NURSING REVIEW Nclex review |NURSING REVIEW Nclex review

NURSING REVIEW Nclex review |NURSING REVIEW Nclex reviewTitle : NCLEX REVIEW NO.1 A depressed client is seen at the mental health center for follow-up afer an atempted suicide 1 week ago. She has taken phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor, for 7 straight days. She states that she is not feeling any beter. The nurse explains that the drug must accumulate to an effectve level before symptoms are totally relieved. Symptom relief is expected to occur within: A. 10 days B. 2-4 weeks C. 2 months D. 3 months Answer: B Explanaton: (A) This answer is incorrect. It can take up to 1 month for therapeutc effect of the medicaton. (B) This answer is correct. Because MAO inhibitors are slow to act, it takes 2-4 weeks before improvement of symptoms is noted. (C) This answer is incorrect. It can take up to 1 month for therapeutc effect of the medicaton. (D) This answer is incorrect. Therapeutc effects of the medicaton are noted within 1 month of drug therapy. NO.2 Cystc fbrosis is transmited as an autosomal recessive trait. This means that: A. Mothers carry the gene and pass it to their sons B. Fathers carry the gene and pass it to their daughters C. Both parents must have the disease for a child to have the disease D. Both parents must be carriers for a child to have the disease Answer: D Explanaton: (A) Cystc fbrosis is not an X-linked or sex-linked disease. (B) The only characteristc on the Y chromosome is the trait for hairy ears. (C) Both parents do not need to have the disease but must be carriers. (D) If a trait is recessive, two genes (one from each parent) are necessary to produce an affected child. NO.3 A 24-year-old client presents to the emergency department protestng "I am God." The nurse identfes this as a: A. Delusion B. Illusion 1C. Hallucinaton D. Conversion Answer: A Explanaton: (A) Delusion is a false belief. (B) Illusion is the misrepresentaton of a real, external sensory experience. (C) Hallucinaton is a false sensory percepton involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestatons. NO.4 In acute episodes of mania, lithium is effectve in 1-2 weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully. Sometmes an antpsychotc agent is prescribed during the frst few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotc symptoms. In additon to the lithium, which one of the following medicatons might the physician prescribe? A. Diazepam (Valium) B. Haloperidol (Haldol) C. Sertraline (Zolof) D. Alprazolam (Xanax) Answer: B Explanaton: (A) Diazepam is an antanxiety medicaton and is not designed to reduce psychotc symptoms. (B) Haloperidol is an antpsychotc medicaton and may be used untl the lithium takes effect. (C) Sertraline is an antdepressant and is used primarily to reduce symptoms of depression. (D) Alprazolam is an antanxiety medicaton and is not designed to reduce psychotc symptoms. NO.5 A violent client remains in restraints for several hours. Which of the following interventons is most appropriate while he is in restraints? A. Give fluids if the client requests them. B. Assess skin integrity and circulaton of extremites before applying restraints and as they areremoved. C. Measure vital signs at least every 4 hours. D. Release restraints every 2 hours for client to exercise. Answer: D Explanaton: (A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not. (B) Skin integrity and circulaton of the extremites should be checked regularly while the client is restrained, not only before restraints are applied and afer they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains agitated in restraints, vital signs should be monitored even more closely, perhaps every 1-2 hours. (D) Restraints should be released every 2 hours for exercise, one extremity at a tme, to maintain muscle tone, skin and joint integrity, and circulaton. NO.6 The pediatrician has diagnosed tnea capits in an 8- year-old girl and has placed her on oral griseofulvin. The nurse should emphasize which of these instructons to the mother and/or child? A. Administer oral griseofulvin on an empty stomach for best results. B. Discontnue drug therapy if food tastes funny. C. May discontnue medicaton when the child experiences symptomatc relief. D. Observe for headaches, dizziness, and anorexia. 2Answer: D Explanaton: (A) Giving the drug with or afer meals may allay gastrointestnal discomfort. Giving the drug with a faty meal (ice cream or milk) increases absorpton rate. (B) Griseofulvin may alter taste sensatons and thereby decrease the appette. Monitoring of food intake is important, and inadequate nutrient intake should be reported to the physician. (C) The child may experience symptomatc relief afer 4896 hours of therapy. It is important to stress contnuing the drug therapy to prevent relapse (usually about 6 weeks). (D) The incidence of side effects is low; however, headaches are common. Nausea, vomitng, diarrhea, and anorexia may occur. Dizziness, although uncommon, should be reported to the physician. NO.7 A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The ratonale for this therapy is to: A. Prevent systemic infecton B. Promote diuresis C. Decrease ammonia formaton D. Acidify the small bowel Answer: C Explanaton: (A) Neomycin is an antbiotc, but this is not the Ratonale for administering it to a client in hepatc coma. (B) Diuretcs and salt-free albumin are used to promote diuresis in clients with cirrhosis of the liver. (C) Neomycin destroys the bacteria in the intestnes. It is the bacteria in the bowel that break down protein into ammonia. (D) Lactulose is administered to create an acid environment in the bowel. Ammonia leaves the blood and migrates to this acidic environment where it is trapped and excreted. NO.8 A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures should be included in the postoperatve care? A. Encourage the child to cough up blood if present. B. Give warm clear liquids when fully alert. C. Have child gargle and do toothbrushing to remove old blood. D. Observe for evidence of bleeding. Answer: D Explanaton: (A) The nurse should discourage the child from coughing, clearing the throat, or putng objects in his mouth. These may induce bleeding. (B) Cool, clear liquids may be given when child is fully alert. Warm liquids may dislodge a blood clot. The nurse should avoid red- or brown-colored liquids to distnguish fresh or old blood from ingested liquid should the child vomit. (C) Gargles and vigorous toothbrushing could initate bleeding. (D) Postoperatve hemorrhage, though unusual, may occur. The nurse should observe for bleeding by looking directly into the throat and for vomitng of bright red blood, contnuous swallowing, and changes in vital signs. NO.9 An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his lef leg that started approximately 20 minutes ago. When performing the admission assessment, the nurse would expect to observe which of the following: 3A. Both lower extremites warm to touch with 2_pedal pulses B. Both lower extremites cyanotc when placed in a dependent positon C. Decreased or absent pedal pulse in the lef leg D. The lef leg warmer to touch than the right leg Answer: C Explanaton: (A) This statement describes a normal assessment fnding of the lower extremites. (B) This assessment fnding reflects problems caused by venous insufciency. (C) Decreased or absentpedal pulses reflect a problem caused by arterial insufciency. (D) The leg that is experiencing arterial insufciency would be cool to touch due to the decreased circulaton. NO.10 A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notfcaton of physician? A. pH 7.39 B. White blood cell (WBC) count 10,000 WBCs/mm3 C. Hematocrit 60% D. Bleeding tme of 4 minutes Answer: C Explanaton: (A) Normal pH of arterial blood gases for an infant is 7.35-7.45. (B) Normal white blood cell count in an infant is 6,000-17,500 WBCs/mm3. (C) Normal hematocrit in infant is 28%-42%. A 60% hematocrit may indicate polycythemia, a common complicaton of cyanotc heart disease. (D) Normal bleeding tme is 2-7 minutes. NO.11 A male client is experiencing extreme distress. He begins to pace up and down the corridor. What nursing interventon is appropriate when communicatng with the pacing client? A. Ask him to sit down. Speak slowly and use short, simple sentences. B. Help him to recognize his anxiety. C. Walk with him as he paces. D. Increase the level of his supervision. Answer: C Explanaton: (A) The nurse should not ask him to sit down. Pacing is the actvity he has chosen to deal with his anxiety. The nurse dealing with this client should speak slowly and with short, simplesentences. (B) The client may already recognize the anxiety and is atemptng to deal with it. (C) Walk with the client as he paces. This gives support while he uses anxiety-generated energy. (D) Increasing the level of supervision may be appropriate afer he stops pacing. It would minimize self-injury and/or loss of control. NO.12 Prior to an amniocentesis, a fetal ultrasound is done in order to: A. Evaluate fetal lung maturity B. Evaluate the amount of amniotc fluid C. Locate the positon of the placenta and fetus D. Ensure that the fetus is mature enough to perform the amniocentesis 4Answer: C Explanaton: (A) Amniocentesis can be performed to assess for lung maturity. Fetal ultrasound can be used for gestatonal datng, although it does not separately determine lung maturity. (B) Ultrasound can evaluate amniotc fluid volume, which may be used to determine congenital anomalies. (C) Amniocentesis involves removal of amniotc fluid for evaluaton. The needle, inserted through the abdomen, is guided by ultrasound to avoid needle injuries, and the test evaluates the positon of the placenta and the fetus. (D) Amniocentesis can be performed as early as the 15th-17th week of pregnancy. NO.13 A 25-year-old client believes she may be pregnant with her frst child. She schedules an obstetric examinaton with the nurse practtoner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estmated date of confnement using Nagele's rule is: A. March 27 B. February 1 C. February 27 D. January 3 Answer: C Explanaton: (A)March 27 is a miscalculaton. (B) February 1 is a miscalculaton. (C) February 27 is the correct answer. To calculate the estmated date of confnement using Nagele's rule, subtract 3 months from the date that the last menstrual cycle began and then add 7 days to the result. (D) January 3 is a miscalculaton. NO.14 A client is now pregnant for the second tme. Her frst child weighed 4536 g at delivery. The client's glucose tolerance test shows elevated blood sugar levels. Because she only shows signs of diabetes when she is pregnant, she is classifed as having: A. Insulin-dependent diabetes B. Type II diabetes mellitus C. Type I diabetes mellitus D. Gestatonal diabetes mellitus Answer: D Explanaton: (A) Insulin-dependent diabetes mellitus, also known as type I diabetes, usually appears before the age of 30 years with an abrupt onset of symptoms requiring insulin for management. It is not related to onset during pregnancy. (B) Non-insulin-dependent diabetes (type II diabetes) usually appears in older adults. It has a slow onset and progression of symptoms. (C) This type of diabetes is the same as insulin-dependent diabetes. (D) Gestatonal diabetes mellitus has its onset of symptoms during pregnancy and usually disappears afer delivery. These symptoms are usually mild and not life threatening, although they are associated with increased fetal morbidity and other fetal complicatons. NO.15 A 44-year-old female client is receiving external radiaton to her scapula for metastasis of breast cancer. 5Teaching related to skin care for the client would include which of the following? A. Teach her to completely clean the skin to remove all ointments and markings afer each treatment . B. Teach her to cover broken skin in the treated area with a medicated ointment. C. Encourage her to wear a tght-ftng vest to support her scapula. D. Encourage her to avoid direct sunlight on the area being treated. Answer: D Explanaton: (A) The skin in a treatment area should be rinsed with water and pated dry. Markings should be lef intact, and the skin should not be scrubbed. (B) Clients should avoid putng any creams or lotons on the treated area. This could interfere with treatment. (C) Radiaton therapy clients should wear looseftng clothes and avoid tght, irritatng fabrics. (D) The area of skin being treated is sensitve to sunlight, and the client should take care to prevent sun damage by avoiding direct sunlight and covering the area when she is in the sun. NO.16 The nurse is assistng a 4th-day postoperatve cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essental in promotng tssue healing? A. Vitamin C B. Vitamin B1 C. Vitamin D D. Vitamin AAnswer: A Explanaton: (A) Vitamin C (ascorbic acid) is essental in promotng wound healing and collagen formaton. (B) Vitamin B1 (thiamine) maintains normal gastrointestnal (GI) functoning, oxidizes carbohydrates, and is essental for normal functoning of nervous tssue. (C) Vitamin D regulates absorpton of calcium and phosphorus from the GI tract and helps prevent rickets. (D) Vitamin A is necessary for the formaton and maintenance of skin and mucous membranes. It is also essental for normal growth and development of bones and teeth. NO.17 A 10-year-old client with a pin in the right femur is immobilized in tracton. He is exhibitng behavioral changes including restlessness, difculty with problem solving, inability to concentrate on actvites, and monotony. Which of the following nursing implementatons would be most effectve in helping him cope with immobility? A. Providing him with books, challenging puzzles, and games as diversionary actvites B. Allowing him to do as much for himself as he is able, including learning to do pin-site care undersupervision C. Having a volunteer come in to sit with the client and to read him stories D. Stmulatng rest and relaxaton by gentle rubbing with loton and changing the client's positonfrequently Answer: B Explanaton: (A) These actvites could be frustratng for the client if he is having difculty with problem solving and concentraton. (B) Selfcare is usually well received by the child, and it is one of the most useful interventons to help the child cope with immobility. (C) This may be helpful to the client if he has no visitors, but it does litle to help him develop coping skills. (D) This will helpto prevent skin irritaton or breakdown related to immobility but will not help to prevent behavioral changes related to immobility. 6NO.18 In client teaching, the nurse should emphasize that fetal damage occurs more frequently with ingeston of drugs during: A. First trimester B. Second trimester C. Third trimester D. Every trimester Answer: A Explanaton: (A) Organogenesis occurs in the frst trimester. Fetus is most susceptble to malformaton during this period. (B) Organogenesis has occurred by the second trimester. (C) Fetal development is complete by this tme. (D) The dangerous period for fetal damage is the frst trimester, not the entre pregnancy. NO.19 On admission, the client has signs and symptoms of pulmonary edema. The nurse places the client in the most appropriate positon for a client in pulmonary edema, which is: A. High Fowler B. Lying on the lef side C. Sitng in a chair D. Supine with feet elevated Answer: A Explanaton: (A) High Fowler positon decreases venous return to the heart and permits greater lung expansion so that oxygenaton is maximized. (B) Lying on the lef side may improve perfusion to the lef lung but does not promote lung expansion. (C) Sitng in a chair will decrease venous return and promote maximal lung expansion. However, clients with pulmonary edema can deteriorate quickly and require intubaton and mechanical ventlaton. If a client is sitng in achair when this deterioraton happens, it will be difcult to intervene quickly. (D) The supine with feet elevated positon increases venous return and will worsen pulmonary edema. NO.20 A client has returned to the unit from the recovery room afer having a thyroidectomy. The nurse knows that a major complicaton afer a thyroidectomy is: A. Respiratory obstructon B. Hypercalcemia C. Fistula formaton D. Myxedema Answer: A Explanaton: (A) Respiratory obstructon due to edema of the glots, bilateral laryngeal nerve damage, or tracheal compression from hemorrhage is a major complicaton afer a thyroidectomy. (B) Hypocalcemia accompanied by tetany from accidental removal of one or more parathyroid glands is a major complicaton, not hypercalcemia. (C) Fistula formaton is not a major complicaton associated with a thyroidectomy. It is a major complicaton with a laryngectomy.(D) Myxedema is 7hypothyroidism that occurs in adults and is not a complicaton of a thyroidectomy. A thyroidectomy client tends to develop thyroid storm, which is excess producton of thyroid hormone. NO.21 The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase? A. Mother is concerned about her recovery. B. Mother calls infant by name. C. Mother lightly touches infant. D. Mother is concerned about her weight gain. Answer: B Explanaton: (A) This observaton can be made during the taking-in phase when the mother's needs are more important. (B) This observaton can be made during the taking-hold phase when the mother is actvely involved with herself and the infant. (C, D) This observaton can be made during the taking-in phase. NO.22 A female client has just died. Her family is requestng that all nursing staff leave the room. The family's religious leader has arrived and is ready to conduct a ceremony for the deceased in the room, requestng that only family members be present. The nurse assigned to the client should perform the appropriate nursing acton, which might include: A. Inform the family that it is the hospital's policy not to conduct religious ceremonies in client rooms . B. Refuse to leave the room because the client's body is entrusted in the nurse's care untl it can bebrought to the morgue. C. Tell the family that they may conduct their ceremony in the client's room; however, the nursemust atend. D. Respect the client's family's wishes. Answer: D Explanaton: (A) It is rare that a hospital has a specifc policy addressing this partcular issue. If the statement is true, the nurse should show evidence of the policy to the family and suggest alternatves, such as the hospital chapel. (B) Refusal to leave the room demonstrates a lack of understanding related to the family's need to grieve in their own manner. (C) The nurse should leave the room and allow the family privacy in their grief. (D) The family's wish to conduct a religious ceremony in the client's room is part of the grief process. The request is based on specifc cultural and religious differences dictatng social customs. NO.23 A woman diagnosed with multple sclerosis is disturbed with diplopia. The nurse will teach her to: A. Limit actvites which require focusing (close vision) B. Take more frequent naps C. Use artfcial tears D. Wear a patch over one eye Answer: D Explanaton: (A) 8Limitng actvites requiring close vision will not alleviate the discomfort of double vision. (B) Frequent naps may be comfortng, but they will not prevent double vision. (C) Artfcial tears are necessary in the absence of a corneal reflex, but they have no effect on diplopia. (D) An eye patch over either eye will eliminate the effects of double vision during the tme the eye patch is worn. An eye patch is safe for a person with an intact corneal reflex. NO.24 One of the most reliable assessment tools for adequacy of fluid resuscitaton in burned children is: A. Blood pressure B. Level of consciousness C. Skin turgor D. Fluid intake Answer: B Explanaton: (A) Blood pressure can remain normotensive in a state of hypovolemia. (B) Capillary refll, alteratons in sensorium, and urine output are the most reliable indicators for assessing hydraton. (C) Skin turgor is not a reliable indicator for assessing hydraton in a burn client. (D) Fluid intake does not indicate adequacy of fluid resuscitaton in a burn client. NO.25 Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitaton in a 3-year-old child who suffered partal- and fullthickness burns to 25% of her body? A. Urine output B. Edema C. Hypertension D. Bulging fontanelle Answer: A Explanaton: (A) Urinary output is a reliable indicator of renal perfusion, which in turn indicates that fluid resuscitaton is adequate. IV fluids are adjusted based on the urinary output of the child during fluid resuscitaton. (B) Edema is an indicaton of increased capillary permeability following a burn injury. (C) Hypertension is an indicator of fluid volume excess. (D) Fontanelles close by 18 months of age. NO.26 A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report: A. Dizziness and tachypnea B. Circumoral pallor and lightheadedness C. Headache and facial flushing D. Pallor and itching of the face and neck 9Answer: C Explanaton: (A) Tachypnea is not a symptom. (B) Circumoral pallor is not a symptom. (C) Autonomic dysreflexia is an uninhibited and exaggerated reflex of the autonomic nervous system to stmulaton, which results in vasoconstricton and elevated blood pressure. (D) Pallor and itching are not symptoms. NO.27 A client states to his nurse that "I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells." Based on this informaton, which drug might the nurse expect to be discontnued? A. Prednisone B. Timolol maleate (Blocadren) C. Garamycin (Gentamicin) D. Phenytoin (Dilantn) Answer: D Explanaton: (A) Prednisone is not linked with hematological side effects. (B) Timolol, a -adrenergic blocker is metabolized by the liver. It has not been linked to blood dyscrasia. (C) Gentamicin is ototoxic and nephrotoxic. (D) Phenytoin usage has been linked to blood dyscrasias such as aplastc anemia. The drug most commonly linked to aplastc anemia is chloramphenicol (Chlormycetn). NO.28 A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should: A. Notfy the physician immediately B. Hold the morning lithium dose and contnue to observe the client C. Administer the morning lithium dose as scheduled D. Obtain an order for benztropine (Cogentn) Answer: C Explanaton: (A) There is no need to phone the physician because the lithium level is within therapeutc range and because there are no indicatons of toxicity present. (B) There is no reason to withhold the lithium because the blood level is within therapeutc range. Also, it is necessary to give the medicaton as scheduled to maintain adequate blood levels. (C) The lab results indicate that the client's lithium level is within therapeutc range (0.2-1.4 mEq/L), so the medicaton should be given as ordered. (D) Benztropine is an antparkinsonism drug frequently given to counteractextrapyramidal symptoms associated with the administraton of antpsychotc drugs (not lithium). NO.29 The primary focus of nursing interventons for the child experiencing sickle cell crisis is aimed toward: A. Maintaining an adequate level of hydraton B. Providing pain relief C. Preventng infecton D. O2 therapy Answer: A Explanaton: 10(A) Maintaining the hydraton level is the focus for nursing interventon because dehydraton enhances the sickling process. Both oral and parenteral fluids are used. (B) The pain is a result of the sickling process. Analgesics or narcotcs will be used for symptom relief, but the underlying cause of the pain will be resolved with hydraton. (C) Serious bacterial infectons may result owing to splenic dysfuncton. This is true at all tmes, not just during the acute period of a crisis. (D) O2 therapy is used for symptomatc relief of the hypoxia resultng from the sickling process. Hydraton is the primary interventon to alleviate the dehydraton that enhances the sickling process. NO.30 Three weeks following discharge, a male client is readmited to the psychiatric unit for depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse admits him to the unit, he says, "I wish I were dead because I am worthless to everyone; I guess I am just no good." Which response by the nurse is most appropriate at this tme? A. "I don't think you are worthless. I'm glad to see you, and we will help you." B. "Don't you think this is a sign of your illness?" C. "I know with your wife and new baby that you do have a lot to live for." D. "You've been feeling sad and alone for some tme now?" Answer: D Explanaton: (A) This response does not acknowledge the client's feelings. (B) This is a closed queston and does not encourage communicaton. (C) This response negates the client's feelings and does not require a response from the client. (D) This acknowledges the client's implied thoughts and feelings and encourages a response. NO.31 A 52-year-old client is scheduled for a small-bowel resecton in the morning. In conjuncton with other preoperatve preparaton, the nurse is teaching her diaphragmatc breathing exercises. She will teach the client to: A. Inhale slowly and deeply through the nose untl the lungs are fully expanded, hold the breath acouple of seconds, and then exhale slowly through the mouth. Repeat 2-3 more tmes to complete the series every 1-2 hours while awake B. Purse the lips and take quick, short breaths approximately 18-20 tmes/min C. Take a large gulp of air into the mouth, hold it for 10-15 seconds, and then expel it through thenose. Repeat 4-5 tmes to complete the series D. Inhale as deeply as possible and then immediately exhale as deeply as possible at a rate ofapproximately 20-24 tmes/min Answer: A Explanaton: (A) This is the correct method of teaching diaphragmatc breathing, which allows full lung expansion to increase oxygenaton, prevent atelectasis, and move secretons up and out of the lungs to decrease risk of pneumonia. (B) Quick, short breaths do not allow for full lung expansion and movement of secretons up and out of the lungs. Quick, short breaths may lead to O2 depleton, hyperventlaton, and hypoxia. (C) Expelling breaths through the nose does not allow for full lung expansion and the 11use of diaphragmatc muscles to assist in moving secretons up and out of the lungs. (D) Inhaling and exhaling at a rate of 20-24 tmes/min does not allow tme for full lung expansion to increase oxygenaton. This would most likely lead to O2 depleton and hypoxia. NO.32 The nurse enters the playroom and fnds an 8-year-old child having a grand mal seizure. Which one of the following actons should the nurse take? A. Place a tongue blade in the child's mouth. B. Restrain the child so he will not injure himself. C. Go to the nurses staton and call the physician. D. Move furniture out of the way and place a blanket under his head. Answer: D Explanaton: (A) The nurse should not put anything in the child's mouth during a seizure; this acton could obstruct the airway. (B) Restraining the child's movements could cause constrictve injury. (C) Staying with the child during a seizure provides protecton and allows the nurse to observe the seizure actvity. (D) The nurse should provide safety for the child by moving objects and protectng the head. NO.33 An 11-year-old boy has received a partal-thickness burn to both legs. He presents to the emergency room approximately 15 minutes afer the accident in excruciatng pain with charred clothing to both legs. What is the frst nursing acton? A. Apply ice packs to both legs. B. Begin debridement by removing all charred clothing from wound. C. Apply Silvadene cream (silver sulfadiazine). D. Immerse both legs in cool water. Answer: D Explanaton: (A) Ice creates a dramatc temperature change in the tssue, which can cause further thermal injury. (B) Charred clothing should not be removed from wound frst. This creates further tssue damage. Debridement is not the frst nursing acton. (C) Applying silver sulfadiazine cream frst insulates heat in injured tssue and increases potental for infecton. (D) Emergency care of a thermal burn is immersing both legs in cool water. Cool water permits gradual temperature change and prevents further thermal damage. NO.34 The nurse notes scatered crackles in both lungs and 1+ pitng edema when assessing a cardiac client. The physician is notfed and orders furosemide (Lasix) 80 mg IV push stat. Which of the following diagnostc studies is monitored to assess for a major complicaton of this therapy? A. Serum electrolytes B. Arterial blood gases C. Complete blood count D. 12-Lead ECG Answer: A Explanaton: (A) Furosemide, a potassium-depletng diuretc, inhibits the reabsorpton of sodium and chloride from the loop of Henle and the distal renal tubules. Serum electrolytes are monitored for hypokalemia. (B) Severe acid-base imbalances influence the movement of potassium into and out of the cells, but 12arterial blood gases to not measure the serum potassium level. (C) Furosemide is a potassiumdepletng diuretc. A complete blood count does not reflect potassium levels. (D) Abnormalites in potassium (both hyperkalemia and hypokalemia) are reflected in ECG changes, but these changes do not occur untl the abnormality is severe. NO.35 A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements? A. "When I get home, I will need to take my medicines and call my therapist if I have any side effectsor begin to hear voices." B. "If I have any side effects from my medicines, I will take an extra dose of Cogentn." C. "When I get home, I should be able to taper myself off the Haldol because the voices are gonenow." D. "As soon as I leave here, I'm throwing away my medicines. I never thought I needed themanyway." Answer: A Explanaton: (A) The client verbalizes that he is responsible for compliance and keeping the treatment team member informed of progress. This behavior puts him at the lowest risk for relapse. (B) Noncompliance is a major cause of relapse. This statement reflects lack of responsibility for his own health maintenance. (C) This statement reflects lack of insight into the importance of compliance. (D) This statement reflects no insight into his illness or his responsibility in health maintenance. NO.36 A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routne examinaton and screening. Which of these plans by the nurse would be most successful? A. Examine the 4 year old frst. B. Provide tme for play and becoming acquainted. C. Have the mother leave the room with one child, and examine the other child privately. D. Examine painful areas frst to get them "over with." Answer: B Explanaton: (A) The 6 month old should be examined frst. If several children will be examined, begin with the most cooperatve and less anxious child to provide modeling. (B) Providing tme for play and getng acquainted minimizes stress and anxiety associated with assessment of body parts. (C) Children generally cooperate best when their mother remains with them. (D) Painful areas are best examined last and will permit maximum accuracy of assessment. NO.37 Diagnostc assessment fndings for an infant with possible coarctaton of the aorta would include: A. A third heart sound B. A diastolic murmur C. Pulse pressure difference between the upper extremites 13D. Diminished or absent femoral pulses Answer: D Explanaton: (A) S1 and S2 in an infant with coarctaton of the aorta are usually normal. S3 and S4 do not exist with this diagnosis. (B) Either no murmur will be heard or a systolic murmur from an associated cardiac defect will be heard along the lef upper sternal border. A diastolic murmur is not associated with coarctaton of the aorta. (C) Pulse pressure differences of>20 mm Hg exist between the upper extremites and the lower extremites. It is important to evaluate the upper and lower extremites with the appropriate- sized cuffs. (D) Femoral and pedal pulses will be diminished or absent in infants with coarctaton of the aorta. NO.38 During a client's frst postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus. This may be due to: A. Endometrits B. Fibroid tumor on the uterus C. Displacement due to bowel distenton D. Urine retenton or a distended bladder Answer: D Explanaton: (A, B) Endometrits, urine retenton, or bladder distenton provide good distractors because they may delay involuton but do not usually cause the uterus to be lateral. (C) Bowel distenton and constpaton are common in the postpartum period but do not displace the uterus laterally. (D) Urine retenton or bladder distenton commonly displaces the uterus to the right and may delay involuton. NO.39 An 80-year-old widow is living with her son and daughter- in-law. The home health nurse has been making weekly visits to draw blood for a prothrombin tme test. The client is taking 5 mg of coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is suspected. Which of the following are signs of persons who are at risk for abusing an elderly person? A. A family member who is having marital problems and is regularly abusing alcohol B. A person with adequate communicaton and coping skills who is employed by the family C. A friend of the family who wants to help but is minimally competent D. A lifelong friend of the client who is ofen confused Answer: A Explanaton: (A) This answer is correct. Two risk factors are identfed in this answer. (B) This answer is incorrect. Persons at risk tend to lack communicaton skills and effectve coping paterns. (C) This answer is incorrect. Persons at risk are usually family members or those reluctant to provide care. (D) This answer is incorrect. This individual has a vested interest in providing care. NO.40 A 32-year-old female client is being treated for Guillain- Barre syndrome. She complains of gradually increasing muscle weakness over the past several days. She has notced an increased 14difculty in ambulatng and fell yesterday. When conductng a nursing assessment, which fnding would indicate a need for immediate further evaluaton? A. Complaints of a headache B. Loss of superfcial and deep tendon reflexes C. Complaints of shortness of breath D. Facial paralysis Answer: C Explanaton: (A) Headaches are not associated with Guillain-Barre syndrome. (B) Loss of superfcial and deep tendon reflexes is expected with this diagnosis. (C) Complaints of shortness of breath must be further evaluated. Forty percent of all clients have some detectable respiratory weakness and should be prepared for a possible tracheostomy. Pneumonia is also a common complicaton of this syndrome. (D) Facial paralysis is expected and is not considered abnormal. NO.41 Plans for the care of a client with an ulcer caused by emotonal problems need to take into consideraton that: A. His priority needs are limited to medical management B. There is no real psychological basis for his illness C. The disorder is a threat to his physical well-being D. He is unable to partcipate in planning his care Answer: C Explanaton: (A) There may be a medical emergency that takes top priority; however, the basis of the problem is emotonal. (B) The problem is a physical manifestaton of an emotonal conflict. (C) The bleeding ulcer can be life threatening. (D) For lifestyle change to occur, the client must partcipate in the planning of his care so that he is commited to changes that will have positve results. NO.42 A 55-year-old man has recently been diagnosed with hypertension. His physician orders a lowsodium diet for him. When he asks, "What does salt have to do with high blood pressure?'' the nurse's inital response would be: A. "The reason is not known why hypertension is associated with a high-salt diet." B. "Large amounts of salt in your diet can cause you to retain fluid, which increases your bloodpressure." C. "Salt affects your blood vessels and causes your blood pressure to be high." D. "Salt is needed to maintain blood pressure, but too much causes hypertension." Answer: B Explanaton: (A) This response is untrue. (B) Decreasing salt intake reduces fluid retenton and decreases blood pressure. (C) Salt does not have an effect on the blood vessels themselves, but on fluid retenton, which accompanies salt intake. (D) This response is untrue. NO.43 A client is medically cleared for ECT and is tentatvely scheduled for six treatments over a 2week period. Her husband asks, "Isn't that a lot?" The nurse's best response is: 15A. "Yes, that does seem like a lot." B. "You'll have to talk to the doctor about that. The physician knows what's best for the client." C. "Six to 10 treatments are common. Are you concerned about permanent effects?" D. "Don't worry. Some clients have lots more than that." Answer: C Explanaton: (A) This response indicates that the nurse is unsure of herself and not knowledgeable about ECT. It also reinforces the husband's fears. (B) This response is "passing the buck" unnecessarily. The informaton needed to appropriately answer the husband's queston is well within the nurse's knowledge base. (C) The most common range for affectve disorders is 6-10 treatments. This response confrms and reinforces the physician's plan for treatment. It also opens communicatonwith the husband to identfy underlying fears and knowledge defcits. (D) This response offers false reassurance and dismisses the husband's underlying concerns about his wife. NO.44 A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complicatons may occur initally, so the nurse will monitor him closely for serum: A. Chloride level of 99 mEq/L B. Sodium level of 136 mEq/L C. Potassium level of 3.1 mEq/L D. Potassium level of 6.3 mEq/L Answer: D Explanaton: (A) The chloride level is within acceptable limits. (B) The sodium level is within acceptable limits. (C) This value indicates hypokalemia, rather than the hyperkalemia that occurs during diabetc ketoacidosis. (D) When diabetc ketoacidosis exists, intracellular dehydraton occurs and potassium leaves the cells and enters the vascular system, thus increasing the serum level beyond an acceptable range. When insulin and fluids are administered, cell walls are repaired and potassium is transported back into the cells. Normal serum potassium levels range from 3.5-5.0 mEq/L. NO.45 A 27-year-old primigravida at 32 weeks' gestaton has been diagnosed with complete placenta previa. Conservatve management including bed rest is the proper medical management. The goal for fetal survival is based on fetal lung maturity. The test used to determine fetal lung maturity is: A. Dinitrophenylhydrazine B. Metachromatc stain C. Blood serum phenylalanine test D. Lecithin-sphingomyelin rato Answer: D Explanaton: (A) Dinitrophenylhydrazine is a laboratory test used to detect phenylketonuria, maple syrup urine disease, and Lowe's syndrome. (B) Metachromatc stain is a laboratory test that may be used to diagnose Tay-Sachs and other lipid diseases of the central nervous system. (C) The blood serum phenylalanine test is diagnostc of phenylketonuria and can be used for wide-scale screening. (D) A lecithin-sphingomyelin rato of at least 2:1 is indicatve of fetal lung maturity, and survival of the fetus is likely. 16NO.46 One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid. A lithium level is ordered. The client's level is 1.3 mEq/L. The nurse recognizes that this level is considered to be: A. Within therapeutc range B. Below therapeutc range C. Above therapeutc range D. At a level of toxic poisoning Answer: A Explanaton: (A) This answer is correct. The therapeutc range is 1.0-1.5 mEq/L in the acute phase. Maintenance control levels are 0.6-1.2 mEq/L. (B, C) This answer is incorrect. A level of 1.3 mEq/L is within therapeutc range. (D) This answer is incorrect. Toxic poisoning is usually at the 2.0 level or higher. NO.47 When discussing the relatonship between exercise and insulin requirements, a 26-year-old client with IDDM should be instructed that: A. When exercise is increased, insulin needs are increased B. When exercise is increased, insulin needs are decreased C. When exercise is increased, there is no change in insulin needs D. When exercise is decreased, insulin needs are decreased Answer: B Explanaton: (A) If the client's insulin is increased when actvity level is increased, hypoglycemia may result. (B) Exercise decreased the blood sugar by promotng uptake of glucose by the muscles. Consequently, less insulin is needed to metabolize ingested carbohydrates. Extra food may be required for extra actvity. (C) This statement directly contradicts the correct answer and is inaccurate. (D) When exercise is decreased, the client's insulin dose does not need to be altered unless the blood sugar becomes unstable. NO.48 A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the incision, a small part of the abdominal viscera is seen protruding through the incision. This complicaton of wound healing is known as: A. Excoriaton B. Dehiscence C. Decortcaton D. Evisceraton Answer: D Explanaton: (A) Excoriaton is abrasion of the epidermis or of the coatng of any organ of the body by trauma, chemicals, burns, or other causes. (B) Dehiscence is a partal or complete separaton of the wound edges with no protrusion of abdominal tssue. (C) Decortcaton is removal of the surface layer of an organ or structure. It is a type of surgery, such as removing the fbrinous peel from the visceral pleura in thoracic surgery. (D) Evisceraton occurs when the incision separates and the contents of the cavity spill out. 17NO.49 A 3-year-old child is admited with a diagnosis of possible noncommunicatng hydrocephalus. What is the frst symptom that indicates increased intracranial pressure? A. Bulging fontanelles B. Seizure C. Headache D. Ataxia Answer: C Explanaton: (A) Bulging fontanelles are a symptom of increased intracranial pressure in infants. (B) Seizure is a late sign of increased intracranial pressure. (C) Headache is a very early symptom of increased intracranial pressure in the child. (D) Ataxia is a late sign of increased intracranial pressure. NO.50 Which nursing implicaton is appropriate for a client undergoing a paracentesis? A. Have the client void before the procedure. B. Keep the client NPO. C. Observe the client for hypertension following the procedure. D. Place the client on the right side following the procedure. Answer: A Explanaton: (A) A full bladder would impede withdrawal of ascitc fluid. (B) Keeping the client NPO is not necessary. (C) The client may exhibit signs and symptoms of shock and hypertension. (D) No positon change is needed afer the procedure. NO.51 A client is placed in fve-point restraints afer exhibitng sudden violence afer illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. Afer 1 hour, his behavior is more subdued, but he tells the nurse, "The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart." The nurse's best response is: A. "I know you're feeling frightened right now, but I want you to know that I don't see anyone in thecorner." B. "You'll probably see strange things for a while untl the PCP wears off." C. "Try to sleep. When you wake up, the devil will be gone." D. "You're probably feeling guilty because you used illegal drugs tonight." Answer: A Explanaton: (A) The nurse is the client's link to reality. This response validates the authentcity of the client's experience by castng doubt on his belief and reinforcing reality. (B) Although this statement may be literally correct, it is nontherapeutc because it lacks validaton. (C) This response encourages the client to atempt to do something that may be impossible at this tme, offers false reassurance, and reinforces delusional content. (D) The nurse is making an incorrect assumpton about the client's feelings by offering a nontherapeutc interpretaton of the motvaton for the client's actons. NO.52 To facilitate maximum air exchange, the nurse should positon the client in: A. High Fowler B. OrthopneicC. Prone D. Flat-supine 18Answer: B Explanaton: (A) The high Fowler positon does increase air exchange, but not to the extent of orthopneic positon. (B) The orthopneic positon is a sitng positon that allows maximum lung expansion. (C) The prone positon places pressure on diaphragm and does not promote maximum air exchange. (D) The flatsupine positon places pressure on diaphragm by abdominal organs and does not promote maximum air exchange. NO.53 A 48-year-old client is in the surgical intensive care unit afer having had three-vessel coronary artery bypass surgery yesterday. She is extubated, awake, alert and talking. She is receiving digitalis for atrial arrhythmias. This morning serum electrolytes were drawn. Which abnormality would require immediate interventon by the nurse afer contactng the physician? A. Serum osmolality is elevated indicatng hemoconcentraton. The nurse should increase IV fluidrate. B. Serum sodium is low. The nurse should change IV fluids to normal saline. C. Blood urea nitrogen is subnormal. The nurse should increase the protein in the client's diet as soonas possible. D. Serum potassium is low. The nurse should administer KCl as ordered. Answer: D Explanaton: (A) An elevated serum osmolality poses no immediate danger and is not corrected rapidly. (B) A low serum sodium alone does not warrant changing IV fluids to normal saline. Other assessment parameters, such as hydraton status, must be considered. (C) A low serum blood urea nitrogen is not necessarily indicatve of protein deprivaton. It may also be the result of overhydraton. (D)A low serum potassium potentates the effects of digitalis, predisposing the client to dangerous arrhythmias. It must be corrected immediately. NO.54 A male client is scheduled to have angiography of his lef leg. The nurse needs to include which of the following when preparing the client for this procedure? A. Validate that he is not allergic to iodine or shellfsh. B. Instruct him to start actve range of moton of his lef leg immediately following the procedure. C. Inform him that he will not be able to eat or drink anything for 4 hours afer the procedure. D. Inform him that vital signs will be taken every hour for 4 hours afer the procedure.Answer: A Explanaton: (A) Angiography, an invasive radiographic examinaton, involves the injecton of a contrast soluton (iodine) through a catheter that has been inserted into an artery. (B) The client is kept on complete bed rest for 6-12 hours afer the procedure. The extremity in which the catheter was inserted must be immobilized and kept straight during this tme. (C) The contrast dye, iodine, is nephrotoxic. The client must be instructed to drink a large quantty of fluids to assist the kidneys in excretng this contrast media. (D) The major complicaton of this procedure is hemorrhage. Vital signs are assessed every 15 minutes initally for signs of bleeding. NO.55 A client had a transurethral resecton of the prostate yesterday. He is concerned about the small amount of blood that is stll in his urine. The nurse explains that the blood in his urine: 19A. Should not be there on the second day B. Will stop when the Foley catheter is removed C. Is normal and he need not be concerned about it D. Can be removed by irrigatng the bladder Answer: C Explanaton: (A) Some hematuria is usual for several days afer surgery. (B) The client will contnue to have a small amount of hematuria even afer the Foley catheter is removed. (C) Some hematuria is usual for several days afer surgery. The client should not be concerned about it unless it increases. (D) Irrigatng the bladder will not remove the hematuria. Irrigaton is done to remove blood clots and facilitate urinary drainage. NO.56 The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a fullstrength tube feeding at 75 mL/hr. Prior to startng the tube feeding, the nurse confrms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctoning, the nurse notces the sputum to be a blue color. This is indicatve of which of the following? A. The client aspirated tube feeding. B. The nurse has placed the sucton catheter in the esophagus. C. This is a normal fnding. D. The feeding is infusing into the trachea. Answer: A Explanaton: (A) Once the feeding tube placement is confrmed in the stomach, aspiraton can occur if the client's stomach becomes too full. When suctoning the trachea, if secretons resemble tube feeding, the client has aspirated the feeding. (B) Because the trachea provides direct access to a client's airway, it would not be possible to place the catheter in the esophagus. (C) Blue-colored sputum is never considered a normal fnding and should be reported and documented. (D) The nurse confrmed placement of the feeding tube in the stomach prior to initatng the tube feeding; therefore, it is highly unlikely that the feeding tube would be located in the trachea. NO.57 A 3-year-old child has had symptoms of influenza including fever, productve cough, nausea, vomitng, and sore throat for the past several days. In caring for a young child with symptoms of influenza, the mother must be cautoned about: A. Giving aspirin and bismuth subsalicylate (Pepto-Bismol) to treat the symptoms B. Giving clear liquids too soon C. Allowing the child to come in contact with other children for 3 days D. The possibility of pneumonia as a complicaton Answer: A Explanaton: (A) Aspirin should never be given to children with influenza because of the possibility of causing 20Reye's syndrome. Pepto- Bismol is also classifed as a salicylate and should be avoided. (B) Depending on the severity of symptoms, the child may be receiving IV therapy or clear liquids. (C) The disease has a 1-3 day incubaton period and affected children are most infectous 24 hours before and afer the onset of symptoms. (D) Although viral pneumonia can be a complicaton of influenza, this would not be an inital priority. NO.58 A male client is considering having laser abdominal surgery and asks the nurse if there is any advantage in having this type of surgery? The nurse will respond based on the knowledge that laser surgery: A. Has a smaller postoperatve infecton rate than routne surgery B. Will eliminate the need for preoperatve sedaton C. Will result in less operatng tme D. Generally eliminates problems with complicatons Answer: A Explanaton: (A) A lower postoperatve infecton has been documented as a result of laser therapy versus routne surgery. (B) Clients will stll need preoperatve sedaton to facilitate anxiety reducton. (C) Operatng tme may actually increase in some laser surgeries. (D) The client must stll be observed for postoperatve complicatons. NO.59 Based on your knowledge of genetc inheritance, which of these statements is true for autosomal recessive genetc disorders? A. Heterozygotes are affected. B. The disorder is always carried on the X chromosome. C. Only females are affected. D. Two affected parents always have affected children. Answer: D Explanaton: (A) The term heterozygote refers to an individual with one normal and one mutant allele at a given locus on a pair of homologous chromosomes. An individual who is heterozygous for the abnormal gene does not manifest obvious symptoms. (B) Disorders carried on either the X or Y sex chromosome are referred to as sex-linked recessive. (C) Either sex may be affected by autosomal recessive genetc disorders because the responsible allele can be on any one of the 46 chromosomes. (D) If both parents are affected by the disorder and are not just carriers, then all their children would manifest the same disorder. NO.60 The pediatric nurse charts that the parents of a 4-yearold child are very anxious. Which observaton would indicate to the nurse unhealthy coping by these parents: A. Discussing their needs with the nursing staff B. Discussing their needs with other family members C. Seeking support from their minister D. Refusing to partcipate in the child's care Answer: D Explanaton: 21(A, B, C) These methods are healthy ways of dealing with anxiety. (D) Partcipaton minimizes feelings of helplessness and powerlessness. It is important that parents have accurate informaton and that they seek support from sources available to them. NO.61 The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is: A. 900 mL/24 hr B. 1300 mL/24 hr C. 1600 mL/24 hr D. 2000 mL/24 hr Answer: C Explanaton: (A, B, D) These values are incorrect. Normal intake for a child of 2 years is about 1600 mL in 24 hours. (C) This value is correct. Normal intake for a child of 2 years is about 1600 mL in 24 hours. NO.62 A couple is planning the concepton of their frst child. The wife, whose normal menstrual cycle is 34 days in length, correctly identfes the tme that she is most likely to ovulate if she states that ovulaton should occur on day: A. 14+2 days B. 20+2 days C. 16+2 days D. 22+2 days Answer: B Explanaton: (A) Ovulaton is dependent on average length of menstrual cycle, not standard 14 days. (B) Ovulaton occurs 14+2 days before next menses (34 minus 14 does not equal 16). (C) Ovulaton occurs 14+2 days before next menses (34 minus 14 equals 20). (D) Ovulaton occurs 14+2 days before next menses (34 minus 14 does not equal 22). NO.63 The nurse is collectng a nutritonal history on a 28- year-old female client with iron-defciency anemia and learns that the client likes to eat white chalk. When implementng a teaching plan, the nurse should explain that this practce: A. Will bind calcium and therefore interfere with its metabolism B. Will cause more premenstrual cramping C. Interferes with iron absorpton because the iron precipitates as an insoluble substance D. Causes competton at iron-receptor sites between iron and vitamin B1 Answer: C Explanaton: (A) Eatng chalk is not related to calcium and its absorpton. (B) Poor nutritonal habits may result in increased discomfort during premenstrual days, but this is not a primary reason for the client to stop eatng chalk. Premenstrual discomfort has not been mentoned. (C) Iron is rendered insoluble and is excreted through the gastrointestnal tract. (D) There is no competton between the two nutrients. NO.64 A child becomes neutropenic and is placed on protectve isolaton. The purpose of protectve isolaton is to: 22A. Protect the child from infecton B. Provide the child with privacy C. Protect the family from curious visitors D. Isolate the child from other clients and the nursing staff Answer: A Explanaton: (A) The child no longer has normal white blood cells and is extremely susceptble to infecton. (B) There are more appropriate ways to provide privacy, and there is no need to protect the child from healthy visitors. (C) Visitors and visitng hours may be at the client's and/or family's request without regard to the isolaton precauton. (D) The child may have strong positve relatonships with other clients or staff. As long as proper precautons are observed, there is no reason to isolate her from them. NO.65 A schizophrenic client who is experiencing thoughts of having special powers states that "I am a messenger from another planet and can rule the earth." The nurse assesses this behavior as: A. Ideas of reference B. Delusions of persecuton C. Thought broadcastng D. Delusions of grandeur Answer: D Explanaton: (A) Clients experiencing ideas of reference believe that informaton from the environment (e.g., the television) is referring to them. (B) Clients experiencing delusions of persecuton believe that others in the environment are plotng against them. (C) Clients experiencing thought broadcastng perceive that others can hear their thoughts. (D) Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers. NO.66 Following a gastric resecton, which of the following actons would the nurse reinforce with the client in order to alleviate the distress from dumping syndrome? A. Eatng three large meals a day B. Drinking small amounts of liquids with meals C. Taking a long walk afer meals D. Eatng a low-carbohydrate diet Answer: D Explanaton: (A) Six small meals are recommended. (B) Liquids afer meals increase the tme food emptes from the stomach. (C) Lying down afer meals is recommended to prevent gravity from producing dumping. (D) A low-carbohydrate diet will prevent a hypertonic bolus, which causes dumping. NO.67 A 6-year-old child is atending a pediatric clinic for a routne examinaton. What should the nurse assess for while conductng a vision screening? A. Hearing test B. Gait C. Strabismus D. Papilledema 23Answer: C Explanaton: (A) Hearing should be assessed separately. (B) Gait should be assessed separately. Client usually remains in one place for vision screening. Gait is part of neurological assessment. (C) Strabismus is crossing of eyes or outward deviaton, which may cause diplopia or ambylopia. It is easily assessed during vision screening. (D) Papilledema is assessed by an ophthalmoscopic examinaton, which follows vision screening. It is part of neurological assessment. NO.68 Which of the following ECG changes would be seen as a positve myocardial stress test response? A. Hyperacute T wave B. Prolongaton of the PR interval C. ST-segment depression D. Pathological Q wave Answer: C Explanaton: (A) Hyperacute T waves occur with hyperkalemia. (B) Prolongaton of the P R interval occurs with frstdegree AV block. (C) Horizontal ST-segment depression of>1 mm during exercise isdefnitely a positve criterion on the exercise ECG test. (D) Patho-logical Q waves occur with MI. NO.69 A client with cystc fbrosis exhibits actvity intolerance related to the pulmonary problems associated with his disease. However, he needs to be encouraged to partcipate in daily physical exercise. The ultmate aim of exercise is to: A. Create a sense of well-being and self-worth B. Help him overcome respiratory infectons C. Establish an effectve, habitual breathing patern D. Promote normal growth and development Answer: C Explanaton: (A) Regular exercise does promote a sense of well-being and selfworth, but this is not the ultmate goal of exercise for this client. (B) Regular chest physiotherapy, not exercise per se, helps to prevent respiratory infectons. (C) Physical exercise is an important adjunct to chest physiotherapy. It stmulates mucus secreton, promotes a feeling of well-being, and helps to establish a habitual breathing patern. (D) Along with adequate nutriton and minimizaton of pulmonary complicatons, exercise does help promote normal growth and development. However, exercise is promoted primarily to help establish a habitual breathing patern. NO.70 A common complicaton of cirrhosis of the liver is prolonged bleeding. The nurse should be prepared to administer? A. Vitamin C B. Vitamin K C. Vitamin E D. Vitamin AAnswer: B Explanaton: 24(A) Vitamin C does not directly affect clotng. (B) Vitamin K is a fat-soluble vitamin that depends on liver functon for absorpton. Vitamin K is essental for clotng. (C) Vitamin E does not directly affect clotng. (D) Vitamin A does not directly affect clotng. NO.71 The nurse in the mental health center is instructng a depressed client about the dietary restrictons necessary in taking her medicaton, which is a monoamine oxidase (MAO) inhibitor. Which of the following is she restrictng from the client's diet? A. Cream cheese B. Fresh fruits C. Aged cheese D. Yeast bread Answer: C Explanaton: (A) Cream cheese does not contain tyramine, which might cause a hypertensive crisis. (B) Fresh fruits do not contain tyramine, which might cause a hypertensive crisis. (C) Aged or matured cheese combined with a monoamine oxidase predisposes the client to a hypertensive crisis. (D) Bread products raised with yeast do not contain tyramine. NO.72 A 67-year-old client will be undergoing a coronary arteriography in the morning. Client teaching about postprocedure nursing care should include that: A. Bed rest with bathroom privileges will be ordered B. He will be kept NPO for 8-12 hours C. Some oozing of blood at the arterial puncture site is normal D. The leg used for arterial puncture should be kept straight for 8-12 hours Answer: D Explanaton: (A) Bed rest will be ordered for 8-12 hours postprocedure. Flexing of the leg at the arterial puncture site will occur if the client gets out of bed, and this is contraindicated afer arteriography. (B) The client will be able to eat as soon as he is alert enough to swallow safely and that will depend on what medicatons areused for sedaton during the procedure. (C) Oozing at the arterial puncture site is not normal and should be closely evaluated. (D) The leg where the arterial puncture occurred must be kept straight for 8-12 hours to minimize the risk of bleeding. NO.73 The nurse is assessing breath sounds in a bronchovesicular client. She should expect that: A. Inspiraton is longer than expiraton B. Breath sounds are high pitched C. Breath sounds are slightly mufed D. Inspiraton and expiraton are equal Answer: D Explanaton: (A) Inspiraton is normally longer in vesicular areas. (B) Highpitched sounds are normal in bronchial area. (C) Mufed sounds are considered abnormal. (D) Inspiraton and expiraton are equal normally in this area, and sounds are medium pitched. 25NO.74 Parents should be taught not to prop the botle when feeding their infants. In additon to the risk of choking, it puts the infant at risk for: A. Otts media B. Asthma C. Conjunctvits D. Tonsillits Answer: A Explanaton: (A) Because the eustachian tube is short and straight in the infant, formula that pools in the back of the throat atacks bacteria which can enter the middle ear and cause an infecton. (B) Asthma is not associated with propping the botle. (C) Conjunctvits is an eye infecton and not associated with propping the botle. (D) Tonsillits is usually a result of pharyngits and not propping the botle. NO.75 A client undergoes a transurethral resecton, prostate (TURP). He returns from surgery with a three-way contnuous Foley irrigaton of normal saline in progress. The purpose of this bladder irrigaton is to prevent: A. Bladder spasms B. Clot formaton C. Scrotal edema D. Prostatc infecton Answer: B Explanaton: (A) The purpose of bladder irrigaton is not to prevent bladder spasms, but to drain the bladder and decrease clot formaton and obstructon. (B) A three-way system of bladder irrigaton will cleanse the bladder and prevent formaton of blood clots. A catheter obstructed by clots or other debris will cause prostatc distenton and hemorrhage. (C) Scrotal edema seldom occurs afer TURP. Bladder irrigaton will not prevent this complicaton. (D) Prostatc infecton seldom occurs afer TURP. Bladder irrigaton will not prevent this complicaton. NO.76 Priapism may be a sign of: A.