NCLEX RN AUGUST

• NCLEX RN 2022 • TESTED AUGUST • 145 QUESTIONS AND ANSWERS • (THEY CAME AS SCREENSHOTS BUT I TYPED THEM DOWN FOR YOU GUYS) 1. Children often experience visual impairments. Refractive errors affect the child’s visual activity. The main refractive error seen in children is myopia. The nurse explains to the child’s parents that myopia may also be described as: Nearsightedness 2. Which of the following serum laboratory values would the nurse monitor during gentamicin therapy? Creatinine 3. A 33-year-old client was brought into the emergency room unconscious, and it is determined that surgery is needed. Informed consent must be obtained from his next of kin. The sequence in which thenext of kin would be asked for the consent would be: Spouse, adult child, parent, sibling 4. Based on your knowledge of genetic inheritance, which of these statements is true for autosomalrecessive genetic disorders? Two affected parents always have affected children. 5. Prior to an amniocentesis, a fetal ultrasound is done in order to: Locate the position of the placenta and fetus 6. An expected response to sodium polystyrene sulfonate (Kayexalate) is: Decrease in serum potassium 6. A client who was started on antipsychotic medication 2 weeks ago is preparing for discharge from the hospital. Compliance with the medication regimen is important despite the mild side effects encountered. In order to increase the likelihood of medication compliance, the nurse would: Discuss the disease process and the importance of the medication in prevention of symptoms. 7. A 37-year-old client has been taking antipsychotic medication for the past 10 days. The nurse observes her walking with a shuffling gait and postural rigidity and notes a masklike expression on her face. Whichside effect is this client exhibiting? Parkinsonism 8. A client is being discharged from the hospital tomorrow following a colon resection with a left colostomy. The nurse knows that the client understands the discharge teaching about care of her colostomy when she says: “My stoma should be red and slightly raised.” 9. A 25-year-old outpatient presents with a diagnosis of compulsive personality disorder. His coworkers become annoyed with his rigid, perfectionistic manner and preoccupation with trivial details and schedules. Anursing intervention appropriate for this client would include: Contracting with him for the amount of time he will spend on the compulsive behaviors 10. A 1-year-old child is to receive an IM injection ordered by his pediatrician. He has fallen asleep in his mother's arms when the nurse approaches. Which approach is most appropriate at this time? Awaken the child first and give the injection in the ventrogluteal site. 11. The physician has ordered that ampicillin 250 mg IV be given over 30 minutes. The medication is diluted as recommended in 10 mL in the volume control chamber of a set that has a tubing of 12 mL. Which nursing measure is most accurate considering these facts? Infuse volume at 44 mL/hr. 12. An infant weighing 15 lb has just been treated for severe diarrhea in the hospital. Discharge instructions by the nurse will include maintenance fluid requirements for the pediatric client. Which of the following values best indicates the nurse's understanding of normal fluid requirements for this infant? 680 mL/day 13. A normal 3-year-old child is suspected of having meningitis. The doctor has ordered a lumbar puncture. In light of this procedure and developmental characteristics of this age group, which nursing measure is most appropriate? Emphasize those aspects of the procedure that require cooperation. 14. A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful? Provide time for play and becoming acquainted. 15. An 11-month-old infant is admitted with a possible diagnosis of pyloric stenosis. Which of the following best describes the characteristic clinical manifestations of pyloric stenosis? Palpable olive-shaped mass in the epigastrium just right of the umbilical cord 16. A 15-year-old child is admitted to the pediatric unit with a diagnosis of thalassemia. Which of the following would be included in educating the mother and child as part of discharge planning? Know the signs and symptoms of iron overload. 17. Iron dextran (Imferon) is a parenteral iron preparation. The nurse should know that it: Requires use of the Z-track method 18. The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage. These signs and symptoms would include: Eye pain and itching 19. The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every 1–2 minutes; strong, large amount of “bloody show.” The most appropriate nursing goal for thisclient would be: Provide strategies to maintain client control. 20. A complication for which the nurse should be alert following a liver biopsy is: Shock 21. A 42-year-old client on an inpatient psychiatric unit comments that he was brought to the hospital by hiswife because he had taken too many pills and states, “I just couldn’t take it anymore.” The nurse’s best response to this disclosure would be: “Tell me more about what you couldn’t take anymore.” 22. After a 10-year-old child with insulin-dependent diabetes mellitus receives her dinner tray, she tells the nurse that she hates broccoli and wants some corn on the cob. The nurse’s appropriate response is: “Corn and other starchy vegetables are considered to be bread exchanges.” 23. Which of the following signs might indicate a complication during the labor process with vertex presentation? Appearance of dark-colored amniotic fluid 24. The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay? Vaginal discharge or rubra, serosa, then rubra 25. MgSO4 blood levels are monitored and the nurse would be prepared to administer the following antidote for MgSO4 side effects or toxicity: Calcium gluconate 26. A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursingaction is the most appropriate? Put in a nasogastric tube and lavage the child’s stomach. 27. A 32-year-old mother of two was brought to the hospital by her husband. He reported that his wife could no longer manage the house and children. She does not sleep and talks day and night. She has purchased some very expensive clothes. The nurse noted that the client speaks rapidly and changes the subject irrationally. This is an example of: Flight of ideas 28. A client is placed on lithium therapy for her manicdepressive illness. When monitoring the client, the nurse assesses the laboratory blood values. Toxicity may occur with lithium therapy when the blood level is above: 1.5 mEq/L 29. A client's behavior is annoying other clients on the unit. He is meddling with their belongings and dominating the group. The best approach by the nurse is to: Set limits on his behavior. 30. A client is hyperactive and not sleeping. She will not remain at the table during mealtime. She is getting very limited calories and is using a lot of energy in her hyperactive state. The most therapeutic nursing action is to: Provide nutritious finger foods several times a day. 31. A hyperactive client is experiencing flight of ideas. The most therapeutic activity for him wouldbe: Playing basketball in the gym 32. A client is a depressed, 48-year-old salesman. A serious concern for the nurse working with depressed clients is the potential of suicide. The time that suicide is most likely to occur is: When the depression starts to lift 33. Succinylcholine chloride (Anectine) is ordered prior to electroconvulsive therapy treatment for depressed clients. The nurse explains that the purpose of the drug is to: Relax muscles 34. The nurse teaches a pregnant client that a high-risk symptom occurring at any time during pregnancy that needs to be reported immediately to a healthcare provider is: Abdominal pain 35. At her first prenatal visit, a 21-year-old woman who is gravida 2, para 0, ab 1, is currently at 32 weeks' gestation and has a history of drug abuse, smoking, and occasional ethyl alcohol use. Fetal ultrasound tests indicate poor fetal growth. The most likely reason for the infant's intrauterine growth retardation is: The client's history of drug, ethyl alcohol, and tobacco use 36. When teaching a class of nursing students, the nurse asks why the embryonic period (weeks 48) of pregnancy is so critical. Organogenesis occurs. 37. After the fetal activity test (nonstress test) is completed, the RN is looking at the test results on the monitor strip. The RN observes that the fetal heart accelerated 5 beats/min with each fetal movement. The accelerations lasted 15 seconds and occurred 3 times during the 20- minute test. The RN knows thatthese test results will be interpreted as: A reactive test 38. A 70-year-old client has pneumonia and has just had a respiratory arrest. He has just been intubated with an 8- mm endotracheal tube. During auscultation of his chest, breath sounds were found to be absent on the left side. The nurse identifies the most likely cause of this as: Right mainstem bronchus intubation 39. After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located wherein the pelvis? One centimeter above the ischial spines 40 .A 47-year-old client has been admitted to the general surgery unit for bowel obstruction. The doctor has ordered that an NG tube be inserted to aid in bowel de-compression. When preparing to insert a NG tube, the nurse measures from the: Tip of the nose to the ear lobe to the xiphoid process or midepigastric area 41. Because a client is taking an MAO inhibitor, it is necessary to discuss the need for adherence to a low- tyramine diet. Which of the following are foods that she should avoid? Pickled, aged, smoked, and fermented foods 42. The nurse documents a client’s surgical incision as having red granulated tissue. This indicates that the wound is: Healing 43. A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse: Must use the least restrictive measure possible to control the behavior 44. A client returns to the cardiovascular intensive care unit following his coronary artery bypass graft. In planning his care, the most important electrolyte the nurse needs to monitor will be: Potassium 45. A client is admitted to the hospital with diabetic ketoacidosis. The emergency room nurse should anticipate the administration of: Humulin R 46. A client with open‐angle glaucoma is receiving timolol (Timoptic) for treatment. When assessing the client’s response to the medication, the nurse expects therapeutic effects to be the result of which of the following: A decrease in aqueous humor production 47. 3 It is winter, and the client has extremely dry skin. Which type of preparation should the nurse recommend first? Emollient or emollient‐containing lotion 48. The nurse should teach a client to use which one of the following for a skin disorder in which the use of mild soap is needed? Dove 49. The nurse recommends the use of a topical cream to a client who needs which of the following ingredients in a skin product? Emulsifying agent 50. The nurse who is working in a women’s health clinic has several clients to see during the day. Which of these clients does the nurse anticipate will need medication teaching for calcium supplementation to treat primary osteoporosis? A Caucasian client 51. A 52-year-old client who underwent an exploratory laparotomy for a bowel obstruction begins to complain of hunger on the third postoperative day. His nasogastric (NG) tube was removed this morning, and he has an IV of D5W with 0.45% normal saline running at 125 mL/hr. He asks when he can get rid of his IV and start eating. The nurse recognizes that he will be able to begin taking oral fluids and nourishment when: The nurse can detect bowel sounds in all four quadrants 52. A 22-year-old client who is being seen in the clinic for a possible asthma attack stops wheezing suddenly as the nurse is doing a lung assessment. Which one of the following nursing interventions is most important? Draw a blood sample for arterial blood gases. 53. A 48-year-old client is being seen in her physician’s office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days’ duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment? Murphy’s sign 54. A 29-year-old client delivered her fifth child by the Lamaze method and developed a postpartal hemorrhage in the recovery room. What are the initial symptoms of shock that she may experience? Rapid pulse; narrowed pulse pressure; cool, moist skin 55. A client is a depressed, 48-year-old salesman. A serious concern for the nurse working with depressed clients is the potential of suicide. The time that suicide is most likely to occur is: When the depression starts to lift 56. The nurse assesses a client on the second postpartum day and finds a dark red discharge on the peripad. The stain appears to be about 5 inches long. Which of the following correctly describes the character and amount of lochia? Lochia rubra, moderate following nursing diagnoses would be given the highest priority in the first 8 hours’ post burn? Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to alteration in skin integrity 57. A 9-month-old infant was diagnosed with nonorganic failure to thrive. During her hospitalization, primary nurses were assigned to initiate all infant feedings. The infant’s parents question why they cannot feed their own child. Which of the following responses would be most appropriate by the nurse? By assigning the same nurses to the child, the nurses can begin to learn the infant’s cues and feeding behaviors. 58. A client was admitted to the hospital after falling in her home. At the time of admission, her blood alcohol level was 0.27 mg%. Her family indicates that she has been drinking a fifth of vodka a day for the past 9 months. She had her last drink 30 minutes prior to admission. Alcohol withdrawal symptoms would most likely be exhibited by her: Six to 8 hours after the last drink 59. A client’s renal calculi are identified as consisting of calcium phosphate. Which of the following diets would be appropriate? Low calcium and phosphorus, acid ash 60. A 47-year-old client comes to the emergency department complaining of moderate flank, abdominal, and testicular pain with nausea of 4 hours’ duration. After physical examination and obtaining the client’s history, the physician suspects urethral obstruction by calculi. The nurse realizes that the physician will order which one of the following diagnostic studies to best confirm the diagnosis? Intravenous pyelogram with excretory urogram 61. A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of: Aspiration and weight loss 62. A client had a ruptured abdominal aortic aneurysm that was repaired surgically. Her postoperative recovery progressed without complications, and she is ready for discharge. Client education in preparation for discharge began 7 days ago on her admission to the nursing unit. Evaluation of nursing care related to client education is based on evaluation of expected outcomes. Which statement made by the client would indicate that she is ready for discharge? “I am allowed to exercise by walking for short periods.” 63. A client has been diagnosed with congestive heart failure. His fluid intake and output are strictly regulated. For lunch, he drank 8 oz of milk, 4 oz of tea, and 6 oz of coffee. His intake would be recorded as: 540 mL 64. A client takes warfarin (Coumadin) 15 mg po daily. To evaluate the medication’s effectiveness, the nurse should monitor the: prothrombin time (PT) 65. A client is being evaluated for control of type 2 diabetes mellitus with exercise, diet, and oral medication therapy. A glycosylated hemoglobin test is ordered. The client asks the nurse what that test is for. Which of the following is the best response by the nurse "Results of this test show your average blood glucose over the last several weeks. 66. A client is taking bismuth for diarrhea. For which of the following side effects unique to this medication would a nurse monitor Darkening of the tongue 67. The nurse is caring for a client with gastroesophageal reflux disease (GERD) who is taking metoclopramide (Reglan). The nurse determines that the client understands the purpose of the medication when the client verbalizes that the medication has which of the following actions? Increases GI motility 68. 2 A 3‐year‐old client weighing 33 pounds is to receive liquid Advil (ibuprofen) 150 mg PO q6 hours prn for temperature above 101 degrees F. The nurse should administer mL to the client from a bottle labeled 100 mg/5 mL. Fill in the numeric answer below. Correct answer: 7.5 69. A health care provider prescribed a prochlorperazine (Compazine) 12.5 mg suppository for a client with severe nausea. The nurse has on hand a 25 mg suppository. The next step for the nurse includes which of the following? Contact the prescriber, if unable to locate the dosage 70. The nurse is planning to administer furosemide (Lasix) 40 mg by the IV push route. The nurse uses which of the following techniques in administering this medication? Injects the medication over 2–3 minutes. 71. A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the client's self- esteem by: Allowing him to plan, assist in, and perform his own care whenever possible 72. A 20-year-old client presents to the obstetrics-gynecology clinic for the first time. She tells the nurse that she is pregnant and wants to start prenatal care. After collecting some initial assessment data, the nurse measures her fundal height to be at the level of the umbilicus. The nurse estimates the fetal gestational age to be approximately: 20 weeks 73. A female client presents to the obstetric-gynecology clinic for a pregnancy test, the result which turns out to be positive. Her last menstrual period began December 10, 1993. Using Nägele's rule, the nurse estimates her date of delivery to be: September 17, 1994 74. A female client comes for her second prenatal visit. The nurse-midwife tells her, "Your blood tests reveal that you do not show immunity to the German measles." Which notation will the nurse include in her plan of care for the client? "Will need . . . Rubella vaccine after delivery on the day of discharge" 75. A female client at 37 weeks' gestation has just undergone a nonstress test. The results were two fetal movements with a corresponding increase in fetal heart rate (FHR) of 15 bpm lasting 15 seconds within a 20- minute period. Her results would be classified as: A. Reactive; no contraction stress test required 76. A female client at 36 weeks' gestation has been treated successfully for premature labor for 4 weeks. She has begun having uterine contractions today and has been admitted to the labor and delivery suite. Her amniocentesis results reveal a lecithin/sphingomyelin (L/S) ratio of 2 and positive phosphatidylglycerol (PG). These lab values indicate: Fetal lung maturity 77. A primigravida with a blood type a negative is at 28 weeks' gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy? "I'm getting this shot so that my baby won't develop antibodies against my blood, right?" 78. at her monthly prenatal visit, a client reports experiencing heartburn. Which nursing measure should be included in her plan of care to help alleviate it? Eat small, frequent bland meals. 79. A client is dilated 8 cm and entering the transition phase of labor. Common behaviors of the laboring woman during transition are: Frustration, vague in communication 80. The FHR pattern in a laboring client begins to show early decelerations. The nurse would best respond by: Continuing to monitor the FHR closely 81. A female client is admitted to the emergency department complaining of severe right-sided abdominal pain and vaginal spotting. She states that her last menstrual period was about 2 months ago. A positive pregnancy test result and ultrasonography confirm an ectopic pregnancy. The nurse could best explain to the client that her condition is caused by: A distended or ruptured fallopian tube 82. A female client at 10 weeks' gestation complains to her physician of slight vaginal bleeding and mild cramps. On examination, her physician determines that A threatened abortion An incomplete abortion 83. A female client at 36 weeks' gestation is experiencing preterm labor. Her physician has prescribed two doses of betamethasone 12 mg IM q24h. The nurse explains that she is receiving this drug to: Promote fetal lung maturation 84. A client has returned to the unit following a left femoral popliteal bypass graft. Six hours later, his dorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse should: Notify the physician immediately 85. A client is to have a coronary artery bypass graft performed in the morning using a saphenous vein. He wants to know why the physician does not use the internal mammary artery for his bypass graft because his friend's physician uses this artery. The nurse tells the client that the internal mammary artery: Takes more time to remove 86. A client returns to the cardiovascular intensive care unit following his coronary artery bypass graft. In planning his care, the most important electrolyte the nurse needs to monitor will be: Potassium 87. A client is being discharged from the hospital today. The discharge teaching for care of her colostomy included which of the following basic principles for protecting the skin around her stoma: Using a skin sealant under pouch adhesives 88. A client is being discharged from the hospital tomorrow following a colon resection with a left colostomy. The nurse knows that the client understands the discharge teaching about care of her colostomy when she says: 89. A client had a right below-the-knee amputation 4 days ago. He is complaining of pain in his right lower leg. The nurse should: Give the client his order of Demerol 50 mg IM prn 90. A client has returned to the unit from the recovery room after having a thyroidectomy. The nurse knows that a major complication after a thyroidectomy is: Respiratory obstruction 91. A client had a transurethral resection of the prostate yesterday. He is concerned about the small amount of blood that is still in his urine. The nurse explains that the blood in his urine: Is normal and he need not be concerned about it 92. A 72-year-old male client had the Foley catheter that was inserted during the transurethral resection of his prostate removed today. He is concerned about the urinary incontinence he is having since removal of the Foley catheter. The nurse explains that: This is usually temporary 93. A 48-year-old female client is going to have a cholecystectomy in the morning. In planning for her postoperative care, the nurse is aware that a priority nursing diagnosis for her will be high risk for: Ineffective breathing pattern 94. A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy would include: Monitoring the right lung for an increase in rales 95. A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first: Notify the physician. 96. A client had a renal transplant 3 months ago. He has suddenly developed graft tenderness, an increased white blood cell count, and malaise. The client is experiencing which type of rejection? Acute 97. A client has received preoperative teaching for the vertical partial laryngectomy that he is scheduled to have in the morning. The nurse determines that the teaching has been effective when the client states: "I will have very little difficulty swallowing after surgery." 98. A client being discharged from the hospital is beginning medication therapy with bumetanide (Bumex). The nurse instructs the client to contact the prescriber if which of the following contraindications for use develops while using this medication? Absence of urine output 99. The nurse should review the results of which of the following to evaluate a client's response to a lipid‐ lowering agent Liver function tests 100. A client taking cholestyramine (Questran) to lower lipid levels should be monitored for possible deficiency of which vitamin(s)? Vitamins A and D 101. After beginning an antihypertensive medication, the client returns for a follow‐up visit and complains of a dry, nonproductive cough. The nurse knows that this side effect is mostly caused by which type of antihypertensive medication? Angiotensin‐converting enzyme (ACE) inhibitor 102. A 28-year-old client performs a long, involved ritual in getting up and preparing for the day. He became unable to get to his job before noon. His family, in desperation, has admitted him to the hospital’s psychiatric unit. On the unit, he is always late for breakfast, which is served at 8 am. The nurse identifiesthat the best approach to this problem is to: Get him up early so that he can complete the ritual before breakfast 103. A client is diagnosed with Mycobacterium tuberculosis. He is placed in respiratory isolation, intubated,and receives mechanical ventilation. When performing suctioning, the nurse should: Hyperoxygenate before and after suctioning 104. A 67-year-old postoperative TURP client has hematuria. The nurse caring for him reviews his postoperative orders and recognizes that which one of thefollowing prescribed medications would best relieve this problem? Aminocaproic acid (Amicar) 6 g/24 hr 105. Before completing a nursing diagnosis, the nurse must first: Perform an assessment 106. A 22-year-old client presents with a diagnosis of antisocial personality disorder and a history of using drugs, writing numerous checks with insufficient funds, and stealing. He appears charming and intelligent, and the other clients are impressed and want to be liked by him. The greatest problem thatmay arise from this situation is that: He will manipulate the other clients for his own benefit 107. A 45-year-old client has a permanent colostomy. Which of the following foods should he avoid? Corn beef and cabbage and boiled potatoes 108. A client presents to the emergency room with cyanosis, coughing, tachypnea, and tachycardi She has a history of asthma 109. A. Arterial blood gas values are pH 7.28, PaO2 54, PaCO2 60, and HCO3 24. The nursing assessment ofarterial blood gases indicate the presence of: Respiratory acidosis 110. A 55-year-old client is admitted with a diagnosis of renal calculi. He presented with severe right flankpain, nausea, and vomiting. The most important nursing action for him at this time is: Straining of all urine 111. A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, shenotices fresh blood on the dressing. The nurse should first: Notify the physician. 112. A 5-year-old child cries continually in her bed. Her parents have been unsuccessful in assisting her in expressing her feelings. Which activity should the nurse provide the child to assist her in expressing herfeelings? Puppets 113. Which of the following blood gas parameters primarily reflects respiratory function? PCO2 114. A 2-day-old infant boy has been diagnosed with an atrial septal defect due to a persistent patent foramen ovale. When explaining the diagnosis to the mother, the nurse includes in the discussion thefunction of the foramen ovale. In fetal circulation, the foramen ovale allows a portion of the blood tobypass the: Pulmonary system 115. A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood wasrunning down her legs. She denies any pain previously or currently. The client is very concerned about whether her baby will be all right. Her vital signs include P 120 bpm, respirations 26 breaths/min, BP 104/58 mm Hg, temperature 98.2_F, and fetal heart rate 146 bpm. Laboratory findings revealed hemoglobin 9.0 g/dL, hematocrit 26%, and coagulation studies within normal range. On admission, the peripad she worewas noted to be half saturated with bright red blood. A medical diagnosis of placenta previa is made. The priority nursing diagnosis for this client would be: Decreased cardiac output related to excessive bleeding 116. Home-care instructions for the child following a cardiac catheterization should include: Use sponge bathing until stitches are removed. 117. 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 starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following? The client aspirated tube feeding. 118. A client has returned to the unit following a left femoral popliteal bypass graft. Six hours later, hisdorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse should: Notify the physician immediately 119. A 2-year-old child will undergo a cardiac catheterization tomorrow to evaluate his ventricular septal defect. Based on his developmental stage, the nurse: Explains the procedure using simple words and sentences just before the preoperative sedation 120. After 7 hours in restraints and a total of 30-mg haloperidol in divided doses, a client complains of stiffness in his neck and his tongue "pulling to one side." These extrapyramidal symptoms (EPS) will most likely be relieved by the administration of: Benztropine (Cogentin) 121. Medication is administered to a client who has been placed in restraints after a sudden violent episode, and his EPSs subside. Restraints can be removed when: The violent behavior subsides, and the client agrees to behave 122. A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5'4" and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to: Assess vital signs 122. Assessment of a client reveals a 30% loss of preillness weight, lanugo, and cessation of menses for 3 months. Her vital signs are BP 90/50, P 96 bpm, respirations 30, and temperature 97 F. She admits to the nurse that she has induced vomiting 3 times this morning, but she had to continue exercising to lose "just 5 more lb." Her symptoms are consistent with: Anorexia nervosa 123. Blood work reveals the following lab values for a client who has been diagnosed with anorexia nervosa: hemoglobin 9.6 g/dL, hemocrit 27%, potassium 2.7 mEq/L, sodium 126 mEq/L. The greatest danger to her at this time is: Possible cardiac dysrhythmias secondary to hypokalemia 124. A client suspected of having anorexia nervosa is placed on bed rest with an IV infusion and a high-carbohydrate liquid diet. Within 72 hours, the results of her lab work show a return to normal limits. She is transferred to the psychiatric service for further treatment. A behavior modification plan is initiated. Three days after her transfer, the client tells the nurse, "I haven't exercised in 6 days. I won't be eating lunch today." This statement by her most likely reflects: Her lack of internal awareness about the outcome of the behavior 125. A client who has been diagnosed with anorexia nervosa refuses to eat lunch. The most therapeutic response by the nurse to her refusal is: "We will not allow you to starve yourself. You may choose to eat voluntarily or be fed." 126. A client who has been diagnosed with anorexia nervosa reluctantly agrees to eat all prescribed meals. The most important intervention in monitoring her dietary compliance would be to: Observe behavior for 12 hours after meals to prevent vomiting 127. A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to: Cry 128. 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: 1600 mL/24 hr 129. A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib andhitting his head. The nurse calls the physician to report: Temperature rose to 102_F rectally 130. A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 stationwith the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction. One comfort measure the nurse can employ is to: Apply strong sacral pressure during the contraction 131. The nurse is admitting an infant with bacterial meningitis and is prepared to manage the followingpossible effects of meningitis: Seizure 132. The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to: Cleanse and wipe the perineum from front to back 133. On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and exhibiting a coarse hand tremor. Which one of the followingnursing actions is essential at this time? Withhold her lithium, and report her symptoms to the physician. 134. A registered nurse is trying to determine the appropriate care that she should provide for her obstetricalclients. Which of the following documents is considered the legal standard of practice? State nursing practice act 135. A 26-year-old female client presents at 10 weeks’ gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes. The client’sprevious delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is 130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes? Previous birth of an infant weighing>9 lb 136. A client’s membranes have just ruptured spontaneously. Which of the following nursing actions should take priority? Assess fetal heart rate (FHR). 137. After several days, an IDDM client’s serum glucose stabilizes, and the registered nurse continues clientteaching in preparation for his discharge. The nurse helps him plan an American Diabetes Association diet and explains how foods can be substituted on the exchange list. He can substitute 1 oz of poultry for: One-fourth cup dry cottage cheese 138. An IDDM client’s condition stabilizes. He begins to receive a daily injection of NPH insulin at 6:30 AM. The nurse can most likely expect a hypoglycemic reaction to occur that same day at: 2:30 PM–4:30 PM 139. A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse’s best response is: “Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after each treatment.” 140. A female client admitted to the labor and delivery unit thinks her bag of water “broke” approximately 2hours ago. She is having mild contractions 5 minutes apart. The most immediate nursing intervention would be to: Assess the FHR. 141. Medication is administered to a client who has been placed in restraints after a sudden violent episode,and his EPSs subside. Restraints can be removed when: A therapeutic alliance has been established, and violent behavior subsides 142. The nurse assesses a client’s monitor strip and finds the following: uterine contractions every 3–4 minutes, lasting 60–70 seconds; FHR baseline 134–146 bpm, with accelerations to 158 bpm with fetalmovement. Which nursing intervention is appropriate? Evaluate to see if the monitor strip is reassuring. 143. A 14-year-old boy fell off his bike while “popping a wheelie” on the dirt trails. He has sustained a head injury with laceration of his scalp over his temporal lobe. If he were to complain of headache during thefirst 24 hours of his hospitalization, the nurse would: Offer diversionary activities 144. A client at 6 months’ gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL,and her hematocrit value is 32%. Her nutritional intake is assessed as sufficient. The most likely diagnosis is: Iron-deficiency anemia 145. A baby is circumcised. Immediate postoperative care should include: Taking the baby to his mother for cuddling