#1 sample

Question 1

The nurse in the psychiatric emergency room assesses 4 clients. Which of the following clients should the nurse see FIRST?

1. A patient was raped 30 minutes ago and expresses feelings of self-blame, anxiety, and worthlessness.
2. A patient indicates an intent to kill himself and says he has access to a gun.
3. A patient had a miscarriage last evening and is experiencing anger and resentment.
4. A patient witnessed a child stabbed to death 2 weeks ago and is experiencing anxiety.

Answer 1

Strategy: “FIRST” indicates priority.

1) need to assess physical needs and examine patient; second patient to see
2) CORRECT— patient is at risk for self-harm; client has intent and a way to carry out threat
3) allow client to verbalize feelings
4) allow client to verbalize feelings

Question 2

The nurse in a small town is called to a neighbor’s house in the middle of a blizzard. The neighbor woman states she is in the 39th week of gestation with her second baby and has been having contractions for several hours. The woman has been unable to obtain assistance because the roads are impassable. The nurse determines that the woman is in the second stage of labor. It is MOST important for the nurse to take which of the following actions?

1. Time the frequency of the contractions.
2. Assess the type of vaginal discharge.
3. Monitor the strength of the contractions.
4. Observe the perineum.

Answer 2

Strategy: Assess before implementing.

1) priority is assessing if baby is crowning
2) priority is assessing if baby is crowning
3) labor is not the priority; nurse should determine if the birth is imminent
4) CORRECT— baby will descend into birth canal and may crown, major responsibility in second state of labor; support infant’s head; apply slight pressure to control delivery

Question 3

The nurse receives a call from the emergency management team that 50 victims will be transported to the hospital in 15 minutes by ambulance. Which of the following actions should the nurse take FIRST?

1. Contact the nursing supervisor.
2. Tell the emergency management team they will have to re-route 25 victims.
3. Activate the hospital’s disaster plan.
4. Inform the emergency department nurses they must work overtime.

Answer 3

Strategy: “FIRST” indicates priority.

1) CORRECT— nurse must follow chain of command
2) not the nurse’s responsibility
3) must notify immediate supervisor about the call; disaster plans are hospital policies that detail how nurses are to perform duties
4) not the responsibility or role of the nurse

Question 4

As a part of discharge teaching, the nurse instructs a client receiving citalopram (Celexa) 20 mg OD. The nurse determines that further teaching is necessary if the client states which of the following?”

1. “This medication helps me with my depression.”
2. “I will notify my physician if I show signs of hyperactivity and mania.”
3. “I will see improvement in my symptoms in 1 to 4 weeks.”
4. “If I experience a fever I will take Tylenol.”

Answer 4

Strategy: “Further teaching is necessary” indicates incorrect information.

1) Celexa is a selective serotonin reuptake inhibitor (SSRI) used to treat depression
2) side effects: mania, hypomania, insomnia, impotence, headache, and dry mouth
3) true statement
4) correct— should notify physician immediately to assess for serotonin syndrome, which is a rare, life threatening event caused by SSRIs; symptoms include abdominal pain, fever, sweating, tachycardia, hypertension, delirium, myoclonus, irritability, and mood changes; may result in death

Question 5

The nurse has just received change-of-shift report. Which of the following clients should the nurse see FIRST?

1. A client diagnosed with COPD with an PaO 2 of 70%.
2. A client diagnosed with type 1 diabetes who was just informed her husband is seriously injured.
3. A client scheduled to leave for the operating room in 30 minutes for a heart valve replacement.
4. A client 10 hours postop after a right mastectomy complaining of wet sheets under her back.

Answer 5

Strategy: “FIRST” indicates priority.

1) oxygenation considered “normal to good” for client with COPD; stable client
2) physical needs take priority
3) requires preop injection; all other preparation should be completed; stable client
4) CORRECT— may indicate hemorrhage from operative site; unstable client

Question 6

The nurse instructs a mother of a child diagnosed with a myelomeningocele who developed an allergy to latex. The nurse determines that teaching is effective if the mother selects which of the following menus for her child?

1. Guacamole with pita bread, lettuce, tomato juice.
2. Poached halibut, brown rice, carrots, peach cobbler.
3. Scrambled eggs, whole wheat toast, grapes, skim milk.
4. Baked chicken leg, mashed potatoes, spinach, milkshake.

Answer 6

Strategy: “Teaching is effective” indicates correct information.

1) if a person has a latex allergy, there is cross-reaction to tomatoes and avocados
2) peach is a cross-reactive food with latex
3) grapes are cross-reactive with latex
4) CORRECT— this meal does not have any cross-reactive foods with latex; foods to avoid include apricots, cherries, grapes, kiwis, passion fruit, bananas, avocados, chestnuts, tomatoes, and peaches

Question 7

The nurse plans care for a patient in hemorrhagic shock from injuries sustained in a fall. It is MOST important for the nurse to take which of the following actions?

1. Obtain vital signs.
2. Identify the source of the bleeding.
3. Elevate the head of the bed 30°.
4. Administer 0.9% NaCl IV.

Answer 7

Strategy: Assess before implementing.

1) assessment; more important to determine the source of bleeding
2) CORRECT— assessment first step; initial priority to identify and then apply direct pressure and elevate affected area if possible
3) intervention; elevate the extremities
4) intervention; 1–2 liter bolus of isotonic fluids (lactated Ringer or 0.9% NaCl) will be given

Question 8

The nurse cares for children in the outpatient pediatric clinic. It is MOST important for the nurse to perform tuberculosis screening on which of the following children?

1. A child just returned from a 2-week trip to Europe.
2. A child recently moved to an apartment because the family lost their home.
3. A child with a new nanny who just emigrated from Latin America.
4. A child who weighed 4 lb, 10 oz at birth.

Answer 8

Strategy: All answers are assessments. Determine how they relate to risk factors for tuberculosis.

1) tuberculosis is endemic to Asia, Middle East, Africa, Latin America, and Caribbean; consider screening if child has traveled to an endemic region
2) the homeless and impoverished are at risk for developing tuberculosis
3) CORRECT— children traveling to endemic areas or who have prolonged, close contact with indigenous persons should undergo immediate skin testing
4) no reasons to undergo immediate screening

Question 9

The nurse cares for children in the outpatient pediatric clinic. It is MOST important for the nurse to perform tuberculosis screening on which of the following children?

1. A child just returned from a 2-week trip to Europe.
2. A child recently moved to an apartment because the family lost their home.
3. A child with a new nanny who just emigrated from Latin America.
4. A child who weighed 4 lb, 10 oz at birth.

Answer 9

Strategy: All answers are assessments. Determine how they relate to risk factors for tuberculosis.

1) tuberculosis is endemic to Asia, Middle East, Africa, Latin America, and Caribbean; consider screening if child has traveled to an endemic region
2) the homeless and impoverished are at risk for developing tuberculosis
3) CORRECT— children traveling to endemic areas or who have prolonged, close contact with indigenous persons should undergo immediate skin testing
4) no reasons to undergo immediate screening

Question 10

During the change-of-shift report, the charge nurse overhears two nurses exchanging loud, rude remarks about one nurse’s excessive use of overtime. Which of the following statements by the charge nurse is MOST appropriate?

1. “I want to see both of you in my office right away.”
2. “Would you please lower your voices and finish the report.”
3. “I want the two of you to stop yelling and work this problem out.”
4. “Both of you are good nurses and are under a lot of stress right now.”

Answer 10

Strategy: Determine the outcome of each response. Is it appropriate?

1) confrontation is not the appropriate conflict management approach when emotions are high
2) CORRECT— forcing is the most appropriate conflict management technique; enables nurses to exchange information; client care takes priority over interpersonal conflict
3) . need cooling-off period before issues can be discussed; communicating about patient care takes priority
4) “don’t worry” response; may make the nurses feel better but does not address the immediate task of completing the reportA 25-year-old woman is receiving aminophylline 0.7 mg/kg/h by continuous IV infusion into her left arm. It is MOST important for the nurse to observe her for which of the following?

1. Slowed pulse and reduced blood pressure.
2. Constipation and decreased bowel sounds.
3. Palpitations and nervousness.
4. Difficulty voiding and oliguria.

Strategy: “MOST important” indicates discrimination is required to answer the question.

1) causes rapid pulse and dysrhythmias; decrease intake of colas, coffee, and chocolate because they contain xanthine
2) causes diarrhea, nausea, and vomiting; administer with food or full glass of water
3) CORRECT— effects of aminophylline include nervousness, nausea, dizziness, tachycardia, seizures
4) medication has no effect on the kidneys; encourage intake of 2,000 cc per day to decrease viscosity of airway secretions

Question 11

A 25-year-old woman is receiving aminophylline 0.7 mg/kg/h by continuous IV infusion into her left arm. It is MOST important for the nurse to observe her for which of the following?

1. Slowed pulse and reduced blood pressure.
2. Constipation and decreased bowel sounds.
3. Palpitations and nervousness.
4. Difficulty voiding and oliguria.

Answer 11

Strategy: “MOST important” indicates discrimination is required to answer the question.

1) causes rapid pulse and dysrhythmias; decrease intake of colas, coffee, and chocolate because they contain xanthine
2) causes diarrhea, nausea, and vomiting; administer with food or full glass of water
3) CORRECT— effects of aminophylline include nervousness, nausea, dizziness, tachycardia, seizures
4) medication has no effect on the kidneys; encourage intake of 2,000 cc per day to decrease viscosity of airway secretions

Question 12

The home care nurse visits a client diagnosed with type 1 diabetes being managed with insulin in the am and pm. The nurse identifies that which of the following BEST measures the overall therapeutic response to management of the diabetes?

1. Glycosylated hemoglobin (HbA 1 c) 5% of total Hb.
2. Fasting blood sugar 128 mg/dL.
3. Blood pressure 130/82.
4. Serum amylase 100 Somogyi U/dL.

Answer 12

Strategy: Think about each answer.

1) CORRECT— indicates overall glucose control for the previous 120 days; normal is 4.5–7.6% of total hemoglobin
2) normal fasting is 60–110 mg/dL; HbA 1 c more accurate indicator of glucose control
3) evaluates response to antihypertensive medication
4) elevated in acute pancreatitis; normal is 60–160 Somogyi U/dL

Question 13

The nurse cares for a client in labor. The client’s examination reveals that the cervix is 5 cm dilated and 100% effaced and the fetal head is at –1. The membranes rupture and the nurse notes clear fluid. Which of the following actions should the nurse take FIRST?

1. Ambulate the client for 15 minutes and evaluate the fetal heart rate every 30 minutes.
2. Prepare for delivery and notify the care provider.
3. Apply an electronic fetal monitor and start an IV.
4. Encourage the client to void every 1–2 hours and take her temperature every hour.

Answer 13

Strategy: “FIRST” indicates priority.

1) do not ambulate the client; head is too high, may cause cord to prolapse
2) too early to set up for delivery, has approximately 2–3 remaining hours of labor; sterile equipment should be opened for no more than 1 hour
3) no indication that the client is in trouble
4) CORRECT— facilitates descent of the fetal head; temperature evaluation is necessary because of ruptured membranes

Question 14

The nurse cares for a client receiving a heparin drip via an infusion pump. The physician orders warfarin (Coumadin) 5 mg PO. Which of the following actions should the nurse take NEXT?

1. Administer medication as ordered.
2. Notify the physician.
3. Check the most recent serum partial prothrombin levels.
4. Assess client for signs/symptoms of bleeding.

Answer 14

Strategy: “NEXT” indicates priority

1) CORRECT— warfarin interferes with the hepatic synthesis of vitamin K–dependent clotting factors; oral anticoagulant therapy should be instituted 4 to 5 days before discontinuing the heparin therapy
2) no reason to notify the physician
3) partial thromboplastin time used to monitor effectiveness of heparin; therapeutic level is 1.5 to 2.5 times the control
4) warfarin takes 3 to 5 days to reach peak levels

Question 15

The nurse plans care for a 14-year-old hospitalized with a diagnosis of anorexia nervosa. The nurse identifies that which of the following activities is MOST appropriate for this client?

1. Making jewelry with the occupational therapist.
2. Exercising in the physical therapy department.
3. Assisting the dietician to plan the week’s menus.
4. Reading teen magazines with other patients her age.

Answer 15

Strategy: Determine the outcome of each answer.

1) CORRECT— one of the goals for a client with anorexia is to achieve a sense of self-worth and self-acceptance that is not based on appearance; this activity will promote socialization and increase self-esteem
2) goal is for client to achieve 85–95% of ideal body weight; may be able to exercise after short term goals are met
3) meal planning is a part of self-care activities, but more important for client to achieve a sense of self-worth
4) can read magazines in the presence of others without interacting

Question 16

A mother reports to the clinic nurse that her daughter developed a large welt, red rash, and shortness of breath after being stung by a bee. The mother asks the nurse, “What should I do if she gets stung again?” Which of the following responses by the nurse is BEST?

1. “Make a paste of baking soda and water and apply it to the sting.”
2. “Remove the stinger and immediately apply ice to the site.”
3. “Give 12.5 mg of Benadryl by mouth.”
4. “Administer 0.3 mg of epinephrine subcutaneously.”

Answer 16

Strategy: Determine the outcome of each answer. Is it desired?

1) treatment for sting in persons not allergic to bee stings; treats local reaction
2) not appropriate for this child because she has demonstrated hypersensitivity to bee sting; if no previous hypersensitivity; initial action is to remove stinger as quickly as possible to decrease the amount of venom injected into wound, wash with soap and water, apply cool compress
3) will not work fast enough to prevent anaphylactic reaction
4) CORRECT— child who has demonstrated previous hypersensitivity should have an EpiPen available; instruct child to wear medical identification bracelet

Question 17

The nurse counsels the mother of a child diagnosed with impetigo. The nurse notes that the infection has not improved and learns the mother has not been caring for the child’s skin because it “takes too much time.” It is MOST important for the nurse to assess for which of the following?

1. White patches on buccal mucosa.
2. Hearing loss.
3. Respiratory wheezing.
4. Periorbital edema.

Answer 17

Strategy: What indicates a complication?

1) describes Candida , a fungal infection
2) not caused by impetigo
3) not caused by impetigo
4) CORRECT— impetigo is caused by Staphylococcus and Streptococcus ; untreated, can cause acute glomerulonephritis; periorbital edema indicates poststreptococcal glomerulonephritis

Question 18

The nurse on a college campus is informed by the microbiology department that they accidentally received a shipment of highly toxic, contagious bacteria. Which of the following actions should the nurse take FIRST?

1. Determine if there are adequate supplies of antibiotics and antipyretics.
2. Order necessary equipment and supplies.
3. Contact the Red Cross.
4. Identify who was exposed to the shipment.

Answer 18

Strategy: “FIRST” indicates priority.

1) may be required, but not the first action; affected people will most likely be treated in a treatment facility
2) more important to determine who was exposed to the bacteria
3) if exposure is widespread, they may send health care providers; determine scope of problem first
4) CORRECT— assess before implementing; after determining who has been exposed, appropriate treatment can be instituted

Question 19

The nurse administers promethazine (Phenergan) 25 mg IM to a client complaining of nausea and vomiting. After receiving the medication, the client complains of dizziness when standing up. Which of the following actions should the nurse take FIRST?

1. Notify physician.
2. Monitor severity of symptoms.
3. Instruct client to ask for assistance before ambulating.
4. Assess client’s hydration status.

Answer 19

Strategy: Complete assessment before implementing

1) complete assessment before contacting physician
2) is complaining of orthostatic hypotension; determine if fluid volume deficit contributing to dizziness
3) appropriate action, but nurse should first complete assessment
4) CORRECT— side effects include anorexia, dry mouth and eyes, constipation, orthostatic hypotension; client is at risk for fluid volume deficit due to vomiting, which exacerbates the orthostatic hypotension

Question 20

The nurse in the outpatient clinic has four unscheduled clients waiting to see the physician. Which of the following clients should the nurse see FIRST?

1. A client complaining of a sore throat and nasal drainage.
2. A client with a history of kidney stones complaining of severe flank pain.
3. A client complaining of redness and pain in his left great toe.
4. A client receiving digoxin (Lanoxin) complaining of nausea and vomiting.

Answer 20

Strategy: “FIRST” indicates priority

1) symptoms consistent with viral rhinitis; encourage to gargle with salt water and increase fluid intake
2) second client that should be seen; administer opioid analgesics to prevent shock and syncope
3) indications of acute gout; attack subsides spontaneously in 3 to 4 days; administer colchicine (Colsalide) and NSAIDS
4) CORRECT— early effects of digitalis toxicity; hold medication and monitor client’s symptoms

Question 21

The nurse cares for a client diagnosed with a recurrence of colon cancer. The client tells the nurse that she is dreading taking chemotherapy again. Which of the following responses by the nurse is MOST appropriate?

1. “There are web sites that provide information about chemotherapy.”
2. “Have you discussed this with your physician?”
3. “I can give you a handout about how to treat the side effects of chemotherapy.”
4. “What are your concerns about taking chemotherapy?”

Answer 21

Strategy: Assessment before implementation

1) assumes that client needs more information about chemotherapy; nurse should respond to client’s concerns
2) don’t pass the buck; responding to client’s concerns is a nursing responsibility
3) assess before implementing
4) CORRECT— think about the nursing process when selecting answers; allows nurse to gather data about what is concerning the client

Question 22

The nurse in the outpatient clinic receives a call from a client who has been receiving continuous ambulatory peritoneal dialysis (CAPD) for 1 year. The client states that he infused 2 L of dialysate and 1200 cc returned. Which of the following statements by the nurse is BEST?

1. “Record the difference as intake.”
2. “When was your last bowel movement?”
3. “Are you having shoulder pain?”
4. “Increase your fluid intake.”

Answer 22

Strategy: Determine if it is appropriate to assess or implement.

1) the difference between inflow and outflow is counted as intake; ensure that all fluid has drained from the peritoneal cavity; change positions or ask client to walk around
2) CORRECT— full colon can create outflow problems; ensure that bowel evacuation has occurred
3) referred shoulder pain may be caused by rapid infusion of dialysate; instruct to decrease infusion rate; this client is having an outflow problem
4) will not affect outflow

Question 23

The nurse evaluates assignments on the unit. The nurse determines that assignments are appropriate if the LPN/LVN is assigned to which client?

1. A client with type 1 diabetes scheduled for discharge.
2. A client newly admitted to the unit with chest pain.
3. A client receiving chemotherapy.
4. A client diagnosed with myasthenia gravis.

Answer 23

Strategy: Assign stable clients with expected outcomes.

1) requires teaching; LPN/LVN can reinforce teaching but cannot perform initial teaching
2) is not a stable client with an expected outcome; requires assessment
3) is not a stable client with an expected outcome; requires assessment
4) CORRECT— no indication that client is not stable; myasthenia gravis is deficiency of acetylcholine at myoneural junction; symptoms include muscular weakness produced by repeated movements that soon disappear following rest

Question 24

An elderly client is brought to the emergency department complaining of acute back pain. The client denies any chronic illness, allergies, or previous hospitalizations. Which of the following is the BEST initial response for the nurse to make to this client?

1. “We’ll get this pain under control in no time.”
2. “Are you sure you’ve never been in the hospital?”
3. “Did you fall, lift something heavy, or turn the wrong way?”
4. “On a scale of 1 to 10, with 10 being the worst, rate the pain you are experiencing.”

Answer 24

Strategy: “BEST” indicates priority.

1) false reassurance; nurse should complete assessment
2) confrontational response; pain assessment is priority
3) should first assess intensity of pain as well as location
4) CORRECT— assessment, is objective and clear, and responds directly to client’s complaint; gives information for further intervention

Question 25

A nurse observes a student nurse administer carvedilol (Coreg) to an elderly patient. The patient refuses medication, saying, “Go away. It makes me dizzy.” The nurse should intervene if the student nurse states which of the following?

1. “If you don’t take this medication, you will be restrained.”
2. “This medication will help control your blood pressure.”
3. “Side effects of this medication make some patients feel uncomfortable.”
4. “When do you notice the dizziness?”

Answer 25

Strategy: “nurse should intervene” indicates something is wrong.

1) CORRECT— inappropriate action; client has the right to refuse medication; restraining client is an example of battery
2) Coreg is a nonselective beta-blocker used to treat hypertension and heart failure
3) side effects include dizziness, fatigue, weakness, orthostatic hypotension; instruct client to change positions slowly
4) allows nurse to teach about medication

Question 26

The nurse cares for clients in the emergency department (ED). An 82-year-old client comes to the ED complaining of muscle weakness and drowsiness. The nurse notes decreased deep tendon reflexes and hypotension. Which of the following actions should the nurse take FIRST?

1. Escort the client to an emergency room unit.
2. Ask the client if he has been taking antacids.
3. Assess for Chvostek’s sign.
4. Measure client’s intake and output

Answer 26

Strategy: “FIRST” indicates priority

1) delegate to other personnel
2) CORRECT— increased intake of magnesium-containing antacids and laxatives can cause hypermagnesemia (> 2.5 mEq/L); depresses CNS and cardiac impulse transmission; discontinue oral Mg, support ventilation, administer loop diuretics or IV calcium, teach about OTC drugs that contain Mg
3) seen with hypocalcemia; tap face just below and anterior to the ear to trigger facial twitching on that side of face
4) renal insufficiency can cause decreased excretion of magnesium; not appropriate for this setting

Question 27

A tornado has just leveled a large housing division near the hospital, and a disaster alarm has been declared at the hospital. The nurse caring for clients on the maternal-child unit considers which of the following clients appropriate for discharge within the next hour?

Select all that apply.

1. A multipara client who delivered over an intact perineum 12 hours ago.
2. A postpartum client with an infection who has been on antibiotics for the past 24 hours.
3. A 3-year-old with newly diagnosed type 1 diabetes, diarrhea, and vomiting.
4. A 3-day-old breast-feeding infant with a total serum bilirubin of 14 mg/dL.
5. A client at 34 weeks’ gestation diagnosed with generalized edema and complaints of epigastric pain.
6. A 2-day-old infant delivered of a mother receiving intrapartum antibiotic therapy for vaginal group B-streptococcus (GBS).

Answer 27

Strategy: Determine the most stable clients.

1) CORRECT— stable patient
2) do not know if antibiotics are effective or the current WBC count
3) requires frequent assessment of hydration status and blood glucose levels
4) CORRECT— phototherapy considered for the infant with total serum bilirubin of greater than 15 mg/dL at 72 hours of age
5) epigastric pain indicates pending eclampsia
6) CORRECT— group B streptococcal (GBS) disease causes sepsis; because mother received intrapartum prophylaxis, infant has 1-in-4,000 chance of developing sepsis due to GBS

Question 28

The nurse cares for a client following a scleral buckling. Which of the following nursing actions is MOST important?

1. Remove all reading material.
2. Assess for nausea.
3. Assess drainage from affected eye.
4. Irrigate affected eye every 3 hours.

Answer 28

Strategy: “MOST important” indicates priority.

1) scleral buckling compresses the sclera to repair a detached retina; should take precautions to prevent moving eyes rapidly
2) CORRECT— nausea and vomiting increase intraocular pressure and could cause damage to the area repaired
3) wear eye shield; avoid sneezing, coughing, straining at stool
4) do not irrigate

Question 29

The nurse supervises care for a patient admitted to the psychiatric unit with a diagnosis of bipolar disorder: manic phase. A student nurse plans activities for the patient. The nurse should intervene if the student nurse chooses which of the following activities?

1. Volleyball.
2. Painting.
3. Walking.
4. Dancing.

Answer 29

Strategy: “Nurse should intervene” indicates an incorrect action.

1) CORRECT— avoid competitive games because they increase agitation; assign to a single room away from activity; keep noise level low and lighting soft
2) appropriate activity; will not provoke or over-stimulate client
3) appropriate activity; activity that uses large movements until acute mania subsides
4) appropriate activity; provides structure and safety in the milieu

Question 30

The nurse on the medical/surgical unit is approached by an LPN/LVN from a different team. The LPN/LVN expresses concern because one of her patients is diagnosed with COPD and the RN (a new graduate) is giving the patient oxygen at 2 L/min. Which of the following statements by the nurse is MOST appropriate?

1. “I will assess the patient for oxygen toxicity.”
2. “Are you concerned about the oxygen or the new graduate’s competency?”
3. “Please tell me more about your concerns.”
4. “Leave the oxygen in place.”

Answer 30

Strategy: “MOST appropriate” indicates discrimination is required to answer the question.

1) client is assigned to another nurse; usurps assigned nurse’s authority
2) yes/no question; nontherapeutic; should allow LPN/LVN to express her concerns
3) CORRECT— open-ended statement; therapeutic; allows the LPN/LVN to express specific concerns and enables the nurse to further assess
4) not enough information to make a judgment; assess before implementing

Question 31

The nurse cares for an infant diagnosed with congenital heart disease. The nurse notes that the infant becomes easily fatigued during feedings and the infant’s pulse and respirations increase. The nurse should take which action?

1. Feed the infant soon after awakening.
2. Change the infant’s diaper before feeding.
3. Increase the caloric content of the feeding to 30 kcal/oz.
4. Mix rice cereal in the formula.

Answer 31

The nurse cares for an infant diagnosed with congenital heart disease. The nurse notes that the infant becomes easily fatigued during feedings and the infant’s pulse and respirations increase. The nurse should take which action?

1. Feed the infant soon after awakening.
2. Change the infant’s diaper before feeding.
3. Increase the caloric content of the feeding to 30 kcal/oz.
4. Mix rice cereal in the formula.

Question 32

The nurse instructs a client who is scheduled for a 24-hour creatinine clearance test. Which statement, if made by the client to the nurse, indicates further teaching is required?

1. “I will eat a high-protein meal before the test begins.”
2. “I will use the specimen collection time to catch up on my reading.”
3. “I will drink as much fluid as I want before and during the test.”
4. “I will save all of my urine during the 24 hours and keep it in the refrigerator.”

Answer 32

Strategy: “Further teaching is necessary” indicates incorrect information.

1) CORRECT— high-protein diet before the test may increase creatinine clearance and affect the accuracy of the test
2) appropriate action; avoid strenuous physical activity, will increase creatinine excretion and compromise the accuracy of the test
3) appropriate action
4) appropriate action; bottle should contain a preservative

Question 33

The nurse prepares to admit a 6-month-old diagnosed with rotavirus, severe diarrhea, and dehydration. The nurse should place the infant in which of the following rooms?

1. In a semiprivate room with a 2-year-old in traction due to a fracture.
2. In a semiprivate room with a 9-month-old admitted for a shunt revision.
3. In a private room that is close to the nurse’s station.
4. In any private room that is available.

Answer 33

Strategy: Think about the outcome of each answer.

1) a diapered or incontinent client diagnosed with rotavirus requires contact precautions for the duration of the illness; is a significant nosocomial pathogen
2) requires a private room; do not place a client with an infection in a room with a client who does not have an infection
3) CORRECT— rotavirus is spread by fecal-oral route and requires contact precautions if client is diapered or incontinent
4) due to severe nature of the symptoms requiring hospitalization, infant requires close observation for changes in condition

Question 34

A patient returns from surgery for a total replacement of the right hip with a large surgical dressing and a Jackson-Pratt drain. Which of the following, if observed by the nurse 2 hours after surgery, necessitates calling the physician?

1. There is a small amount of bloody drainage on the surgical dressing.
2. The patient complains of increased hip pain.
3. A harsh, hollow sound is auscultated over the trachea.
4. The patient’s blood pressure is 136/86.

Answer 34

Strategy: “necessitates calling the physician” indicates a complication.

1) expected outcome, complications of total hip replacement include dislocation of prosthesis, excessive wound drainage, thromboembolism, and infection
2) CORRECT— indicates dislocation of prosthesis; other indications include shortening of affected leg, leg rotation, soft popping sound heard when affected leg is moved; maintain abduction, use wedge pillow, avoid stopping, do not sleep on operated side until directed to do so, flex hip only 1/4 circle, never cross legs, avoid position of flexion during sexual activity, walking is excellent exercise, avoid overexertion; in 3 months will be able to resume ADLs, except strenuous sports
3) describes normal breathing sounds
4) within normal limits

Question 35

An older client is placed in balanced suspension traction for a compound fracture of the femur. The client reports, “My hands, feet, and nose feel cold. Which action should the nurse take FIRST?

1. Provide the client with more blankets.
2. Assess for dependent edema.
3. Assess that client is exhaling when moving in bed.
4. Increase the temperature of the room.

Answer 35

trategy: Determine if it is time to assess or implement.
1) treats a symptom, not the cause of the problem
2) CORRECT— because of recumbent position, cardiac workload increases; if heart is unable to handle increased workload, peripheral areas of body will be colder; more important to assess cardiovascular status; edema caused by heart’s inability to handle increased workload; assess sacrum, legs, and feet; also assess peripheral pulses
3) Valsalva maneuver increases workload on heart; to prevent, teach immobilized clients about exhaling when moving about in bed; should first assess client complaints
4) assess the client; cold extremities may indicate heart is not able to tolerate increased workload

Question 36

The nurse cares for a client at term in labor. The client’s blood pressure is 182/88 and fetal heart rate (FHR) is 132–134 with minimal beat-to-beat variability. Her bloody show is dark red and there is more bleeding than anticipated. Her abdomen is firm between contractions and she complains of back pain. The nurse understands that the client is at risk for which of the following?

1. Placenta previa.
2. Abruptio placenta.
3. Miscarriage.
4. Imminent delivery.

Answer 36

Strategy: Think about each answer.

1) placenta is implanted near or over the cervical os; symptoms include painless, sudden, profuse bleeding in third trimester
2) CORRECT— premature separation of placenta; painful vaginal bleeding, abdomen is tender, painful, tense, possible fetal distress; prepare for immediate delivery
3) occurs before 20–24 weeks of pregnancy; indications are persistent uterine bleeding and cramp-like pain
4) symptoms are classic signs of abruption

Question 37

The nurse cares for an older client diagnosed with terminal lung cancer. When told about the diagnosis, the client becomes very angry. He curses, throws objects, and hits the nurse tech and LPN/LVN when they attempted provide care for him. It is MOST important for the nurse to take which of the following actions?

1. Inform client that injury or risk of injury to staff is not acceptable.
2. Send the staff out of the room.
3. Administer prescribed antianxiety with full glass of water.
4. Report signs/symptoms to physician immediately.

Answer 37

Strategy: “FIRST” indicates priority

1) CORRECT— set limits on client’s behavior; staff has the right to work in a safe environment
2) gives client the power; speak calmly to client, help to verbalize feelings, use nonthreatening body language
3) nurse should use least restrictive interventions to assist the client to regain control
4) passing the buck; it is the nurse’s responsibility to care for the client

Question 38

The nurse, caring for clients in the outpatient clinic, performs a chart review for clients who are receiving medication. The nurse determines that which of the following clients is at risk to develop problems with hearing?

1. A client receiving spironolactone (Aldactone) and cefaclor (Ceclor).
2. A client receiving metformin (Glucophage) and alendronate (Fosamax).
3. A client receiving paroxetine (Paxil) and cholestyramine (Questran).
4. A client receiving furosemide (Lasix) and indomethacin (Indocin).

Answer 38

Strategy: Think about each answer.

1) Aldactone is a potassium-sparing diuretic and Ceclor is a second-generation cephalosporin; neither drug is ototoxic
2) Glucophage is an oral hypoglycemic and Fosamax is a bone resorption inhibitor; neither is ototoxic
3) Paxil is a selective serotonin reuptake inhibitor (SSRI) and Questran is an antihyperlipidemic agent; neither is ototoxic
4) CORRECT— Lasix is a loop diuretic and is ototoxic, especially when given with other ototoxic drugs; Indocin is a NSAID and is also ototoxic

Question 39

The nurse in the pediatric clinic receives a phone call from the mother of a 3-year-old child. The mother reports that her child has been complaining of a sore throat, has a temperature of 102°F (39°C), and he has suddenly begun drooling. Which of the following suggestions should the nurse make FIRST?

1. “Place a cold water vaporizer in your child’s room.”
2. “Take your child to the emergency department immediately.”
3. “Look into your child’s throat and tell me what you see.”
4. “Frequently offer your child oral fluids.”

Answer 39

Strategy: “FIRST” indicates priority.

1) appropriate action if the child has croup
2) CORRECT— symptoms indicate acute epiglottitis which can be life threatening; drooling occurs because of difficulty swallowing; child may become apprehensive or anxious; transport to hospital sitting in the parent’s lap to reduce stress
3) do not inspect the throat unless immediate intubation can be performed if needed
4) transport to the hospital

Question 40

The nurse cares for a 27-year-old female diagnosed with type 1 diabetes. Two days after admission, the client begins complaining of severe nausea. Which of the following actions should the nurse take FIRST?

1. Determine the client’s most recent fasting serum glucose level.
2. Perform a comprehensive client assessment.
3. Ask the client if she is pregnant.
4. Administer an antiemetic.

Answer 40

Strategy: “FIRST” indicates priority.

1) no relationship between diabetes and nausea; last glucose reading does not give the nurse information about client’s current condition
2) CORRECT— nausea not usually associated with diabetes; assess before implementing
3) nurse is making assumptions based on client’s age; should perform a comprehensive assessment
4) assess before implementing

Question 41

A new registered nurse asks the assigned nurse mentor to check on 4 clients who are receiving oxygen therapy. It is MOST important for the nurse mentor to ask the nurse which of the following questions?

1. “Which client should I see first?”
2. “Have you completed your assessment?”
3. “What are your specific concerns?”
4. “Don’t you think you should be able to care for the clients?”

Answer 41

Strategy: “MOST important” indicates discrimination may be required to answer the question.

1) nurse mentor should find out about the nurse’s specific concerns
2) yes/no question; doesn’t allow nurse mentor to assess the nurse’s needs
3) CORRECT— clarifies the nurse’s concerns and will help the new nurse become a safe practitioner
4) yes/no question; nontherapeutic; does not allow nurse mentor to assess new nurse’s concerns

Question 42

The nurse cares for a client receiving chlordiazepoxide (Librium). It is MOST important for the nurse to observe for which of the following?

1. Skeletal muscle spasms and insomnia.
2. Anorexia and dry mouth.
3. Diarrhea and euphoria.
4. Drowsiness and confusion.

Answer 42

Strategy: Think about each answer.

1) dystonia is side effect of antipsychotics; insomnia caused by SSRIs
2) Ritalin causes anorexia; dry mouth is side effect of tricyclic antidepressants
3) not caused by Librium
4) CORRECT— antianxiety and sedative/hypnotic used to treat anxiety and alcohol withdrawal; causes drowsiness and sedation; use caution when driving or operating equipment; confusion may indicate immediate n

Question 43

Following the administration of meperidine HCl (Demerol) for an adult client, the nurse expects which of the following?

1. The client states that he feels better.
2. The client is talking with visitors.
3. The client appears to be physically relaxed.
4. The client is no longer crying or moaning.

Answer 43

Strategy: Think about how each answer relates to pain.

1) client may express pain relief, but in reality may still be experiencing pain
2) client may still be in pain
3) CORRECT— nonverbal cues are the best indication of pain relief
4) not best indication of relief of pain

Question 44

After being admitted for management of a cervical spine injury, a client in a rehabilitation center reports a severe headache. Which of the following actions should the nurse take FIRST?

1. Administer an analgesic medication
2. Ask the client to rank the pain from 1 to 10.
3. Ask the client if he is worried about something.
4. Place the client in a sitting position.

Answer 44

Strategy: “FIRST” indicates priority.

1) priority is to decrease blood pressure
2) cervical spine injury and severe headache should clue nurse that client is possibly in imminent danger

3) assess for physical causes before psychosocial causes
After being admitted for management of a cervical spine injury, a client in a rehabilitation center reports a severe headache. Which of the following actions should the nurse take FIRST?

1. Administer an analgesic medication
2. Ask the client to rank the pain from 1 to 10.
3. Ask the client if he is worried about something.
4. Place the client in a sitting position.

4) CORRECT— pounding headache and profuse sweating are indications of autonomic hyperreflexia; place in a sitting position immediately to decrease blood pressure and reduce risk of cerebral hemorrhage

Question 45

The nurse receives report on the medical/surgical unit. Which of the following clients should the nurse see FIRST?

1. A client newly diagnosed with type 1 diabetes who had a myocardial infarction 2 days ago.
2. A client diagnosed with right-sided heart failure and glaucoma.
3. A client diagnosed with chronic obstructive pulmonary disease and psoriasis.
4. A client diagnosed with rheumatoid arthritis and malnutrition.

Answer 45

Strategy: Determine the most unstable client.

1) CORRECT— both diseases are in the dynamic phase and require close monitoring; most unstable client
2) client should be seen second
3) two chronic illnesses
4) client more stable than #1

Question 46

The nurse cares for a 4–year–old on the pediatric unit. The child is unable to go to sleep while in the hospital. It is MOST important for the nurse to take which of the following actions?

1. Turn out the light and close the door.
2. Encourage the child to exercise during the evening.
3. Identify the child’s home bedtime ritual.
4. Ask the child’s siblings to visit during the evening.

Answer 46

Strategy: Assess before implementing

1) will increase the child’s fears; preschoolers fear injury, mutilation, and punishment
2) will not promote sleep
3) CORRECT— preschoolers require bedtime rituals that should be followed in hospital; nurse should assess before implementing
4) will be comforting to child, but to promote sleep it is more important to determine bedtime routine

Question 47

The nurse prepares an elderly client newly diagnosed with type 1 diabetes for discharge. The client is alert and oriented and lives alone in her home. It is MOST important for the nurse to assess for which of the following?

1. Client’s vision and manual dexterity.
2. Client’s understanding of diabetes.
3. Client’s need for visits from the home care nurse.
4. Client’s ability to perform blood glucose monitoring.

Answer 47

Strategy: “MOST important” indicates discrimination is required to answer the question.

1) CORRECT— client must have the visual acuity and manual dexterity to draw up and administer insulin
2) it is important that the client understands diabetes, but priority is assessing client’s ability to manage insulin administration
3) may be necessary
4) important, but first assess the client’s vision and manual dexterity

Question 48

The nursing assistive personnel inform the nurse that the elderly client admitted following a hemorrhagic stroke ate half of the food on the tray. The food left on the tray looked as if someone had drawn a straight line down the center of the plate and eaten the food only to one side of the line. Which instruction by the nurse is MOSTimportant?

1. “Rotate the plate so that the food is on the other side.”
2. “Offer him a snack later in the day.”
3. “Ask the client’s family to assist him with the next meal.”
4. “Which foods did he omit?”

Answer 48

Strategy: “MOST important” indicates discrimination is required to answer the question.

1) CORRECT— indicates homonymous hemianopsia (loss of half of the visual field); client neglects one side of body; instruct client to turn head in direction of visual loss
2) food pattern on plate indicates loss of visual field
3) passing the buck
4) situation does not require further assessment

Question 49

The nurse evaluates care for a client who demonstrates manipulative behavior. The nurse should intervene if which of the following is observed?

1. The staff discusses with the client the consequences of his manipulative behavior.
2. The staff establishes limits on the client’s manipulative behavior.
3. The staff clarifies the consequences of the client’s manipulative behavior.
4. The staff decreases the demands on the client.

Answer 49

Strategy: “nurse should intervene” indicates something is wrong.

1) appropriate that the staff help to client learn to see the consequences of his behavior
2) appropriate; staff should communicate clearly defined expectations and carry out limit-setting
3) appropriate behavior
4) CORRECT— fosters a sense of entitlement

Question 50

The nurse in the pediatric clinic performs a well-child assessment on a 20-month-old. The child’s mother tells the nurse that she is earning extra money by growing houseplants in her home. Which of the following responses by the nurse is MOST appropriate?

1. “How did you get into that business?”
2. “What a great opportunity.”
3. “You should not have plants in your home.”
4. “Where do you keep the plants?”

Answer 50

Strategy: “MOST appropriate” indicates discrimination is required to answer the question.

1) encourages the mother to talk about her interests but does not address safety issue of toddler
2) closed response; does not give client opportunity to respond
3) not all plants are toxic; nurse is expressing an opinion without completing the assessment
4) CORRECT— toddlers explore by putting things in their mouth; all potentially toxic agents should be placed out of reach of the toddler; nurse should assess the type of plants in the home and the location of the plants

Question 51

The nurse performs discharge teaching for a client diagnosed with gastroesophageal reflux disease (GERD). The nurse determines that teaching is successful if the client selects which of the following menus?

1. Pork loin, lettuce and tomato salad with vinegar and oil dressing, jello, and cola.
2. Cheddar cheese omelet, spinach salad, chocolate brownie, and milk.
3. Broiled chicken, cream of broccoli soup, rice pudding, and apple juice.
4. Baked salmon with lemon butter, baked potato, mint chocolate chip ice cream, and lemonade.

Answer 51

Strategy: “Teaching is successful” indicates correct information.

1) oil dressing high in fat, tomato exacerbates GERD, as do carbonated beverages
2) fatty foods and chocolate exacerbate GERD
3) CORRECT— menu low in fat and contains non-acidic foods
4) lemonade and mint exacerbate GERD