antidiabetic agent.
C.Prescribe an additional oral antidiabetic agent.
D.Restrict carbohydrate intake to less than 30% of the total caloric intake.
A B C D
B
Many clients (25% to 60%) with secondary failure respond to a different oral antidiabetic agent. Therefore, it wouldn't be appropriate to initiate insulin therapy at this time. However, if a new oral antidiabetic agent is unsuccessful in keeping glucose leveis at an acceptable level, insulin may be used in addition to the antidiabetic agent. A client who has diabetes should get about 70% of his calories from carbohydrates and monounsaturated fats.
15. The nurse is caring for a 40-year-old woman who is a black Muslim. Which of the following choices is a concept on which black Muslims focus?
A.Celibacy.
B.Prophecy.
C.Reincarnation.
D.Self-esteem.
A B C D
D
Black Muslims stress the importance of cooperation among black business and education in the elevation of the self-esteem of its adherents. Prophecy is a focus of such religions as Seventh-Day Adventism and Fundamental Baptist. Reincarnation is associated with Far Eastern religions, and celibacy is a practice in a number of the world's religions.
16. When a client being seen in a fertility clinic doesn't respond to the clomiphene citrate, the physician prescribes IM menotropins (Pergonal). This drug increases her risk of producing multiple follicles that could mature to ovulation. To reduce the high risk of multifetal pregnancy and its possible adverse effects the nurse should monitor
A.ultrasound study results and serum estradiol levels.
B.ultrasound study results and serum progesterone levels.
C.results of tests to detect luteinizing hormone (LH) in urine.
D.serum levels of human chorionic gonadotropin (HCG).
A B C D
A
The objective of menotropins therapy is to produce one or two healthy follicles; by carefully monitoring the client's ultrasound study results and serum estradiol levels, the nurse can determine the number of maturing follicles. Serum progesterone levels indicate whether ovulation has occurred and correlate well with basal body temperature changes but don't indicate the number of follicles. The test to detect urinary levels of LH is a hormonal assessment of ovulatory function--not an assessment of the number of maturing cells. Serum levels of HCG indicate whether the corpus luteum is producing enough estrogen and progesterone to maintain the pregnancy until the placenta develops further.
17. A client in acute renal failure is admitted to the nephrology unit. The period of oliguria in these clients usually lasts about t0 days. Which of the following assessments of kidney function would the nurse make during the oliguric phase?
A.No urine output; kidneys in a state of suppression.
B.Urine output of 30 to 60 mL/hr.
C.Urine output of less than 400 to 600 mL in 24 hours.
D.Urine output directly related to the amount of IV fluids infused.
A B C D
C
The three phases of acute renal failure are the oliguria phase (less than 400 to 600 mL of urine produced in 24 hours), diuresis, and recovery. The kidneys aren't in a state of suppression, the average output isn't 30 to 60 mL/hr, and the amount of output isn't related to IV fluids infused.
18. A client with thyroid cancer undergoes a thyroidectomy. After surgery, the client develops peripheral numbness and tingling and muscle twitching and spasms. The nurse should expect to administer
A.thyroid supplements.
B.antispasmodics.
C.barbiturates.
D.IV calcium.
A B C D
D
Removal of the thyroid gland can cause hyposecretion of parathormone leading to calcium deficiency. Manifestations of calcium deficiency include numbness, tingling, and muscle spasms. Treatment includes immediate administration of calcium. Thyroid supplements will be necessary following thyroidectomy but aren't specifically related to the identified problem. Antispasmodics don't treat the problem's cause. Barbiturates aren't indicated.
19. When caring for a client who is having her second baby, the nurse can anticipate the client's labor will be which of the following?
A.Shorter than her first labor.
B.About half as long as her first labor.
C.About the same length of time as her first labor.
D.A length of time that can't be determined based on her first labor.
A B C D
B
A woman having her second baby can anticipate a labor about half as long as her first labor. The other options are incorrect.
20. An 82-year-old female is transferred to the hospital from a long-term care facility because of severe diarrhea. She is weak and dehydrated. Which acid-base imbalance could the client develop as a result of diarrhea?
A.Respiratory acidosis.
B.Metabolic acidosis.
C.Carbonic acid deficit.
D.Metabolic alkalosis.
A B C D
B
Diarrhea causes the body to lose bicarbonate, which may cause metabolic acidosis. Respiratory acidosis is caused by alveolar hypoventilation. Carbonic acid excess occurs with respiratory alkalosis. Vomiting could lead to metabolic alkalosis.
21. The nurse is assessing a postcraniotomy client and finds the urine output from a catheter is 1,500 mL for the 1st hour and the same for the 2nd hour. The nurse should suspect
A.Cushing's syndrome.
B.diabetes mellitus.
C.adrenal crisis.
D.diabetes insipidus.
A B C D
D
Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in clients after brain surgery. Cushing's syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. Diabetes mellitus is a hyperglycemic state marked by polyuria, polydipsia, and polyphagia. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.
22. When teaching the parents of a toddler with a congenital heart defect, the nurse should explain all medical treatments and should emphasize which instruction about their child?
A.Reduce the caloric intake to decrease cardiac demand.
B.Relax discipline and limit setting to prevent crying.
C.Avoid contact with small children to reduce overstimulation.
D.Try to maintain the usual lifestyle to promote normal development.
A B C D
D
Parents of a child with a heart defect should treat the child normally and allow self-limited activity. Reducing the child's caloric intake doesn't necessarily reduce cardiac demand. Altering disciplinary patterns and deliberately preventing crying or interactions with other children can foster maladaptive behaviors. Contact with peers promotes normal growth and development and therefore should be encouraged.
23. On a routine visit to the physician, a client with chronic arterial occlusive disease reports stopping smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, the nurse should recommend which additional measure?
A.Taking daily walks.
B.Engaging in anaerobic exercise.
C.Reducing daily fat intake to less than 45% of total calories.
D.Avoiding foods that increase levels of high-density lipoproteins (HDLs).
A B C D
A
Daily walks relieve symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may exacerbate these symptoms. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat foods that raise HDL levels.
24. The nurse is evaluating a client who is complaining of shortness of breath. The client's respiratory rate is 26 breaths per minute so the nurse documents that he is tachypneic. The nurse understands that tachypnea means
A.frequent bowel sounds.
B.heart rate greater than 100 beats/minute
C.hyperventilation.
D.respiratory rate greater than 20 breaths/minute
A B C D
D
A respiratory rate greater than 20 breaths/minute is tachypnea. A heart rate greater than 100 beats/minute is tachycardia. Frequent bowel sounds refers to hyperactive bowel sounds. Hyperventilation may increase respirations, but it also refers to deep, large breaths.
25. A preschool-age child with sickle cell anemia is admitted to the health care facility in vaso-occlusive crisis after developing a fever and joint pain. What is the nurse's highest priority when caring for this child?
A.Providing fluids.
B.Maintaining protective isolation.
C.Applying cool compresses to affected joints.
D.Administering antipyretics, as prescribed.
A B C D
A
During a vaso-occlusive crisis, sickle-shaped red blood cells (RBCs) clump together and obstruct blood vessels, causing ischemia and tissue damage. Providing IV and oral fluids promotes hemodilution, which aids the free flow of RBCs through blood vessels. The client must be kept away from known infection sources but doesn't require protective isolation. Warm compresses may be applied to painful joints to promote comfort; cool compresses would cause vasoconstriction, which exacerbates sickling. Antipyretics may be administered to reduce fever but don't play a crucial role in resolving the crisis.
26. The nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first
A.establish unresponsiveness.
B.call for help.
C.open the airway.
D.assess the client for a carotid pulse.
A B C D
A
The correct sequence begins with establishing unresponsiveness. The nurse should then call for help, assess the client for breathing while opening the airway, deliver two breaths, and check for a carotid pulse.
27. A client who survived an airplane crash has a diagnosis of posttraumatic stress disorder (PTSD). He has a history of nightmares, depression, hopelessness, and alcohol abuse. Which option offers the client the most lasting relief for his symptoms?
A.The opportunity to verbalize memories of trauma to a sympathetic listener.
B.Family support.
C.Prescribed medications taken as ordered.
D.Alcoholics Anonymous (AA) meetings.
A B C D
A
Although talking about their experiences can be difficult, clients with PTSD can obtain the most lasting relief if they verbalize memories of the trauma to a sympathetic listener. Family members are commonly frightened by the information and can't be consistently supportive. Antidepressants may help but these drugs can mask feelings and can't provide lasting relief. Treatment for alcohol abuse, including AA meetings, must be considered when planning care but alone doesn't provide lasting relief.
28. The nurse is teaching the mother of a neonate. The nurse should instruct the mother to introduce her infant to solid foods at what age?
A.2 months.
B.4 months.
C.6 months.
D.8 months.
A B C D
C
Solid foods are typically introduced around age 6 months. They aren't recommended at an earlier age because of the protrusion and sucking reflexes and the immaturity of the infant's GI tract and immune system. By age 8 months, the infant usually has been introduced to iron-fortified infant cereal and vegetables and will begin to try fruits.
29. A client with shock brought on by hemorrhage has a temperature of 97.6°F (36.4℃), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mmHg. For this client the nurse should question which physician order?
A."Monitor urine output every hour. "
B."Infuse IV fluids at 83 mL/hr"
C."Administer oxygen by nasal cannula at 3 L/min"
D."Draw samples for hemoglobin and hematocrit every 6 hours. "
A B C D
B
Because shock signals a severe fluid volume loss (700 to 1300 mL) its treatment includes rapid IV fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An IV infusion rate of 83 mL/hr wouldn't begin to replace the necessary fluids and reverse the problem. The other options are appropriate for this client.
30. A client asks the nurse what PSA is. The nurse should reply that it stands for
A.prostate-specific antigen, used to screen for prostate cancer.
B.protein serum antigen, used to determine protein levels.
C.pneumococcal strep antigen, a bacteria that causes pneumonia.
D.papanicolaou-specific antigen, used to screen for cervical cancer.
A B C D
A
PSA stands for prostate-specific antigen, which is used to screen for prostate cancer.
Part Two You will have one hour and 50 minutes to complete Part Two.
1. The nurse is caring for a client who has a tracheostomy tube and is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by
A.suctioning the tracheostomy tube frequently.
B.using a cuffed tracheostomy tube.
C.using the minimal air leak technique with cuff pressure less than 25 cmH2O.
D.keeping the tracheostomy tube plugged.
A B C D
C
To prevent tracheal dilation, a minimal-leak technique should be used and the pressure should be kept at less than 25 cmH2O. Suctioning is vital but won't prevent tracheal dilation. Use of a cuffed tube alone won't prevent tracheal dilation. The tracheostomy shouldn't be plugged to prevent tracheal dilation. This technique is used when weaning the client from tracheal support.
2. An otherwise healthy adolescent has meningitis and is receiving IV and oral fluids. The nurse should monitor this client's fluid intake because fluid overload may cause
A.cerebral edema.
B.dehydration.
C.heart failure.
D.hypovolemic shock.
A B C D
A
Because of the inflammation of the meninges, the client is vulnerable to developing cerebral edema and increased intracranial pressure. Fluid overload won't cause dehydration. It would be unusual for an adolescent to develop heart failure unless the overhydration was extreme. Hypovolemic shock would occur with an extreme loss of fluid or blood.
3. Following a unilateral adrenalectomy, the nurse would assess for hyperkalemia shown by which of the following?
A.Muscle weakness.
B.Tremors.
C.Diaphoresis.
D.Constipation.
A B C D
A
Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which is transient and occurs from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren't seen in hyperkalemia.
4. After cancer chemotherapy, a client develops nausea and vomiting. For this client, the nurse should give the highest priority to which action in the plan of care?
A.Serve small portions of bland food.
B.Encourage rhythmic breathing exercise.
C.Administer metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed.
D.Withhold fluids for the first 4 to 6 hours after chemotherapy administration.
A B C D
C
Administration of an antiemetic, such as metoclopramide, and an anti-inflammatory, such as dexamethasone, can reduce the severity of chemotherapy-induced nausea and vomiting. This in turn, helps prevent dehydration, a common complication of chemotherapy. The remaining options are unlikely to be as successful' in achieving this outcome.
5. A client is hospitalized with a diagnosis of chronic renal failure. An arteriovenous fistula was created in his left arm for hemodialysis. When preparing the client for discharge, the nurse should reinforce which dietary instruction?
A."Be sure to eat meat at every meal. "
B."Monitor your fruit intake and eat plenty of bananas. "
C."Restrict your salt intake. "
D."Drink plenty of fluids. "
A B C D
C
In a client with chronic renal failure, unrestricted intake of sodium, protein, potassium, and fluids may lead to a dangerous accumulation of electrolytes and protein metabolic products, such as amino acids and ammonia. Therefore, the client must limit his intake of sodium, meat (high in protein), bananas (high in potassium), and fluid because the kidneys can't secrete adequate urine.
6. The nurse is caring for a neonate 12 hours after birth. Which clinical manifestation would be the earliest indication that the neonate may have cystic fibrosis?
A.Steatorrhea.
B.Meconium ileus.
C.Decreased sodium levels.
D.Rhinorrhea.
A B C D
B
In cystic fibrosis, the small intestine becomes blocked with thick meconium; therefore, meconium ileus is the earliest indication that a neonate has the disorder. Steatorrhea may be present later and may be used as a guideline for administration of pancreatic enzymes. Infants and children with this disorder have increased sodium levels, and rhinorrhea isn't usually present.
7. For a client with a head injury whose neck has been stabilized, the preferred bed position is
A.Trendelenburg's.
B.30-degree head elevation.
C.flat.
D.side-lying.
A B C D
B
For clients with increased intracranial pressure (ICP), the head of the bed is elevated to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. Side-lying isn't specifically a therapeutic treatment for increased ICP.
8. A client diagnosed with anxiety disorder is prescribed buspirone (BuSpar). Teaching instructions for newly prescribed buspirone should include which of the following?
A.A warning that immediate sedation can occur with a resultant drop in pulse.
B.A reminder of the need to schedule blood work in 1 week to check blood levels of the drug.
C.A warning about the incidence of neuroleptic malignant syndrome (NMS).
D.A warning about the drug's delayed therapeutic effect, which is from 14 to 30 days.
A B C D
D
The client should be informed that the drug's therapeutic effect might not be reached for 14 to 30 days. The client must be instructed to continue taking the drug as directed. Blood level checks aren't necessary. NMS hasn't been reported with this drug, but tachycardia is frequently reported.
9. The nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are
A.tracheal.
B.fine crackles.
C.coarse crackles.
D.friction rubs.
A B C D
B
Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation.
10. 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.
11. During her first prenatal visit, a client expresses concern about gaining weight. Which of the following would be the nurse's best action?
A.Ask the client how she feels about gaining weight and provide instructions about expected weight gain and diet.
B.Be alert for a possible eating problem and do a further in-depth assessment.
C.Report the client's concerns to her caregiver.
D.Ask her to come back to the clinic every 2 weeks for a weight check.
A B C D
A
Weight gain during pregnancy is a normal concern for most women. The nurse must first teach the client about normal weight gain and diet in pregnancy, then assess the client's response to that information. It's also important for the nurse to determine whether the client has any complicating problems such as an eating disorder. Reporting the client's concern about weight gain to the health care provider isn't necessary at this time. A weight check every 2 weeks also is unnecessary.
12. A child is to receive intrathecal methotrexate (Folex) for treatment of meningeal leukemia. For which reason would intrathecal administration be selected?
A.The child has very poor veins and is unable to receive drugs IV.
B.This drug would be destroyed by gastric acid and so it can't be given by mouth.
C.This drug is poorly transported across the blood-brain barrier, so it's administered intrathecally.
D.Because the drug is rapidly absorbed if given IM, adverse effects may appear more quickly.
A B C D
C
Because the IV route doesn't allow chemotherapeutic agents to reach all areas invaded by leukemic cells, this medication is administered intrathecally to ensure the entire body receives treatment. Although this medication may be given by mouth, IM, or IV, these routes would be inappropriate in this situation.
13. A client being evaluated in the emergency department complains of chest pain that radiates to his neck, shoulders, back, and arms, which decreases when he sits up and leans forward. Based on this assessment, the nurse suspects that he has
A.developed another myocardial infarction (MI).
B.endocarditis.
C.pericarditis.
D.myocarditis.
A B C D
C
Pericarditis is an inflammation of the fibroserous sac that envelops the heart. Unlike the pain of an MI, pericardial pain is commonly pleuritie and eases when the heart is pulled away from the diaphragmatic pleurae of the lungs. The hallmark indication of endocarditis is intermittent fever and malaise resulting from infection of the endocardium. Myocarditis has nonspecific symptoms that reflect the accompanying systemic infection.
14. After a cerebrovascular accident (CVA) a client develops aphasia. Which assessment finding is most typical in aphasia?
A.Arm and leg weakness.
B.Absence of the gag reflex.
C.Difficulty swallowing.
D.Inability to speak clearly.
A B C D
D
Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. The client may have arm and leg weakness or an absent gag reflex after a CVA, but these findings aren't related to aphasia. Difficulty swallowing is called dysphagia.
15. The nurse is caring for a client with a new donor site that was harvested to treat a new burn. The nurse should position the client to
A.allow ventilation of the site.
B.make the site dependent.
C.avoid pressure on the site.
D.keep the site fully covered.
A B C D
C
A universal concern in the care of donor sites for burn care is to keep the site away from sources of pressure. Ventilation of the site and keeping the site fully covered are practices in some institutions but aren't hallmarks of donor site care. Placing the site in a position of dependence isn't a justified aspect of donor site care.
16. An elderly client's lithium level is 1.4 mEq/L. She complains of diarrhea, tremors, and nausea. The nurse's first action is to
A.hold the lithium (Lithobid) and notify the physician.
B.reassure the client that these are normal adverse effects.
C.administer another lithium dose.
D.discontinue the lithium.
A B C D
A
The client has symptoms of lithium toxicity. Therefore, her lithium should be held and the physician notified immediately. These aren't normal adverse effects, and administering another dose would increase the toxic effects. A nurse can't discontinue a medication without a physician's order.
17. A client is admitted with a suspected diagnosis of an acute myocardial infarction. When providing care for the client, the nurse should avoid which route when taking a temperature?
A.Oral.
B.Rectal.
C.Axillary.
D.Tympanic.
A B C D
B
When caring for the client with a cardiac disorder, the rectal route should be avoided. Introducing a thermometer into the rectum may stimulate the vagus nerve, causing vasodilation and bradycardia. The oral, axillary, and tympanic routes are appropriate for measuring the temperature of cardiac clients.
18. A client is admitted to the hospital for treatment of Prinzmetal's angina. When developing the client's plan of care, the nurse should remember that this type of angina is triggered by
A.coronary artery spasm.
B.an unpredictable amount of activity.
C.activities that increase oxygen demand.
D.an unknown source.
A B C D
A
Prinzmetal's or variant angina is triggered by coronary artery spasm, An unpredictable amount of activity may trigger unstable angina. Activities that increase myocardial oxygen demand may trigger predictable stable angina.
19. A client is admitted to the hospital in the manic phase of bipolar disorder. When placing a diet order for the client, which foods would be most appropriate?
A.A bowl of soup, crackers, and a dish of peaches.
B.A cheese sandwich, carrot sticks, fresh grapes, and cookies.
C.Roast chicken, mashed potatoes, and peas.
D.A tuna sandwich, an apple, and a dish of ice cream.
A B C D
B
The client may have a difficult time sitting long enough to eat his meal; therefore, finger foods that can be eaten easily are most appropriate. The other foods require the client to sit and eat, a task the client will be unable to achieve at this time.
20. The nurse is caring for a client who complains of chronic pain. Given this complaint, why would the nurse simultaneously evaluate both general physical and psychosocial problems?
A.Depression is commonly characterized by pain disorders and somatic complaints.
B.Combining evaluations will save time and allow for quicker delivery of health care.
C.Most insurance plans won't cover evaluation of both as separate entities.
D.The physician doesn't have the training to evaluate for psychosocial considerations.
A B C D
A
Psychosocial factors should be suspected when pain persists beyond the normal tissue healing time and physical causes have been investigated. The other choices may or may not be correct but certainly aren't credible in all cases.
21. A client refuses his evening dose of haloperidol (Haldol) then becomes extremely agitated in the day room while other clients are watching television. He begins cursing and throwing furniture. The nurse's first action is to
A.check the client's medical record for an order for an IM as needed dose of medication for agitation.
B.place the client in full leather restraints.
C.call the physician and report the behavior.
D.remove all other clients from the day room.
A B C D
D
The nurse's first priority is to consider the safety of the clients in the therapeutic setting. The other actions are appropriate responses after ensuring the safety of other individuals.
22. Conditions necessary for the development of a positive sense of self-esteem include
A.consistent limits.
B.critical environment.
C.inconsistent boundaries.
D.physical discipline.
A B C D
A
A structured lifestyle demonstrates acceptance and caring and provides a sense of security. A critical environment erodes a person's esteem. Inconsistent boundaries lead to feelings of insecurity and lack of concern. Physical discipline can decrease self-esteem.
23. A client is to be discharged from an acute care facility after treatment of right leg thrombophlebitis. The nurse notes that the client's leg is pain free, without redness or edema. The nurse's actions reflect which step in the nursing process?
A.Assessment.
B.Analysis.
C.Implementation.
D.Evaluation.
A B C D
D
The nursing actions described constitute evaluation of expected outcomes. The findings show that the expected outcomes have been achieved. Assessment consists of the client's history, physical examination, and laboratory studies. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. Implementation is the phase of the nursing process where the nurse puts the plan of care into actiorn.
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