NCLEX.Braindumps.NCLEX-PN by Nelda

NCLEX-PN QUESTION 1 A middle-aged woman tells the nurse that she has been experiencing irregular menses for the past six months. The nurse should assess the woman for other symptoms of: A. climacteric. B. menopause. C. perimenopause. D. postmenopause. Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: Perimenopause refers to a period of time in which hormonal changes occur gradually, ovarian function diminishes, and menses become irregular. Perimenopause lasts approximately five years. Climacteric is a term applied to the period of life in which physiologic changes occur and result in cessation of a woman's reproductive ability and lessened sexual activity in males. The term applies to both genders. Climacteric and menopause are interchangeable terms when used for females. Menopause is the period when permanent cessation of menses has occurred. Postmenopause refers to the period after the changes accompanying menopause are complete.Health Promotion and Maintenance QUESTION 2 When obtaining a health history on a menopausal woman, which information should a nurse recognize as a contraindication for hormone replacement therapy? A. familyhistoryofstroke B. ovariesremovedbeforeage45 C. frequent hot flashes and/or night sweats D. unexplained vaginal bleeding Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: Unexplained vaginal bleeding is a contraindication for hormone replacement therapy. Family history of stroke is not a contraindication for hormone replacement therapy. If the woman herself had a history of stroke or other blood-clotting events, hormone therapy could be contraindicated. Frequent hot flashes and/or night sweats can be relieved by hormone replacement therapy.Health Promotion and Maintenance QUESTION 3 Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care? A. "Ishouldputalcoholonmybaby'scord34timesaday." B. "Ishouldputthebaby'sdiaperonsothatitcoversthecord." C. "I should call the physician if the cord becomes dark." D. "I should wash my hands before and after I take care of the cord." Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: Parents should be taught to wash their hands before and after providing cord care. This prevents transferring pathogens to and from the cord. Folding the diaper below the cord exposes the cord to air and allows for drying. It also prevents wet or soiled diapers from coming into contact with the cord. Current recommendations include cleaning the area around the cord 34 times a day with a cotton swab but do not include putting alcohol or other antimicrobials on the cord. It is normal for the cord to turn dark as it dries.Health Promotion and Maintenance QUESTION 4 The nurse is teaching parents of a newborn about feeding their infant. Which of the following instructions should the nurse include? A. Usethedefrostsettingonmicrowaveovenstowarmbottles. B. Whenrefrigeratingformula,don'tfeedthebabypartiallyusedbottlesafter24hours. C. When using formula concentrate, mix two parts water and one part concentrate. D. If a portion of one bottle is left for the next feeding, go ahead and add new formula to fill it. Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: Parents must be careful when warming bottles in a microwave oven because the milk can become superheated. When a microwave oven is used, the defrost setting should be chosen, and the temperature of the formula should be checked before giving it to the baby. Refrigerated, partially used bottles should be discarded after 4 hours because the baby might have introduced some pathogens into the formula. Returning the bottle to the refrigerator does not destroy pathogens. Formula concentrate and water are usually mixed in a 1:1 ratio of one part concentrate and one part water. Infants should be offered fresh formula at each feeding. Partially used bottles should not have fresh formula added to them. Pathogens can grow in partially used bottles of formula and be transferred to the new formula.Health Promotion and Maintenance QUESTION 5 The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine? A. 6 B. 8 C. 12 D. 16 Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: In general, children begin dentition around 6 months of age. During the first 2 years of life, a quick guide to the number of teeth a child should have is as follows: Subtract the number 6 from the number of months in the age of the child. In this example, the child is 18 months old, so the formula is 18 6 = 12. An 18-month-old child should have approximately 12 teeth.Health Promotion and Maintenance QUESTION 6 Which of the following physical findings indicates that an 1112-month-old child is at risk for developmental dysplasia of the hip? A. refusaltowalk B. notpullingtoastandingposition C. negative Trendelenburg sign D. negative Ortolani sign Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: The nurse might be concerned about developmental dysplasia of the hip if an 1112-month-old child doesn't pull to a standing position. An infant who does not walk by 15 months of age should be evaluated. Children should start walking between 1115 months of age. Trendelenberg sign is related to weakness of the gluteus medius muscle, not hip dysplasia. Ortolani sign is used to identify congenital subluxation or dislocation of the hip in infants.Health Promotion and Maintenance QUESTION 7 When administering intravenous electrolyte solution, the nurse should take which of the following precautions? A. Infusehypertonicsolutionsrapidly. B. Mixnomorethan80mEqofpotassiumperliteroffluid. C. Prevent infiltration of calcium, which causes tissue necrosis and sloughing. D. As appropriate, reevaluate the client's digitalis dosage. He might need an increased dosage because IV calcium diminishes digitalis's action. Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: Preventing tissue infiltration is important to avoid tissue necrosis. Choice 1 is incorrect because hypertonic solutions should be infused cautiously and checked with the RN if there is a concern. Choice 2 is incorrect because potassium, mixed in the pharmacy per physician order, is mixed at a concentration no higher than 60 mEq/ L. Physiological Adaptation QUESTION 8 Teaching about the need to avoid foods high in potassium is most important for which client? A. aclientreceivingdiuretictherapy B. aclientwithanileostomy C. a client with metabolic alkalosis D. a client with renal disease Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. Choices 1, 2, and 3 are incorrect because clients receiving diuretics with ileostomy or with metabolic alkalosis are at risk for hypokalemia and should be encouraged to eat foods high in potassium.Physiological Adaptation QUESTION 9 What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36mmHg, and HCO3 24 mEq/ L? A. metabolicalkalosis B. homeostasis C. respiratoryacidosis D. respiratoryalkalosis Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: These ABG values are within normal limits. Choices 1, 3, and 4 are incorrect because the ABG values indicate none of these acid-base disturbances.Physiological Adaptation QUESTION 10 The major electrolytes in the extracellular fluid are: A. potassiumandchloride. B. potassiumandphosphate. C. sodium and chloride. D. sodium and phosphate. Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: Sodium and chloride are the major electrolytes in the extracellular fluid.Physiological Adaptation QUESTION 11 A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image? A. administeringimmuneglobulinintravenously B. assessingtheextremitiesforedema,rednessanddesquamationevery8hours C. explaining progression of the disease to the client and his or her family D. assessing heart sounds and rhythm Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: Teaching the client and family about progression of the disease includes explaining when symptoms can be expected to improve and resolve. Knowledge of the course of the disease can help them understand that no permanent disruption in physical appearance will occur that could negatively affect body image. Clients with Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary artery lesions and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to body image. The nurse assesses symptoms to assist in evaluation of treatment and progression of the disease.Health Promotion and Maintenance QUESTION 12 Which of the following is most likely to impact the body image of an infant newly diagnosed with Hemophilia? A. immobility B. alteredgrowthanddevelopment C. hemarthrosis D. alteredfamilyprocesses Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: Altered Family Processes is a potential nursing diagnosis for the family and client with a new diagnosis of Hemophilia. Infants are aware of how their caregivers respond to their needs. Stresses can have an immediate impact on the infant's development of trust and how others relate to them because of their diagnosis. The longterm effects of hemophilia can include problems related to immobility. Altered growth and development could not have developed in a newly diagnosed client. Hemarthrosis is acute bleeding into a joint space that is characteristic of hemophilia. It does not have an immediate effect on the body image of a newly diagnosed hemophiliac.Health Promotion and Maintenance QUESTION 13 While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse? A. "Iwillassistyouinarrangingtohaveamedicinewomanpresent." B. "Wedonotallowmedicinewomeninexamrooms." C. "That does not make any difference in the outcome." D. "It is old-fashioned to believe in that." Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: This statement reflects cultural awareness and acceptance that receiving support from a medicine woman is important to the client. The other statements are culturally insensitive and unprofessional.Reduction of Risk Potential QUESTION 14 All of the following should be performed when fetal heart monitoring indicates fetal distress except: A. increasematernalfluids. B. administeroxygen. C. decrease maternal fluids. D. turn the mother. Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: Decreasing maternal fluids is the only intervention that shouldnotbe performed when fetal distress is indicated.Reduction of Risk Potential QUESTION 15 Which fetal heart monitor pattern can indicate cord compression? A. variabledecelerations B. earlydecelerations C. bradycardia D. tachycardia Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: Variable decelerations can be related to cord compression. The other patterns are not.Reduction of Risk Potential QUESTION 16 Which of the following conditions is mammography used to detect? A. pain B. tumor C. edema D. epilepsy Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: Mammography is used to detect tumors or cysts in the breasts, not the other conditions.Reduction of Risk Potential QUESTION 17 Why might breast implants interfere with mammography? A. Theymightcauseadditionaldiscomfort. B. Theyarecontraindicationstomammography. C. Theyarelikelytobedislodged. D. They might prevent detection of masses. Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: Breast implants can prevent detection of masses. Choices 1, 2, and 3 are not ways in which breast implants interfere with mammography.Reduction of Risk Potential QUESTION 18 Which of the following instructions should the nurse give a client who will be undergoing mammography? A. Besuretouseunderarmdeodorant. B. Donotuseunderarmdeodorant. C. Do not eat or drink after midnight. D. Have a friend drive you home. Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: Underarm deodorant should not be used because it might cause confusing shadows on the X-ray film. There are no restrictions on food or fluid intake. No sedation is used, so the client can drive herself home.Reduction of Risk Potential QUESTION 19 Which of the following diseases or conditions is least likely to be associated with increased potential for bleeding? A. metastaticlivercancer B. gram-negativesepticemia C. pernicious anemia D. iron-deficiencyanemia Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: Pernicious anemia results from vitamin B12 deficiency due to lack of intrinsic factor. This can result from inadequate dietary intake, faulty absorption from the GI tract due to a lack of secretion of intrinsic factor normally produced by gastric mucosal cells and certain disorders of the small intestine that impair absorption. The nurse should instruct the client in the need for lifelong replacement of vitamin B12, as well as the need for folic acid, rest, diet, and support.Physiological Adaptation QUESTION 20 A client has been diagnosed with Disseminated Intravascular Coagulation (DIC) and transferred to the medical intensive care unit (ICU) subsequent to an acute bleeding episode. In the ICU, continuous Heparin drip therapy is initiated. Which of the following assessment findings indicates a positive response to Heparin therapy? A. increasedplateletcount B. increasedfibrinogen C. decreased fibrin split products D. decreased bleeding Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: Effective Heparin therapy should stop the process of intravascular coagulation and result in increased availability of fibrinogen. Heparin administration interferes with thrombin-induced conversion of fibrinogen to fibrin. Bleeding should cease due to the increased availability of platelets and coagulation factors.Physiological Adaptation QUESTION 21 A client, age 28, was recently diagnosed with Hodgkin's disease. After staging, therapy is planned to include combination radiation therapy and systemic chemotherapy with MOPP-- nitrogen mustard, vincristine (Onconvin), prednisone, and procarbazine. In planning care for this client, the nurse should anticipate which of the following side effects to contribute to a sense of altered body image? A. cushingoidappearance B. alopecia C. temporary or permanent sterility D. pathologic fractures Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: Pathologic fractures are not common to the disease process. Its treatment through osteoporosis is a potential complication of steroid use. Hodgkin's disease most commonly affects young adults (males), is spread through lymphatic channels to contiguous nodes, and also might spread via the hematogenous route to extradal sites (GI, bone marrow, skin, and other organs). A working staging classification is performed for clinical use and care. Physiological Adaptation QUESTION 22 Which of the following is an inappropriate item to include in planning care for a severely neutropenic client? A. Transfusenetrophils(granulocytes)topreventinfection. B. Excluderawvegetablesfromthediet. C. Avoidadministeringrectalsuppositories. D. Prohibit vases of fresh flowers and plants in the client's room. Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: Granulocyte transfusion is not indicated to prevent infection. Produced in the bone marrow, granulocytes normally comprise 70% of all WBCs. They are subdivided into three types based on staining properties: neutrophils, eosinophils, and basophils. They can be beneficial in a selected population of infected, severely granulocytopenic clients (less than 500/mm3) who do not respond to antibiotic therapy and who are expected to experience prolonged suppression of granulocyte production.Physiological Adaptation QUESTION 23 Which sign might the nurse see in a client with a high ammonia level? A. coma B. edema C. hypoxia D. polyuria Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: Coma might be seen in a client with a high ammonia level.Reduction of Risk Potential QUESTION 24 A client with which of the following conditions is at risk for developing a high ammonia level? A. renalfailure B. psoriasis C. lupus D. cirrhosis Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: A client with cirrhosis is at risk for developing a high ammonia level.Reduction of Risk Potential QUESTION 25 For which of the following conditions might blood be drawn for uric acid level? A. asthma B. gout C. diverticulitis D. meningitis Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: Uric acid levels are indicated for clients with gout.Reduction of Risk Potential QUESTION 26 Which of the following foods might a client with a hypercholesterolemia need to decrease his or her intake of? A. broiledcatfish B. hamburgers C. wheat bread D. fresh apples Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: Due to the high cholesterol content of red meats, such as hamburger, intake needs to be decreased. The other options do not have high cholesterol content, so they do not need to be decreased.Reduction of Risk Potential QUESTION 27 Which of the following lab values is associated with a decreased risk of cardiovascular disease? A. highHDLcholesterol B. lowHDLcholesterol C. low total cholesterol D. low triglycerides Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: High HDL cholesterol and low LDL cholesterol are associated with a decreased risk of cardiovascular disease.Reduction of Risk Potential QUESTION 28 Which of the following organs of the digestive system has a primary function of absorption? A. stomach B. pancreas C. small intestine D. gallbladder Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: The small intestine has a primary function of absorption. The remaining digestive organs have other primary functions.Physiological Adaptation QUESTION 29 For a client with suspected appendicitis, the nurse should expect to find abdominal tenderness in which quadrant? A. upperright B. upperleft C. lower right D. lower left Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: The nurse should expect to find abdominal tenderness in the lower-right quadrant in a client with appendicitis. Physiological Adaptation QUESTION 30 A 20-year-old obese female client is preparing to have gastric bypass surgery for weight loss. She says to the nurse, "I need this surgery because nothing else I have done has helped me to lose weight." Which response by the nurse is most appropriate? A. "Ifyoueatless,youcansavesomemoney." B. "Exerciseisahealthierwaytoloseweight." C. "You should try the Atkins diet first." D. "I respect your decision to choose surgery." Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: This statement is most appropriate, as it shows respect and empathy. The other statements are both insensitive and unprofessional.Physiological Adaptation QUESTION 31 A pregnant Asian client who is experiencing morning sickness wants to take ginger to relieve the nausea. Which of the following responses by the nurse is appropriate? A. "Iwillcallyourphysiciantoseeifwecanstartsomeginger." B. "Wedon'tusehomeremediesinthisclinic." C. "Herbs are not as effective as regular medicines." D. "Just eat some dry crackers instead." Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: This statement reveals cultural sensitivity. Ginger is sometimes used to relieve nausea. The other statements are culturally insensitive and do not show an awareness of herbal pharmacology.Physiological Adaptation QUESTION 32 Which of the following medications is a serotonin antagonist that might be used to relieve nausea and vomiting? A. metoclopramide(Reglan) B. onedansetron(Zofran) C. hydroxyzine (Vistaril) D. prochlorperazine (Compazine) Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: Zofran is a serotonin antagonist that can be used to relieve nausea and vomiting. The other medications can be used for nausea and vomiting, but they have different mechanisms of action.Physiological Adaptation QUESTION 33 Which of the following is likely to increase the risk of sexually transmitted disease? A. alcoholuse B. certaintypesofsexualpractices C. oral contraception use D. all of the above Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: STDs affect certain groups in groups in greater numbers. Factors associated with risk include being younger than 25 years of age, being a member of a minority group, residing in an urban setting, being impoverished, and using crack cocaine.Physiological Adaptation QUESTION 34 Teaching the client with gonorrhea how to prevent reinfection and further spread is an example of: A. primaryprevention. B. secondaryprevention. C. tertiaryprevention. D. primary health care prevention. Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: Secondary prevention targets the reduction of disease prevalence and disease morbidity through early diagnosis and treatment.Physiological Adaptation QUESTION 35 The nurse teaching about preventable diseases should emphasize the importance of getting the following vaccines: A. humanpapillomavirus,genitalherpes,measles. B. pneumonia,HIV,mumps. C. syphilis, gonorrhea, pneumonia. D. polio, pertussis, measles. Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: Vaccines are one of the most effective methods of preventing and controlling certain communicable diseases. The smallpox vaccine is not currently in use because the smallpox virus has been declared eradicated from the world's population. Diseases such as polio, diphtheria, pertussis, and measles are mostly controlled by routine childhood immunization. They have not, however, been eradicated, so children need to be immunized against these diseases.Physiological Adaptation QUESTION 36 Acyclovir is the drug of choice for: A. HIV. B. HSV1and2andVZV. C. CMV. D. influenza A viruses. Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: Acyclovir (Zovirax) is specific for treatment of herpes virus infections. There is no cure for herpes. Acyclovir is excreted unchanged in the urine and therefore must be used cautiously in the presence of renal impairment. Drugs that treat herpes inhibit viral DNA replication by competing with viral substrates to form shorter, ineffective DNA chains.Physiological Adaptation QUESTION 37 A safety measure to implement when transferring a client with hemiparesis from a bed to a wheelchair is: A. standingtheclientandwalkinghimorhertothewheelchair. B. movingthewheelchairclosetoclient'sbedandstandingandpivotingtheclientonhisunaffected extremity to the wheelchair. C. moving the wheelchair close to client's bed and standing and pivoting the client on his affected extremity to the wheelchair. D. having the client stand and push his body to the wheelchair. Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: Moving the wheelchair close to client's bed and having him stand and pivot on his unaffected extremity to the wheelchair is safer because it provides support with the unaffected limb.Basic Care and Comfort QUESTION 38 Assessment of a client with a cast should include: A. capillaryrefill,warmtoes,nodiscomfort. B. posteriortibialpulses,warmtoes. C. moist skin essential, pain threshold. D. discomfort of the metacarpals. Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: Assessment for adequate circulation is necessary. Signs of impaired circulation include slow capillary refill, cool fingers or toes, and pain.Basic Care and Comfort QUESTION 39 In teaching clients with Buck's Traction, the major areas of importance should be: A. nutrition,ROMexercises. B. ROMexercises,transportation. C. nutrition, elimination, comfort, safety. D. elimination, safety, isotonic exercises. Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: Nutrition, elimination, comfort, and safety are the major areas of importance. The diet should be high in protein with adequate fluids.Basic Care and Comfort QUESTION 40 When a client informs the nurse that he is experiencing hypoglycemia, the nurse provides immediate intervention by providing: A. onecommerciallypreparedglucosetablet. B. twohardcandies. C. 46 ounces of fruit juice with 1 teaspoon of sugar added. D. 23 teaspoons of honey. Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: The usual recommendation for treatment of hypoglycemia is 1015 grams of a fast-acting simple carbohydrate, orally, if the client is conscious and able to swallow (for example, 34 commercially prepared glucose tablets or 46 oz of fruit juice). It is not necessary to add sugar to juice, even if it is labeled as unsweetened juice because the fruit sugar in juice contains enough simple carbohydrate to raise the blood glucose level. Addition of sugar might result in a sharp rise in blood sugar that could last for several hours.Physiological Adaptation QUESTION 41 A client comes to the clinic for assessment of his physical status and guidelines for starting a weight- reduction diet. The client's weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as: A. withinnormallimits,soaweight-reductiondietisunnecessary. B. lowerthannormal,soeducationaboutnutrient-densefoodsisneeded. C. indicating obesity because the BMI is 35. D. indicating overweight status because the BMI is 27. Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. It is calculated by utilizing a chart or nomogram that plots height and weight. This client's BMI is 35, indicating obesity. Goals of diet therapy are aimed at decreasing weight and increasing activity to healthy levels based on a client's BMI, activity status, and energy requirements.Physiological Adaptation QUESTION 42 Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority? A. openlegfracture B. openheadinjury C. stab wound to the chest D. traumatic amputation of a thumb Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of ABC (airway, breathing, and circulation) prioritizes care decisions.Physiological Adaptation QUESTION 43 Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma? A. Theclothingisthepropertyofanotherandmustbetreatedwithcare. B. Suchcarefacilitatesrepairandsalvageoftheclothing. C. The clothing of a trauma victim is potential evidence with legal implications. D. Such care decreases trauma to the family members receiving the clothing. Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until is has served its purpose in the legal investigation of an incident.Physiological Adaptation QUESTION 44 Which of the following terms refers to soft-tissue injury caused by blunt force? A. contusion B. strain C. sprain D. dislocation Correct Answer: A Section: (none) Explanation Explanation/Reference: Explanation: A contusion is a soft-tissue injury caused by blunt force. It is an injury that does not break the skin, is caused by a blow and is characterized by swelling, discoloration, and pain. The immediate application of cold might limit the development of a contusion. A strain is a muscle pull from overuse, overstretching, or excessive stress. A sprain is caused by a wrenching or twisting motion. A dislocation is a condition in which the articular surfaces of the bones forming a joint are no longer in anatomic contact.Physiological Adaptation QUESTION 45 A client with dumping syndrome should ___________ while a client with GERD should ___________. A. situp1houraftermeals;lieflat30minutesaftermeals B. liedown1houraftereating;situpatleast30minutesaftereating C. sit up after meals; sit up after meals D. lie down after meals; lie down after meals Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: Clients with dumping syndrome should lie down after eating to decrease dumping syndrome. GERD clients should sit up to prevent backflow of acid into the esophagus.Basic Care and Comfort QUESTION 46 A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction? A. calcium B. magnesium C. potassium D. sodium chloride Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: Duodenal intestinal fluid is rich in K+, NA+, and bicarbonate. Suctioning to remove excess fluids decreases the client's K+ and NA+ levels.Basic Care and Comfort QUESTION 47 Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguious drainage on the dressing. The most appropriate intervention is to: A. notifythephysicianofthedrainage. B. changethedressing. C. reinforce the dressing. D. apply an abdominal binder. Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: Serosanguious drainage is expected at this time. The dressing should be reinforced. Changing a new postop dressing increases the risk of infection. An abdominal binder interferes with visualization of the dressing.Basic Care and Comfort QUESTION 48 A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered? A. Advil B. Anasaid C. Clinocil D. Colace Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: Colace is a stool softener that acts by pulling more water into the bowel lumen, making the stool soft and easier to evacuate.Basic Care and Comfort QUESTION 49 A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as: A. plantarfasciitis. B. halluxvalgus. C. hammertoe. D. Morton's neuroma. Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: Morton's neuroma is a small mass or tumor in a digital nerve of the foot. Hallux valgus is referred to in lay terms as abunion.Hammertoe is where one toe is cocked up over another toe. Plantar fasciitis is an inflammation of, or pain in, the arch of the foot.Basic Care and Comfort QUESTION 50 A client turns her ankle. She is diagnosed as having a Pulled Ligament. This should be documented as a: A. sprain. B. strain. C. subluxation. D. distoration. Correct Answer: B Section: (none) Explanation Explanation/Reference: Explanation: A strain is excessive stretching of a ligament. A sprain involves a twisting motion involving muscles.Basic Care and Comfort QUESTION 51 To remove hard contact lenses from an unresponsive client, the nurse should: A. gentlyirrigatetheeyewithanirrigatingsolutionfromtheinnercanthusoutward. B. graspthelenswithagentlepinchingmotion. C. don sterile gloves before attempting the procedure. D. ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. Correct Answer: D Section: (none) Explanation Explanation/Reference: Explanation: To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye. The lens must be situated on the cornea, not the sclera, before removal. An attempt to grasp a hard lens might result in a scratch on the cornea. Clean gloves are an option if drainage is present.Basic Care and Comfort QUESTION 52 To remove a client's gown when she has an intravenous line, the nurse should: A. temporarilydisconnecttheintravenoustubingatapointclosetotheclientandthreaditthroughthe gown. B. cutthegownwithscissors. C. thread the bag and tubing through the gown sleeve, keeping the line intact. D. temporarily disconnect the tubing from the intravenous container and thread it through the gown. Correct Answer: C Section: (none) Explanation Explanation/Reference: Explanation: Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an intravenous line causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative except in an emergency. IV gowns, which open along sleeves, are widely available.Basic Care and Comfort QUESTION 53 When making an occupied bed, it is important for the nurse to: A. keepthebedinthelowposition. B. useabathblanketortopsheetforwarmthandprivacy. C. constantly keep side rails raised on both sides. D. move back and forth from one side to the other when adjusting the linens.