NCLEX RN JULY 2022 FILES

NCLEX RN ACTUAL TEST 2022 TESTED OCTOBER VERIFIED QUESTIONS AND ANSWERS CHRISJAY FILES The nurse is completing an assessment of a child in the clinic. Which of the following should be documented in the child's health history? Select all that apply. 1.‐ The child was born by cesarean section. 2.‐ Mother states child has a rash 3.‐ Child appears feverish 4.‐ Diminished reflexes 5.‐ Older sister had the chicken pox recently. A 10-month-old infant's mother says that he takes fresh whole milk eagerly, but that when she offered him baby foods at 6 months of age, he pushed them out of his mouth. Because he has gained weight appropriately, she has quit trying to get him to eat other foods. The nurse's response is based on the knowledge that: A. Milk intake should be limited to no more than four 8-oz bottles per day and should be followed by iron-enriched cereal or other solid foods or juices B. Milk is an excellent food and will meet his nutritional needs adequately until he is ready to eat solid foods C. It is acceptable to continue to give him whole milk and to delay giving solid foods as long as he takes a vitamin supplement daily D. He should be started on iron-enriched cereal, meat, vegetables, fruits, and juices prior to bottle feeds. Milk intake should be limited to 1 qt/day 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? A. By assigning the same nurses to the child, the nurses can begin to learn the infant's cues and feeding behaviors. B. The same nurses will prevent parental fatigue and frustration. C. The same nurses will prevent infant fatigue and frustration. D. Primary nurses will ensure privacy. The parents of a 2-year-old child are ready to begin toilet training activities with him. His parents feel he is ready to train because he is now 2 years old. What would the nurse identify as readiness in this child? A. Patience by the child when wearing soiled diapers B. Communicating the urge to defecate or urinate C. The child awakening wet from his naps D. The age at which the child's siblings were trained A 5-year-old child is hospitalized for an acute illness. The nurse encourages the family to bring her favorite objects from home. What is the nurse's rationale? A. To reduce fear of the unknown B. To keep the child calm C. To establish a trusting relationship CHRISJAY FILES D. To prevent or minimize separation anxiety A 3-year-old child was hospitalized for acute laryngotracheobronchitis. During her hospitalization, the child was placed under an oxygen mist tent. The nurse's frequent monitoring of the child's temperature frightened her parents. Which response by the nurse would be most appropriate? A. Monitoring the temperature prevents undue chilling. B. Rapid temperature elevations can occur in children. C. Checking the temperature will prevent febrile seizures. D. Taking the child's temperature can prevent airway obstruction. The nurse is teaching a group of adults about health screenings for cancer. The nurse would include in the discussion which of the following points? Select all that apply. 1.‐ Genetic screening is helpful in identification of cancer risks. 2.‐ Annual medical exams uncover most tumors. 3.‐ Men need to perform breast and testicle exams monthly. 4.‐ Annual mammograms are recommended after a total mastectomy. 5.‐ Inspection of the skin for cancer becomes less important as one ages. A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardia. What first nursing actions would be essential in this situation? A. Hold the child's discharge for 1 hour. B. Notify the physician immediately. C. Discharge the child as the physician ordered. D. Administer an antiemetic as necessary. A neonate was admitted to the hospital with projectile vomiting. According to the parents, the baby had experienced vomiting episodes after feeding for the last 2 days. A medical diagnosis of hypertrophic pyloric stenosis was made. On assessment, the infant had poor skin turgor, sunken eyeballs, dry skin, and weight loss. Identify the number-one priority nursing diagnosis. A. Fluid volume deficit B. Altered nutrition C. Altered bowel elimination D. Anxiety A baby who was diagnosed with pyloric stenosis has continued to have projectile vomiting. With prolonged vomiting, the infant is prone to: A. Respiratory acidosis CHRISJAY FILES B. Respiratory alkalosis C. Metabolic acidosis CHRISJAY FILES D. Metabolic alkalosis Parents of young children often need anticipatory guidance from the nurse. Parents may have little knowledge regarding growth and development. Which of the following toys and activities would the nurse suggest as appropriate for a toddler? A. Cutting, pasting, string beads, music, dolls B. Mobiles, rattle, squeeze toys C. Pull-toys, large ball, dolls, sand and water play, music D. Simple card games, puzzles, bicycle, television 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 her feelings? A. Books with colorful pictures B. Music C. Riding toys CHRISJAY FILES D. Puppets During his hospitalization, a 3-year-old child has become unusually aggressive in his play activities. His parents report this change in behavior to the primary nurse. How could the nurse explain the child's change in behavior? A. Deep-seated feelings of hostility B. A lack of interest in socializing C. Usual behavior for this child D. A coping response Following her surgery, a 5-year-old child will return to the pediatric unit with a long-arm cast. She experienced a supracondylar fracture of the humerus near the elbow. Which nursing action is most essential during the first 24 hours after surgery and cast application? A. Mobilization of the child B. Discharge teaching C. Pain management D. Assessment of neurovascular status A 9-month-old infant visits her pediatrician for a routine visit. A developmental assessment was initiated by the nurse. Which skill would cause the nurse to be concerned about the infant's developmental progression? A. She sits briefly alone with assistance. B. She creeps and crawls. C. She pulls herself to her feet with help. D. She stands while holding onto furniture. 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: A. Cataracts B. Farsightedness C. Nearsightedness D. Lazy eye CHRISJAY FILES A client is experiencing visual problems at school. She has complained of difficulty seeing the blackboard and squinting. She no longer likes to participate in physical activities such as softball. The client has displayed possible classic symptoms of which refractive error? A. Astigmatism B. Hyperopia C. Myopia D. Amblyopia An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to: A. A tension pneumothorax B. An asthma attack C. Pneumonia D. Pulmonary embolus The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing? A. Vitamin C B. Vitamin B1 C. Vitamin D D. Vitamin A As a postoperative cholecystectomy client completes tomorrow's dinner menu, the nurse knows that one of the following meal choices will best provide the essential vitamin(s) necessary for proper tissue healing? A. Liver, white rice, spinach, tossed salad, custard pudding B. Fish fillet, carrots, mashed potatoes, butterscotch pudding C. Roast chicken, gelatin with sliced fruit D. Chicken breast fillet in tomato sauce, potatoes, mustard greens, orange and strawberry slices The pediatric nurse would perform abdominal percussion to assess which of the following? (Select all that apply.) 1.‐ Generalized tenderness 2.‐ Local inflammation 3.‐ Density of tissues and organs 4.‐ Size and placement of liver 5.‐ Borders and size of abdominal organs CHRISJAY FILES A 71-year-old client fell and injured her left leg while cooking in the kitchen. Her husband calls the ambulance, and she is taken to the emergency department at a local hospital. X-ray reports confirm that she has an intertrochanteric fracture of the left femur. Her left leg will require skeletal traction initially and then surgery. The nurse knows that this type of traction will be used: A. By inserting pins to provide steady pull on the bone B. To suspend the leg in a sling without pull on the extremity C. Intermittently to place a pull over the pelvis and lower spine D. With weights at both ends of the bed to maintain pull on the upper extremity Pin care is a part of the care plan for a client who is in skeletal traction. When assessing the site of pin insertion, which one of the following findings would the nurse know as an indicator of normal wound healing? A. Exudate B. Crust C. Edema D. Erythema 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? A. Cystoscopy B. Kidneys, ureter, bladder, x-ray of abdomen C. Intravenous pyelogram with excretory urogram D. Ureterolithotomy An obstructing stone in the renal pelvis or upper ureter causes: A. Radiating pain into the urethra with labia pain experienced in females or testicular pain in males B. Urinary frequency and dysuria C. Severe flank and abdominal pain with nausea, vomiting, diaphoresis, and pallor D. Dull, aching, back pain A client who has gout is most likely to form which type of renal calculi? A. Struvite stones B. Staghorn calculi C. Uric acid stones D. Calcium stones CHRISJAY FILES A 75-year-old client is hospitalized with pneumonia caused by gram-positive bacteria. Which one of the following best describes a gram-positive bacterial pneumonia? A. Klebsiellapneumonia B. Pneumococcal pneumonia C. Legionella pneumophilapneumonia D. Escherichia colipneumonia The nurse caring for a client who has pneumonia, which is caused by a gram-positive bacteria, inspects her sputum. Because the client's pneumonia is caused by a gram-positive bacteria, the nurse experts to find the sputum to be: A. Bright red with streaks B. Rust colored C. Green colored D. Pink-tinged and frothy The nurse who is caring for a client with pneumonia assesses that the client has become increasingly irritable and restless. The nurse realizes that this is a result of: A. Prolonged bed rest B. The client's maintaining a semi-Fowler position C. Cerebral hypoxia D. IV fluids of 2.53 liters in 24 hours 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? A. Place the client in a supine position. B. Draw a blood sample for arterial blood gases. C. Start O2 at 4 L/min. D. Establish a patent airway. A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, "The doctor said I have stones that need to be removed; where are they?" The nurse knows that the best explanation for this is to tell her that: A. There are stones present in her gallbladder B. There are stones present in her kidneys C. There are stones present in her common bile duct D. There are no stones, but her gallbladder is irritated and caused her nausea, vomiting, and pain CHRISJAY FILES 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? A. Cullen's sign B. Rebound tenderness C. Murphy's sign D. Turner's sign When caring for a postoperative cholecystectomy client, the nurse assesses patency and documents drainage of the T-tube. The nurse recognizes that the expected amount of drainage during the first 24 hours postoperatively is: A. 50100 mL B. mL C. mL D. mL The nurse recognizes that a client with the diagnosis of cholecystitis and cholelithiasis would expect to have stools that are: A. Clay or gray colored B. Watery and loose C. Bright-red streaked D. Black CHRISJAY FILES 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: A. It is determined that he has no signs of wound infection B. He is able to eat a full meal without evidence of nausea or vomiting C. The nurse can detect bowel sounds in all four quadrants D. His blood pressure returns to its preoperative baseline level or greater 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 decompression. When preparing to insert a NG tube, the nurse measures from the: A. Lower lip to the shoulder to the upper sternum B. Tip of the nose to the lower lip to the umbilicus C. End of the tube to the first measurement line on the tube D. Tip of the nose to the ear lobe to the xiphoid process or midepigastric area A 65-year-old client who has a new colostomy is preparing for discharge from the hospital. As part of the instructions on colostomy care, the nurse explains to the client that to regulate the bowel, colostomy irrigation should be performed at the same time each day. The best time is: A. After meals B. Before meals C. Every 2 hours D. At bedtime A 72-year-old client with a new colostomy is being evaluated at the clinic today for constipation. When discussing diet with the client, the nurse recognizes that which one of the following foods most likely caused this problem? A. Fried chicken B. Eggs C. Tapioca D. Cabbage When giving discharge instructions to a 24-year-old client who had a short-arm cast applied for a fractured right ulna, the nurse recognizes the importance of telling him that the drying time for a plaster of Paris cast is approximately: A. 30 minutes B. 14 hours C. 1224 hours CHRISJAY FILES D. 2472 hours CHRISJAY FILES A 58-year-old client on a general surgery unit is scheduled for transurethral resection of the prostate (TURP) in 2 hours. The nurse explains to the client that this procedure means: A. Removal of the prostate tissue by way of a lower abdominal midline incision through the bladder and into the prostate gland B. Removal of prostate tissue by a resectoscope that is inserted through the penile urethra C. Removal of the prostate tissue by an open surgical approach through an incision between the ischial tuberosities, the scrotum, and the rectum D. Removal of prostate tissue by an open surgical approach through a low horizontal incision, bypassing the bladder, to the prostate gland A postoperative TURP client returns from the recovery room to the general surgery unit and is in stable condition. One hour later the nurse assesses him and finds him to be confused and disoriented. She recognizes that this is most likely caused by: A. Hypovolemic shock B. Hypokalemia C. Hypernatremia D. Hyponatremia A postoperative TURP client is ordered continuous bladder irrigations. Later in the evening on the first postoperative day, he complains of increasing suprapubic pain. When assessing the client, the nurse notes diminished flow of bloody urine and several large blood clots in the drainage tubing. Which one of the following should be the initial nursing intervention? A. Call the physician about the problem. B. Irrigate the Foley catheter. C. Change the Foley catheter. D. Administer a prescribed narcotic analgesic. A postoperative prostatectomy client is preparing for discharge from the hospital the next morning. The nurse realizes that additional instructions are necessary when he states: A. "If I drink 10 to 12 glasses of fluids each day, that will help to prevent any clot formation in my urine." B. "The isometric exercises will help to strengthen my perineal muscles and help me control my urine." C. "If I feel as though I have developed a fever, I will take a rectal temperature, which is the most accurate." D. "I do not plan to do any heavy lifting until I visit my doctor again." A 67-year-old postoperative TURP client has hematuria. The nurse caring for him reviews his postoperative orders and recognizes that which one of the following prescribed medications would best relieve this problem? A. Acetaminophen suppository 650 mg B. Meperidine 50 mg IM C. Promethazine 25 mg IM D. Aminocaproic acid (Amicar) 6 g/24 hr CHRISJAY FILES A 52-year-old client is scheduled for a small-bowel resection in the morning. In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises. She will teach the client to: A. Inhale slowly and deeply through the nose until the lungs are fully expanded, hold the breath a couple of seconds, and then exhale slowly through the mouth. Repeat 23 more times to complete the series every 12 hours while awake B. Purse the lips and take quick, short breaths approximately 1820 times/min C. Take a large gulp of air into the mouth, hold it for 1015 seconds, and then expel it through the nose. Repeat 45 times to complete the series D. Inhale as deeply as possible and then immediately exhale as deeply as possible at a rate of approximately 2024 times/min A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband at 32 weeks' gestation. She experienced a sudden onset of painless vaginal bleeding. Following an ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made. Expected assessment findings concerning the abdomen would include: A. A rigid, boardlike abdomen B. Uterine atony C. A soft relaxed abdomen D. Hypertonicity of the uterus A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood was running 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 wore was 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: A. Decreased cardiac output related to excessive bleeding B. Potential for fluid volume excess related to fluid resuscitation C. Anxiety related to threat to self D. Alteration in parenting related to potential fetal injury A 27-year-old primigravida at 32 weeks' gestation has been diagnosed with complete placenta previa. Conservative management including bed rest is the proper medical management. The goal for fetal survival is based on fetal lung maturity. The test used to determine fetal lung maturity is: A. Dinitrophenylhydrazine B. Metachromatic stain C. Blood serum phenylalanine test D. Lecithin-sphingomyelin ratio The physician of a client diagnosed with alcoholism orders neomycin 0.5 g q6h to prevent hepatic coma. Neomycin decreases serum ammonia levels by: CHRISJAY FILES A. Decreasing nitrogen-forming bacteria in the intestines B. Acidifying colon contents by causing ammonia retention in the colon C. Decreasing the uptake of vitamin D, thereby drawing more water into the colon D. Irritating the bowel and promoting evacuation of stool A 26-year-old male client is brought by his wife to the emergency department (ED) unconscious. Blood is drawn for a stat blood count (CBC), fasting blood sugar level, and electrolytes. An indwelling urinary catheter is inserted. He has a history of type 1 diabetes (insulindependent diabetes mellitus [IDDM]). A diagnosis of ketoacidosis is made. Stat lab values reveal a blood sugar level of 520 mg/dL. Which of the following should the nurse expect to administer in the ER? A. D50W by IV push B. NPH insulin SC C. Regular insulin by IV infusion D. Sweetened grape juice by mouth A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse will monitor him closely for serum: A. Chloride level of 99 mEq/L B. Sodium level of 136 mEq/L C. Potassium level of 3.1 mEq/L D. Potassium level of 6.3 mEq/L 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: A. 8:30 AM10:30 AM B. 2:30 PM4:30 PM C. 7:30 PM9:30 PM D. 10:30 PM11:30 PM After several days, an IDDM client's serum glucose stabilizes, and the registered nurse continues client teaching 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: A. One frankfurter B. One ounce of ham C. Two slices of bacon D. One-fourth cup dry cottage cheese CHRISJAY FILES When discussing the relationship between exercise and insulin requirements, a 26-year-old client with IDDM should be instructed that: A. When exercise is increased, insulin needs are increased B. When exercise is increased, insulin needs are decreased C. When exercise is increased, there is no change in insulin needs D. When exercise is decreased, insulin needs are decreased A 64-year-old client is admitted to the hospital with benign prostatic hypertrophy (BPH). He has a history of adult-onset diabetes and hypertension and is scheduled to undergo a resection of the prostate. When recording his health history, the nurse asks about his chief complaint. The most serious symptom that may accompany BPH is: A. Acute urinary retention B. Hesitancy in starting urination C. Increased frequency of urination D. Decreased force of the urinary stream A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent: A. Bladder spasms B. Clot formation C. Scrotal edema D. Prostatic infection Following TURP, which of the following instructions would be appropriate to prevent or alleviate anxiety concerning the client's sexual functioning? A. "You may resume sexual intercourse in 2 weeks." B. "Many men experience impotence following TURP." CHRISJAY FILES D. "Check with your doctor about resuming sexual activity." Correct Answer: C A client is having an amniocentesis. Prior to the procedure, an ultrasound is performed. In preparing the client, the nurse explains the reason for a sonogram in this situation to be: A. Determination of multiple gestations B. Determination of gross anomalies C. Determination of placental location D. Determination of fetal age A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would recognize the following finding to be typical: A. Thready pulse B. Irregular pulse C. Tachycardia D. Bradycardia A nurse has delegated a venipuncture to an unlicensed assistant (UA) who has been off orientation for five days. The UA reports to the nurse, “This client has a large, raised red area where the needle was inserted.” The nurse assesses the area and finds the client has a hematoma. What elements of delegation have been breached? Select all that apply. 1.‐ Task 2.‐ Circumstance 3.‐ Communication 4.‐ Supervision 5.‐ Skill A client is being admitted to the labor and delivery unit. She has had previous admissions for "false labor." Which clinical manifestation would be most indicative of true labor? A. Increased bloody show B. Progressive dilatation and effacement of the cervix C. Uterine contractions D. Decreased discomfort with ambulation In evaluating the effectiveness of magnesium sulfate (MgSO4), which of the following might indicate that the client was developing MgSO4 toxicity? CHRISJAY FILES A. A 31 patellar tendon reflex B. Respirations of 12 breaths/min C. Urine output of 40 mL/hr D. A 21 proteinuria value A client has had amniocentesis. One of the tests performed on the amniotic fluid is a lecithin/sphingomyelin (L/S) ratio. The results show a ratio of 1:1. This is indicative of: A. Lung immaturity B. Intrauterine growth retardation (IUGR) C. Intrauterine infection D. Neural tube defect On admission to the postpartal unit, the nurse's assessment identifies the client's fundus to be soft, 2 fingerbreadths above the umbilicus, and deviated to the right. This is most likely an indication of: A. Normal involution B. A full bladder C. An infection pain D. A hemorrhage A client's membranes have just ruptured spontaneously. Which of the following nursing actions should take priority? A. Assess quantity of fluid. B. Assess color and odor of fluid. C. Document on fetal monitor strip and chart. D. Assess fetal heart rate (FHR). The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have: A. A low birth weight B. A birth defect C. Anemia D. Nicotine withdrawal Which of the following blood values would require further nursing action in a newborn who is 4 hours old? A. Hemoglobin 17.2 g/dL CHRISJAY FILES B. Platelets 250,000/mm3 C. Serum glucose 30 mg/dL D. White blood cells 18,000/mm3 A client is admitted to the psychiatric unit after lavage and stabilization in the emergency room for an overdose of antidepressants. This is her third attempt in 2 years. The highest priority intervention at this time is to: A. Assess level of consciousness B. Assess suicide potential C. Observe for sedation and hypotension D. Orient to her room and unit rules A client's record from the ED indicates that she overdosed on phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor. Which diet would be the most appropriate at this time? A. High carbohydrate, low cholesterol B. High protein, high carbohydrate C. 1 g sodium D. Tyramine-free Two weeks after a client's admission for depression, the physician orders a consult for electroconvulsive therapy (ECT). Which of the following conditions, if present, would be a contraindication for ECT? A. Brain tumor or other space-occupying lesion B. History of mitral valve prolapse C. Surgically repaired herniated lumbar disk D. History of frequent urinary tract infections A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2- week period. Her husband asks, "Isn't that a lot?" The nurse's best response is: A. "Yes, that does seem like a lot." B. "You'll have to talk to the doctor about that. The physician knows what's best for the client." C. "Six to 10 treatments are common. Are you concerned about permanent effects?" D. "Don't worry. Some clients have lots more than that." 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: A. "You'll have to get permission from the physician to visit. Clients are pretty sick after the first treatment." CHRISJAY FILES B. "Visitors are not allowed. We will telephone you to inform you of her progress." C. "There's really no need to stay with her. She's going to sleep for several hours after the treatment." D. "Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after each treatment." A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, "The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart." The nurse's best response is: A. "I know you're feeling frightened right now, but I want you to know that I don't see anyone in the corner." B. "You'll probably see strange things for a while until the PCP wears off." C. "Try to sleep. When you wake up, the devil will be gone." D. "You're probably feeling guilty because you used illegal drugs tonight." A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints? A. Give fluids if the client requests them. B. Assess skin integrity and circulation of extremities before applying restraints and as they are removed. C. Measure vital signs at least every 4 hours. D. Release restraints every 2 hours for client to exercise. 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: A. Lorazepam (Ativan) B. Benztropine (Cogentin) C. Thiothixene (Navane) D. Flurazepan (Dalmane) CHRISJAY FILES 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. The physician orders it B. A therapeutic alliance has been established, and violent behavior subsides C. The violent behavior subsides, and the client agrees to behave D. The nurse deems that removal of restraints is necessary (I don’t know answer) QUESTION 73 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: A. Obtain an accurate weight B. Search the client's purse for pills C. Assess vital signs D. Assign her to a room with someone her own age Correct Answer: C 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: A. Pregnancy B. Bulimia C. Gastritis D. Anorexia nervosa 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: A. Hypoglycemia from low-carbohydrate intake B. Possible cardiac dysrhythmias secondary to hypokalemia CHRISJAY FILES D. Anoxia secondary to anemia 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: A. Her lack of internal awareness about the outcome of the behavior B. Increased knowledge about personal exercise plans C. A manipulative technique to trick the nurse into allowing her to miss a meal D. A true desire to stay fit while in the hospital A client who has been diagnosed with anorexia nervosa refuses to eat lunch. The most therapeutic response by the nurse to her refusal is: A. "Okay, missing one meal won't hurt." B. "You'll have to eat lunch, or we'll force-feed you." C. "It's not appropriate for you to try to manipulate the staff into granting your wishes." D. "We will not allow you to starve yourself. You may choose to eat voluntarily or be fed." 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: A. Allow her privacy at mealtimes B. Praise her for eating everything C. Observe behavior for 12 hours after meals to prevent vomiting D. Encourage her to eat in moderation, choose foods that she likes, and avoid foods that she dislikes 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: CHRISJAY FILES A. Be comforted when he is held B. Cry C. Not notice that his mother has left D. Withdraw and become listless The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is: A. 900 mL/24 hr B. 1300 mL/24 hr C. 1600 mL/24 hr D. 2000 mL/24 hr A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from: A. Crying B. Falling asleep C. Rolling from his back to his tummy D. Sucking his thumb A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to: A. Encourage him to drink plenty of fluids B. Expect him to have nausea with vomiting C. Keep him awake for the next 12 hours D. Wake him up every 12 hours during the night 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 the first 24 hours of his hospitalization, the nurse would: A. Ask the physician to order a sedative B. Have the client describe his headache every 15 minutes CHRISJAY FILES C. Increase his fluid intake to 3000 mL/24 hr D. Offer diversionary activities An 18-year-old girl is admitted to the hospital with a depressed skull fracture as a result of a car accident. If the nurse were to observe a rising pulse rate and lowering blood pressure, the nurse would suspect that the client: A. Has a sudden and severe increase in intracranial pressure B. Has sustained an internal injury in addition to the head injury C. Is beginning to experience a dangerously high level of anxiety D. Is having intracranial bleeding A. Call the doctor immediately B. Help her to blow her nose carefully C. Test the discharge for sugar D. Turn her to her side Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, "Begin oxytocin induction at 1 mU/min." The nurse should: A. Begin the oxytocin induction as ordered B. Increase the dosage by 2 mU/min increments at15-minute intervals C. Maintain the dosage when duration of contractions is 4060 seconds and frequency is at 21/2 4 minute intervals D. Question the order A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse? A. "Keep breathing with your abdominal muscles as long as you can." B. "Make sure you take a deep cleansing breath as the contractions start, focus on an object, and breathe about 1620 times a minute with shallow chest breaths." C. "Find a comfortable position before you start a contraction. Once the contraction has started, take slow breaths using your abdominal muscles." D. "If a woman in labor listens to her body and takes rapid, deep breaths, she will be able to deal with her contractions quite well." A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching? A. "If he develops diarrhea lasting for more than 23 days, I will contact the doctor or nurse." B. "I should anticipate that he will gain about 1 lb/day now that he is on continuous feedings." CHRISJAY FILES C. "It is important to keep the head of his bed elevated or sit him in the chair during feedings." D. "I should use prepared or open formula within 24 hours and store unused portions in the refrigerator." A 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as "a cramp in my leg." An appropriate nursing action is to: A. Assess for pain with plantiflexion B. Assess for edema and heat of the right leg C. Instruct him to rub the cramp out of his leg D. Elevate right lower extremity with pillows propped under the knee A male client is started on IV anticoagulant therapy with heparin. Which of the following laboratory studies will be ordered to monitor the therapeutic effects of heparin? A. Partial thromboplastin time B. Hemoglobin C. Red blood cell (RBC) count D. Prothrombin time A client is being discharged on warfarin (Coumadin), an oral anticoagulant. The nurse instructs him about using this drug. Which following response by the client indicates the need for further teaching? A. "I should shave with my electric razor while on Coumadin." B. "I will inform my dentist that I am on anticoagulant therapy before receiving dental work." C. "I will continue with my usual dosage of aspirin for my arthritis when I return home." D. "I will wear an ID bracelet stating that I am on anticoagulants." A 68-year-old woman is admitted to the hospital with chronic obstructive pulmonary disease (COPD). She is started on an aminophylline infusion. Three days later she is breathing easier. A serum theophylline level is drawn. Which of the following values represents a therapeutic level? A. 14 µ g/mL B. 25 µ g/mL C. 4 µ g/mL D. 30 µ g/mL A client is being discharged with albuterol (Proventil) and beclomethasone dipropionate (Vanceril) to be administered via inhalation three times a day and at bedtime. Client teaching regarding the sequential order in which the drugs should be administered includes: A. Glucocorticoid followed by the bronchodilator B. Bronchodilator followed by the glucocorticoid C. Alternate successive administrations CHRISJAY FILES D. According to the client's preference To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to: A. Rinse the plastic holder that aerosolizes the drug with hydrogen peroxide every other day B. Rinse the mouth and gargle with warm water after each use of the inhaler C. Take antacids immediately before inhalation to neutralize mucous membranes and prevent infection D. Rinse the mouth before each use to eliminate colonization of bacteria Which of the following would indicate the need for further teaching for the client with COPD? The client verbalizes the need to: A. Eat high-calorie, high-protein foods B. Take vitamin supplementation C. Eliminate intake of milk and milk products D. Eat small, frequent meals A dose of theophylline may need to be altered if a client with COPD: A. Is allergic to morphine B. Has a history of arthritis C. Operates machinery D. Is concurrently on cimetidine for ulcers The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because: A. Immediate treatment of mild PIH includes the administration of a variety of medications B. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation C. Self-discipline is required to control caloric intake throughout the pregnancy D. The client may not recognize the early symptoms of PIH Which of the following changes in blood pressure readings should be of greatest concern to the nurse when assessing a prenatal client? A. 130/88 to 144/92 B. 136/90 to 148/100 C. 150/96 to 160/104 D. 118/70 to 130/88 A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her 7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The client's weight increase is most likely due to: CHRISJAY FILES A. Overeating and subsequent obesity B. Obesity prior to conception C. Hypertension due to kidney lesions D. Fluid retention MgSO4 is ordered IV following the established protocol for a client with severe PIH. The anticipated effects of this therapy are anticonvulsant and: A. Vasoconstrictive B. Vasodilative C. Hypertensive D. Antiemetic A nurse should carefully monitor a client for the following side effect of MgSO4: A. Visual blurring B. Tachypnea C. Epigastric pain D. Respiratory depression MgSO4 blood levels are monitored and the nurse would be prepared to administer the following antidote for MgSO4 side effects or toxicity: A. Magnesium oxide B. Calcium hydroxide C. Calcium gluconate D. Naloxone (Narcan) A client with severe PIH receiving MgSO4 is placed in a quiet, darkened room. The nurse bases this action on the following understanding: A. The client is restless. B. The elevated blood pressure causes photophobia. C. Noise or bright lights may precipitate a convulsion. D. External stimuli are annoying to the client with PIH. A 26-year-old client is admitted to the labor, delivery, recovery, postpartum unit. The nurse completes her assessment and determines the client is in the first stage of labor. The nurse should instruct her: A. To hold her breath during contractions B. To be flat on her back CHRISJAY FILES C. Not to push with her contractions D. To push before becoming fully dilated In addition to changing the mother's position to relieve cord pressure, the nurse may employ the following measure (s) in the event that she observes the cord out of the vagina: A. Immediately pour sterile saline on the cord, and repeat this every 15 minutes to prevent drying. B. Cover the cord with a wet sponge. C. Apply a cord clamp to the exposed cord, and cover with a sterile towel. D. Keep the cord warm and moist by continuous applications of warm, sterile saline compresses. Which of the following signs might indicate a complication during the labor process with vertex presentation? A. Fetal tachycardia to 170 bpm during a contraction B. Nausea and vomiting at 810 cm dilation C. Contraction lasting 60 seconds D. Appearance of dark-colored amniotic fluid A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin. The nurse's first intervention should be to: A. Check FHT B. Notify the attending physician C. Turn off the IV oxytocin D. Prepare for the delivery because the client is probably in transition During a client's first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus. This may be due to: A. Endometritis B. Fibroid tumor on the uterus C. Displacement due to bowel distention D. Urine retention or a distended bladder The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay? A. Pulse rate of 5070 bpm by her third postpartum day B. Diuresis by her second or third postpartum day C. Vaginal discharge or rubra, serosa, then rubra D. Diaphoresis by her third postpartum day CHRISJAY FILES A postpartum client complains of rectal pressure and severe pain in her perineum; this may be indicative of: A. Afterbirth pains B. Constipation C. Cystitis D. A hematoma of the vagina or vulva 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: A. "No vegetable exchanges are allowed." B. "Corn and other starchy vegetables are considered to be bread exchanges." C. "Yes, you may exchange any vegetable for any other vegetable." D. "Yes, but only one-half ear is allowed." The nurse is teaching a 10-year-old insulin-dependent diabetic how to administer insulin. Which one of the following steps must be taught for insulin administration? A. Never use abdominal site for a rotation site. B. Pinch the skin up to form a subcutaneous pocket. C. Avoid applying pressure after injection. D. Change needles after injection. In assessing the nature of the stool of a client who has cystic fibrosis, what would the nurse expect to see? A. Clay-colored stools B. Steatorrhea stools C. Dark brown stools D. Blood-tinged stools A group of nursing students at a local preschool day care center are going to screen each child's fine and gross motor, language, and social skills. The students will use which one of the most widely used screening tests? CHRISJAY FILES A. Revised Prescreening Developmental Questionnaire B. Goodenough Draw-a-Person Screening Test C. Denver Development Screening Test D. Caldwell Home Inventory A mother came to the pediatric clinic with her 17- month-old child. The mother would like to begin toilet training. What should the nurse teach her about implementing toilet training? A. Take two or three favorite toys with the child. B. Have a child-sized toilet seat or training potty on hand. C. Explain to the child she is going to "void" and "defecate." D. Show disapproval if she does not void or defecate. A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of growth and development, what toy would the nurse suggest? B. A mobile to improve hand-eye coordination C. A large toy with movable parts to improve pincer grasp D. Various large colored blocks to teach visual discrimination Correct Answer: A A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention? A. Increased pulse rate B. Increased expectorate of secretions C. Decreased inspiratory difficulty D. Increased respiratory rate Respiratory function is altered in a 16-year-old asthmatic. Which of the following is the cause of this alteration? A. Altered surfactant production B. Paradoxical movements of the chest wall C. Increased airway resistance D. Continuous changes in respiratory rate and depth A mother frantically calls the emergency room (ER) asking what to do about her 3-year-old girl who was found eating pills out of a bottle in the medicine cabinet. The ER nurse tells the mother to: CHRISJAY FILES A. Give the child 15 mL of syrup of ipecac. B. Give the child 10 mL of syrup of ipecac with a sip of water. C. Give the child 1 cup of water to induce vomiting. D. Bring the child to the ER immediately. 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 nursing action is the most appropriate? A. Put in a nasogastric tube and lavage the child's stomach. B. Monitor muscular status. C. Teach mother poison prevention techniques. D. Place child on respiratory assistance. A parent told the public health nurse that her 6-year-old son has been taking tetracycline for a chronic skin condition. The parent asked if this could cause any problems for the child. What should the nurse explain to the parent? A. Giving tetracycline to a child younger than 8 years may cause permanent staining of his teeth. B. If you give tetracycline with milk, it may be absorbed readily. C. The medication should be given to adults, not children. D. Secondary infections of chronic skin disorders do not respond to antibiotics. A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation? A. Responsive to touch, wants to be held B. Uncomforted by touch, refuses bottle C. Maintains eye-to-eye contact D. Finicky eater, easily pacified, cuddly A mother continues to breast-feed her 3-month-old infant. She tells the nurse that over the past 3 days she has not been producing enough milk to satisfy the infant. The nurse advises the mother to do which of the following? A. "Start the child on solid food." B. "Nurse the child more frequently during this growth spurt." C. "Provide supplements for the child between breastfeeding so you will have enough milk." D. "Wait 4 hours between feedings so that your breasts will fill up." CHRIS JAY CHRISJAY FILES