A nurse evaluates the arterial blood gas (ABG) results of a client who is receiving supplemental oxygen. Which finding would indicate that the oxygen level was adequate?
Options:
A) A Po2 of 80 mmHg
B) A Po2 of 60 mmHg
C) A Po2 of 50 mmHg
D) A Po2 of 45 mmHg
Correct Answer is: A
Explanation : The normal Po2 level is 80 to 100 mmHg. Options 2, 3, and 4 are low values and do not indicate adequate oxygen levels.
101. A home care nurse is providing instructions to a client who is taking zolpidem (Ambien) for insomnia. To produce a maximal effect of the medication, the nurse tells the
client to the medication:
Options:
A) With a full glass of water on an empty stomach
B) Following the evening meal
C) At bedtime with a snack
D) With milk or an antacid
Correct Answer is: A
Explanation : the client should be instructed to take the medication at bedtime and to swallow the medication whole with a full glass of water. For faster onset of sleep, the client
should be instructed not to administer the medication with milk or food, or immediately after a meal. Antacids should be avoided with the administration of the medication
because of interactive effects.
102. A registered nurse is discussing treatment for a client who is hospitalized with acute systemic lupus erythematosus (SLE) with a nursing student assigned to care for the
client. The registered nurse determines that the nursing student needs to research information about the disease if the student states that which of the following is a clinical
manifestation of SLE?
Options:
A) Fever
B) Muscular aches and pains
C) Butterfly rash on the face
D) Bradycardia
Correct Answer is: D
Explanation : Manifestations of acute SLE may include fever, musculoskeletal aches and pains, butterfly rash on the face, pleural effusion, basilar pneumonia, generalized
lymphadenopathy, pericarditis, tachycardia, hepatosplenomegaly, nephritis, delirium, convulsions, psychosis, and coma.
103. A client is seen in the health care clinic and anemia has been diagnosed. On further assessment, the nurse notes that the client appears pale and complains of fatigue,
weakness, dizziness, headache, loss of appetite, and palpitations. Based on the client’s symptoms, the nurse would expect that the hemoglobin results would indicate which of
the following?
Options:
A) Hemoglobin of 14 g/dL
B) Hemoglobin of 12 g/dL
C) Hemoglobin of 10 g/dL
D) Hemoglobin of 7 g/dL
Correct Answer is: D
Explanation : Severely anemic persons (those with a hemoglobin below 8 g/dL) appear pale and always feel exhausted. They may have palpitations, sensitivity to cold, loss of
appetite, profound weakness, dizziness, and headaches.
104. A nurse in the newborn nursery is performing vital signs on the newborn infant. Which finding would indicate a normal respiratory rate?
Options:
A) 28 breaths per minute
B) 50 breaths per minute
C) 70 breaths per minute
D) 80 breaths per minute
Correct Answer is: B
Explanation : The normal respiratory rate for a newborn infant is 30 to 60 breaths per minute. Therefore, options 1, 3, and 4 are incorrect.
105. A nurse is assessing a client with a diagnosis of polycythemia vera. Which clinical manifestation would the nurse expect to note in this client?
Options:
A) Pallor
B) Hypertension
C) Pale mucous membranes
D) A low hematocrit level
Correct Answer is: B
Explanation : Manifestations of polycythemia vera include a ruddy complexion, dusky red mucosa, hypertension, dizziness headache, and a sense of fullness in the head. Signs
,of congestive heart failure may also be present. The hematocrit level is usually greater than 54% in men and 49% in women.
106. When reviewing the laboratory results of a client with leukemia who is receiving chemotherapy, the registered nurse notes that the neutrophil count is less than 500/mm3.
The registered nurse reviews the laboratory result with a nursing student caring for the client and asks the student to identify the appropriate precautions that need to be
instituted. Which intervention identified by the student indicates a need for teaching?
Options:
A) Padding the side rails and removing all hazardous and sharp objects from the environment
B) Restricting visitors with colds or respiratory infections
C) Removing all live plants, flowers, and stuffed animals in the client’s room
D) Placing the client on a low-bacteria diet that excludes raw foods and vegetables.
Correct Answer is: A
Explanation : When the neutrophil count is less than 500 mm3, visitors should be screened for the presence of infection, and nay visitors or staff with colds or respiratory
infections should not be allowed in the client’s room. All live plants, flowers, and stuffed animals are removed from the client’s room. The client is placed on a low-bacteria diet
that excludes raw fruits and vegetables. Padding the side rails and removing all hazardous and sharp objects from the environment would be instituted if the client is at risk for
bleeding. This client is at risk for infection.
107. A nurse is delivering care to a client who was diagnosed with toxic shock syndrome (TSS). The nurse monitors the client for which complication of this syndrome?
Options:
A) Pulmonary embolism
B) Disseminated intravascular coagulopathy (DIC)
C) Vitamin K deficiency
D) Factor VIII deficiency
Correct Answer is: B
Explanation : Toxic shock syndrome is caused by infection and is often associated with tampon use. DIC is a complication of TSS. The nurse monitors the client for signs of this
complication, and notifies the physician promptly if signs and symptoms are noted. Options 1, 3, and 4 are not complications of TSS.
108. A nurse is caring for a client with an acute head injury. The nurse carefully assesses which neurological sign as the most sensitive indicator of neurological status?
Options:
A) Vital signs
B) Level of consciousness
C) Sensory function
D) Motor function
Correct Answer is: B
Explanation : The level of consciousness is the most sensitive indicator of neurological status. An alteration in the level of consciousness occurs before any other changes in
neurologic signs or vital signs. Vital sign changes occur late.
109. A client is admitted to the hospital with Cushing’s syndrome. The nurse reviews the results of the client’s laboratory studies for which manifestation of this disorder?
Options:
A) Hypokalemia
B) Hyperglycemia
C) Low white blood cell (WBC) count
D) Decreased plasma cortisol levels
Correct Answer is: B
Explanation : The client with adrenocorticosteroid excess experiences hyperkalemia, hyperglycemia, elevated WBC count, and elevated plasma cortisol and adrenocorticotropic
hormone (ACTH) levels. These abnormalities are caused by the effects of excess glucocorticoids and mineralocorticoids on the body.
110. A nurse is going to suction an adult client with a tracheostomy who has copious amounts of secretions. The nurse does which of the following to accomplish this procedure
safely and effectively?
Options:
A) Occludes the Y-port of the catheter while advancing it into the tracheostomy
B) Applies continuous suction in the airway for up to 20 seconds
C) Hyperoxygenates the client after the procedure only
D) Sets the wall suction pressure range between 80 to 120 mmHg
Correct Answer is: D
Explanation : The safe wall suction range of an adult is 80 to 120 mmHg (120 to 150 mmHg with the tubing occluded), making option 4 the action that is consistent with safe and
effective practice. The nurse should hyperoxygenate the client both before and after suctioning. The nurse should advance the catheter into the tracheostomy without occluding
the Y-port to minimize mucosal trauma and aspiration of the client’s oxygen. The nurse should use intermittent suction in the airway (not constant) for up to 10 to 15 seconds.
111. A nurse is caring for a hospitalized client who has been taking clozapine (Clozaril) for the treatment of a schizophrenic disorder, and the nurse reviews the laboratory studies
that have been prescribed for the client. Which laboratory study will the nurse specifically review to monitor for an adverse effect associated with the use of this medication?
Options:
A) White blood cell count
B) Platelet count
C) Cholesterol level
D) Blood urea nitrogen
,Correct Answer is: A
Explanation : Hematological reactions can occur in the client taking clozapine and include agranulocytosis and mild leucopenia. The white blood cell count should be assessed
before initiating treatment and should be monitored closely during the use of this medication. The client should also be monitored for signs indicating agranulocytosis, which
may include sore throat, malaise, and fever. Options 2, 3, and 4 are unrelated to the use of this medication.
112. A nurse is monitoring the function of a client’s chest tube. The chest tube is attached to a Pleur-Evac drainage system. The nurse notes that the fluid in the water seal
chamber is below the 2 cm mark. The nurse determines that:
Options:
A) Suction should be added to the system
B) There is a leak in the system
C) This is caused by client pneumothorax
D) Water should be added to the chamber
Correct Answer is: D
Explanation : The water seal chamber should be filled to the 2 cm mark to provide an adequate water seal between the external environment and client’s pleural cavity. The water
seal prevents air from reentering the pleural cavity. Because evaporation of water can occur, the nurse should remedy this problem by adding water until the level is again at the
2 cm mark. The other interpretations are incorrect.
113. A client has decided to use a transcutaneous electrical nerve stimulation (TENS) as prescribed by the physician for the relief of chronic pain, and the nurse has provided
instructions to the client regarding the TENS unit. Which statement by the client would indicate a need for further instructions regarding this pain relief measure?
Options:
A) “I am not sure that I am going to like those electrodes attached to my skin.”
B) “I am not real happy that I have to stay in the hospital for this treatment.”
C) “This unit will eliminate the need for taking so many pain medications.”
D) “I understand that this will help relieve the pain.”
Correct Answer is: B
Explanation : The TENS unit is a portable unit, and the client controls the system for relieving pain and reducing and need for analgesics. It is attached to the skin of the body by
electrodes. It is not necessary that the client remain in the hospital for this treatment.
114. A client with chronic renal failure has a protein restriction in the diet. The nurse would include in a teaching plan to avoid which of the following sources of incomplete
protein in the diet?
Options:
A) Nuts
B) Eggs
C) Milk
D) Fish
Correct Answer is: A
Explanation : The client whose diet has a protein restriction should be careful to ensure that the proteins eaten are complete proteins with highest biologic value. Foods such as
meat, fish milk, and eggs are complete proteins, which are optimal for the client with chronic renal failure.
115. A newborn infant is diagnosed with imperforate anus. The nurse plans care, knowing that which of the following most appropriately describes a characteristic of this
disorder?
Options:
A) Incomplete development of the anus
B) Invagination of a section of the intestine into the distal bowel
C) The infrequent and difficult passage of dry stools
D) The presence of fecal incontinence
Correct Answer is: A
Explanation : Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum. Option 2 describes
intussusception. Option 3 describes constipation. Option 4 describes encopresis. Constipation can affect any child at any time, although it peaks at age 2 to 3 years, Encopresis
generally affects preschool and school-aged children.
116. A nurse is providing bottle-feeding instructions to the mother of a newborn infant. The nurse provides instructions regarding the amount of formula to be given, knowing
that the stomach capacity for a newborn infant is approximately:
Options:
A) 5 to 10 mL
B) 10 to 20 mL
C) 30 to 90 mL
D) 75 to 100 mL
Correct Answer is: B
Explanation : The stomach capacity of a newborn infant is approximately 10 to 20 mL. It is 30 to 90 mL for a 1-week-old infant, and 75 to 100 mL for a 2- to 3-week-old infant.
117. A mother who is breastfeeding her newborn infant is experiencing nipple soreness, and the nurse provides instructions regarding measures to relieve the soreness. Which
statement by the mother indicates an understanding of the instructions?
, Options:
A) “I need to avoid rotating breastfeeding positions so that the nipple will toughen.”
B) “I need to stop nursing during the period of nipple soreness to allow the nipples to heal.”
C) “I need to nurse less frequently and substitute a bottle feeding until the nipples becomes less more.”
D) “I need to position my infant with her ear, shoulder, and hip in straight alignment and place her stomach against me.”
Correct Answer is: D
Explanation : Comfort measures for nipple soreness include positioning the infant with the ear, shoulder, and hip in straight alignment and with the infant’s stomach against the
mother’s. Additional measures include rotating breastfeeding positions breaking suction with the little finger; nursing frequently; beginning feeding on the less sore nipple; not
allowing the infant to chew on the nipple or to sleep holding the nipple in the mouth; and applying tea bags soaked in warm water to the nipple. Options 1, 2, and 3 are incorrect.
118. A client with acute myocardial infarction receivews therapy with altepalse recombinant, or tissue plasminogen activator (tPA), and the nurse monitors the client for
complications of this treatment. Which finding would indicate a possible complication?
Options:
A) Epistaxis
B) Vomiting
C) ECG changes
D) Absent pedal pulses
Correct Answer is: A
Explanation : Bleeding is a major side effect of t-PA therapy. The bleeding can be superficial on internal and can be spontaneous. Options 2, 3, and 4 are not side or adverse
effects of t-PA therapy.
119. A nurse is performing an assessment on a mother who just delivered a healthy newborn infant. The nurse checks the uterine fundus, expecting to note that the fundus is
positioned:
Options:
A) At the level of the umbilicus
B) Above the level of the umbilicus
C) One fingerbreadth above the symphysis pubis
D) To the right of the abdomen
Correct Answer is: A
Explanation : Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. If the
fundus is above the umbilious, this may indicate that blood clots in the uterus need to be expelled by fundal massage. A fundus that is not located in the midline may indicate a
full bladder.
120. A nurse obtains the vital signs on a mother who delivered a healthy newborn infant 2 hours ago and notes that the mother’s temperature is 120oF. The most appropriate
nursing action would be to:
Options:
A) Document the finding and recheck the temperature in 4 hours
B) Notify the physician
C) Administer acetaminophen (Tylenol) and recheck the temperature in 4 hours
D) Remove the blanket from the client’s bed
Correct Answer is: B
Explanation : Vital signs return to normal within the first hour postpartum if no complications arise. If the temperature is greater than 2 F above normal, this may indicate
infection, and the physician should be notified. Options 1, 3, and 4 are inaccurate nursing interventions for a temperature of 102oF 2 hours following delivery.
121. A nurse in the postpartum unit is caring for a mother following vaginal delivery of a healthy newborn infant. The client received epidural anesthesia for the delivery. One-half
hour after admission to the postpartum unit, the nurse checks the client and suspects the presence of a vaginal hematoma. Which finding would be the best indicator of the
presence of this type of hematoma?
Options:
A) Client complaints of tearing sensation
B) Client complaints of intense vaginal pressure
C) Changes in vital signs
D) Sings of vaginal bruising
Correct Answer is: C
Explanation : Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with a vaginal hematoma. Because the client received anesthesia, she would
not feel pain or pressure. Vaginal bruising may be present, but this may be a result of the delivery process and additionally is not the best indicator of the presence of a
hematoma.
122. A client with acute renal failure has an elevated blood urea nitrogen (BUN). The client is experiencing difficulty remembering information due to uremia. The nurse avoids
which of the following when communicating with this client?
Options:
A) Include the family in discussions related to care
B) Give thorough, lengthy explanations of procedures
C) Give simple, clear directions
D) Explain treatments using understandable language
Options:
A) A Po2 of 80 mmHg
B) A Po2 of 60 mmHg
C) A Po2 of 50 mmHg
D) A Po2 of 45 mmHg
Correct Answer is: A
Explanation : The normal Po2 level is 80 to 100 mmHg. Options 2, 3, and 4 are low values and do not indicate adequate oxygen levels.
101. A home care nurse is providing instructions to a client who is taking zolpidem (Ambien) for insomnia. To produce a maximal effect of the medication, the nurse tells the
client to the medication:
Options:
A) With a full glass of water on an empty stomach
B) Following the evening meal
C) At bedtime with a snack
D) With milk or an antacid
Correct Answer is: A
Explanation : the client should be instructed to take the medication at bedtime and to swallow the medication whole with a full glass of water. For faster onset of sleep, the client
should be instructed not to administer the medication with milk or food, or immediately after a meal. Antacids should be avoided with the administration of the medication
because of interactive effects.
102. A registered nurse is discussing treatment for a client who is hospitalized with acute systemic lupus erythematosus (SLE) with a nursing student assigned to care for the
client. The registered nurse determines that the nursing student needs to research information about the disease if the student states that which of the following is a clinical
manifestation of SLE?
Options:
A) Fever
B) Muscular aches and pains
C) Butterfly rash on the face
D) Bradycardia
Correct Answer is: D
Explanation : Manifestations of acute SLE may include fever, musculoskeletal aches and pains, butterfly rash on the face, pleural effusion, basilar pneumonia, generalized
lymphadenopathy, pericarditis, tachycardia, hepatosplenomegaly, nephritis, delirium, convulsions, psychosis, and coma.
103. A client is seen in the health care clinic and anemia has been diagnosed. On further assessment, the nurse notes that the client appears pale and complains of fatigue,
weakness, dizziness, headache, loss of appetite, and palpitations. Based on the client’s symptoms, the nurse would expect that the hemoglobin results would indicate which of
the following?
Options:
A) Hemoglobin of 14 g/dL
B) Hemoglobin of 12 g/dL
C) Hemoglobin of 10 g/dL
D) Hemoglobin of 7 g/dL
Correct Answer is: D
Explanation : Severely anemic persons (those with a hemoglobin below 8 g/dL) appear pale and always feel exhausted. They may have palpitations, sensitivity to cold, loss of
appetite, profound weakness, dizziness, and headaches.
104. A nurse in the newborn nursery is performing vital signs on the newborn infant. Which finding would indicate a normal respiratory rate?
Options:
A) 28 breaths per minute
B) 50 breaths per minute
C) 70 breaths per minute
D) 80 breaths per minute
Correct Answer is: B
Explanation : The normal respiratory rate for a newborn infant is 30 to 60 breaths per minute. Therefore, options 1, 3, and 4 are incorrect.
105. A nurse is assessing a client with a diagnosis of polycythemia vera. Which clinical manifestation would the nurse expect to note in this client?
Options:
A) Pallor
B) Hypertension
C) Pale mucous membranes
D) A low hematocrit level
Correct Answer is: B
Explanation : Manifestations of polycythemia vera include a ruddy complexion, dusky red mucosa, hypertension, dizziness headache, and a sense of fullness in the head. Signs
,of congestive heart failure may also be present. The hematocrit level is usually greater than 54% in men and 49% in women.
106. When reviewing the laboratory results of a client with leukemia who is receiving chemotherapy, the registered nurse notes that the neutrophil count is less than 500/mm3.
The registered nurse reviews the laboratory result with a nursing student caring for the client and asks the student to identify the appropriate precautions that need to be
instituted. Which intervention identified by the student indicates a need for teaching?
Options:
A) Padding the side rails and removing all hazardous and sharp objects from the environment
B) Restricting visitors with colds or respiratory infections
C) Removing all live plants, flowers, and stuffed animals in the client’s room
D) Placing the client on a low-bacteria diet that excludes raw foods and vegetables.
Correct Answer is: A
Explanation : When the neutrophil count is less than 500 mm3, visitors should be screened for the presence of infection, and nay visitors or staff with colds or respiratory
infections should not be allowed in the client’s room. All live plants, flowers, and stuffed animals are removed from the client’s room. The client is placed on a low-bacteria diet
that excludes raw fruits and vegetables. Padding the side rails and removing all hazardous and sharp objects from the environment would be instituted if the client is at risk for
bleeding. This client is at risk for infection.
107. A nurse is delivering care to a client who was diagnosed with toxic shock syndrome (TSS). The nurse monitors the client for which complication of this syndrome?
Options:
A) Pulmonary embolism
B) Disseminated intravascular coagulopathy (DIC)
C) Vitamin K deficiency
D) Factor VIII deficiency
Correct Answer is: B
Explanation : Toxic shock syndrome is caused by infection and is often associated with tampon use. DIC is a complication of TSS. The nurse monitors the client for signs of this
complication, and notifies the physician promptly if signs and symptoms are noted. Options 1, 3, and 4 are not complications of TSS.
108. A nurse is caring for a client with an acute head injury. The nurse carefully assesses which neurological sign as the most sensitive indicator of neurological status?
Options:
A) Vital signs
B) Level of consciousness
C) Sensory function
D) Motor function
Correct Answer is: B
Explanation : The level of consciousness is the most sensitive indicator of neurological status. An alteration in the level of consciousness occurs before any other changes in
neurologic signs or vital signs. Vital sign changes occur late.
109. A client is admitted to the hospital with Cushing’s syndrome. The nurse reviews the results of the client’s laboratory studies for which manifestation of this disorder?
Options:
A) Hypokalemia
B) Hyperglycemia
C) Low white blood cell (WBC) count
D) Decreased plasma cortisol levels
Correct Answer is: B
Explanation : The client with adrenocorticosteroid excess experiences hyperkalemia, hyperglycemia, elevated WBC count, and elevated plasma cortisol and adrenocorticotropic
hormone (ACTH) levels. These abnormalities are caused by the effects of excess glucocorticoids and mineralocorticoids on the body.
110. A nurse is going to suction an adult client with a tracheostomy who has copious amounts of secretions. The nurse does which of the following to accomplish this procedure
safely and effectively?
Options:
A) Occludes the Y-port of the catheter while advancing it into the tracheostomy
B) Applies continuous suction in the airway for up to 20 seconds
C) Hyperoxygenates the client after the procedure only
D) Sets the wall suction pressure range between 80 to 120 mmHg
Correct Answer is: D
Explanation : The safe wall suction range of an adult is 80 to 120 mmHg (120 to 150 mmHg with the tubing occluded), making option 4 the action that is consistent with safe and
effective practice. The nurse should hyperoxygenate the client both before and after suctioning. The nurse should advance the catheter into the tracheostomy without occluding
the Y-port to minimize mucosal trauma and aspiration of the client’s oxygen. The nurse should use intermittent suction in the airway (not constant) for up to 10 to 15 seconds.
111. A nurse is caring for a hospitalized client who has been taking clozapine (Clozaril) for the treatment of a schizophrenic disorder, and the nurse reviews the laboratory studies
that have been prescribed for the client. Which laboratory study will the nurse specifically review to monitor for an adverse effect associated with the use of this medication?
Options:
A) White blood cell count
B) Platelet count
C) Cholesterol level
D) Blood urea nitrogen
,Correct Answer is: A
Explanation : Hematological reactions can occur in the client taking clozapine and include agranulocytosis and mild leucopenia. The white blood cell count should be assessed
before initiating treatment and should be monitored closely during the use of this medication. The client should also be monitored for signs indicating agranulocytosis, which
may include sore throat, malaise, and fever. Options 2, 3, and 4 are unrelated to the use of this medication.
112. A nurse is monitoring the function of a client’s chest tube. The chest tube is attached to a Pleur-Evac drainage system. The nurse notes that the fluid in the water seal
chamber is below the 2 cm mark. The nurse determines that:
Options:
A) Suction should be added to the system
B) There is a leak in the system
C) This is caused by client pneumothorax
D) Water should be added to the chamber
Correct Answer is: D
Explanation : The water seal chamber should be filled to the 2 cm mark to provide an adequate water seal between the external environment and client’s pleural cavity. The water
seal prevents air from reentering the pleural cavity. Because evaporation of water can occur, the nurse should remedy this problem by adding water until the level is again at the
2 cm mark. The other interpretations are incorrect.
113. A client has decided to use a transcutaneous electrical nerve stimulation (TENS) as prescribed by the physician for the relief of chronic pain, and the nurse has provided
instructions to the client regarding the TENS unit. Which statement by the client would indicate a need for further instructions regarding this pain relief measure?
Options:
A) “I am not sure that I am going to like those electrodes attached to my skin.”
B) “I am not real happy that I have to stay in the hospital for this treatment.”
C) “This unit will eliminate the need for taking so many pain medications.”
D) “I understand that this will help relieve the pain.”
Correct Answer is: B
Explanation : The TENS unit is a portable unit, and the client controls the system for relieving pain and reducing and need for analgesics. It is attached to the skin of the body by
electrodes. It is not necessary that the client remain in the hospital for this treatment.
114. A client with chronic renal failure has a protein restriction in the diet. The nurse would include in a teaching plan to avoid which of the following sources of incomplete
protein in the diet?
Options:
A) Nuts
B) Eggs
C) Milk
D) Fish
Correct Answer is: A
Explanation : The client whose diet has a protein restriction should be careful to ensure that the proteins eaten are complete proteins with highest biologic value. Foods such as
meat, fish milk, and eggs are complete proteins, which are optimal for the client with chronic renal failure.
115. A newborn infant is diagnosed with imperforate anus. The nurse plans care, knowing that which of the following most appropriately describes a characteristic of this
disorder?
Options:
A) Incomplete development of the anus
B) Invagination of a section of the intestine into the distal bowel
C) The infrequent and difficult passage of dry stools
D) The presence of fecal incontinence
Correct Answer is: A
Explanation : Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum. Option 2 describes
intussusception. Option 3 describes constipation. Option 4 describes encopresis. Constipation can affect any child at any time, although it peaks at age 2 to 3 years, Encopresis
generally affects preschool and school-aged children.
116. A nurse is providing bottle-feeding instructions to the mother of a newborn infant. The nurse provides instructions regarding the amount of formula to be given, knowing
that the stomach capacity for a newborn infant is approximately:
Options:
A) 5 to 10 mL
B) 10 to 20 mL
C) 30 to 90 mL
D) 75 to 100 mL
Correct Answer is: B
Explanation : The stomach capacity of a newborn infant is approximately 10 to 20 mL. It is 30 to 90 mL for a 1-week-old infant, and 75 to 100 mL for a 2- to 3-week-old infant.
117. A mother who is breastfeeding her newborn infant is experiencing nipple soreness, and the nurse provides instructions regarding measures to relieve the soreness. Which
statement by the mother indicates an understanding of the instructions?
, Options:
A) “I need to avoid rotating breastfeeding positions so that the nipple will toughen.”
B) “I need to stop nursing during the period of nipple soreness to allow the nipples to heal.”
C) “I need to nurse less frequently and substitute a bottle feeding until the nipples becomes less more.”
D) “I need to position my infant with her ear, shoulder, and hip in straight alignment and place her stomach against me.”
Correct Answer is: D
Explanation : Comfort measures for nipple soreness include positioning the infant with the ear, shoulder, and hip in straight alignment and with the infant’s stomach against the
mother’s. Additional measures include rotating breastfeeding positions breaking suction with the little finger; nursing frequently; beginning feeding on the less sore nipple; not
allowing the infant to chew on the nipple or to sleep holding the nipple in the mouth; and applying tea bags soaked in warm water to the nipple. Options 1, 2, and 3 are incorrect.
118. A client with acute myocardial infarction receivews therapy with altepalse recombinant, or tissue plasminogen activator (tPA), and the nurse monitors the client for
complications of this treatment. Which finding would indicate a possible complication?
Options:
A) Epistaxis
B) Vomiting
C) ECG changes
D) Absent pedal pulses
Correct Answer is: A
Explanation : Bleeding is a major side effect of t-PA therapy. The bleeding can be superficial on internal and can be spontaneous. Options 2, 3, and 4 are not side or adverse
effects of t-PA therapy.
119. A nurse is performing an assessment on a mother who just delivered a healthy newborn infant. The nurse checks the uterine fundus, expecting to note that the fundus is
positioned:
Options:
A) At the level of the umbilicus
B) Above the level of the umbilicus
C) One fingerbreadth above the symphysis pubis
D) To the right of the abdomen
Correct Answer is: A
Explanation : Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. If the
fundus is above the umbilious, this may indicate that blood clots in the uterus need to be expelled by fundal massage. A fundus that is not located in the midline may indicate a
full bladder.
120. A nurse obtains the vital signs on a mother who delivered a healthy newborn infant 2 hours ago and notes that the mother’s temperature is 120oF. The most appropriate
nursing action would be to:
Options:
A) Document the finding and recheck the temperature in 4 hours
B) Notify the physician
C) Administer acetaminophen (Tylenol) and recheck the temperature in 4 hours
D) Remove the blanket from the client’s bed
Correct Answer is: B
Explanation : Vital signs return to normal within the first hour postpartum if no complications arise. If the temperature is greater than 2 F above normal, this may indicate
infection, and the physician should be notified. Options 1, 3, and 4 are inaccurate nursing interventions for a temperature of 102oF 2 hours following delivery.
121. A nurse in the postpartum unit is caring for a mother following vaginal delivery of a healthy newborn infant. The client received epidural anesthesia for the delivery. One-half
hour after admission to the postpartum unit, the nurse checks the client and suspects the presence of a vaginal hematoma. Which finding would be the best indicator of the
presence of this type of hematoma?
Options:
A) Client complaints of tearing sensation
B) Client complaints of intense vaginal pressure
C) Changes in vital signs
D) Sings of vaginal bruising
Correct Answer is: C
Explanation : Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with a vaginal hematoma. Because the client received anesthesia, she would
not feel pain or pressure. Vaginal bruising may be present, but this may be a result of the delivery process and additionally is not the best indicator of the presence of a
hematoma.
122. A client with acute renal failure has an elevated blood urea nitrogen (BUN). The client is experiencing difficulty remembering information due to uremia. The nurse avoids
which of the following when communicating with this client?
Options:
A) Include the family in discussions related to care
B) Give thorough, lengthy explanations of procedures
C) Give simple, clear directions
D) Explain treatments using understandable language
