Exam The correct answer is C: Diarrhea, dry mouth, weight loss, reduced
1. A 72 year-old client is scheduled to have a cardioversion. A nurse libido Commonly reported side effects for fluoxetine (Prozac) are
reviews the client’s medication administration record. The nurse diarrhea, dry mouth, weight loss and reduced libido
should notify the health care provider if the client received which
medication during the preceding 24 hours? 7. The nurse is preparing to administer a tube feeding to a post-
A) digoxin (Lanoxin) operative client. To accurately assess for agastostomy tube
B) diltiazam (Cardizem) placement, the priority is to
C) nitroglycerine ointment A) Auscultate the abdomen while instilling 10 cc of air into the
D) metoprolol (Toprol XL) tube
The correct answer is A: digoxin (Lanoxin) Digoxin increases B) Place the end of the tube in water to check for air bubbles
ventricular irritability and increases the risk of ventricular C) Retract the tube several inches to check for resistance
fibrillation following cardioversion. The other medications do not D) Measure the length of tubing from nose to epigastrium
increase ventricular irritability The correct answer is A: Auscultate the abdomen while instilling 10
2. Which of these clients, who all have the findings of a board-like cc of air into the tube If a swoosh of air is heard over the abdominal
abdomen, would the nurse suggest that the health care provider cavity while instilling air into the gastric tube, this indicates that it is
examine first? accurately placed in the stomach. The feeding can begin after
A) An elderly client who stated that "My awful pain in my right assessing the client for bowel sounds
side suddenly stopped about 3 hours ago."
B) A pregnant woman of 8 weeks newly diagnosed with an 8.Which of these questions is priority when assessing a client with
ectopic pregnancy hypertension?
C) A middle-aged client admitted with diverticulitis and has A) "What over-the-counter medications do you take?"
taken only clear liquids for the past week B) "Describe your usual exercise and activity patterns."
D) A teenager with a history of falling off a bicycle and did not C) "Tell me about your usual diet."
hit the handle bars D) "Describe your family's cardiovascular history."
The correct answer is A: An elderly client who stated that "My awful The correct answer is A: "What over-the-counter medications do you
pain in my right side suddenly stopped about 3 hours ago." This take?" Over-the-counter medications, especially those that contain
client has the highest risk for hypovolemic and septic shock since cold preparations can increase the blood pressure to the point of
the appendix has most likely ruptured as based on the history of the hypertension.
pain suddenly stopping over three hours ago. Being elderly there, is
less reserve for the body to cope with shock and infection over long 9. The nurse is teaching parents of a 7 month-old about adding table
periods. The others are at risk for shock also. However, given that foods. Which of the following is anappropriate finger food?
they fall in younger age groups, they would more likely be able to A) Hot dog pieces
tolerate an inbalance in circulation. A common complication of B) Sliced bananas
falling off a bicycle is hitting the handle bars in the upper abdomen C) Whole grapes
often on the left, resulting in a ruptured spleen. D) Popcorn
The correct answer is B: Sliced bananas Finger foods should be bite-
3. The nurse manager informs the nursing staff at morning report size pieces of soft food such as bananas. Hot dogs and grapes can
that the clinical nurse specialist will be conducting a research study accidentally be swallowed whole and can occlude the airway.
on staff attitudes toward client care. All staff are invited to Popcorn is too difficult to chew at this age and can irritate the
participate in the study if they wish. This affirms the ethical airway if swallowed
principle of 10 client is ordered warfarin sodium (Coumadin) to be continued at
A) Anonymity home. Which focus is critical to be included in the nurse’s discharge
B) Beneficence instruction?
C) Justice A) Maintain a consistent intake of green leafy foods
D) Autonomy B) Report any nose or gum bleeds
The correct answer is D: Autonomy Individuals must be free to C) Take Tylenol for minor pains
make independent decisions about participation in research without D) Use a soft toothbrush
coercion from others. The correct answer is B: Report any nose or gum bleeds The client
4. Which statement made by a nurse about the goal of total quality should notify the health care provider if blood is noted in their stools
management or continuous quality improvement in a health care or urine, or any other signs of bleeding occ
setting is correct?
A) “It is to observe reactive service and product problem 11. The nurse is assessing a comatose client receiving gastric tube
solving." feedings. Which of the following assessments requires an immediate
B) Improvement of the processes in a proactive, preventive response from the nurse?
mode is paramount. A) Decreased breath sounds in right lower lobe
C) A chart audits to finds common errors in practice and B) Aspiration of a residual of 100cc of formula
outcomes associated with goals. C) Decrease in bowel sounds
D) A flow chart to organize daily tasks is critical to the initial D) Urine output of 250 cc in past 8 hours
stages. The correct answer is A: Decreased breath sounds in right lower lobe
The correct answer is B: Improvement of the processes in a The most common problem associated with enteral feedings is
proactive, preventive mode is paramount. Total quality management atelectasis. Maintain client at 30 degrees during feedings and
and continuous quality improvement have a major goal of monitor for signs of aspiration. Check for tube placement prior to
identifying ways to do the right thing at the right time in the right each feeding or every 4 to 8 hours if continuous feeding
way by proactive problem-solving.
12. The nurse is talking with the family of an 18 months-old newly
5. A client with chronic obstructive pulmonary disease (COPD) and diagnosed with retinoblastoma. A priority in communicating with
a history of coronary artery disease is receiving Aminophylline, the parents is
25mg/hour. Which one of the following findings by the nurse would A) Discuss the need for genetic counseling
require immediate intervention? B) Inform them that combined therapy is seldom effective
A) Decreased blood pressure and respirations. C) Prepare for the child's permanent disfigurement
B) Flushing and headache. D) Suggest that total blindness may follow surgery
C) Restlessness and palpitations. The correct answer is A: Discussing the need for genetic counseling
D) Increased heart rate and blood pressure. The hereditary aspects of this disease are well documented. While
The correct answer is C: Restlessness and palpitations. Side effects the parents focus on the needs of this child, they should be aware
of Aminophylline include restlessness and palpitations that the risk is high for future offspring
6. When teaching a client about the side effects of fluoxetine Question Number 13 of 40
(Prozac), which of the following will be included? The nurse is performing an assessment on a client who is cachectic
,B) Blood for coagulation studies will be drawn To prevent drug resistance common to tubercle bacilli, the nurse is
C) Total parenteral nutrition (TPN) will be started aware that which of the following agents are usually added to drug
D) Serum lipase levels will be evaluated therapy?
The correct answer is C: Total parenteral nutrition (TPN) will be A) Anti-inflammatory agent
started The client is not absorbing nutrients adequately as evidenced B) High doses of B complex vitamins
by the cachexia and low protein levels. (A normal total serum C) Aminoglycoside antibiotic
protein level is 6.0-8.0.) TPN will maintain a positive nitrogen D) Two anti-tuberculosis drugs
balance in the client who is unable to digest and absorb nutrients The correct answer is D: Two anti-tuberculosis drugs Resistance of
adequately. the tubercle bacilli often occurs to a single antimicrobial agent.
Therefore, therapy with multiple drugs over a long period of time
Question Number 14 of 40 helps to ensure eradication of the organism.
The nurse is teaching about nonsteroidal anti-inflammatory drugs to
a group of arthritic clients. To minimize the side effects, the nurse Question Number 20 of 40
should emphasize which of the following actions? While assessing the vital signs in children, the nurse should know
A) Reporting joint stiffness in the morning that the apical heart rate is preferred until the radial pulse can be
B) Taking the medication 1 hour before or 2 hours after meals accurately assessed at about what age?
C) Using alcohol in moderation unless driving A) 1 year of age
D) Continuing to take aspirin for short term relief B) 2 years of age
The correct answer is B: Taking the medication 1 hour before or 2 C) 3 years of age
hours after meals Taking the medication 1 hour before or 2 hours D) 4 years of age
after meals will result in a more rapid effect. The correct answer is B: 2 years of age A child should be at least 2
years of age to use the radial pulse to assess heart rate.
Question Number 15 of 40
Which approach is a priority for the nurse who works with clients Question Number 21 of 40
from many different cultures? Which of these clients would the nurse monitor for the complication
A) Speak at least 2 other languages of clients in the of C. difficile diarrhea?
neighborhood A) An adolescent taking medications for acne
B) Learn about the cultures of clients who are most often B) An elderly client living in a retirement center taking
encountered prednisone
C) Have a list of persons for referral when interaction with these C) A young adult at home taking a prescribed aminoglycoside
clients occur D) A hospitalized middle aged client receiving clindamycin
D) Recognize personal attitudes about cultural differences and The correct answer is D: A hospitalized middle aged client receiving
real or expected biases clindamycin Hospitalized patients, especially those receiving
The correct answer is D: Recognize personal attitudes about cultural antibiotic therapy, are primary targets for C. difficile. Of patients
differences and real or expected biases The nurse must discover receiving antibiotics, 5-38% experience antibiotic-associated
personal attitudes, prejudices and biases specific to different diarrhea; C. difficile causes 15 to 20% of the cases. Several antibiotic
cultures. Sensitivity to these will affect interactions with clients and agents have been associated with C. difficile. Broad-spectrum
families across cultures. agents, such as clindamycin, ampicillin, amoxicillin, and
cephalosporins, are the most frequent sources of C. difficile. Also, C.
Question Number 16 of 40 difficile infection has been caused by the administration of agents
A 35-year-old client of Puerto Rican-American descent is diagnosed containing beta-lactamase inhibitors (ie, clavulanic acid, sulbactam,
with ovarian cancer. The client states “I refuse both radiation and tazobactam) and intravenous agents that achieve substantial colonic
chemotherapy because they are 'hot.'” The next action for the nurse intraluminal concentrations (ie, ceftriaxone, nafcillin, oxacillin).
to take is to Fluoroquinolones, aminoglycosides, vancomycin, and trimethoprim
A) Document the situation in the notes are seldom associated with C. difficile infection or
B) Report the situation to the health care provider pseudomembranous colitis.
C) Talk with the client's family about the situation
D) Ask the client to talk about the concerns about the "hot" Question Number 22 of 40
treatments The nurse is preparing to take a toddler's blood pressure for the first
The correct answer is D: Ask the client to talk about the concerns time. Which of the following actions should the nurse do first?
about the "hot" treatments The "hot-cold" system is found among A) Explain that the procedure will help him to get well
Mexican-Americans, Puerto Ricans, and other Hispanic-Latinos. B) Show a cartoon character with a blood pressure cuff
Most foods, beverages, herbs, and medicines are categorized as hot C) Explain that the blood pressure checks the heart pump
or cold, which are symbolic designations and do not necessarily D) Permit handling the equipment before putting the cuff in
indicate temperature or spiciness. Care and treatment regimens can place
be negotiated with clients within this framework. The correct answer is D: Permit handling the equipment before
putting the cuff in place The best way to gain the toddler''s
Question Number 17 of 40 cooperation is to encourage handling the equipment. Detailed
During a routine check-up, an insulin-dependent diabetic has his explanations are not helpful.
glycosylated hemoglobin checked. The results indicate a level of 11%.
Based on this result, what teaching should the nurse emphasize? Question Number 23 of 40
A) Rotation of injection sites The nurse is performing an assessment of the motor function in a
B) Insulin mixing and preparation client with a head injury. The best technique is
C) Daily blood sugar monitoring A) A firm touch to the trapezius muscle or arm
D) Regular high protein diet B) Pinching any body part
C) Sternal rub
The correct answer is C: Daily blood sugar monitoring Normal D) Gentle pressure on eye orbit
hemoglobin A1C (glycosylated hemoglobin) level is 7 to 9%. The correct answer is D: Gentle pressure on eye orbit This is an
Elevation indicates elevated glucose levels over time. acceptable stimuli only after progressing from lighter to stimuli to
more obnoxious.
Question Number 18 of 40
The nurse is assigned to care for 4 clients. Which of the following Question Number 24 of 40
should be assessed immediately after hearing the report? The nurse is caring for a client with Hodgkin's disease who will be
A) The client with asthma who is now ready for discharge receiving radiation therapy. The nurse recognizes that, as a result of
B) The client with a peptic ulcer who has been vomiting all night the radiation therapy, the client is most likely to experience
C) The client with chronic renal failure returning from dialysis A) High fever
D) The client with pancreatitis who was admitted yesterday B) Nausea
The correct answer is B: The client with a peptic ulcer who has been C) Face and neck edema
, A pregnant client who is at 34 weeks gestation is diagnosed with a B) Sit upright for at least 1 hour after eating
pulmonary embolism (PE). Which of these mediations would the C) Maintain a diet of soft foods and cooked vegetables
nurse anticipate the health care provider ordering? D) Avoid eating 2 hours before going to sleep
A) Oral Coumadin therapy The correct answer is D: Avoid eating2 hours before going to sleep
B) Heparin 5000 units subcutaneously b.i.d. Eating before sleeping enhances the regurgitation of stomach
C) Heparin infusion to maintain the PTT at 1.5-2.5 times the contents which have increased acidity into the esophagus.
control value Maintaining an upright posture should be for about 2 hours after
D) Heparin by subcutaneous injection to maintain the PTT at 1.5 eating to allow for the stomach emptying. The options A and C are
times the control value interventions for clients with swallowing difficulties
The correct answer is D: Heparin by subcutaneous injection to
maintain the PTT at 1.5 times the control value Several studies have Question Number 32 of 40
been conducted in pregnant women where oral anticoagulation As a part of a 9 pound full-term newborn's assessment, the nurse
agents are contraindicated. Warfarin (Coumadin) is known to cross performs a dextro-stick at 1 hour post birth. The serum glucose
the placenta and is therefore reported to be teratogenic. reading is 45 mg/dl. What action by the nurse is appropriate at this
time?
Question Number 26 of 40 A) Give oral glucose water
A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses B) Notify the pediatrician
the newborn at home 2 days later and finds the weight to be 6 C) Repeat the test in 2 hours
pounds 7 ounces. What should the nurse tell the parents about this D) Check the pulse oximetry reading
weight loss? The correct answer is C: Repeat the test in two hours This blood
A) The newborn needs additional assessments sugar is within the normal range for a full-term newborn. Normal
B) The mother should breast feed more often values are: Premature infant: 20-60 mg/dl or 1.1-3.3 mmol/L,
C) A change to formula is indicated Neonate: 30-60 mg/dl or 1.7-3.3 mmol/L, Infant: 40-90 mg/dl or
D) The loss is within normal limits 2.2-5.0 mmol/L. Critical values are: Infant: <40 mg/dl and in a
The correct answer is D: The loss is within normal limits A newborn Newborn: <30 and >300 mg/dl. Because of the increased birth
is expected to lose 5-10% of the birth weight in the first few days weight which can be associated with diabetes mellitus, repeated
because of changes in elimination and feeding. blood sugars will be drawn.
Question Number 33 of 40
Question Number 27 of 40 An 18 month-old child is on peritoneal dialysis in preparation for a
A client is receiving Total Parenteral Nutrition (TPN) via Hickman renal transplant in the near future. When the nurse obtains the
catheter. The catheter accidentally becomes dislodged from the site. child's health history, the mother indicates that the child has not
Which action by the nurse should take priority? had the first measles, mumps, rubella (MMR) immunization. The
A) Check that the catheter tip is intact nurse understands that which of the following is true in regards to
B) Apply a pressure dressing to the site giving immunizations to this child?
C) Monitor respiratory status A) Live vaccines are withheld in children with renal chronic
D) Assess for mental status changes illness
The correct answer is B: Apply a pressure dressing to the site The B) The MMR vaccine should be given now, prior to the
client is at risk of bleeding or the development of an air embolus if transplant
the catheter exit site is not covered immediately C) An inactivated form of the vaccine can be given at any time
D) The risk of vaccine side effects precludes giving the vaccine
Question Number 28 of 40 The correct answer is B: The MMR vaccine should be given now,
A client with a panic disorder has a new prescription for Xanax prior to the transplant MMR is a live virus vaccine, and should be
(Alpazolam). In teaching the client about the drug's actions and side given at this time. Post-transplant, immunosuppressive drugs will
effects, which of the following should the nurse emphasize? be given and the administration of the live vaccine at that time
A) Short-term relief can be expected would be contraindicated because of the compromised immune
B) The medication acts as a stimulant system.
C) Dosage will be increased as tolerated
D) Initial side effects often continue Question Number 34 of 40
The correct answer is A: Short-term relief can be expected Xanax is A nurse admits a client transferred from the emergency room. The
a short-acting benzodiazepine useful in controlling panic symptoms client, diagnosed with a myocardial infarction, is complaining of
quickly. substernal chest pain, diaphoresis and nausea. The first action by
the nurse should be
Question Number 29 of 40 A) Order an EKG
A client is brought to the emergency room following a motor vehicle B) Administer morphine sulphate
accident. When assessing the client one-half hour after admission, C) Start an IV
the nurse notes several physical changes. Which changes would D) Measure vital signs
require the nurse's immediate attention? The correct answer is B: Administer pain medication as ordered
A) Increased restlessness Decreasing the clients pain is the most important priority at this
B) Tachycardia time. As long as pain is present there is danger in extending the
C) Tracheal deviation infarcted area. Morphine will decrease the oxygen demands of the
D) Tachypnea heart and act as a mild diuretic as well.
The correct answer is C: Tracheal deviation The deviated trachea is a
sign that a mediastinal shift has occurred. This is a medical Question Number 35 of 40
emergency. The clinic nurse is counseling a substance-abusing post partum
client on the risks of continued cocaine use. In order to provide
Question Number 30 of 40 continuity of care, which nursing diagnosis is a priority ?
A client being discharged from the cardiac step-down unit following A) Social isolation
a myocardial infarction ( MI), is given a prescription for a beta- B) Ineffective coping
blocking drug. A nursing student asks the charge nurse why this C) Altered parenting
drug would be used by a client who is not hypertensive. What is an D) Sexual dysfunction
appropriate response by the charge nurse? The correct answer is C: Altered parenting The cocaine abusing
A) "Most people develop hypertension following an MI." mother puts her newborn and other children at risk for neglect and
B) "A beta-Blocker will prevent orthostatic hypotension." abuse. Continuing to use drugs has the potential to impact parenting
C) "This drug will decrease the workload on his heart." behaviors. Social service referrals are indicated
D) "Beta-blockers increase the strength of heart contractions."
The correct answer is C: "This drug will decrease the workload on Question Number 36 of 40
his heart." One action of beta-blockers is to decrease systemic The nurse admits a 2 year-old child who has had a seizure. Which of
vascular resistance by dilating arterioles. This is useful for the client the following statement by the child's parent would be important in
1. A 72 year-old client is scheduled to have a cardioversion. A nurse libido Commonly reported side effects for fluoxetine (Prozac) are
reviews the client’s medication administration record. The nurse diarrhea, dry mouth, weight loss and reduced libido
should notify the health care provider if the client received which
medication during the preceding 24 hours? 7. The nurse is preparing to administer a tube feeding to a post-
A) digoxin (Lanoxin) operative client. To accurately assess for agastostomy tube
B) diltiazam (Cardizem) placement, the priority is to
C) nitroglycerine ointment A) Auscultate the abdomen while instilling 10 cc of air into the
D) metoprolol (Toprol XL) tube
The correct answer is A: digoxin (Lanoxin) Digoxin increases B) Place the end of the tube in water to check for air bubbles
ventricular irritability and increases the risk of ventricular C) Retract the tube several inches to check for resistance
fibrillation following cardioversion. The other medications do not D) Measure the length of tubing from nose to epigastrium
increase ventricular irritability The correct answer is A: Auscultate the abdomen while instilling 10
2. Which of these clients, who all have the findings of a board-like cc of air into the tube If a swoosh of air is heard over the abdominal
abdomen, would the nurse suggest that the health care provider cavity while instilling air into the gastric tube, this indicates that it is
examine first? accurately placed in the stomach. The feeding can begin after
A) An elderly client who stated that "My awful pain in my right assessing the client for bowel sounds
side suddenly stopped about 3 hours ago."
B) A pregnant woman of 8 weeks newly diagnosed with an 8.Which of these questions is priority when assessing a client with
ectopic pregnancy hypertension?
C) A middle-aged client admitted with diverticulitis and has A) "What over-the-counter medications do you take?"
taken only clear liquids for the past week B) "Describe your usual exercise and activity patterns."
D) A teenager with a history of falling off a bicycle and did not C) "Tell me about your usual diet."
hit the handle bars D) "Describe your family's cardiovascular history."
The correct answer is A: An elderly client who stated that "My awful The correct answer is A: "What over-the-counter medications do you
pain in my right side suddenly stopped about 3 hours ago." This take?" Over-the-counter medications, especially those that contain
client has the highest risk for hypovolemic and septic shock since cold preparations can increase the blood pressure to the point of
the appendix has most likely ruptured as based on the history of the hypertension.
pain suddenly stopping over three hours ago. Being elderly there, is
less reserve for the body to cope with shock and infection over long 9. The nurse is teaching parents of a 7 month-old about adding table
periods. The others are at risk for shock also. However, given that foods. Which of the following is anappropriate finger food?
they fall in younger age groups, they would more likely be able to A) Hot dog pieces
tolerate an inbalance in circulation. A common complication of B) Sliced bananas
falling off a bicycle is hitting the handle bars in the upper abdomen C) Whole grapes
often on the left, resulting in a ruptured spleen. D) Popcorn
The correct answer is B: Sliced bananas Finger foods should be bite-
3. The nurse manager informs the nursing staff at morning report size pieces of soft food such as bananas. Hot dogs and grapes can
that the clinical nurse specialist will be conducting a research study accidentally be swallowed whole and can occlude the airway.
on staff attitudes toward client care. All staff are invited to Popcorn is too difficult to chew at this age and can irritate the
participate in the study if they wish. This affirms the ethical airway if swallowed
principle of 10 client is ordered warfarin sodium (Coumadin) to be continued at
A) Anonymity home. Which focus is critical to be included in the nurse’s discharge
B) Beneficence instruction?
C) Justice A) Maintain a consistent intake of green leafy foods
D) Autonomy B) Report any nose or gum bleeds
The correct answer is D: Autonomy Individuals must be free to C) Take Tylenol for minor pains
make independent decisions about participation in research without D) Use a soft toothbrush
coercion from others. The correct answer is B: Report any nose or gum bleeds The client
4. Which statement made by a nurse about the goal of total quality should notify the health care provider if blood is noted in their stools
management or continuous quality improvement in a health care or urine, or any other signs of bleeding occ
setting is correct?
A) “It is to observe reactive service and product problem 11. The nurse is assessing a comatose client receiving gastric tube
solving." feedings. Which of the following assessments requires an immediate
B) Improvement of the processes in a proactive, preventive response from the nurse?
mode is paramount. A) Decreased breath sounds in right lower lobe
C) A chart audits to finds common errors in practice and B) Aspiration of a residual of 100cc of formula
outcomes associated with goals. C) Decrease in bowel sounds
D) A flow chart to organize daily tasks is critical to the initial D) Urine output of 250 cc in past 8 hours
stages. The correct answer is A: Decreased breath sounds in right lower lobe
The correct answer is B: Improvement of the processes in a The most common problem associated with enteral feedings is
proactive, preventive mode is paramount. Total quality management atelectasis. Maintain client at 30 degrees during feedings and
and continuous quality improvement have a major goal of monitor for signs of aspiration. Check for tube placement prior to
identifying ways to do the right thing at the right time in the right each feeding or every 4 to 8 hours if continuous feeding
way by proactive problem-solving.
12. The nurse is talking with the family of an 18 months-old newly
5. A client with chronic obstructive pulmonary disease (COPD) and diagnosed with retinoblastoma. A priority in communicating with
a history of coronary artery disease is receiving Aminophylline, the parents is
25mg/hour. Which one of the following findings by the nurse would A) Discuss the need for genetic counseling
require immediate intervention? B) Inform them that combined therapy is seldom effective
A) Decreased blood pressure and respirations. C) Prepare for the child's permanent disfigurement
B) Flushing and headache. D) Suggest that total blindness may follow surgery
C) Restlessness and palpitations. The correct answer is A: Discussing the need for genetic counseling
D) Increased heart rate and blood pressure. The hereditary aspects of this disease are well documented. While
The correct answer is C: Restlessness and palpitations. Side effects the parents focus on the needs of this child, they should be aware
of Aminophylline include restlessness and palpitations that the risk is high for future offspring
6. When teaching a client about the side effects of fluoxetine Question Number 13 of 40
(Prozac), which of the following will be included? The nurse is performing an assessment on a client who is cachectic
,B) Blood for coagulation studies will be drawn To prevent drug resistance common to tubercle bacilli, the nurse is
C) Total parenteral nutrition (TPN) will be started aware that which of the following agents are usually added to drug
D) Serum lipase levels will be evaluated therapy?
The correct answer is C: Total parenteral nutrition (TPN) will be A) Anti-inflammatory agent
started The client is not absorbing nutrients adequately as evidenced B) High doses of B complex vitamins
by the cachexia and low protein levels. (A normal total serum C) Aminoglycoside antibiotic
protein level is 6.0-8.0.) TPN will maintain a positive nitrogen D) Two anti-tuberculosis drugs
balance in the client who is unable to digest and absorb nutrients The correct answer is D: Two anti-tuberculosis drugs Resistance of
adequately. the tubercle bacilli often occurs to a single antimicrobial agent.
Therefore, therapy with multiple drugs over a long period of time
Question Number 14 of 40 helps to ensure eradication of the organism.
The nurse is teaching about nonsteroidal anti-inflammatory drugs to
a group of arthritic clients. To minimize the side effects, the nurse Question Number 20 of 40
should emphasize which of the following actions? While assessing the vital signs in children, the nurse should know
A) Reporting joint stiffness in the morning that the apical heart rate is preferred until the radial pulse can be
B) Taking the medication 1 hour before or 2 hours after meals accurately assessed at about what age?
C) Using alcohol in moderation unless driving A) 1 year of age
D) Continuing to take aspirin for short term relief B) 2 years of age
The correct answer is B: Taking the medication 1 hour before or 2 C) 3 years of age
hours after meals Taking the medication 1 hour before or 2 hours D) 4 years of age
after meals will result in a more rapid effect. The correct answer is B: 2 years of age A child should be at least 2
years of age to use the radial pulse to assess heart rate.
Question Number 15 of 40
Which approach is a priority for the nurse who works with clients Question Number 21 of 40
from many different cultures? Which of these clients would the nurse monitor for the complication
A) Speak at least 2 other languages of clients in the of C. difficile diarrhea?
neighborhood A) An adolescent taking medications for acne
B) Learn about the cultures of clients who are most often B) An elderly client living in a retirement center taking
encountered prednisone
C) Have a list of persons for referral when interaction with these C) A young adult at home taking a prescribed aminoglycoside
clients occur D) A hospitalized middle aged client receiving clindamycin
D) Recognize personal attitudes about cultural differences and The correct answer is D: A hospitalized middle aged client receiving
real or expected biases clindamycin Hospitalized patients, especially those receiving
The correct answer is D: Recognize personal attitudes about cultural antibiotic therapy, are primary targets for C. difficile. Of patients
differences and real or expected biases The nurse must discover receiving antibiotics, 5-38% experience antibiotic-associated
personal attitudes, prejudices and biases specific to different diarrhea; C. difficile causes 15 to 20% of the cases. Several antibiotic
cultures. Sensitivity to these will affect interactions with clients and agents have been associated with C. difficile. Broad-spectrum
families across cultures. agents, such as clindamycin, ampicillin, amoxicillin, and
cephalosporins, are the most frequent sources of C. difficile. Also, C.
Question Number 16 of 40 difficile infection has been caused by the administration of agents
A 35-year-old client of Puerto Rican-American descent is diagnosed containing beta-lactamase inhibitors (ie, clavulanic acid, sulbactam,
with ovarian cancer. The client states “I refuse both radiation and tazobactam) and intravenous agents that achieve substantial colonic
chemotherapy because they are 'hot.'” The next action for the nurse intraluminal concentrations (ie, ceftriaxone, nafcillin, oxacillin).
to take is to Fluoroquinolones, aminoglycosides, vancomycin, and trimethoprim
A) Document the situation in the notes are seldom associated with C. difficile infection or
B) Report the situation to the health care provider pseudomembranous colitis.
C) Talk with the client's family about the situation
D) Ask the client to talk about the concerns about the "hot" Question Number 22 of 40
treatments The nurse is preparing to take a toddler's blood pressure for the first
The correct answer is D: Ask the client to talk about the concerns time. Which of the following actions should the nurse do first?
about the "hot" treatments The "hot-cold" system is found among A) Explain that the procedure will help him to get well
Mexican-Americans, Puerto Ricans, and other Hispanic-Latinos. B) Show a cartoon character with a blood pressure cuff
Most foods, beverages, herbs, and medicines are categorized as hot C) Explain that the blood pressure checks the heart pump
or cold, which are symbolic designations and do not necessarily D) Permit handling the equipment before putting the cuff in
indicate temperature or spiciness. Care and treatment regimens can place
be negotiated with clients within this framework. The correct answer is D: Permit handling the equipment before
putting the cuff in place The best way to gain the toddler''s
Question Number 17 of 40 cooperation is to encourage handling the equipment. Detailed
During a routine check-up, an insulin-dependent diabetic has his explanations are not helpful.
glycosylated hemoglobin checked. The results indicate a level of 11%.
Based on this result, what teaching should the nurse emphasize? Question Number 23 of 40
A) Rotation of injection sites The nurse is performing an assessment of the motor function in a
B) Insulin mixing and preparation client with a head injury. The best technique is
C) Daily blood sugar monitoring A) A firm touch to the trapezius muscle or arm
D) Regular high protein diet B) Pinching any body part
C) Sternal rub
The correct answer is C: Daily blood sugar monitoring Normal D) Gentle pressure on eye orbit
hemoglobin A1C (glycosylated hemoglobin) level is 7 to 9%. The correct answer is D: Gentle pressure on eye orbit This is an
Elevation indicates elevated glucose levels over time. acceptable stimuli only after progressing from lighter to stimuli to
more obnoxious.
Question Number 18 of 40
The nurse is assigned to care for 4 clients. Which of the following Question Number 24 of 40
should be assessed immediately after hearing the report? The nurse is caring for a client with Hodgkin's disease who will be
A) The client with asthma who is now ready for discharge receiving radiation therapy. The nurse recognizes that, as a result of
B) The client with a peptic ulcer who has been vomiting all night the radiation therapy, the client is most likely to experience
C) The client with chronic renal failure returning from dialysis A) High fever
D) The client with pancreatitis who was admitted yesterday B) Nausea
The correct answer is B: The client with a peptic ulcer who has been C) Face and neck edema
, A pregnant client who is at 34 weeks gestation is diagnosed with a B) Sit upright for at least 1 hour after eating
pulmonary embolism (PE). Which of these mediations would the C) Maintain a diet of soft foods and cooked vegetables
nurse anticipate the health care provider ordering? D) Avoid eating 2 hours before going to sleep
A) Oral Coumadin therapy The correct answer is D: Avoid eating2 hours before going to sleep
B) Heparin 5000 units subcutaneously b.i.d. Eating before sleeping enhances the regurgitation of stomach
C) Heparin infusion to maintain the PTT at 1.5-2.5 times the contents which have increased acidity into the esophagus.
control value Maintaining an upright posture should be for about 2 hours after
D) Heparin by subcutaneous injection to maintain the PTT at 1.5 eating to allow for the stomach emptying. The options A and C are
times the control value interventions for clients with swallowing difficulties
The correct answer is D: Heparin by subcutaneous injection to
maintain the PTT at 1.5 times the control value Several studies have Question Number 32 of 40
been conducted in pregnant women where oral anticoagulation As a part of a 9 pound full-term newborn's assessment, the nurse
agents are contraindicated. Warfarin (Coumadin) is known to cross performs a dextro-stick at 1 hour post birth. The serum glucose
the placenta and is therefore reported to be teratogenic. reading is 45 mg/dl. What action by the nurse is appropriate at this
time?
Question Number 26 of 40 A) Give oral glucose water
A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses B) Notify the pediatrician
the newborn at home 2 days later and finds the weight to be 6 C) Repeat the test in 2 hours
pounds 7 ounces. What should the nurse tell the parents about this D) Check the pulse oximetry reading
weight loss? The correct answer is C: Repeat the test in two hours This blood
A) The newborn needs additional assessments sugar is within the normal range for a full-term newborn. Normal
B) The mother should breast feed more often values are: Premature infant: 20-60 mg/dl or 1.1-3.3 mmol/L,
C) A change to formula is indicated Neonate: 30-60 mg/dl or 1.7-3.3 mmol/L, Infant: 40-90 mg/dl or
D) The loss is within normal limits 2.2-5.0 mmol/L. Critical values are: Infant: <40 mg/dl and in a
The correct answer is D: The loss is within normal limits A newborn Newborn: <30 and >300 mg/dl. Because of the increased birth
is expected to lose 5-10% of the birth weight in the first few days weight which can be associated with diabetes mellitus, repeated
because of changes in elimination and feeding. blood sugars will be drawn.
Question Number 33 of 40
Question Number 27 of 40 An 18 month-old child is on peritoneal dialysis in preparation for a
A client is receiving Total Parenteral Nutrition (TPN) via Hickman renal transplant in the near future. When the nurse obtains the
catheter. The catheter accidentally becomes dislodged from the site. child's health history, the mother indicates that the child has not
Which action by the nurse should take priority? had the first measles, mumps, rubella (MMR) immunization. The
A) Check that the catheter tip is intact nurse understands that which of the following is true in regards to
B) Apply a pressure dressing to the site giving immunizations to this child?
C) Monitor respiratory status A) Live vaccines are withheld in children with renal chronic
D) Assess for mental status changes illness
The correct answer is B: Apply a pressure dressing to the site The B) The MMR vaccine should be given now, prior to the
client is at risk of bleeding or the development of an air embolus if transplant
the catheter exit site is not covered immediately C) An inactivated form of the vaccine can be given at any time
D) The risk of vaccine side effects precludes giving the vaccine
Question Number 28 of 40 The correct answer is B: The MMR vaccine should be given now,
A client with a panic disorder has a new prescription for Xanax prior to the transplant MMR is a live virus vaccine, and should be
(Alpazolam). In teaching the client about the drug's actions and side given at this time. Post-transplant, immunosuppressive drugs will
effects, which of the following should the nurse emphasize? be given and the administration of the live vaccine at that time
A) Short-term relief can be expected would be contraindicated because of the compromised immune
B) The medication acts as a stimulant system.
C) Dosage will be increased as tolerated
D) Initial side effects often continue Question Number 34 of 40
The correct answer is A: Short-term relief can be expected Xanax is A nurse admits a client transferred from the emergency room. The
a short-acting benzodiazepine useful in controlling panic symptoms client, diagnosed with a myocardial infarction, is complaining of
quickly. substernal chest pain, diaphoresis and nausea. The first action by
the nurse should be
Question Number 29 of 40 A) Order an EKG
A client is brought to the emergency room following a motor vehicle B) Administer morphine sulphate
accident. When assessing the client one-half hour after admission, C) Start an IV
the nurse notes several physical changes. Which changes would D) Measure vital signs
require the nurse's immediate attention? The correct answer is B: Administer pain medication as ordered
A) Increased restlessness Decreasing the clients pain is the most important priority at this
B) Tachycardia time. As long as pain is present there is danger in extending the
C) Tracheal deviation infarcted area. Morphine will decrease the oxygen demands of the
D) Tachypnea heart and act as a mild diuretic as well.
The correct answer is C: Tracheal deviation The deviated trachea is a
sign that a mediastinal shift has occurred. This is a medical Question Number 35 of 40
emergency. The clinic nurse is counseling a substance-abusing post partum
client on the risks of continued cocaine use. In order to provide
Question Number 30 of 40 continuity of care, which nursing diagnosis is a priority ?
A client being discharged from the cardiac step-down unit following A) Social isolation
a myocardial infarction ( MI), is given a prescription for a beta- B) Ineffective coping
blocking drug. A nursing student asks the charge nurse why this C) Altered parenting
drug would be used by a client who is not hypertensive. What is an D) Sexual dysfunction
appropriate response by the charge nurse? The correct answer is C: Altered parenting The cocaine abusing
A) "Most people develop hypertension following an MI." mother puts her newborn and other children at risk for neglect and
B) "A beta-Blocker will prevent orthostatic hypotension." abuse. Continuing to use drugs has the potential to impact parenting
C) "This drug will decrease the workload on his heart." behaviors. Social service referrals are indicated
D) "Beta-blockers increase the strength of heart contractions."
The correct answer is C: "This drug will decrease the workload on Question Number 36 of 40
his heart." One action of beta-blockers is to decrease systemic The nurse admits a 2 year-old child who has had a seizure. Which of
vascular resistance by dilating arterioles. This is useful for the client the following statement by the child's parent would be important in
