Final exam Nclex Questions and Answers 2022 update |Rated A+

Final exam Nclex 1. The nurse is preparing a patient for an 8:00 AM outpatient electroconvulsive (ECT) treatment. Which of the following questions is the MOST important for the nurse to ask? 1. “Did you have anything to eat or drink before you came in today?” 2. “Have you had any headaches since your last treatment?” 3. “Who came with you to the hospital today?” 4. “Have you had much memory loss since you began your treatments?” Strategy: Determine how each answer choice relates to ECT. (1) correct–client given general anesthesia for ECT; NPO after midnight (2) not relevant to ECT (3) not most important (4) memory loss is an expected outcome 2. A 36-year-old man has a flaccid bladder following a spinal cord injury. The nurse is teaching the client about dietary changes. Which of the following beverages, if selected by the client, would indicate to the nurse that teaching was effective? 1. Lemonade. 2. Prune juice. 3. Milk. 4. Orange juice. Strategy: “Teaching was effective” indicates you are looking for a true statement. (1) promotes alkaline urine, should also avoid citrus juices, excessive amounts of milk, carbonated beverages (2) correct– promotes acidic urine, minimizes risk of urinary tract infection and stone formation, also use cranberry, tomato juice, bouillon (3) excessive amounts of milk promotes alkaline urine (4) promotes alkaline urine, should also avoid citrus juices, excessive amounts of milk and carbonated beverages 3. The nurse is caring for a client with a long history of alcohol and drug dependence. It would be MOST important for the nurse to include which of the following as a part of his discharge planning? 1. Referral to a social service agency for assistance with housing. 2. Referral to an aftercare center in the community. 3. Participation in Alcoholics Anonymous (AA) meetings with a sponsor. 4. A prescription for an antidepressant medication. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may be of some help, but will not directly provide support necessary to maintain sobriety (2) may be of some help, but will not directly provide support necessary to maintain sobriety (3) correct–self-help groups have greatest success rate as a sustained support system in the community (4) unnecessary 4. A client has come to the clinic for a hepatitis B vaccine and asks if he has to be re-vaccinated after his first injection. Which of the following responses by the nurse is BEST? 1. “A booster shot is required yearly.” 2. “Additional injections are given at one and six months.” 3. “Repeat doses are given at two and four months.” 4. “Revaccination is not required.” Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) yearly doses are given for flu shots, not for hepatitis B vaccine (2) correct–hepatitis B vaccine is repeated at one and six months (3) schedule for infant immunizations for OPV and DPT (4) inaccurate 5. The nurse is planning care for a 56-year-old man who returned from surgery for a bowel resection with an IV of 0.9% NaCl infusing at 100 cc/h into his left wrist. Which of the following actions, if performed by the nurse, is BEST? 1. Change the IV tubing each time a new IV solution is hung. 2. Cleanse the IV site with an alcohol swab using long strokes. 3. Limit manipulation of the cannula at the IV insertion site. 4. Adjust the drop rate to keep the total volume of IV fluids on schedule. Strategy: The topic of the question is unstated. Read the answer choices to determine the topic. “BEST” indicates that this is a priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unnecessary, changed every 48–72 hrs (2) should move swab in a circular motion outward (3) correct–will prevent dislodgment of needle (4) should give IV at rate ordered by physician, don’t play “catch-up” with fluids 6. The nurse notes that one of the staff members caring for clients has a watery discharge from the right eye and the eye appears red. Which of the following actions, if taken by the nurse, is BEST? 1. Send the staff member home. 2. Assess the staff member’s compliance with standard precautions. 3. Assign the staff member only to clients with chronic diseases. 4. Re-assign the staff member to clean the supply closet. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct–extreme tearing, redness, foreign body sensation are symptoms of viral conjunctivitis, highly contagious; infected employees cannot work until symptoms have resolved in 3–7 days (2) restrict from patient contact and the patient’s environment (3) restrict from patient contact and the patient’s environment (4) cannot work 7. The nursing staff is planning to use behavior modification techniques for an elderly woman who constantly screams. Which of the following nursing assessments is necessary to establish a successful program? 1. Monitor the client’s ability to complete her activities of daily living (ADL). 2. Assess the client’s levels of pain and correlate it with her response to analgesia. 3. Observe the client’s behavior at regular intervals to obtain baseline information related to her screaming. 4. Ask the client why she is screaming and document it on her nursing assessment record. Strategy: Determine what is being assessed in each answer choice and how it relates to screaming. (1) important because activities of daily living can contribute to the targeted behavior of screaming; assessing only the area of ADLs does not provide comprehensive data for developing a behavior management program (2) important because activities of pain can contribute to the targeted behavior of screaming; assessing only the area of pain does not provide comprehensive data for developing a behavior management program (3) correct–to design an effective behavior modification program, accurate baseline data must first be collected about the target behavior in relation to frequency, amount, time, and precipitating factors (4) client may be unable to state why she is screaming; asking “why” questions is nontherapeutic 4. Preparation for the Nursing Licensure Examination 8. The nurse observes a student nurse checking the placement of a nasogastric (NG) tube. Which of the following actions, if performed by the student nurse, would require an intervention by the nurse? 1. Places the end of the NG tube in a cup of water and watches for bubble formation. 2. Checks the pH of the contents aspirated from the NG tube. 3. Positions a stethoscope on the upper abdomen and listens as air is introduced into the NG tube. 4. Uses a large barreled syringe to aspirate for stomach contents. Strategy: “Require an intervention” indicates that you are looking for an incorrect behavior. (1) correct–not considered acceptable procedure (2) gastric contents are acidic (3) “swoosh” of air indicates proper placement (4) acceptable action 9. While scheduling the administration of bromocriptine (Parlodel), which nursing action has the HIGHEST priority? 1. The medication should be taken once a day for six weeks. 2. The medication should be taken with orange juice. 3. The medication should be taken in the morning and at bedtime. 4. The medication should be taken with meals. Strategy: Answers are implementations. Determine the outcome of each answer. Is it desired? (1) is taken twice a day for two to three weeks (2) unnecessary (3) will cause GI upset unless taken with meals (4) correct–will decrease GI upset 10. A brace is ordered for a young teen with scoliosis. The nurse knows that teaching has been effective if the client makes which of the following statements? 1. “I will have my parents put bed-boards on my bed.” 2. “I should decrease my caloric intake.” 3. “I should only take tub baths.” 4. “I can remove the brace for one hour a day.” Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) bed-boards maintain proper vertebral alignment, but can’t correct lateral curvature of scoliosis (2) diet should be high-calorie due to age of child and growth requirements; diet doesn’t affect curvature of the spine (3) either tub bathing or a shower is permitted (4) correct–should be worn at all times, except when bathing 11. The nurse in a long-term care facility is reviewing the nurse’s notes in a client’s chart. The nurse would be MOST concerned by which of the following entries? 1. “Foley catheter draining clear urine and the pH is 6.5.” 2. “The client’s skin is blanched over the scapular areas.” 3. “Vital signs are within normal limits.” 4. “The client drinks three glasses of orange juice every day.” Strategy: Remember the rules of charting. (1) appropriate charting of normal urine (2) correct–blanching or hyperemia that does not disappear in a short time is a warning sign of pressure ulcers (3) although the charting is not objective, blanching of the skin takes priority because it indicates a problem (4) appropriate charting 12. The nurse is caring for clients in the outpatient clinic. The nurse returns to the desk and finds four phone messages. Which of the following messages should the nurse return FIRST? 1. A client with cold symptoms has an oral temperature of 103°F (39.4°C). 2. A client with stage II decubitus ulcer reports that the dressing has come off. 3. A client is nauseated and has vomited 6 times in the previous 24 hours. 4. A client is complaining of leg pain after walking half a mile. Strategy: Eliminate the two most stable clients. Use the ABCs to determine the most unstable client. (1) elevated temperature indicates infection; determine the underlying cause, encourage fluids (2) stable client (3) correct–assess amount, character, symptoms of fluid volume deficit (4) stable client, complaint indicates intermittent claudication 13. A client has a bovine graft inserted into the left arm for hemodialysis. During the immediate postoperative period, which of the following actions, if performed by the nurse, is BEST? 1. Restart the IV above the level of the graft. 2. Take blood pressures only on the right arm. 3. Elevate the left arm above the level of the heart. 4. Check the radial pulse on the left arm q4h. Strategy: Determine the outcome of each answer choice. (1) IVs should not be started in the grafted arm (2) correct–BP should always be taken on the opposite arm from the graft (3) unnecessary (4) would not prevent complications, but would identify complications 14. The nurse assesses a prolonged deceleration of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. The priority nursing intervention would be to 1. discontinue the infusion. 2. turn client to the left side. 3. change the fluids to LR. 4. increase the IV flow rate. Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct–will decrease contractions and thus possibly remove uterine pressure to the fetus, which is possibly cause of deceleration (2) may help the deceleration, but is not a priority (3) will have no influence on the fetal heart rate (4) will have no influence on the fetal heart rate 15. The nurse is caring for a patient recovering from abdominal surgery. While ambulating, the patient complains to the nurse that she has a dull ache in her left leg. The nurse should 1. place the patient on bedrest and elevate the foot of the bed six inches. 2. ask the patient to remain in bed and place a pillow under the knee to elevate her left leg. 3. ambulate the patient as directed to prevent complications of bedrest. 4. obtain thigh-high compression or elastic stockings and continue ambulating the patient. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct–promotes venous return and decreases venous pressure relieving pain and edema (2) would obstruct venous flow increasing chance for thrombus formation (3) would cause pressure fluctuations in venous system; could cause emboli, should be on bedrest 5–7 days (4) used to prevent deep vein thrombosis, should be on bedrest initially 16. A middle-aged female client begins outpatient therapy sessions with a psychiatric clinical nurse specialist for management of a phobic disorder. Which of the following nursing interventions should be an initial approach in symptom reduction? 1. Referral for psychopharmacologic intervention. 2. Group psychotherapy. 3. Systematic desensitization. 4. Biofeedback. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) reasonable treatment options as the nurse obtains further information (2) reasonable treatment options as the nurse obtains further information (3) correct–phobic disorders are learned responses; learned responses can be unlearned through certain techniques, such as behavioral modification; systematic desensitization is a form of behavior modification; is a strategy used in conjunction with deep muscle relaxation to decrease the extreme response to anxiety-producing situations as they are gradually exposed; then exposure is increased; goal is to eradicate the phobic response by replacing it with the relaxation response (4) is usually more useful for reducing stress associated with physiologically based disorders 17. The nurse is caring for a client with Cushing’s syndrome. Which of the following nursing actions would be of HIGHEST priority? 1. Implement measures to prevent skin breakdown. 2. Plan measures to prevent infections. 3. Teach the client signs and symptoms of hyperglycemia. 4. Instigate measures to prevent fluid overload. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) clients are susceptible to skin breakdown and infections (2) clients are susceptible to skin breakdown and infections (3) impaired glucose tolerance often leads to hyperglycemia, but is not highest priority (4) correct–respirations are the first priority; clients with Cushing’s syndrome are prone to fluid overload and CHF due to sodium and water retention 18. The nurse is assessing a client with a diagnosis of detached retina. Which of the following observations would support this diagnosis? 1. Loss of acuity in the peripheral visual field. 2. Increased lacrimation, blurred vision. 3. Conjunctivitis, dilated pupils bilaterally. 4. Photophobia, loss of a portion of the visual field. Strategy: Think about each answer choice. (1) loss of peripheral vision occurs with glaucoma; loss of acuity occurs with cataracts (2) occurs with ocular infections (3) has no correlation with detached retina (4) correct–bright flashes of light and client stating that portion of visual field is dark are classic symptoms 19. The physician orders indomethacin (Indocin) 25 mg PO bid for a 34-year-old woman. It would be most important for the nurse to make which of the following statements? 1. “Take this medication with food.” 2. “Take this medication one hour before meals.” 3. “Take this medication one hour after meals.” 4. “Take this medication with orange juice.” Strategy: “MOST important” indicates there may be more than one correct response. (1) correct–reduces GI upset (2) risk of GI upset (3) should be given with food (4) risk of GI upset 20. A child comes to the school nurse with a honey-colored crusted lesion below her right nostril. Which of the following actions should the nurse take FIRST? 1. Remove the scab. 2. Apply a wet cloth to the lesion. 3. Notify the child’s parents. 4. Contact the health department. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) notify parents first; loosen scab with Burrow’s solution compress; gently remove, topical ointment (2) notify parents first, use compress made of Burrow’s solution (3) correct–describes impetigo, highly infectious superficial bacterial infection; notify parents so they can contact the physician (4) unnecessary to report impetigo to the health department 21. Which of the following nursing actions should be the priority for an infant admitted with a positive stool culture for Salmonella? 1. Change the diet to clear liquids. 2. Initiate intravenous fluids. 3. Maintain contact precautions. 4. Apply cloth diapers. Strategy: All answers are implementation. Determine the outcome of each answer choice. Is it desired? (1) may be appropriate, but is not a priority over answer choice #3, which will prevent transmission (2) may be appropriate but is not a priority over answer choice #3, which will prevent transmission (3) correct–prevents transmission of this bacterium to other individuals (4) may be appropriate, but is not a priority over answer choice #3, which will prevent transmission 22. A client admitted four days ago for treatment of alcohol dependence is now displaying the following symptoms: slurred speech, ataxia, uncoordinated movements, and headache. Which of the following nursing actions should be taken FIRST? 1. Observe the client for eight hours to collect additional data. 2. Perform a complete physical assessment. 3. Collect a urine specimen for a drug screen. 4. Encourage the client to talk about whatever is bothering him. Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires validation? Yes. (1) will not provide the data that a physical assessment would; may be a medical emergency requiring an immediate intervention (2) correct–best way to identify possible physical complications of alcohol dependence is through a complete physical assessment (3) should be done after the physical assessment is completed (4) inaccurate because the symptoms are most likely caused by physical and not psychological stressors 23. The nurse would identify which of the following clients as being at the highest risk for developing a pulmonary embolus? 1. A 19-year-old four days postpartum with an obstetrical history of placenta previa. 2. An obese 40-year-old man with multiple pelvic fractures from an auto accident two days ago. 3. A 65-year-old woman who had a fractured hip repaired 10 days ago and who is in physical therapy daily. 4. A 22-year-old leukemic client with a platelet count of 120,000/mm3 and a hemoglobin level of 9.0 g. Strategy: Determine how each answer choice relates to pulmonary embolism. (1) at high risk for shock and bleeding complications (2) correct–obesity, immobility, and pooling of blood in the pelvic cavity contribute to development of pulmonary emboli (3) client does not have a high risk for pulmonary emboli (4) at high risk for shock and bleeding complications 24. The nurse is supervising a student nurse administer a tube feeding to a client via a Levin tube. Which of the following actions, if performed by the student nurse, indicates a proper understanding of the correct procedure? 1. The Levin tube remains unclamped for 30 minutes after the feeding. 2. Sterile equipment is used to administer the feeding. 3. The amount of the feeding is varied according to the patient’s tolerance. 4. The tube feeding is given at room temperature. Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) clamping tube between feedings prevents introduction of air and loss of liquid (2) clean, not sterile, supplies are required (3) physician will order amount of feedings, usually begin with a small amount and increases 50- 100 cc until nutritional requirements met (4) correct–minimizes intestinal cramping 25. The nurse is caring for a client with deep vein thrombosis (thrombophlebitis) of the left leg. Which of the following would be an appropriate nursing goal for this client? 1. Decrease inflammatory response in the affected extremity and prevent embolus formation. 2. Increase peripheral circulation and oxygenation of the affected extremity. 3. Prepare the client and family for anticipated vascular surgery on the affected extremity. 4. Prevent hypoxia associated with the development of a pulmonary embolus. Strategy: Think about each answer choice. (1) correct–important to prevent the complication of pulmonary embolism in clients at high risk (2) relates to arterial disease (3) surgery is not anticipated for this client (4) preventing embolism is the first priority 26. The nurse is called to the room of a patient four days after abdominal surgery. The patient had been coughing and said he “felt something give.” The nurse observes that the edges of the incision have separated, and a small loop of the bowel protrudes through the incision. The nurse should position the patient 1. with the head of the bed elevated 30°. 2. with the foot of the bed tilted and the head of the bed down. 3. with the head of the bed elevated 15°. 4. with the head of the bed elevated 90°. Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) semi-Fowler’s, too high, would put pressure on abdominal area (2) Trendelenberg position, would impede respiratory excursion (3) correct–low Fowler’s, reduces stress on suture line, may be placed supine with hips and knees bent (4) high Fowler’s, too high, would put pressure on abdominal area 27. On a home health visit, an elderly client states, “This neighborhood has really gone down. I feel like a prisoner in my own home with all the trouble out there.” Which of the following nursing responses by the nurse is BEST? 1. “Have you and your neighbors formed a neighborhood watch?” 2. “It must be very difficult for you to live in this neighborhood.” 3. “I see a lot of police cars, so you should be pretty safe.” 4. “Tell me what has happened to make you feel that you are not safe.” Strategy: Remember therapeutic communication. (1) jumps ahead to solutions without adequately defining the problem (2) empathetic response, but does not obtain more information from the client or encourage the client to continue (3) false reassurance (4) correct–assessing the basis for client’s fears and encouraging client to talk about them is the first positive step 28. An intravenous pyelogram (IVP) is ordered for a client who is scheduled to have his left kidney removed because of hypertension and renal disease. Which of the following nursing actions has the highest priority the evening prior to the IVP? 1. Administer a cathartic enema to cleanse the bowel. 2. Obtain information about client allergies. 3. Instruct the client to be NPO after midnight. 4. Teach the client that x-rays will be taken at multiple intervals. Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? Yes. (1) implementation, contains correct information, but is not a priority (2) correct–assessment, clients sensitive to iodine can develop anaphylaxis; client should be asked specifically about allergies to iodine; iodine is present in the radiopaque material that is injected IV (3) implementation, contains correct information, but is not a priority (4) implementation, test may be canceled if the client is allergic to iodine 29. The nurse cares for an 8 lb, 8 oz newborn boy. The infant’s history indicates that his mother was given magnesium sulfate IV 4 g in 250 ml D5W several hours before delivery. The nurse would be MOST concerned if which of the following was observed? 1. Temperature 97.6°F (36.5°C). 2. Apical pulse 140 bpm. 3. Respirations 18. 4. BP 80/50. Strategy: “MOST concerned” indicates a complication. (1) normal temp 98.6°F (37°C), magnesium sulfate does not affect temperature (2) normal pulse 120–140, magnesium sulfate does not affect cardiac system of infant (3) correct–magnesium sulfate can cause slowing of respirations and hyporeflexia; normal respirations 30–60/min (4) normal BP 60/40–80/50, magnesium sulfate does not affect BP 30. The nurse is assisting a 58-year-old woman from the bed to the chair for the first time after a right total hip replacement. It is MOST important for the nurse to take which of the following actions? 1. Assist the patient to stand on her right leg and pivot to a low soft chair, keeping her hips straight. 2. Assist the patient to stand on her left leg and pivot to a straight-backed chair, flexing her hips slightly. 3. Ask the patient to bear weight equally on both legs, bend at the waist, and sit in a low soft chair. 4. Assist the patient to stand on both legs and take a few steps to a straight-backed chair. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should not bear weight on affected side, dislocation may occur (2) correct–prevents dislocation (3) no weight bearing on affected leg, dislocation may occur (4) no weight bearing on affected leg, dislocation may occur 31. At approximately 6 PM, the nurse begins to open the nurses’ notes for the evening shift. The last entry is noted for 1 PM, and there is no signature. The MOST appropriate nursing response is to 1. leave approximately three or four lines for the day nurse to enter the day information and sign the chart. 2. review with the client the activities after 1 PM, and enter what are determined to be the activities after 1 PM. 3. begin charting on the next line below the last entry, and make a note for the day nurse to make a late entry to complete the chart. 4. do not enter anything until the day nurse has been notified of the problem and returns to the unit to complete charting. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) blank lines should never be left in the nurses’ notes (2) nurse should chart only the care that s/he has administered (3) correct–day nurse can make a “late entry” to add any additional information (4) unnecessary 32. A client is started on doxepin hydrochloride (Sinequan) 75 mg PO tid. The nurse should recommend a change in the client’s therapy if which of the following occurs? 1. The client refuses to speak and sits quietly in the room. 2. The client becomes excitable and develops tremors. 3. The client refuses to eat breakfast. 4. The client sleeps 18 hours a day. Strategy: Think about the cause of each assessment and how it relates to Sinequan. (1) not relevant to this medication (2) correct–doxepin HCL (Sinequan) is an antidepressant; signs of overdosage include excitability and tremors (3) not relevant to this medication (4) not relevant to this medication 33. Which of the following guidelines is appropriate for the nurse to give a mother concerning the developmental stage of her seven-year-old daughter? 1. The child’s periods of shyness are to be expected. 2. Nightmares are not characteristic of this age and should be investigated. 3. The child should be encouraged to care for her younger sister. 4. Punishment may be necessary for acts of independence. Strategy: Remember growth and development. (1) correct–normal for developmental stage, beginning to show independence from parents (2) nightmares are frequently experienced at this age (3) should be encouraged to be independent, not responsible for sibling, inappropriate for this age group (4) should allow child to be increasingly independent without punishment 34. A client is scheduled for a cardiac catheterization, and the nurse teaches him about the procedure. What statements, if made by the client, would indicate to the nurse that he understands the teaching? 1. “I’m going to feel cold during the procedure.” 2. “I can get up and walk to the bathroom immediately after the procedure.” 3. “The nurse will be checking my foot pulses after the procedure.” 4. “I won’t be able to eat for 24 hours before the procedure.” Strategy: “Understands teaching” indicates that you are looking for a true statement. (1) may feel burning sensation when dye injected (2) on bedrest 8–12 h after procedure with pressure dressing applied over catheter insertion site (3) correct–peripheral pulses checked every 15 min for 1 h, then every 30 min for 2 h, then every 4 h (4) NPO midnight prior to procedure 35. A client had an aortic aneurysm resection two days ago. A complete blood count reveals a decreased red blood cell count. The nursing assessment is MOST likely to reveal which of the following? 1. Fatigue, pallor, and exertional dyspnea. 2. Nausea, vomiting, and diarrhea. 3. Vertigo, dizziness, and shortness of breath. 4. Malaise, flushing, and tachycardia. Strategy: Remember the “comma, comma, and rule”. Each part of the answer choice must be correct in order for the answer to be correct. (1) correct–these “constitutional symptoms” are characteristic of most types of anemia and are predominantly the result of tissue hypoxia secondary to inadequate red blood cells (2) are not as indicative of the loss of red blood cells (3) are not as indicative of the loss of red blood cells (4) are not as indicative of the loss of red blood cells 36. The physician orders meperidine (Demerol) 50 mg IM every 3–4 h PRN for pain for a client. The client asks the nurse for the medication at bedtime. Prior to administering the pain medication, the nurse should 1. take measures to determine if the pain is psychological. 2. check to see if the man has a history of addiction. 3. try several other comfort and pain relief measures. 4. learn the location, character, and intensity of the pain. Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) should assess patient first (2) not highest priority, should assess patient first (3) need to assess before implementing action (4) correct–assessment first step in nursing process 37. The nurse is assessing a pregnant client with problems of mitral stenosis and congestive heart failure (CHF). Which of the following in the client’s history would have a direct correlation with her current problem? 1. History of rheumatic fever four years ago. 2. Presence of ventricular septal defect as an infant. 3. Heart disease in both the maternal and the paternal families. 4. Persistent ear infections and mastoiditis as a child. Strategy: Think about each answer choice. (1) correct–most common cause of mitral valve problems is a history of rheumatic fever with a subsequent complication of carditis, which affects the valve (2) does not contribute to mitral valve disease (3) does not contribute to mitral valve disease (4) does not contribute to mitral valve disease 38. The nurse is preparing a 56-year-old woman for a paracentesis. It is MOST important for the nurse to take which of the following actions? 1. Keep the woman NPO 12 hours before the procedure. 2. Have the woman void just before the procedure. 3. Initiate a bowel preparation program 24 hours before the procedure. 4. Place the woman supine during the procedure. Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) does not need to be NPO (2) correct–prevents puncture of bladder (3) bowel preparation unnecessary (4) would make it more difficult to drain fluid, patient should be positioned sitting upright at side of bed with feet supported 39. The nurse is caring for a client in the ICU. Hemodynamic monitoring is accomplished via a Swan- Ganz catheter. The nurse is aware that this type of monitoring will provide which of the following information? 1. Measures the circulatory volume in the coronary arteries. 2. Indirectly measures the pressure in the ventricles. 3. Analyzes the adequacy of pulmonary circulation. 4. Directly measures the adequacy of CO2 exchange. Strategy: Think about each answer choice. (1) not a function of this catheter, and does not reflect hemodynamic monitoring (2) correct–CVP readings measure the pressure in the right ventricle, the Swan- Ganz catheter measures the pulmonary artery wedge pressure, which is an indirect reading of the pressure in the left ventricle (3) not a function of this catheter, and does not reflect hemodynamic monitoring (4) not a function of this catheter, and does not reflect hemodynamic monitoring 40. A client is admitted with a diagnosis of trigeminal neuralgia (tic douloureux) involving the maxillary branch of the affected nerve. When performing client teaching, it is MOST important for the nurse to include which of the following instructions? 1. Report an increase in blurred vision. 2. Eat soft, warm foods. 3. Change positions slowly. 4. Chew food on the affected side. Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) unnecessary, does not occur with this condition (2) correct–intense facial pain experienced along nerve tract is characteristic of this condition; nursing care should be directed toward preventing stimuli to the area and decreasing pain (3) intervention for Ménière’s disease (4) chewing food on unaffected side less likely to trigger an attack 41. An abdominal wound irrigation with a normal saline solution is ordered for a client. To perform this procedure, the nurse should 1. warm the irrigating solution to 110°F (43.3°C). 2. establish a sterile field that includes the irrigating equipment. 3. direct the irrigating solution at the outer edges of the wound, then the center of the wound. 4. aspirate the irrigating fluid with a syringe to prevent accumulation in the wound. Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) too warm, should be room temperature or 90–95°F (32.2–35°C) (2) correct–requires strict aseptic technique (3) may cause new microorganisms to be flushed into wound (4) fluid should drain by gravity 42. The lab reports a lecithin/sphingomyelin (L/S) ratio of 3:1 for a client who has been on bedrest 48 hours in an unsuccessful attempt to arrest premature labor at 33-weeks gestation. Based on this result, the nurse would anticipate 1. administration of ritodrine hydrochloride (Yutopar). 2. initiation of an oxytocin (Pitocin) drip. 3. delivery of the infant by cesarean section. 4. continuation of bedrest until otherwise indicated. Strategy: Determine the significance of each answer choice and how it related to the L/S ratio. (1) no longer necessary as the results indicate sufficient lung maturity for safe delivery (2) although the lungs are mature enough for safe delivery, client would either be allowed to progress naturally to a vaginal delivery or sectioned, but not induced (3) correct–because the lungs are adequately mature, there is no need to attempt to postpone labor; delivery by cesarean section is generally preferred for preterm infants (4) is no longer necessary with adequately mature lungs 43. The nurse is caring for clients in the hospital. Which of the following nursing activities BEST promotes rest for an elderly hospitalized client? 1. Place a clock at the bedside. 2. Restrict visitors so that the client is alone during the evening. 3. Tell the client how to call for help if needed. 4. Postpone explanation of further tests that the client will need. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not promote rest (2) does not promote rest (3) correct–elderly client who feels isolated and unable to obtain help if needed cannot rest properly (4) elderly client will rest better if s/he understands what is going on with his/her health care 44. The nurse has just received report from the previous shift. Which of the following clients should the nurse see FIRST? 1. A client with chronic renal failure complaining of swollen fingers and ankle edema. 2. A client one-day postoperative after abdominal surgery who has dried blood on the abdominal dressing. 3. A client with type I diabetes mellitus who states, “I have this quivering feeling in my abdomen.” 4. A client on high doses of antibiotics for a resistant infection who complains of diarrhea. Strategy: Determine the least stable client. (1) Indicates peripheral edema, treatment includes fluid and sodium restrictions (2) stable client (3) correct–indicates hypoglycemia; symptoms include tachycardia, cold and clammy skin, weakness and pallor; check blood sugar, offer milk (4) common sequelae of antibiotic therapy, monitor fluid and electrolytes, check for skin breakdown 45. A 57-year-old man admitted with metastatic cancer has been receiving chemotherapy for 3 months. His lab values include: RBC 3.8 million/mm3, WBC 2,000/mm3, Hgb 9.3 g/dL, platelets 50,000/mm3. Which of the following nursing diagnoses is MOST appropriate for this patient? 1. Decreased cardiac output. 2. Ineffective thermoregulation. 3. Risk for injury. 4. Ineffective airway clearance. Strategy: Determine how each answer choice relates to the lab values. (1) will increase due to decreased oxygenation caused by anemia; normal RBC male: 4.3–5.9 million/mm3, female: 3.5–5.5 million/mm3; decreased with anemia, causes heart rate and respirations to increase; normal WBC 4,500–11,000/mm3; decreased (leukopenia) causes susceptibility to infection; normal Hgb: male 13.5–17.5 g/dL, female 12– 16 g/dL; decreased with anemia (2) no change in temperature (3) correct–due to low platelet count, normal platelets 150,000–400,000/mm3, decrease causes problems with blood clotting (4) no information about airway problems 46. A young client with a postoperative abdominal abscess had a drain inserted. Which of the following assessments by the nurse is BEST? 1. Amount of the drainage. 2. Character of the drainage. 3. Consistency of the drainage. 4. Amount of suction on the drainage system. Strategy: Think about the significance of each assessment and how it relates to a wound abscess. (1) lower priority (2) correct–with this complication, the character of the drainage, purulent or otherwise, is a major priority to note and report (3) lower priority (4) unnecessary 47. In caring for an elderly client with a depressed affect, which of the following nursing actions would be MOST appropriate to help the client to complete activities of daily living? 1. Medicate the client before the activities begin. 2. Develop a written schedule of activities, allowing extra time. 3. Assist the client with grooming activities so it doesn’t take as long. 4. Provide frequent forceful direction to keep the client focused. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will not increase the client’s independence and may interfere with the client’s self-esteem (2) correct– written schedule with built-in extra time will allow client to understand what is expected and will allow him to participate at a slower pace (3) will not increase the client’s independence, allow extra time for care (4) will not increase the client’s independence and may interfere with the client’s self-esteem 48. A patient is returned to his room following an appendectomy. The nurse notices a large amount of serosanguineous drainage on the dressing. It is MOST important for the nurse to obtain an answer to which of the following questions? 1. “Were there any intraoperative complications?” 2. “Has the dressing been changed?” 3. “Why didn’t the recovery room nurse report any drainage?” 4. “Was a tissue drain placed during surgery?” Strategy: Determine how each answer choice relates to an appendectomy. (1) doesn’t indicate understanding that drainage may be normal after this surgery (2) first dressing usually changed by physician (3) doesn’t indicate understanding that drainage may be normal after this surgery (4) correct– drain is frequently placed during surgery to prevent accumulation in wound, dressing should be reinforced 49. The nurse is caring for a client in her third trimester of pregnancy. The nurse is MOST concerned by which of the following assessments? 1. The client complains of epigastric pain. 2. The client complains of shortness of breath. 3. The client states she has increased rectal pressure. 4. The client has gained of 33 pounds during her pregnancy. Strategy: Think about the cause of each symptom and how it relates to pregnancy. (1) correct–is usually indicative of an impending convulsion (2) expected observation (3) expected observation (4) is important to address, but is not as high a priority as answer choice #1 50. A middle-aged adult is seen in the emergency room for complaints of severe right-flank pain. The client is twenty pounds overweight, lives a sedentary lifestyle, and was treated for renal calculi four years ago. Which of the following actions, if performed by the nurse, is MOST important? 1. Ensure that the client has nothing to eat or drink. 2. Obtain a “clean-catch” urine specimen for analysis. 3. Provide warm packs to relieve discomfort. 4. Measure and strain the client’s urine. Strategy: “MOST important” indicates a priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should force fluids to 3,000/day to assist client pass stone (2) not most important, used to identify infection (3) not most important, analgesics given to reduce discomfort (4) correct–will document passage of stone and allow composition to be analyzed 51. The nurse is supervising a student nurse teach a client about a newly prescribed medication. Which of the following actions, if observed by the nurse, would require an intervention? 1. The student nurse glances at his/her watch when instructing the client. 2. The student nurse uses culturally appropriate language and teaching materials. 3. The student nurse begins instructions to the client discussing information that concerns the client. 4. The student nurse chooses a time for teaching when there are no visitors. Strategy: “Require an intervention” indicates that you are looking for an incorrect behavior. (1) correct– lack of attending behaviors are always a barrier to learning (2) appropriate teaching strategy (3) appropriate teaching strategy (4) appropriate teaching strategy 52. Prior to a cesarean section delivery, a 24-year-old woman is treated for abruptio placentae. The nurse is caring for the woman during the postpartum period. Which of the following symptoms would be suggestive of disseminated intravascular coagulation (DIC)? 1. The client’s vital signs are: BP 90/58, temperature 101°F (38.3°C), pulse 112, respirations 18. 2. The client’s laboratory results are: Hgb 13 g/dL, Hct 40%, WBC 7,000/mm3. 3. The client is nauseated, lethargic, and has vomited three times. 4. There is oozing blood from the venipuncture site and abdominal incision. Strategy: Determine how each answer choice relates to DIC. (1) may indicate hemorrhage or sepsis (2) results normal, DIC would be reflected in clotting studies (PT, PTT) (3) nonspecific, could be related to anesthesia or pain medication (4) correct–DIC is acquired clotting disorder from overstimulation, prolonged oozing from sites of minor trauma first symptom 53. A four-week-old infant with symptoms of pyloric stenosis is brought to the outpatient clinic by his mother. Which of the following statements would the nurse expect the mother to make about her son’s symptoms? 1. “My son’s bowel movements have turned black and sticky.” 2. “I really have to encourage my son to suck the bottle.” 3. “My son is fussy and seems hungry all the time.” 4. “My son spits up green liquid after feeding.” Strategy: Determine how each statement relates to pyloric stenosis. (1) not expected with pyloric stenosis, suggestive of blood in stool (2) sucking problems not expected with pyloric stenosis (3) correct– becomes lethargic, dehydrated, and malnourished (4) would expect emesis to contain milk or formula, should not be bile-colored 54. The physician prescribes cimetidine (Tagamet) 300 mg PO qid for a 75-year-old man. The nurse instructs the client about the medication. Which of the following statements, if made by the client, would indicate that further teaching is needed? 1. “I’ll take this pill with meals and before bed.” 2. “I may experience mild diarrhea for a while.” 3. “My stools may change color while I’m on this medication.” 4. “I should call my doctor if I get an acne-like rash.” Strategy: “Further teaching” indicates that you are looking for an incorrect statement. (1) taking with meals ensures consistent therapeutic effect (2) common side effect, usually subsides (3) correct–no change in stool color (4) side effect seen with medication 55. A teenager comes to the clinic complaining of fatigue, a sore throat, and flu-like symptoms for the previous two weeks. Physical exam reveals enlarged lymph nodes and temperature of 100.3°F (37.9°C). Which of the following statements by the nurse is BEST? 1. “Cover your mouth and nose when you sneeze or cough.” 2. “Eat in a separate room away from your family.” 3. “Don’t share your drinking glass or silverware with anybody.” 4. “Stay in your room until all of your symptoms are gone.” Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) mononucleosis is spread by direct contact (2) no reason to be isolated (3) correct–symptoms indicate mononucleosis, spread by direct contact; advise family to avoid contact with cups and silverware for about 3 months (4) clients with mononucleosis are not isolated 56. Which of the following strategies would be MOST therapeutic as the nurse tries to analyze a bulimic client’s eating habits and the circumstances that precipitate the client’s eating problems? 1. Observe family communication patterns at a “monitored mealtime.” 2. Distract the client at mealtime. 3. Assign the client a food/feelings/thoughts/actions journal. 4. Assign the client to write a “lifeline” in relation to eating behaviors. Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. (1) assessment, should be done after a food/feelings/actions journal (2) implementation, should be done after a food/feelings/actions journal (3) correct–implementation, nurse is trying to analyze and understand what triggers the client’s binging and purging activities, so therapeutic nursing intervention of assigning a thought/feelings/actions (T/F/A) journal relating to client’s eating behaviors will be most helpful to the nurse and therapeutic to the client; after this information is gained and reviewed, collaboration by the nurse and client on other strategies such as delay and distraction techniques, stress reduction, and developing a “lifeline” in relation to eating behaviors will further benefit the client (4) implementation, should be done after a food/feelings/actions journal 57. A 20-year-old primipara attends a class for women who plan to breastfeed. To prepare for breastfeeding, the nurse should encourage the women to 1. apply moisturizer to their breasts every day after bathing. 2. expose their breasts to air every day for 20 minutes. 3. wash their breasts with water and rub with a towel every day. 4. massage their breasts to increase circulation twice daily. Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) use of creams not recommended, could cause breast tissues to become tender, sebaceous glands keep skin pliable (2) doesn’t prepare breasts for feeding (3) correct–prepares nipples for stretching action of sucking during breastfeeding, soap avoided to prevent drying (4) could cause breast tissues to become tender 58. A 45-year-old client with newly diagnosed IDDM (insulin-dependent diabetes mellitus) is being seen by the home health nurse. The physician has placed him on a 1,800-calorie ADA diet, ordered the client to self-administer 15 units of NPH insulin each day before breakfast, and check his blood sugar qid. When the nurse visits the client at 5 PM, the nurse discovers that the client has not eaten since noon and has just returned from jogging. The client’s vital signs are: BP 110/80, pulse 120, respirations 18, temperature 98.2°F (36.8°C). When the client obtains his blood sugar reading, the nurse would expect it to be 1. 250 mg/dL. 2. 160 mg/dL. 3. 90 mg/dL. 4. 50 mg/dL. Strategy: Think about each answer choice. (1) hyperglycemia symptoms are hot dry skin, rapid, deep respirations (Kussmaul), lethargic, polyuria, polydipsia, polyphagia, glycosuria, nausea and vomiting (2) NPH insulin is intermediate-acting, onset 3–4 hours, peak 8–16 hours, duration 18–26 hours (3) normal blood sugar 70–110 mg/dL (4) correct–hypoglycemia symptoms are cool, clammy skin, diaphoresis, nervousness, weakness, hunger, confusion, headache, slurred speech, coma 59. The mother of an eight-month-old infant prepares to take her child home after treatment for bacterial meningitis. The mother confides to the nurse that she is afraid that her child will have brain damage as a result of his illness. Which of the following is the BEST response by the nurse? 1. “Trust your doctors. They are excellent pediatricians and will know what to look for.” 2. “There is a 20% incidence of residual brain damage after this type of illness, but the odds are in your favor.” 3. “It is an unlikely possibility, but if your child doesn’t develop normally, your pediatrician will help you with any problems.” 4. “You feel guilty about your son’s illness, and that’s understandable. You will feel better after you get home.” Strategy: Remember therapeutic communication. (1) nontherapeutic, diminishes person’s concerns and feelings (2) nontherapeutic to discuss statistics with patients, wrong emphasis for discussion (3) correct–if treated early, good prognosis; may be complications and long-term effects (seizure disorders, hydrocephalus, impaired intelligence, visual and hearing defects), therapeutic response (4) nontherapeutic, interprets person’s feelings 60. The nurse is preparing a client for a herniorrhaphy. It would be MOST important for the nurse to complete which of the following one hour prior to surgery? 1. Administer an enema. 2. Confirm that the consent form has been signed. 3. Perform a preoperative shave and scrub. 4. Evaluate for food or medication allergies. Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate one hour prior to surgery? No. Determine the outcome of each implementation. (1) should be done earlier than one hour before surgery (2) correct–surgical consent should be rechecked prior to going to surgery (3) should be done earlier than one hour before surgery (4) assessment, should be done earlier than one hour before surgery 61. The nurse is caring for an 11-year-old girl being treated for a fractured right femur with balanced suspension traction with a Thomas splint and Pearson attachment. When the nurse checks the patient, the nurse finds the weights on the floor, and the girl’s feet touching the foot of the bed. The nurse should 1. release the traction weights and reposition the patient in bed. 2. pull on the traction weights while two nurse’s aides pull the girl up in bed. 3. steady the traction and have the girl bend her left leg and push up in bed. 4. assess the patient’s right leg for proper position and alignment. Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? No. Determine the outcome of each answer choice. (1) release of weights would change pull of traction, weight should never be released (2) pulling on traction weights would alter proper pull on fracture (3) correct–permits patient to reposition self and reestablish pull of traction weights (4) would not reestablish proper pull of traction 62. The nurse is making rounds on the postpartum unit. The nurse notes that a client’s uterus is relaxed. The nurse should 1. put the infant to the woman’s breast. 2. encourage the woman to drink warm oral fluids. 3. check the woman’s pulse and respirations. 4. continue to monitor the firmness of the uterus. Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each implementation. (1) correct–implementation, causes natural surge of oxytocin that results in contraction of uterus (2) implementation, has no effect on contraction of uterus (3) assessment, not best action, situation does not suggest that patient is in shock (4) assessment, needs manual massage or release of natural oxytocin to contract uterus 63. A client with Addison’s disease is admitted with pneumonia. The nurse suggests salted broth for lunch. The appropriateness of this decision is based on which of the following statements about Addison’s disease? 1. The client requires increased sodium intake to prevent hypotension. 2. A decrease in sodium intake may lead to seizures. 3. Steroid replacement causes rapid loss of sodium. 4. Sodium intake should be increased during periods of stress. Strategy: Think about each answer choice. (1) not as important as answer choice #4 (2) not a correct statement for this condition (3) steroid replacement increases sodium retention (4) correct–with decrease in aldosterone, there is an increased excretion of sodium; sodium intake should be increased 64. The nurse is performing screening at the local senior citizens facility. The nurse would be MOST concerned if which of the following was observed? 1. A 69-year-old man has a slightly elevated systolic blood pressure. 2. The nurse has difficulty palpating an apical pulse on a 74-year-old woman. 3. The nurse auscultates an S3 ventricular gallop on a 78-year-old woman. 4. An 81-year-old man has a temperature of 98.2°F (36.7°C). Strategy: Determine how each assessment relates to an older adult. (1) usual finding for the older adult (2) usual finding for the older adult (3) correct–ventricular gallop is the earliest sign of CHF (4) may be normal in all age groups 65. The nurse is aware that which of the following statements made by a client indicates a correct understanding of patient-controlled analgesia (PCA)? 1. “If I start feeling drowsy, I should notify the nurse.” 2. “This button will give me enough to kill the pain whenever I want it.” 3. “If I start itching, I need to call you.” 4. “This medicine will make me feel no pain.” Strategy: Think about what the words mean. (1) may feel sleepy due to medication (2) preset dose administered with preset lock-out times (3) correct–itching is a common side effect of narcotics used in PCA pain management (4) indicates a need for further teaching or clarification 66. A client taking trifluoperazine (Stelazine) should be instructed to notify the nurse immediately if he experiences which of the following? 1. Dry mouth and nasal stuffiness. 2. Increased sensitivity to heat. 3. Difficulty urinating. 4. Weight gain and constipation. Strategy: Determine the cause of each answer choice and how it relates to Stelazine. (1) possible side effect of antipsychotic medications, but client can be instructed on measures to take at home to resolve this problem (2) possible side effect of antipsychotic medications, but client can be instructed on measures to take at home to resolve this problem (3) correct–is an anticholinergic reaction that may become a severe health problem unless treated (4) possible side effect of antipsychotic medications, but client can be instructed on measures to take at home to resolve this problem 67. A charge nurse is developing the assignment for the evening shift. In a semiprivate room, Client A has neutropenia. Client B has a tracheostomy with purulent drainage and a pending culture and sensitivity (C&S). Which of the following indicates the MOST appropriate assignment? 1. Assign an experienced nurse to care for both clients in the same room. 2. Assign two nurses: one nurse for Client A and another nurse for Client B, in the same room. 3. Place Client A in a private room and assign the same nurse to care for Client A and Client B. 4. Place Client A in a private room and assign different nurses to care for Client A and Client B. Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) should be in a private room away from roommate with infection (2) should be in a private room away from roommate with infection (3) should be cared for by different nurses (4) correct–infection in a neutropenic individual may cause morbidity and fatality; place the neutropenic client in a private room; limit and screen visitors and hospital staff with potentially communicable illnesses 68. A 72-year-old client has an order for digoxin (Lanoxin) 25 mg PO daily. The nurse reviews the following information: apical pulse 68/min, respirations 16/min, plasma digoxin level 2 ng/ml. Based on this assessment, which of the following nursing actions is appropriate? 1. Give the medication on time. 2. Withhold the medication; notify the physician. 3. Administer epinephrine 1:1,000 stat. 4. Check the client’s blood pressure. Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of the implementations. (1) medication should be withheld (2) correct–therapeutic plasma level of digoxin is 0.5–2.0 ng/ml (3) not a correct action (4) assessment, does not address the issue of the elevated blood level of digoxin 69. The nurse is changing the dressing on a woman who had a mastectomy two days ago. After the nurse removes the old dressing, the client turns her head away. Which of the following is the BEST response by the nurse? 1. “I notice that you turn your head away as if you don’t want to look at your incision.” 2. “It’s good that you turn your head away while I am doing this sterile procedure.” 3. “Your incision looks like it’s healing nicely.” 4. “Why don’t you look at the incision while I have the old dressing off?” Strategy: Remember therapeutic communication. (1) correct–states observation (2) doesn’t help patient confront feelings (3) doesn’t deal with avoidance behavior (4) nontherapeutic to ask why, causes patient to be defensive 70. The nurse is caring for a 20-year-old man with a three-chamber water-seal drainage system (Pleur- evac). When the nurse checks the patient, the nurse notices that the fluid in the water-seal chamber does not fluctuate. The nurse should 1. milk the tube gently toward the collection chamber. 2. anticipate the need for a chest x-ray. 3. add water to the water seal chamber to reestablish the system. 4. clamp the chest tube and call the physician. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) milking is done only with order of physician to clear obstruction due to clots, fluid is clear (2) correct– fluctuations stop with re-expansion of lung, x-ray will confirm (3) should be kept at level of 2 cc to maintain negative pressure (4) only clamp tube when checking for air leaks or changing equipment 71. A 10-year-old boy, weighing 50 lbs (23.6 kg), returns from surgery for a skin graft to his left leg. The patient has an IV of D5W infusing into his left arm. The physician’s orders read, “D5W 2,000 cc/24 h.” It is MOST important for the nurse to 1. call the physician to clarify the IV fluid order. 2. keep accurate records of the patient’s intake and output. 3. set the controller on the IV pump to infuse at 84 gtts/min. 4. monitor the patient for fluid and electrolyte balance. Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each implementation. Is it desired? (1) correct–implementation, amount is excessive for child and there are no electrolytes in fluid (2) implementation, may have serious electrolyte disturbances before discrepancies are seen in I and O (3) implementation, rate is correct for amount of fluid ordered, but amount is excessive for child and fluid is inappropriate (4) assessment, should not administer fluids as ordered since they are inappropriate in amount and content 72. The nurse team consists of an RN, two LPN/LVNs, and a nursing assistant. The RN should care for which of the following clients? 1. An infant who is two-days postoperative after repair of cleft lip that requires a tube feeding. 2. A preschool child who is three-days postoperative after surgical removal of Wilms’ tumor that requires a bath. 3. A school-aged child with osteomyelitis that requires a dressing change. 4. A teenager with a head injury, has a Glasgow coma scale of 5, and requires personal care. Strategy: RNs care for clients that require assessment, teaching, and nursing judgment. (1) stable patient with an expect outcome, assigned to the LPN/LVN (2) standard, unchanging procedure, assign to the nursing assistant (3) stable patient with an expect outcome, assign to the LPN/LVN (4) correct–Glasgow coma scale of 5 indicates coma, client requires frequent assessment 73. An elderly female client is frantically yelling for the nurse to come into her room. The nurse enters the room as the client states, “See it? It’s the devil!” Which of the following responses by the nurse is BEST? 1. “The devil is here?” 2. “Show me where the devil appeared to you.” 3. “I don’t see the devil, but I understand that he is real to you.” 4. “The devil is not here, your mind is playing tricks on you.” Strategy: Remember therapeutic communication. (1) yes/no question, attempt to reason or argue with the client will only entrench her more firmly into this distortion (2) attempt to reason or argue with the client will only entrench her more firmly into this distortion (3) correct–nurse should not reinforce client’s hallucinatory experiences; direct challenge to client’s belief about sensory-perceptual intake will only increase mistrust and conflict between nurse and client (4) argumentative, attempt to reason or argue with the client will only entrench her more firmly into this distortion 74. The nurse talks to a 26-year-old woman in the emergency department (ED) immediately after her son’s death from Sudden Infant Death Syndrome (SIDS). The nurse should 1. ask if she has other children at home. 2. explain the cause of SIDS. 3. allow her to cry and talk about her son. 4. ask how her son was positioned in bed. Strategy: The question is unstated. Read the answers to determine the topic of the question. Answers contain both assessments and implementations. Is assessment required at this time? No. Determine the outcome of each implementation. (1) assessment, does not help with current loss (2) implementation, too soon, should allow to vent feelings and experience grief (3) correct–implementation, needs to go through the grieving process (4) assessment, may make her feel guiltier, inappropriate at this time 75. A woman was returned to her room at 10 AM following laparoscopic gall bladder surgery. The nurse plans to get the patient out of bed for the first time at 6 PM. In preparation for this activity, the nurse should 1. cough and deep-breathe the patient at 4 PM. 2. offer pain medication to the patient at 5:30 PM. 3. turn the patient from side to side at noon and 4 PM. 4. encourage the patient to use the incentive spirometer. Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should turn, cough, and deep-breathe patient every 2 hours to prevent postoperative complications, but would not help with ambulation (2) correct–reduction of pain will allow patient to cooperate with activities, such as ambulation, designed to reduce postoperative complications (3) should turn patient every 2 hours to prevent postoperative complications, but would not help with ambulation (4) used to promote complete lung expansion and prevent respiratory complications following surgery, but would not help with ambulation 76. The nurse enters the room of a 17-year-old mother who is breastfeeding her 6 lb 7 oz baby girl. Which of the following observa