Question 1
The nurse is coordinating care for a postpartum client and her newborn with the
unlicensed assistive personnel (UAP). The mother is human immunodeficiency virus (HIV)
positive. The nurse would recognize the need to educate the UAP, who is observed doing
which of the following actions?
A. Assist the mother who is attempting to breastfeed her baby
B. Place the infant on his or her back in the bassinet
C. Wear gloves while changing the newborn's soiled diaper
D. Assist the mother to walk to the bathroom
CORRECT ANSWER
A
In the United States, it is current practice to counsel a mother who is HIV positive, or has
AIDS, against breast feeding; breast feeding can transmit the virus through the breast milk to
the infant. It is correct to place an infant on his or her back to prevent sudden infant death
syndrome. Standard precautions should be followed when caring for any client; health care
providers should wear gloves when they anticipate contact with body secretions (changing a
soiled diaper).
Question 2
The nurse is teaching a client about precautions while taking warfarin. The nurse should
instruct the client to avoid foods with excessive amounts of which nutrient?
A. Calcium
B. Vitamin E
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,C. Iron
D. Vitamin K
CORRECT ANSWER
D
Vitamin K is an essential vitamin required for blood clotting. Eating foods with excessive
amounts of Vitamin K may alter anticoagulant effects. Foods highest in vitamin K include
(dried and fresh) herbs, dark leafy greens, scallions, brussel sprouts, broccoli, chili powder,
prunes, asparagus and cabbage.
Question 3
A newly admitted client reports gaining 5 pounds (2.27 kg) the past week even though he
has hasn't been very hungry. The nurse observes swelling of the feet and ankles. What is
the most likely explanation for the weight gain?
A. Hyperthyroidism
B. Malnutrition
C. Congestive heart failure
D. Acromegaly
CORRECT ANSWER
C
The unexplained rapid weight gain is probably due to fluid retention. Clients who gain as
little as two pounds (0.9 kg) in a week may require hospitalization due to worsening heart
failure. The lack of appetite (or a feeling of being full) and edema are also signs of worsening
heart failure. Hypothyroidism, and not hyperthyroidism, can lead to low body temperature,
which causes fluid retention or bloating. Low protein levels in the blood caused by
malnutrition can cause edema. However, there's not enough information given in the
question to know if this client is malnourished or not. Acromegaly is characterized by
overgrowth of body tissues, not edema, and is caused by excessive secretion of growth
hormone.
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@THE STUDY VAULT
,Question 4
A nurse is caring for a client with acute renal failure who has a subclavian vascular access
port for hemodialysis. Which of these findings necessitates immediate action by the
nurse?
A. Elevated temperature
B. Dry, hacking cough
C. Chronic fatigue
D. Pruritic rash
CORRECT ANSWER
A
An elevated temperature in this client would indicate a possible central line infection. This
finding should be reported to the provider who should order wound and blood cultures. If a
line infection is suspected, the line will need to be removed, necessitating alternate line
placement for hemodialysis. Interventions to prevention line infection through maintenance
of line sterility and stabilization of the site are a priority in any client with a central line. The
other findings should be reported to the health care provider but a febrile reaction is the
priority.
Question 5
The parent of a 2 year-old reports the child has experienced mild diarrhea for the past two
days. Which statement by the nurse provides the best nutritional information for the
child?
A. Clear liquids and gelatin for 24 hours
B. NPO for 24 hours, then rehydrate with milk and water
C. Continue with the regular diet and include oral rehydration fluids
D. Offer bananas, apples, rice and toast as tolerated
CORRECT ANSWER
C
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@THE STUDY VAULT
, Current recommendations for mild to moderate diarrhea are to maintain a normal diet with
fluids to rehydrate. If the diarrhea was severe then the BRAT (for bananas, apples, rice and
toast) diet may be appropriate.
Question 6
An important goal in the development of a therapeutic inpatient milieu is which of these
items?
A. Provide a testing ground for new patterns of behavior while clients take responsibility for
their own actions
B. Discourage expressions of anger because such feelings can be disruptive to other clients
C. Form a group forum in which clients decide on unit rules, regulations and policies
D. Offer a businesslike atmosphere where clients can work on individual goals
CORRECT ANSWER
A
A therapeutic milieu is purposeful and planned to provide safety and a testing ground for
new patterns of behavior. The other approaches may be part of other types of therapies.
Question 7
The nurse is evaluating an adult client who is receiving continuous enteral nutrition (EN)
through a nasogastric tube. Which findings would indicate that the nurse needs to contact
the health care provider? (Select all that apply.)
A. New onset adventitious lung sounds
B. 200 mL dark yellow urine voided in the last eight hours
C. Aspirated gastric fluid has a pH of 4
D. Pale and dry oral mucous membranes
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@THE STUDY VAULT
The nurse is coordinating care for a postpartum client and her newborn with the
unlicensed assistive personnel (UAP). The mother is human immunodeficiency virus (HIV)
positive. The nurse would recognize the need to educate the UAP, who is observed doing
which of the following actions?
A. Assist the mother who is attempting to breastfeed her baby
B. Place the infant on his or her back in the bassinet
C. Wear gloves while changing the newborn's soiled diaper
D. Assist the mother to walk to the bathroom
CORRECT ANSWER
A
In the United States, it is current practice to counsel a mother who is HIV positive, or has
AIDS, against breast feeding; breast feeding can transmit the virus through the breast milk to
the infant. It is correct to place an infant on his or her back to prevent sudden infant death
syndrome. Standard precautions should be followed when caring for any client; health care
providers should wear gloves when they anticipate contact with body secretions (changing a
soiled diaper).
Question 2
The nurse is teaching a client about precautions while taking warfarin. The nurse should
instruct the client to avoid foods with excessive amounts of which nutrient?
A. Calcium
B. Vitamin E
1
@THE STUDY VAULT
,C. Iron
D. Vitamin K
CORRECT ANSWER
D
Vitamin K is an essential vitamin required for blood clotting. Eating foods with excessive
amounts of Vitamin K may alter anticoagulant effects. Foods highest in vitamin K include
(dried and fresh) herbs, dark leafy greens, scallions, brussel sprouts, broccoli, chili powder,
prunes, asparagus and cabbage.
Question 3
A newly admitted client reports gaining 5 pounds (2.27 kg) the past week even though he
has hasn't been very hungry. The nurse observes swelling of the feet and ankles. What is
the most likely explanation for the weight gain?
A. Hyperthyroidism
B. Malnutrition
C. Congestive heart failure
D. Acromegaly
CORRECT ANSWER
C
The unexplained rapid weight gain is probably due to fluid retention. Clients who gain as
little as two pounds (0.9 kg) in a week may require hospitalization due to worsening heart
failure. The lack of appetite (or a feeling of being full) and edema are also signs of worsening
heart failure. Hypothyroidism, and not hyperthyroidism, can lead to low body temperature,
which causes fluid retention or bloating. Low protein levels in the blood caused by
malnutrition can cause edema. However, there's not enough information given in the
question to know if this client is malnourished or not. Acromegaly is characterized by
overgrowth of body tissues, not edema, and is caused by excessive secretion of growth
hormone.
2
@THE STUDY VAULT
,Question 4
A nurse is caring for a client with acute renal failure who has a subclavian vascular access
port for hemodialysis. Which of these findings necessitates immediate action by the
nurse?
A. Elevated temperature
B. Dry, hacking cough
C. Chronic fatigue
D. Pruritic rash
CORRECT ANSWER
A
An elevated temperature in this client would indicate a possible central line infection. This
finding should be reported to the provider who should order wound and blood cultures. If a
line infection is suspected, the line will need to be removed, necessitating alternate line
placement for hemodialysis. Interventions to prevention line infection through maintenance
of line sterility and stabilization of the site are a priority in any client with a central line. The
other findings should be reported to the health care provider but a febrile reaction is the
priority.
Question 5
The parent of a 2 year-old reports the child has experienced mild diarrhea for the past two
days. Which statement by the nurse provides the best nutritional information for the
child?
A. Clear liquids and gelatin for 24 hours
B. NPO for 24 hours, then rehydrate with milk and water
C. Continue with the regular diet and include oral rehydration fluids
D. Offer bananas, apples, rice and toast as tolerated
CORRECT ANSWER
C
3
@THE STUDY VAULT
, Current recommendations for mild to moderate diarrhea are to maintain a normal diet with
fluids to rehydrate. If the diarrhea was severe then the BRAT (for bananas, apples, rice and
toast) diet may be appropriate.
Question 6
An important goal in the development of a therapeutic inpatient milieu is which of these
items?
A. Provide a testing ground for new patterns of behavior while clients take responsibility for
their own actions
B. Discourage expressions of anger because such feelings can be disruptive to other clients
C. Form a group forum in which clients decide on unit rules, regulations and policies
D. Offer a businesslike atmosphere where clients can work on individual goals
CORRECT ANSWER
A
A therapeutic milieu is purposeful and planned to provide safety and a testing ground for
new patterns of behavior. The other approaches may be part of other types of therapies.
Question 7
The nurse is evaluating an adult client who is receiving continuous enteral nutrition (EN)
through a nasogastric tube. Which findings would indicate that the nurse needs to contact
the health care provider? (Select all that apply.)
A. New onset adventitious lung sounds
B. 200 mL dark yellow urine voided in the last eight hours
C. Aspirated gastric fluid has a pH of 4
D. Pale and dry oral mucous membranes
4
@THE STUDY VAULT
