Question 1
A nurse who has recently completed orientation is beginning work in the labor and
delivery unit for the first time. When making assignments, which client should the charge
nurse assign to this new nurse?
A.A primigravida who is 8 cm dilated after 14 hours of labor
B.A client scheduled for a repeat cesarean birth at 38 weeks' gestation
C.A client being induced for fetal demise at 20 weeks' gestation
D.A multiparous client who is dilated 5 cm and 50% effaced
CORRECT ANSWER
D
The new nurse should be assigned the least complicated client to gain experience and
confidence, as well as protect client safety. Of the clients available for assignment, (D) is
progressing well and is the least complicated. (A, B and C) have actual or potential
complications and should be assigned to a more experienced nurse.
Question 2
A client with human immunodeficiency virus (HIV) infection has white lesions in the oral
cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish
and swallow. Which information is most important for the nurse to provide the client?
A.Oral hygiene should be performed before the medication. B.Antifungal medications are
available in tablet, suppository, and liquid forms.
C.Candida albicans is the organism that causes the white lesions in the mouth.
D.The dietary intake of dairy and spicy foods should be limited.
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@THE STUDY VAULT
,CORRECT ANSWER
A
HIV infection causes depression of cell-mediated immunity that allows an overgrowth of
Candida albicans (oral moniliasis), which appears as white, cheesy plaque or lesions that
resemble milk curds. To ensure effective contact of the medication with the oral lesions,
oral liquids should be consumed and oral hygiene performed before swishing the liquid
Mycostatin (A). (B and C) provide the client with additional information about the
pathogenesis and treatment of opportunistic infections, but (A) allows the client to
participate in self-care of the oral infection. Dietary restriction of spicy foods reduces
discomfort associated with stomatitis, but restriction of dairy products is not indicated
(D).
Question 3
A client who is admitted with emphysema is having difficulty breathing. In which position
should the nurse place the client?
A.High Fowler's position without a pillow behind the head
B.Semi-Fowler's position with a single pillow behind the head
C.Right side-lying position with the head of the bed elevated 45 degrees
D.Sitting upright and forward with both arms supported on an over the bed table
CORRECT ANSWER
D
Adequate lung expansion is dependent on deep breaths that allow the respiratory
muscles to increase the longitudinal and anterior-posterior size of the thoracic cage.
Sitting upright and leaning forward with the arms supported on an over the bed table (D)
allows the thoracic cage to expand in all four directions and reduces dyspnea. A high
Fowler's position does not allow maximum expansion of the posterior lobes of the lungs
(A). A semi-Fowler's position restricts expansion of the anterior-posterior diameter of the
thoracic cage (B). Positioning a client on the right side with the head of the bed elevated
(C) does not facilitate lung expansion.
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@THE STUDY VAULT
,Question 4
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ)
PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the client's
serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium
level?
A.The client is noncompliant with his medications.
B.The client recently consumed large quantities of pears or nuts.
C.The client's renal function has affected his potassium level.
D.The client needs to be started on a potassium supplement.
CORRECT ANSWER
C
The client has a normalized potassium level despite diuretic use (C). The kidney
automatically secretes 90% of potassium consumed, but in chronic renal insufficiency
(CRI), less potassium is excreted than normal. Therefore, the two potassium-wasting
drugs, a thiazide diuretic and loop diuretic, are not likely to affect potassium levels. The
normal potassium level is 3.5 to 5 mEq/L, and with a potassium level of 4 mEq/L, there is
no reason to believe that the client is noncompliant with his treatment (A). Pears and
nuts do not affect the serum potassium level (B). There is no need for a potassium
supplement (D) because the client's potassium level is within the normal range.
Question 5
A registered nurse (RN) delivers telehealth services to clients via electronic
communication. Which nursing action creates the greatest risk for professional liability
and has the potential for a malpractice lawsuit?
A.Participating in telephone consultations with clients
B.Identifying oneself by name and title to clients in telehealth communications
C.Sending medical records to health care providers via the Internet
D.Answering a client-initiated health question via electronic mail
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@THE STUDY VAULT
, CORRECT ANSWER
C
Sending medical records over the Internet, even with the latest security protection,
creates the greatest risk for liability because of the high potential of breaching client
confidentiality and the amount of information being transferred (C). Client confidentiality
is protected by federal wiretapping laws making telephone consultation (A) a private and
protected form of communication. By stating one's name and credentials in telehealth
communication (B), one is taking responsibility for the encounter. E-mail initiated by the
client (D) poses less risk than sending records via the Internet.
Question 6
Which pathophysiologic response supports the contraindication for opioids, such as
morphine, in clients with increased intracranial pressure (ICP)?
A.Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated.
B.Higher doses of opioids are required when cerebral blood flow is reduced by an elevated
ICP.
C.Dysphoria from opioids contributes to altered levels of consciousness with an elevated
ICP.
D.Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP.
CORRECT ANSWER
D
The greatest risk associated with opioids such as morphine (D) is respiratory depression
that causes an increase in Pco2, which increases ICP and masks the early signs of
intracranial bleeding in head injury. (A, B, and C) do not support the risks associated with
opioid use in a client with increased ICP.
Question 7
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@THE STUDY VAULT
A nurse who has recently completed orientation is beginning work in the labor and
delivery unit for the first time. When making assignments, which client should the charge
nurse assign to this new nurse?
A.A primigravida who is 8 cm dilated after 14 hours of labor
B.A client scheduled for a repeat cesarean birth at 38 weeks' gestation
C.A client being induced for fetal demise at 20 weeks' gestation
D.A multiparous client who is dilated 5 cm and 50% effaced
CORRECT ANSWER
D
The new nurse should be assigned the least complicated client to gain experience and
confidence, as well as protect client safety. Of the clients available for assignment, (D) is
progressing well and is the least complicated. (A, B and C) have actual or potential
complications and should be assigned to a more experienced nurse.
Question 2
A client with human immunodeficiency virus (HIV) infection has white lesions in the oral
cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish
and swallow. Which information is most important for the nurse to provide the client?
A.Oral hygiene should be performed before the medication. B.Antifungal medications are
available in tablet, suppository, and liquid forms.
C.Candida albicans is the organism that causes the white lesions in the mouth.
D.The dietary intake of dairy and spicy foods should be limited.
1
@THE STUDY VAULT
,CORRECT ANSWER
A
HIV infection causes depression of cell-mediated immunity that allows an overgrowth of
Candida albicans (oral moniliasis), which appears as white, cheesy plaque or lesions that
resemble milk curds. To ensure effective contact of the medication with the oral lesions,
oral liquids should be consumed and oral hygiene performed before swishing the liquid
Mycostatin (A). (B and C) provide the client with additional information about the
pathogenesis and treatment of opportunistic infections, but (A) allows the client to
participate in self-care of the oral infection. Dietary restriction of spicy foods reduces
discomfort associated with stomatitis, but restriction of dairy products is not indicated
(D).
Question 3
A client who is admitted with emphysema is having difficulty breathing. In which position
should the nurse place the client?
A.High Fowler's position without a pillow behind the head
B.Semi-Fowler's position with a single pillow behind the head
C.Right side-lying position with the head of the bed elevated 45 degrees
D.Sitting upright and forward with both arms supported on an over the bed table
CORRECT ANSWER
D
Adequate lung expansion is dependent on deep breaths that allow the respiratory
muscles to increase the longitudinal and anterior-posterior size of the thoracic cage.
Sitting upright and leaning forward with the arms supported on an over the bed table (D)
allows the thoracic cage to expand in all four directions and reduces dyspnea. A high
Fowler's position does not allow maximum expansion of the posterior lobes of the lungs
(A). A semi-Fowler's position restricts expansion of the anterior-posterior diameter of the
thoracic cage (B). Positioning a client on the right side with the head of the bed elevated
(C) does not facilitate lung expansion.
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@THE STUDY VAULT
,Question 4
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ)
PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the client's
serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium
level?
A.The client is noncompliant with his medications.
B.The client recently consumed large quantities of pears or nuts.
C.The client's renal function has affected his potassium level.
D.The client needs to be started on a potassium supplement.
CORRECT ANSWER
C
The client has a normalized potassium level despite diuretic use (C). The kidney
automatically secretes 90% of potassium consumed, but in chronic renal insufficiency
(CRI), less potassium is excreted than normal. Therefore, the two potassium-wasting
drugs, a thiazide diuretic and loop diuretic, are not likely to affect potassium levels. The
normal potassium level is 3.5 to 5 mEq/L, and with a potassium level of 4 mEq/L, there is
no reason to believe that the client is noncompliant with his treatment (A). Pears and
nuts do not affect the serum potassium level (B). There is no need for a potassium
supplement (D) because the client's potassium level is within the normal range.
Question 5
A registered nurse (RN) delivers telehealth services to clients via electronic
communication. Which nursing action creates the greatest risk for professional liability
and has the potential for a malpractice lawsuit?
A.Participating in telephone consultations with clients
B.Identifying oneself by name and title to clients in telehealth communications
C.Sending medical records to health care providers via the Internet
D.Answering a client-initiated health question via electronic mail
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@THE STUDY VAULT
, CORRECT ANSWER
C
Sending medical records over the Internet, even with the latest security protection,
creates the greatest risk for liability because of the high potential of breaching client
confidentiality and the amount of information being transferred (C). Client confidentiality
is protected by federal wiretapping laws making telephone consultation (A) a private and
protected form of communication. By stating one's name and credentials in telehealth
communication (B), one is taking responsibility for the encounter. E-mail initiated by the
client (D) poses less risk than sending records via the Internet.
Question 6
Which pathophysiologic response supports the contraindication for opioids, such as
morphine, in clients with increased intracranial pressure (ICP)?
A.Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated.
B.Higher doses of opioids are required when cerebral blood flow is reduced by an elevated
ICP.
C.Dysphoria from opioids contributes to altered levels of consciousness with an elevated
ICP.
D.Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP.
CORRECT ANSWER
D
The greatest risk associated with opioids such as morphine (D) is respiratory depression
that causes an increase in Pco2, which increases ICP and masks the early signs of
intracranial bleeding in head injury. (A, B, and C) do not support the risks associated with
opioid use in a client with increased ICP.
Question 7
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@THE STUDY VAULT
