ADULT HEALTH - CARDIO

Question 1

Following treatment for a fracture, a client is now undergoing rehabilitation. His regimen involves performing isometric exercises. Which action is evidence that the client has fully understood the proper technique?

A. The patient exercises both extremities simultaneously

B. The client knows that his heart rate should be monitored while exercising

C. The patient practices forced resistance against stable objects

D. The patient swings his limbs through their full range of motion

Answer 1

Explanation

Rationale: Isometric exercises involve applying pressure against a stable object, like pressing the hands together or pushing an extremity against a wall. It does not include the simultaneous use of the extremities; neither does swinging of limbs. Heart rate monitoring is done with aerobic exercises. The correct answer is option C. Options A, B, and D are incorrect.

Reference:

gnatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 2

The mother of a toddler with Celiac disease is being instructed by the nurse regarding dietary modifications for her child. Which food choice by the mother would indicate a need for further discussion?

A. Rice cakes

B. Restaurant French fries

C. Milk shake

D. Grilled Chicken

Answer 2

Explanation

Choice B is correct. Clients with Celiac disease are advised on a gluten-free diet. While potatoes are naturally free of gluten, French fries made at restaurants aren’t necessarily gluten-free. According to the Celiac Disease Foundation, French fries are among the most easily cross-contaminated food in the restaurants. The majority of fast food joints and restaurants fry these fries with other gluten-filled eats (shared fryers), causing cross-contamination. Among the options above, restaurant based French Fried are the ones to avoid unless they are labeled strictly “Gluten-Free.” Such food choice by the mother requires further discussion and clarification.

Choice A is incorrect. Anything made from brown, white, or wild rice, including rice-based products, such as rice cakes and puffed rice usually, do not contain gluten. Therefore, it is safe for the child to eat Rice cakes.

Choice C is incorrect. Milk does not contain gluten; therefore, it is safe for the child.

Choice D is incorrect. Meat is naturally gluten-free. Chicken does not contain gluten; therefore, it is safe for the child to eat.
Reference
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Question 3

A teenager is diagnosed to be suffering from anorexia nervosa. Upon interviewing her friends, the nurse would expect them to describe the patient to be

A. An under achiever

B. Disorderly

C. Independent

D. Obedient

Answer 3

Explanation

A is incorrect. Teens with anorexia nervosa do well at school. They are mostly achievers in school.

B is incorrect. Anorexic teens are orderly and obedient. They try their best to do what is expected of them.

C is incorrect. Anorexic clients are dependent on others.

D is correct. Teens with anorexia nervosa try their best to do what is expected of them at home and school.

Reference

Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4thEdition; Lippincott, Williams & Wilkins, 2003

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6thEdition. Saunders-Elsevier 2014

Question 4

The client who is 10 weeks pregnant is complaining to the nurse on duty in the gynecology clinic about her “worsening varicosities.” The nurse would advise her to:

A. Avoid exercise as blood pools in her legs during movement.

B. Wear knee high hose or garters.

C. Avoid citrus fruits.

D. Sleep in side lying position.

Answer 4

Explanation

A is incorrect. Contrary to the statement, exercise promotes venous return when coupled with frequent rest periods.

B is incorrect. The client should avoid wearing knee-high garters as they occlude venous return. Pregnant women are advised to wear elastic support stockings such as TEDS and should be applied up to above the point of enlargement.

C is incorrect. The client should increase her intake of Vitamin C found in citrus fruits as Vitamin C is involved in the formation of blood vessel collagen and endothelium.

D is correct. Sleeping in a side-lying position removes the weight of the fetus on the superior and inferior vena cava, promoting venous return.

Reference

Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Question 5

hich of the following lipid levels is out of range and should be reported to the physician?

A. Triglycerides: 75 mg/dL

B. Total cholesterol: 6.5 mmol/L

C. High-density lipoprotein (HDL): 60 mg/dL

D. Low-density Lipoprotein (LDL): 95 mg/dL

Answer 5

Explanation

Correct Answer is B. Lipid profile helps physicians determine the patient’s risk of developing heart disease. It is recommended that individuals have a lipid profile done at least every five years as part of a regular medical exam.

The correct answer is B as 6.5 mmol/L exceeds the “high normal” total cholesterol level. The average Total Cholesterol level is 3.5 to 5.0mmol/L. In milligrams, Total Cholesterol of 200 milligrams per deciliter (mg/dL) or lesser is considered desirable for adults

Choices A, C, and D are incorrect. The normal lipid levels for these tests include:
Triglycerides: 50-150 mg/dL
High-density lipoprotein (HDL): 40-80 mg/dL
Low-density lipoprotein (LDL): 85-125 mg/dL

NCSBN Client Need
Topic: Physiological Integrity; Subtopic: Reduction of Risk Potential
Reference:
Fundamentals of Nursing (Kozier and Erbs)

Question 6

The nurse has just finished administering two units of Packed Red Blood Cells to a client with anemia. The client’s Hemoglobin and Hematocrit level before the transfusions were given is Hgb 5.5 g/dL and Hematocrit – 26%. The nurse would expect which laboratory values upon the next blood count?

A. approximately Hgb 10.5 g/dL and Hematocrit – 32%

B. approximately Hgb 7.5 g/dL and Hematocrit – 32%

C. approximately Hgb 10 g/dL and Hematocrit – 33%

D. approximately Hgb 13 g/dL and Hematocrit – 33%

Answer 6

Explanation

A is incorrect. This is not an expected value for hemoglobin and hematocrit after infusion of 2 units of PRBCs.

B is correct. Each unit of PRBCs increases the hemoglobin by 1 g/dL and hematocrit by 3% 4-6 hours after completion of blood transfusion. When two units of PRBCs are infused, the nurse expects the Hgb levels to increase by 2 g/dl and Hct levels to increase by 6%.

C is incorrect. This is not an expected value for hemoglobin and hematocrit after infusion of 2 units of PRBCs.

D is incorrect. This is not an expected value for hemoglobin and hematocrit after infusion of 2 units of PRBCs.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006

Question 7

The nurse unit manager receives a complaint from a client’s family regarding the care that the client received from the night shift nurse. What would be the manager’s most appropriate initial action?

A. Tell the night charge nurse to ensure the night nurse performs her work

B. Talk to the nurse regarding the complaint and discuss the care provided

C. Discuss the situation with the client’s family making the complaint

D. Take note of the complaint and place it in the employee’s file

Answer 7

Explanation

Rationale: The nurse manager should talk to the client’s family first to let them feel that they are being heard and that she can ask questions to investigate further the complaint and determine whether it is valid or not. Once the manager has determined that the claim is correct, the manager would then talk to the nurse regarding the care that she has provided and ask more questions. The incident may go into the nurse’s file, but not without investigating into the matter first.

Reference

Kelly, P; Marthaler, M; Nursing Delegation, Setting Priorities, and Making Patient Care Assignments, 2nd Edition; Cengage Learning, 2010

Question 8

A G1P0 client with a blood type A negative is at her 28th-week gestation and was advised a RhoGAM injection today. Which statement by the client indicates the need for further teaching about this therapy?

A. “This shot is meant to prevent my baby from developing antibodies against my blood, right?”

B. “I understand that if we find out my baby is Rh positive, then I’ll need to get another one of these injections.”

C. “This shot should help to protect me in future pregnancies if this baby comes out Rh positive, like her dad.”

D. “This shot will prevent me from becoming sensitized to Rh-positive blood.”

Answer 8

Explanation

Rationale: RhoGAM is administered to Rh-negative mothers to prevent her from producing antibodies against her Rh-positive fetus. Option A indicates that she needs further teaching. If the infant is Rh-positive, the mother needs to receive another dose after delivery to prevent maternal sensitization. This will also protect future pregnancies as the mother’s blood will be free of antibodies against her fetus. RhoGAM prevents maternal awareness of Rh-positive blood. Options B, C, and D are accurate statements and are, therefore, incorrect answers.

Reference:

Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Question 9

The nurse in the ER is caring for a child having an acute asthma attack. The nurse is reviewing with the mother to determine activities that precipitate the child’s asthma attacks. Which statement by the mother would the nurse provide teaching?

A. My son loves playing trumpet for the grade school band

B. My son rake leaves every Saturday afternoon to help out with the work at home.”

C. My son participates in extracurricular activities

D. My son swims 5 laps twice a week with his friends

Answer 9

Explanation

A is incorrect. Musical instruments such as a trumpet help improve lung function.

B is correct. Raking leaves exposes the child to allergens from the trees. The nurse should advise the mother to find another activity for her child.

C is incorrect. Extracurricular activities are encouraged to promote maturity in the child.

D is incorrect. Swimming is an excellent exercise for the lungs.

Reference

Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 10

The client’s ABG results came in and it shows the following values: pH 7.38, PaO2 76, PaCO2 39, HCO3 23. What should be the initial action of the nurse?

A. Administer oxygen 6 L/min via nasal cannula.

B. Instruct the client to take deep breaths.

C. Administer sodium bicarbonate intravenously.

D. Check the respiratory status of the client.

Answer 10

Explanation

A is correct. The client’s ABG indicates hypoxia. The normal PaO2 is 80-100; therefore, the nurse should give oxygen to address the situation.

B is incorrect. Hypercapnia or a PaCO2 level higher than 45 mm Hg is an indication to take deep breaths to expel the excess carbon dioxide. The client’s PaCO2 is 39, which does not necessitate deep breathing.

C is incorrect. Intravenous sodium bicarbonate should be administered when the client’s HCO3 level is less than 22.

D is incorrect. Respiratory assessment is not needed in this situation.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 11

The RN is in charge of the unit together with an LPN. Which situation indicates proper delegation of tasks by the RN?

A. The RN delegates to LPN to check the circulation on the child with a forearm cast.

B. The LPN is tasked to feed a one-year old that just had a cleft palate repair.

C. The LPN demonstrates urinary catheterization to the mother of a child with neurogenic bladder.

D. The RN checks if the LPN completed all delegated tasks.

Answer 11

xplanation

A is incorrect. The LPN cannot assess a client. This is a task for the RN.

B is incorrect. The child has just undergone a cleft palate repair. There is a risk for the child to damage his incision site and to aspirate if he/she is fed by untrained personnel. This task is for the RN.

C is incorrect. Demonstrating a procedure to the mother is similar to educating or teaching the client. The LPN is not allowed to perform teaching/education.

D is correct. It is the responsibility of the nurse to evaluate and check if the delegated tasks to the LPN have been performed.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012

Question 12

A diabetic client has just given birth to a male neonate. Which assessment finding by the nurse would warrant nursing intervention?

A. Crying

B. Restlessness

C. Twitchiness

D. Yawning

Answer 12

Explanation

A is incorrect. Crying, Restlessness and Yawning are all normal for the newborn.

B is incorrect. Crying, Restlessness and Yawning are all normal for the newborn.

C is correct. Twitchiness or jitteriness is a sign of seizures in the newborn. The nurse should inform the physician.

D is incorrect. Crying, Restlessness and Yawning are all normal for the newborn.

Reference

Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 13

The nurse is about to prepare the morning medications for clients on the ward. Which medication should the nurse prepare and administer first?

A. Prednisolone (Deltsone), a glucocorticoid, to a client with inflammatory bowel disease.

B. Rivastigmine (Exelon),an anticholinesterase inhibitor, to a client with dementia.

C. Sucralfate (Carafate), a mucosal barrier agent, for a client with duodenal ulcer.

D. Enoxaparin (Clexane), an anticoagulant, to a client on bed rest after surgery.

Answer 13

Explanation

A is incorrect. This medication can be given 30 minutes before and after the scheduled time. This medication does not have to be the first medication given.

B is incorrect. Exelon can be given within a 30 minute time frame of the scheduled time. This medication does not have to be given first.

C is correct. Sucralfate is a mucosal barrier agent that must be given 30 minutes before the client’s meal. This medication must be given first to achieve its effect.

D is incorrect. Clexane can be given within a 30 minute time frame of the scheduled time. This medication does not need to be administered first.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Question 14

The nurse is caring for a client receiving total parenteral nutrition for 2 weeks. Which action by the nurse is the most important?

A. Determining weight changes in the client.

B. Monitoring laboratory results.

C. Maintaining strict asepsis during dressing changes in the IV line.

D. Monitoring of blood glucose levels.

Answer 14

Explanation

A is incorrect. Obtaining the client’s weight is essential to assess the client’s nutritional status. However, this is not the nurse’s priority intervention.

B is incorrect. The nurse should monitor laboratory results to monitor changes in electrolytes. However, this is not a priority action.

C is correct. TPN has high glucose content making it an ideal medium for bacterial growth. The nurse should perform strict asepsis during dressing changes in the TPN line.

D is incorrect. TPN may cause an increase in blood sugar levels in the first 48 hours of administration as the client has not yet adjusted to the glucose load of the patient. However, since it is already two weeks of administering the solution, the client should have already changed to the TPN solution.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 15

You are caring for a client with a terminal disease and this person has asked for a curandero. What should you do?

A. Refer the family to a religious shop with Bibles and other holy books.

B. Refer the family and the client to a member of the clergy who may be able to help.

C. Give the client a candle and close all of the shades and blinds to darken the room.

D. Arrange for the client to go to a religious service to get this special blessing.

Answer 15

Explanation

Correct Answer is B

Correct. You would refer the family and the client to a member of the clergy who may be able to help. A curandero is a healer who is believed to supernatural powers that can cure the sick. These powers are derived from the fact that many believe that illnesses and diseases occur as the result of evil spirits and a curse from God.

You would not give the client a candle and close all of the shades and blinds to darken the room because this is not consistent with the person’s desire to have a curandero; a curandero is not a particular religious blessing, and it is not a holy book.

Choice A is incorrect. A curandero is not a holy book.

Choice C is incorrect. A curandero is not a religious or spiritual practice that uses a candle and a darkened room.

Choice D is incorrect. A curandero is not a particular religious blessing.

Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).

Question 16

A 45-year-old man is rushed to the ER with reports of substernal chest pain and diaphoresis. Cardiac troponin levels were taken and found to be elevated. The ER nurse understands that nursing interventions would focus on which priority?

A. Increase oxygenation to the heart and reduce the heart’s workload

B. Prevent complications and confirm a diagnosis of myocardial infarction

C. Alleviate the patient’s anxiety

D. Pain relief

Answer 16

Explanation

A is correct. The client manifests signs and symptoms of myocardial infarction. The priority for nursing care should be focused on increasing oxygen delivery to the heart and reducing its workload to prevent further damage.

B is incorrect. Confirming the diagnosis should be done; however, since the client is already exhibiting signs of reduced myocardial oxygenation (chest pain), the nurse should prioritize oxygen delivery to the client.

C is incorrect. It is the nurse’s responsibility to alleviate the client’s anxiety; however, the nurse should prioritize oxygenation to the client.

D is incorrect. Pain relief should be important in the care of the patient with myocardial infarction; however, it should not take priority over myocardial oxygenation.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 17

A client has just been diagnosed with a terminal illness. She decides to execute a living will in the unit and asks the nurse to be the witness of the will. What is the most appropriate response by the nurse?

A. “I’m sorry, but under the law, we’re not allowed to witness living wills.”

B. “Let me call the doctor. Maybe he can witness it for you.”

C. “Your family is the only ones that can serve as witnesses.”

D. “Let me call the hospital attorney; he needs to be present when you sign your will.”

Answer 17

Explanation

A is correct. Nurses and other healthcare workers working in the facility where the patient is receiving care are forbidden by law from becoming witnesses.

B is incorrect. This statement is inaccurate. Nurses and other healthcare workers working in the facility where the patient is receiving care are forbidden by law from becoming witnesses.

C is incorrect. This statement is false. Witnesses for the signing of the will can be specific individuals. It does not necessarily mean family only.

D is incorrect. The hospital lawyer is not needed to be present in signing the living will.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 18

A client is prescribed bed rest by the physician after surgery. The nurse that is taking care of the patient always avoids putting pressure on the back of the client’s knees. The reason for this is to prevent which complication?

A. Cerebral embolism

B. Pulmonary embolism

C. Limb gangrene

D. Coronary Vessel occlusion.

Answer 18

xplanation

A is incorrect. Once a thrombus is dislodged and travels through the circulatory system, the pulmonary capillary bed will be the first small vessels that the embolus will encounter, not the cerebral blood vessels.

B is correct. Once a thrombus is dislodged and travels through the circulatory system, the pulmonary capillary bed will be the first small vessels that the embolus will encounter, resulting in pulmonary embolism.

C is incorrect. Gangrene occurs when the blood supply to the affected limb is compromised. Putting pressure on the back of the client’s knees, like a pillow, does not impair circulation.

D is incorrect. Once a thrombus is dislodged and travels through the circulatory system, the pulmonary capillary bed will be the first small vessels that the embolus will encounter, not the coronary blood vessels.

Reference

Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012

Question 19

The Licensed Practical Nurse (LPN) informs the nurse that the 1-day post Partum client she is taking care of has changed 3 perineal pads in the last 4 hours. What is the initial action of the nurse?

A. Document the finding.

B. Instruct the LPN to massage the client’s uterus.

C. Assess the patient immediately.

D. Ask the LPN why the nurse was not informed earlier.

Answer 19

Explanation

A is incorrect. Assessment of the client should be done first before investigating whether or not the LPN was negligent.

B is incorrect. Massaging of the uterus must be done by the nurse, not the LPN. However, the nurse needs to assess the patient first for a boggy uterus and confirm excessive bleeding.

C is correct. The initial action of the nurse would be to assess the client first to confirm if she has excessive bleeding.

D is incorrect. The nurse should always verify the information before documenting it.

Reference

Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 20

A client was brought into the emergency department by his wife because he has been vomiting for three days. The wife is worried because he has grown weak and seems to be having a hard time breathing. The nurse notes that he is hypoventilating and has a respiratory rate of 10 breaths/min. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/min. Consequently, arterial blood gases are drawn, and the nurse reviews the results, expecting to note which of the following?

A. A decreased pH and an elevated CO2

B. An elevated pH and a decreased CO2

C. A decreased pH and a decreased HCO3_

D. An increased pH with an increased HCO3_

Answer 20

Explanation

Rationale: Persistent nausea and vomiting would most likely lead to metabolic alkalosis because of the loss of gastric acid, thus causing the pH and HCO3_to increase. Hypoventilation and tachycardia are some symptoms the patient may experience. Option A reflects a respiratory acidotic condition. Option B reflects a respiratory alkalotic status. Option C reflects a metabolic acidotic status. Therefore, option D is the correct answer.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6thEdition. Saunders-Elsevier 2014

Question 21

The home health nurse is visiting an elderly client for the first time in his home. Upon assessment of the client, the nurse notices that the client has been taking 12 prescription medications and five over the counter medications. What is the nurse’s most appropriate action?

A. Check for drug interactions.

B. Check for side effects to the client from the medications.

C. Check for any medication duplication.

D. Ask the client if there are family members helping him with his medications.

Answer 21

Explanation

A is incorrect. Checking for drug interactions should be done after determining the duplication of medications.

B is incorrect. The identification of side effects of medications can be made after the duplication of drugs is determined.

C is correct. Checking for any duplication in medication should be the first action of the nurse to eliminate the risk of adverse effects on the client.

D is incorrect. Asking about family members helping with his medications is irrelevant to the problem of polypharmacy as of the moment.

Reference

Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 22

You are working in an adult telemetry step-down unit and have five patients to manage. You see the following rhythms on the monitor from your patients. Which patient should you assess first? Select the image of the ECG for the patient you would assess first. 
A. NORMAL SINUS RHYTHM
B. UNIFOCAL PVC
C. VENTRICULAR TACHYCARDIA
D. SINUS TACHYCARDIA

Answer 22

Explanation

Answer: C

A - This patient is in normal sinus rhythm. They are not the priority for assessment.

B - This patient is demonstrating normal sinus rhythm is one unifocal pre ventricular contraction. While the nurse does need to assess them, they are not the priority. PVCs can be well-tolerated, and a singular one is not immediately dangerous.

C - This patient is showing sustained ventricular tachycardia on the monitor. This is a fatal rhythm and the nurse must immediately assess the patient as they could quickly arrest and necessitate a code blue. This is the correct patient to assess first.

D - This patient is in sinus tachycardia. This could be caused by a fever, dehydration, or could be the patient’s baseline. While the nurse should assess the patient and determine the cause of the tachycardia, he is not the priority from the five patients shown.

NCSBN Client Need

Topic: Reduction of Risk Potential Subtopic: Diagnostic Tests

Reference:

Silvestri, L.; Saunders Comprehensive Review for the NCLEX-RN Examination, ed 6, St. Louis, 2014, Elsevier, p. 785-787

Question 23

The nurse has instructed a patient who has been diagnosed with atrial fibrillation. Which of the following statements by the patient would require to follow up? Select all that apply.

A. “I have an increased risk for a stroke.”

B. “I should weigh myself daily. at the same time.”

C. “I may be prescribed medications such as amiodarone.”

D. “I should wear a mask when I am in public.”

E. “I should follow-up with my primary healthcare provider (PHCP) if I develop shortness of breath.”

Answer 23

Explanation

Correct Answers are B and D. These two statements indicate that the patient needs further follow-up education to correct the misconceptions. The client does not need to weigh themselves daily (Choice B) as that would be applicable for CHF and not for atrial fibrillation. Considering daily in CHF is useful to detect excess fluid retention, which may precede symptoms such as shortness of breath. Wearing a mask in public is unnecessary as the infection is not a concern here ( Choice D).

Choices A, C, and E are incorrect options because these statements indicate correct understanding by the patient and do not require follow-up teaching. Atrial fibrillation is a common dysrhythmia that results in a decrease in an atrial kick. A client with atrial fibrillation is at risk for an ischemic stroke (Choice A) because of the formation of clots in the atrial appendage. Treatment for AFib ranges from medications (diltiazem, amiodarone) to cardiac ablation ( Choice C).

Finally, the client needs to notify the PHCP if they develop dyspnea because this could be an indication of AFib with a rapid ventricular response (RVR), which requires immediate medical attention (Choice E).
NCSBN Client Need:
Topic: Physiological adaptation; Sub-Topic: Alterations in body systems

Question 24

The patient is receiving instructions from the clinic nurse regarding dietary modifications to help in the treatment of her Cystitis. The nurse is giving her a list of foods to avoid because they irritate her bladder. All of the following are foods that she needs to prevent, except:

A. Coffee

B. Spaghetti

C. Alcohol

D. Cranberry juice

Answer 24

explanation

A is incorrect. Coffee/Caffeine is an irritant to the bladder and should be avoided by patients with Cystitis.

B is incorrect. Spaghetti sauce contains tomatoes which are an irritant to the bladder and should be avoided by patients with Cystitis.

C is incorrect. Alcohol is an irritant to the bladder and should be avoided by patients with Cystitis.

D is correct. Cranberry juice is used to acidify the urine of the patient with Cystitis and should be included in her dietary regimen.

Reference:

Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 25

The nurse is caring for an 8 year old boy in the pediatric unit. The nurse, when caring for this age group should be aware that: A. The child will do something for another if that person does something for the child. B. The child now follows social standards for the good of all. C. The child wants to follow rules because of a need to be seen as “good.” D. The child finds satisfaction in following rules.

Answer 25

Explanation A is incorrect. This pertains to the pre-conventional stage of moral development. The child will carry out actions to satisfy his needs. If a person does something for the child, the child will do something for the person. This applies to children ages 4-7 years old. B is incorrect. This is the post-conventional stage. It applies to adolescents. The child now follows social standards for the good of all people. C is correct. The school-age child aged 7-10 find a need to follow the rules as they want to be a “good” person in their eyes, and for others. D is incorrect. This applies to the 10-12-year-old, still in the current stage. This is where the child finds satisfaction in following rules. Reference Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 26

A woman comes into the emergency room complaining of insomnia, anxiety, the difficulty of breathing, and a sense of impending doom. After being assessed by the physician, no physiological abnormalities were found. However, the client is still anxious and apprehensive. What is the most appropriate statement by the nurse to the patient? A. “Don’t worry, you’re safe here. Just try to relax.” B. “Can you think of anything that happened recently or in the past that might have triggered these feelings?” C. “We gave you something that should calm you down.” D. “Take slow, deep breaths and try to relax. Nothing bad will happen to you here.”

Answer 26

Explanation A is incorrect. This statement disregards the client’s feelings and offers false reassurance. This is an inappropriate response by the nurse. B is correct. This question offers reassurance and provides an opportunity for the nurse to gain insight into the client’s anxiety. This is an appropriate statement by the nurse. C is incorrect. Telling the client that you gave him some medication disregards his feelings and does not allow him to discuss those feelings. This statement also offers some form of false reassurance to the client. D is incorrect. This statement disregards the client’s feelings and offers false reassurance. This is an inappropriate response by the nurse. Reference Halter, MJ. Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 7th Ed. St. Louis, MO: Mosby Elsevier; 2014 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 27

A nurse is reviewing the arterial blood gas results of a client and notes the following: pH 7.45, PCO2 of 30 mm Hg, and HCO3-of 22 mEq/L. Does the nurse know that these results indicate? A. Metabolic acidosis, compensated B. Respiratory alkalosis, compensated C. Metabolic alkalosis, uncompensated D. Respiratory acidosis, uncompensated

Answer 27

Explanation The normal pH ranges between 7.35-7.45. A respiratory condition would show an inverse relationship between the PCO2and the pH, as seen in this case. In a metabolic state, the HCO3- would have direct contact with the pH. Because the pH is at 7.45, which is within the normal range, this is an indication that compensation has occurred. Therefore, option B is the correct answer, while options A, C, and D are incorrect. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6thEdition. Saunders-Elsevier 2014

Question 28

The nurse is discharging the client that has been admitted due to subarachnoid hemorrhage. The client still has some speech and balance deficits. Which referral should the nurse make? A. Refer the client to hospice care. B. Refer the client to speech therapy. C. Refer the client to the physical therapist. D. Refer the client to a home health agency.

Answer 28

Explanation A is incorrect. Hospice care is care that is patterned for clients that are terminally ill. The client is not terminally ill. B is incorrect. Speech therapy aids clients in regaining speech and swallowing abilities. Speech therapy should have been initiated and ongoing while the client is in the hospital admitted. C is incorrect. Physical therapy aids clients in regaining muscle strength and balance. Physical therapy should have been initiated and ongoing while the client is in the hospital admitted. D is correct. The client is going home, thus the client needs to be referred to a home health agency so that there is continuity of care even at home. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Question 29

The nurse in the neurology ward is taking care of a patient with paraplegia due to spinal cord injury. The nurse is planning for his rehabilitation. Which would be the most effective plan for the patient? A. The client and the family will have to arrange for the rehabilitation. B. The plan should be implemented early on in the treatment of the patient C. The patient should plan for minimal and short term rehabilitation as he will be able to return to his former activities D. Long term care should be arranged because the client is no longer capable of self-care

Answer 29

Explanation A is incorrect. The client and the family are not familiar with the options available in the health care system; the nurse should provide need information and support to both the client and his family. B is correct. Rehabilitation should start early in the treatment. This provides the patient with an optimistic atmosphere and makes the transition to discharge a lot easier. C is incorrect. The client is being prepared to adapt to a new lifestyle that will have to adjust to his paralysis. D is incorrect. Self-reliance and independence is the goal of rehabilitation. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Question 30

The nurse is caring for a client that is hypothermic and receiving warmed IV fluids. The nurse understands that rewarming must be done slowly due to which primary reason? A. To prevent burns in the patient. B. To prevent Ventricular Fibrillation and cardiovascular collapse. C. To prevent frostbite. D. To avoid muscle spasms.

Answer 30

Explanation A is incorrect. Preventing burns is a nursing responsibility of the nurse when warming a patient but is not the main reason why rewarming should be done slowly. B is correct. Rewarming must be done slowly because the hypothermic client is especially susceptible to the development of ventricular fibrillation and cardiovascular collapse if warmed blood is returned rapidly to a cold heart. C is incorrect. Frostbite is a product of hypothermia to the extremities, not rewarming. D is incorrect. Muscle spasms cannot be caused by rewarming. Reference Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 31

The nurse in the delivery room has just assisted in the delivery of a newborn and is now attempting to deliver the placenta. The nurse understands that expulsion of the placenta would trigger all of the following processes except: A. Decrease in progesterone. B. Decrease in estrogen. C. Increase in prolactin. D. Production of oxytocin.

Answer 31

Explanation A is incorrect. This is a correct statement. When the placenta is expelled, this causes a decrease in estrogen and progesterone that causes the anterior pituitary gland to increase prolactin. B is incorrect. This is a correct statement. When the placenta is expelled, this causes a decrease in estrogen and progesterone that causes the anterior pituitary gland to increase prolactin. C is incorrect. This is a correct statement. When the placenta is expelled, this causes a decrease in estrogen and progesterone that causes the anterior pituitary gland to increase prolactin. D is correct. Oxytocin production is stimulated by suckling. Suckling stimulates the posterior pituitary gland to produce oxytocin, causing the release of milk from alveoli into the ducts. Reference Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012

Question 32

A client has been admitted to the hospital with findings of urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement and has returned to normal hydration status if the blood urea nitrogen level is A. 5 mg/dL B. 15 mg/dL C. 27 mg/dL D. 34 mg/dL

Answer 32

Explanation Rationale: The average blood urea nitrogen level is 8 to 25 mg/dL. Values such as those in options C and D indicate continued dehydration. Option A reflects a lower than average cost, which may occur with fluid volume overload, among other conditions. Source: Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 33

he nurse is about to start total parenteral nutrition to a patient that just undergone major abdominal surgery. The nurse understands that upon hooking the TPN onto the client, the nurse’s priority action would be to: A. Maintain aseptic technique all throughout handling of the TPN solution B. Ensure that the IV line where the TPN is attached to is patent. C. Monitor the client’s kidney function tests. D. Monitor the client’s glucose levels.

Answer 33

Explanation A is incorrect. TPN solution is an excellent medium for bacterial growth. The nurse must maintain asepsis during handling of the solution; however, this is not a priority action for the first 24 hours of starting the solution. B is incorrect. The solution is extremely irritating to the vein. It is optimally given through a central catheter. This is not however, the priority nursing action. C is incorrect. TPN is not nephrotoxic. There is no need to monitor kidney function tests. D is correct. The nurse must monitor the client’s blood glucose levels as the TPN has a high glucose content. Hyperglycemia may occur during the first days of TPN. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 34

A senior RN is supervising a newly registered nurse fresh from the university in the emergency department. Which situation shall the senior RN intervene? A. The new RN elevates the foot of a 13 year old with a fractured tibia. B. The new RN calls Child Protective services for the child she suspects of being sexually abused. C. The new RN checks the tonsils of a drooling 3 year old with sore throat. D. The new RNgives a nebulization to an 8 year old with asthma.

Answer 34

Explanation A is incorrect. Elevating the foot to relieve swelling and edema in a fractured foot is an accurate nursing action. B is incorrect. For any suspected child abuse, the nurse is obligated by law to report the case to Child Protective Services. C is correct. A child with a sore throat that is drooling may be manifesting epiglottitis. Drooling may indicate that the child is going into respiratory distress and warrants timely intervention by the healthcare team. The senior RN should step in and guide the new RN in what to do. D is incorrect. Giving a nebulization to a child having an asthma attack relaxes the bronchial walls of the child and improves respiratory status. Reference Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 35

The home health nurse is talking to a client with iron-deficiency anemia. Which meal plan would indicate to the nurse that the client understood her discharge instructions? A. Roast beef, gelatin salad, green beans, and peach pie B. Chicken salad, coleslaw, French fries, ice cream C. Egg salad on wheat bread, carrot sticks, lettuce salad, raisins D. Pork chop, creamed potatoes, corn, and coconut cake

Answer 35

Explanation A is incorrect. Roast beef is high in iron; however, the other dishes accompanying the meal are low in iron. B is incorrect. Chicken and green leafy vegetables are rich in iron; however, french fries and ice cream have low nutritional value. C is correct. Foods that are high in iron are egg yolks, wheat bread, carrots, green leafy vegetables, and raisins. This is an optimal meal for the client to increase his dietary iron intake. D is incorrect. Pork chops contain high iron. Potatoes, corn, and coconuts, however, contain low iron. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013 Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 36

The nurse is discharging a client with a new sigmoid colostomy. Which statement from the client indicates a need for further teaching? A. “I will call my doctor immediately if my stoma becomes bluish.” B. “I can eat what I used to eat when I go back home.” C. “I need to wear a pouch over my stoma.” D. “I need to irrigate my colostomy every week with tap water.”

Answer 36

Explanation A is incorrect. Bluish discoloration of the stoma indicates necrosis and requires immediate action. The client needs to call the physician when this happens. The color of a normal, healthy stoma should be reddish to pink. B is incorrect. The client can go back to her regular diet once she is discharged as the stoma is already working. C is incorrect. A colostomy pouch should be worn over the stoma to collect the feces that is coming out of the stoma. D is correct. A colostomy should be irrigated dated so that the client will have a daily bowel movement. This statement signifies the client needs more teaching. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 37

The nurse in the postpartum ward is looking at laboratory results of clients that just arrived. The nurse would go to which client immediately? A. A patient with WBC of 15,000 cu.mm. B. A patient a Creatinine level of 0.8 mg/dL C. A patient with a Platelet count of 360,000 cu.mm. D. A client with a blood glucose of 260 mg/dL

Answer 37

Explanation A is incorrect. During labor and after birth, the WBC count would rise to 25,000. This is a normal response of the body and should not warrant any concern. B is incorrect. The serum creatinine level is within normal limits. This does not need any intervention. C is incorrect. Normal platelet count is 150,000 to 450,000. This is within normal limits. D is correct. The average blood glucose level is 70 – 120 mg/dL. The client’s blood glucose level is 260, thus warranting the attention and intervention of the nurse. Reference Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 38

The nurse in the Recovery room is anticipating the arrival of a client from the OR after a Thyroidectomy. The nurse is aware of the potential complications of such an operation and prepares all necessary equipment except: A. Sphygmomanometer, blood pressure cuff, and stethoscope. B. ECG machine C. Additional pillows, sandbags D. Oxygen, suction equipment, intubation supplies and tracheostomy set

Answer 38

Explanation A is incorrect. The nurse should keep a Sphygmomanometer, blood pressure cuff, and stethoscope for him to assess the patient’s blood pressure frequently. The blood pressure cuff can also be used to evaluate for hypocalcemia by checking for a positive Trousseau’s sign. B is correct. Although an ECG machine may be needed for checking the patient’s heart rhythm, it is not necessary as of the moment. C is incorrect. The nurse should keep pillows and sandbags at the bedside to use them as splints for the client’s neck. The nurse needs to immobilize the client’s neck to prevent damage/strain on his suture line. D is incorrect. The nurse needs to have all these emergency airway equipment at the bedside in the event of respiratory obstruction caused by edema of the glottis. Reference: Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 39

The unit manager notices that the nurse has been taking an extra 15 minutes for the lunch break thrice in the past week. Which action by the nurse manager is most appropriate? A. Continue to observe the nurse’s behavior. B. Make written notes on the nurse’s file. C. Ask the nurse to check in with her before and after taking his lunch. D. Mention the incident to the nurse concerned in an informal manner.

Answer 39

Explanation A is incorrect. The behavior is becoming a pattern and should warrant intervention by the nurse manager. The manager should talk to the concerned nurse regarding the situation. B is incorrect. This is only the third time that the incident occurred and did not warrant any formal documentation of behavior. C is incorrect. This is a punitive action for the nurse manager to take. The manager should talk to the nurse first before implementing action. D is correct. The nurse manager should talk to the nurse regarding the behavior informally. This is to find out the reason behind the issue and provide solutions. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Question 40

The nurse is caring for a G4P3 client in active labor that has undergone three Caesarean sections. The client suddenly screams out in pain and immediately quiets down. The nurse’s initial action would be to A. Prepare the client for delivery B. Notify the physician C. Increase the rate of her IV fluids D. Assess the client’s contraction pattern

Answer 40

Explanation A is incorrect. The client has ruptured her uterus. There is already no chance for the client to deliver her baby spontaneously because of a ruptured uterus. B is incorrect. The nurse should initiate measures to stabilize the client first before calling the physician. C is correct. The client has suffered a ruptured uterus. The client will be at risk for hemorrhage due to the increased vascularity of the uterine structures. The nurse should anticipate this by increasing the rate of IV fluids infusing into the client to counteract the blood loss. D is incorrect. Due to the rupture of the client’s uterus, the contraction pattern can no longer be assessed. Reference Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4thEdition; Lippincott, Williams & Wilkins, 2003 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6thEdition. Saunders-Elsevier 2014

Question 41

A post hemorrhoidectomy client is for discharge. The nurse should highlight which point in the discharge instructions? A. The proper technique for sitz bath B. Restricting fluid intake for 24 hours C. Laxative administration upon discharge D. Lying in the recumbent position

Answer 41

Explanation Rationale: It is important that the client expose the operative site to warm, moist heat, such as a sitz bath, 3–4 times a day for several days post hemorrhoidectomy. Option A is therefore the correct answer. Fluid intake of at least 2 liters/day is recommended, thus, option B is incorrect. Stool softeners, instead of laxatives may be prescribed as laxatives may cause diarrhea and increase pain in the rectal area. Option C is therefore incorrect. The patient is also encouraged to assume the side-lying position to reduce pressure on the surgical site and prevent discomfort. Option D is therefore incorrect. Reference: Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013. Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 42

The nurse is preparing a client for a stress test. Which teaching by the nurse should not be included? A. The client will be made to wear a device on her ankles that measures blood pressure. B. The client should wear loose fitting clothes during the test. C. The client will be walking at a speed of 1.5 - 2 miles per hour. D. The client can stop the test anytime she wants.

Answer 42

Explanation A is incorrect. The nurse should tell the client that her performance on the treadmill test is also gauged by measurement of ankle systolic pressure. B is incorrect. The client should be instructed to wear comfortable clothing during the stress test. C is incorrect. The client is made to walk on the treadmill at speeds of 1.5 – 2 miles per hour at a grade elevation of 10% - 20% and a time limit of 5 minutes. D is correct. The client should be informed that exercise will be stopped at the maximal level of exertion or when manifestations become disabling. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013 Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 43

The nurse is in the screening room of a women’s health clinic. The nurse notices a particular woman that says for the past few months she has back and leg pain, spotting after intercourse with her husband, and vaginal discharge. The nurse suspects: A. Cervical Cancer B. Endometrial Cancer C. Ovarian cancer D. Vaginitis

Answer 43

Explanation A is correct. Signs and symptoms of cervical cancer include back and leg pain, spotting between menstrual periods and after intercourse, vaginal discharge, and lengthening of a menstrual period. A Pap Smear is needed to assess cellular changes and check for cancerous and precancerous conditions. B is incorrect. Endometrial cancer manifests as menorrhagia (excessive menstrual bleeding), low abdominal pain, backache, constipation due to pressure from an enlarging mass. A biopsy is needed to confirm the diagnosis. C is incorrect. Initial signs and symptoms of ovarian cancer include an increasing abdominal girth due to ovarian enlargement; Constipation, due to rectal pressure from the enlarging mass; Anemia, vomiting, and cachexia. D is incorrect. A bacterial infection causes vaginitis. Signs and symptoms include pruritus, burning urination, dysuria, dyspareunia, and a foul-smelling vaginal discharge. Reference Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012

Question 44

A client with prostate cancer is undergoing brachytherapy. His wife is visiting him and asks the nurse if she can spend some time with her husband a little more. The most appropriate response for the nurse should be: A. The hospital does not allow you to stay for more than the allotted visiting hours. B. You do not need to stay for longer than you should. C. Your husband will get better sleep if you go home. D. You can only stay up to half an hour to protect yourself from the radiation.

Answer 44

Explanation A is incorrect. This is an apathetic response from the nurse and is an inappropriate response. B is incorrect. This is an apathetic response from the nurse and is an inappropriate response. C is incorrect. This response does not address the situation. This is also an apathetic response from the nurse and is an inappropriate response. D is correct. Clients undergoing brachytherapy have radium implants. They should have limited close contact with a family of up to only 30 minutes a day. The visitors should limit their time of exposure to radium, have adequate distance between them, and use a lead shield against the radium. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 45

The nurse manager encountered several problems in the unit. She calls a staff meeting and presents several solutions to the staff during the meeting to ask for input. Upon hearing the staff’s opinions, the nurse manager implements several options presented. Which management style does the manager represent? A. Autocratic B. Democratic C. Participative D. Laissez-faire

Answer 45

Explanation A is incorrect. In autocratic leadership, decisions are made with little or no staff input. The manager makes all the decisions in the unit. B is incorrect. In Democratic style management, staff members are encouraged to participate in the decision-making process whenever possible. The majority of the decisions are made by the group, not the manager in this management style. C is correct. In a Participative management style, problems are identified by the manager and presented to the staff with several solutions. Staff members are encouraged to provide input; however, the manager makes the final decision. D is incorrect. Little direction, structure, or support is provided by the manager in a Laissez-faire type of management. The manager abdicates responsibility and decision making whenever possible in this type of control. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012

Question 46

The nurse is caring for a client with a diagnosis of stroke. The client has stage I dysphagia. Which food should the nurse feed the client? A. Peeled, ripe peaches B. Peas, squash, and cooked carrots C. Puréed meat and egg yolks D. Pies, cakes and ice cream

Answer 46

Explanation A is incorrect. A client with stage I dysphagia has severe difficulty in swallowing. Peaches require the client to control food in their mouths and cannot be given to this client. B is incorrect. Peas, squash, and cooked carrots are foods that can be given to a client with stage III dysphagia, where the client is now beginning to control diet in their mouths and can tolerate various food textures. C is correct. A client with stage I dysphagia has severe difficulty in swallowing. They must be fed with puréed foods. These include puréed fruits and vegetables, purréed meats with gravy, egg yolks, and baby food. D is incorrect. Pies, cakes, sherbet, and ice cream are foods that can be given to a client with stage III dysphagia, where the client is now beginning to control diet in their mouths and can tolerate various food textures. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013 Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 47

A client tells the nurse, “I never disagree with anyone. I have never disagreed with anyone I’ve known and probably never will.” The most appropriate response for the nurse would be A. “Wow, how is that even possible?” B. “Really? I find that unbelievable. A lot of people can’t do that.” C. “How do you deal with your feelings of dissatisfaction or anger?” D. “How did you develop such a way of life?”

Answer 47

Explanation Rationale: Option D is an open-ended manner of asking about the client’s way of life and allows the client to express himself or openly talk about himself. Option D is the most appropriate response and the correct answer. Options A and B imply disbelief and may be misinterpreted by the client as a challenge and may make the client defensive. The nurse should not ask about feelings of dissatisfaction or anger because the nurse should not identify the client’s feelings for him. Options A, B, and C are incorrect. Reference: Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 48

The nurse is taking care of a client that is suffering from orthostatic hypotension. The client’s health care provider is contemplating prescribing an alpha-adrenergic agonist. Does the nurse understand that which alpha-adrenergic agonist is most likely to be specified? A. Clonidine B. Phenylephrine C. Ephedrine D. Midodrine

Answer 48

Explanation A is incorrect. Clonidine is an alpha two receptor agonist that is used to treat essential hypertension. B is incorrect. Phenylephrine is a potent vasoconstrictor that is used in many cold and allergy products. C is incorrect. Ephedrine is an adrenergic agonist that is used for chronic management of asthma and allergic rhinitis. D is correct. Midodrine is an oral drug that is used to treat orthostatic hypotension in patients who do not respond to traditional therapy. It causes peripheral vasoconstriction and an increase in vascular tone and blood pressure. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013. Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009 Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006

Question 49

A hospitalized client tells the nurse that she has a living will prepared and that her lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse to help her obtain a witness to the will. Which of the following is the most appropriate response? A. “Don’t worry, I will sign as a witness to your signature.” B. “Because it is a legal document, you will need to find a witness on your own.” C. “Whoever is present at the time will sign as a witness for you.” D. “I will contact the nursing supervisor for assistance regarding your request.”

Answer 49

Explanation Rationale: Living wills are written legal instructions, signed by the client, and must be witnessed by specified individuals or notarized. Laws and guidelines regarding a living will vary from state to state, and it is the responsibility of the nurse to be knowledgeable of the rules. Many rules prohibit an employee, in this case, a nurse of a facility where the client is receiving care from being a witness. Option B is nontherapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor. Reference Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7thed. St. Louis, MO: Elsevier; 2013. Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8thedition, Nebraska: Elsevier 2009

Question 50

The client comes into the Emergency room complaining of unusual tiredness, ankle swelling, and seeing yellow rings all around. Upon assessment, the client has been experiencing loose bowels, and a review of medications reveals that the client is taking Digoxin. What is the nurse’s initial action? A. Reassure the client that he will be okay. B. Obtain an ECG. C. Notify the physician and inform him of the findings. D. Obtain a stool specimen.

Answer 50

Explanation A is incorrect. The client presents signs of digitalis toxicity exacerbated by dehydration and hypokalemia brought about by loose bowel motion. The nurse would reassure the patient but should address his physiological problems beforehand. B is incorrect. An ECG would be helpful to assess the cardiac status of the patient; however, the patient is showing clear signs of digitalis toxicity. The initial action of the nurse would be to inform the physician. C is correct. Signs of digitalis toxicity include an unusual slow irregular pulse, rapid weight gain, yellow vision, unusual tiredness, ankle swelling. Loose bowels may lead to hypokalemia, which increases the toxic effects of digitalis. The nurse should immediately notify the physician that appropriate treatment can be started. D is incorrect. Obtaining a stool specimen can be useful in ascertaining the cause of the patient’s loose stools. This is not, however, a priority nursing action. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013. Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006

Question 51

Upon assessment, the nurse noticed that the site of a client’s peripheral intravenous (IV) catheter is red, warm, painful, and slightly edematous near the insertion point of the IV catheter. After taking appropriate steps to address the issue and care for the client, the nurse documents in the medical record that the client experienced: A. Hypersensitivity to the IV solution B. Infiltration of the IV line C. Phlebitis of the vein D. Allergic reaction to the IV catheter material

Answer 51

Explanation Rationale: The symptoms of phlebitis at an IV site include redness, warmth, and swelling of the area proximal to the catheter. If this occurs, the nurse should discontinue the IV line and insert a new IV line at a different site. If the IV catheter were infiltrated, the area around the site would be cool. An allergic reaction produces a rash, redness, and itching. Therefore, the correct answer is option C, while options A, B, and D are incorrect. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6th Edition. Saunders-Elsevier 2014

Question 52

A client with Raynaud’s disease has just been prescribed ephedrine. What is the nurse’s most appropriate action? A. Provide dietary instructions to the client. B. Question the prescription to the physician. C. Instruct the client regarding adverse effects. D. Administer the medication initially to the client.

Answer 52

Explanation A is incorrect. Providing dietary instructions to the patient is an inappropriate action as this medication is contraindicated for the patient’s existing disease. B is correct. Clients with Raynaud’s disease or any other peripheral vascular disease are contraindicated to receive ephedrine or any other adrenergic agonist as these diseases could be exacerbated by systemic vasoconstriction. The nurse should question the physician regarding this prescription. C is incorrect. The nurse’s most appropriate action would be to question the physician’s prescription as the medication is contraindicated in the patient’s present condition. D is incorrect. The nurse should not administer the initial dose of a medication he knows will do the patient harm. The nurse should question the physician regarding the prescription. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013. Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009 Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006

Question 53

A 78-year-old woman is brought to the emergency department for the treatment of a fractured arm. On physical assessment, the nurse notices old and new ecchymotic areas on the client’s chest and legs and asks the client how the bruises were sustained. The client reluctantly tells the nurse that her son frequently hits her if supper is not ready when he gets home from work. Which of the following is the most appropriate nursing response? A. “Oh, really. Let me talk to your son.” B. “I appreciate your honesty but this is a legal issue, and I must tell you that I will need to report it.” C. “Let’s talk about the ways you can manage your time to prevent your son from getting upset.” D. “Do you have any friends that can help you out or keep you safe until you resolve these important issues with your son?”

Answer 53

Explanation Rationale: The nurse must and is compelled to report situations related to the child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Nurses must refrain from discussing confidential issues with nonmedical personnel or the client’s family or friends without the client’s permission. Clients are assured that information is kept confidential unless it places the nurse under a legal obligation. Options A, C, and D do not address the legal implications of the situation and do not ensure a safe environment for the client. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6thEdition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7thed. St. Louis, MO: Elsevier; 2013. Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8thedition, Nebraska: Elsevier 2009

Question 54

A nurse is assigned to care for a 2-year-old who is newly diagnosed with acute lymphocytic leukemia. Which action should be included in the client’s plan of care that is directed to facilitate growth and development in the acutely ill toddler? A. Focus on educating parents to minimize anxiety over parenting of the child B. Make sure that the toddler is informed in advance of what is to take place in a procedure C. Isolate child from parents, especially if there are temper tantrums. D. Encourage regression to a previous developmental level for familiarity and comfort.

Answer 54

Explanation Rationale: When a toddler is acutely ill, it is best to have parents who are not overly anxious and can work well with hospital personnel. It is, therefore, best to exert effort in educating the parents in this case. Option A is, therefore, the correct answer. Option B is not an appropriate action because a toddler’s thinking is concrete and tangible, and the toddler cannot think beyond the observable. Preparation should be done immediately before the procedure. Temper tantrums are a standard developmental characteristic of a 2-year-old, and the parents must hold her to alleviate fear. Isolating the toddler from her parents is not a therapeutic approach. Option C is, therefore, incorrect. A toddler may regress during hospitalization but will not facilitate comfort. Option D is an inappropriate action. Reference: Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 55

A nurse is assigned to care for a client with liver dysfunction and ascites. She is to measure the patient’s abdominal girth daily. To ensure accuracy, the nurse should use which landmark? A. the xiphoid process B. the umbilicus C. the iliac crest D. the symphysis pubis

Answer 55

Explanation Rationale: The umbilicus is the proper landmark for measuring abdominal girth. The technique involves circumventing the abdomen with a tape measure, with the umbilicus as the landmark. The xiphoid process, iliac crest, or symphysis pubis will most likely give inaccurate measurements. Option B is therefore correct, while options A, C, and D are incorrect. Reference: Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013. Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 56

The nurse is caring for a client in the Intensive Care Unit in acute respiratory failure. The nurse should expect which ABG results? A. pH: 7.29; PCO2: 56; PaO2: 83; HCO3: 22 B. pH: 7.38; PCO2: 40; PaO2: 92; HCO3: 25 C. pH: 7.49; PCO2: 34; PaO2: 96; HCO3: 28 D. pH: 7.40; PCO2: 65; PaO2: 85; HCO3: 16

Answer 56

Explanation A is correct. A client in respiratory distress should be expected to exhibit acidosis, hypoxemia, and hypercapnia (respiratory acidosis) in his ABGs. Option A indicates respiratory acidosis. B is incorrect. This is indicative of a normal Arterial blood gas result. C is incorrect. This is an arterial blood gas results showing respiratory alkalosis. Respiratory alkalosis commonly occurs in hyperventilation wherein more carbon dioxide is eliminated. D is incorrect. This is an example of a compensated respiratory acidosis. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013 Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 57

A patient is about to be inserted a Salem pump NG tube Which position should the nurse place the client? A. Supine, with head of the bed elevated at 30° - 45° B. Supine, with head of the bed elevated at 60° - 90° C. Knee-chest position D. Prone position

Answer 57

Explanation A is incorrect. The nurse should position the patient so that the insertion of the NG tube is facilitated. An elevation of 30° - 45° is not enough to facilitate the movement of the machine down the GI tract. B is correct. A supine position with a 60° - 90° elevation facilitates swallowing of the patient and lets gravity help in the movement of the tube down the GI tract. C is incorrect. A knee-chest position does not facilitate the movement of the tube down the GI tract. D is incorrect. A prone position does not facilitate the insertion of the NG tube. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013 Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 58

A postpartum client is preparing to be discharged home with her full-term newborn. She verbalizes, “I really should not get pregnant in the next three years so I could finish college.” History reveals that she smokes a pack a day of cigarettes. Which method of contraception would be most appropriate for her? A. Depo-Provera injection B. Condoms and foam C. Natural family planning D. Oral contraceptives

Answer 58

Explanation Rationale: Hormonal contraception such as Depo-Provera injection and oral contraceptives increases the risk of clotting and stroke in women who smoke ten or more cigarettes per day, and are not the best option for this client. Options A and D are, therefore, incorrect. Natural family planning involves intricate planning and timing sexual contact around the menstrual cycle and signs of ovulation. Though an effective method of birth control, it entails motivation and maturity. It is not likely to be useful for an older adolescent. Option C is, therefore, incorrect. Combining condoms and contraceptive foam is highly effective in preventing pregnancy. It is accessible, easily obtained, and also inexpensive (free if taken from the public health department). This is the most appropriate method for this client. Therefore, option B is the correct answer. Reference: Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 59

The nurse at an outpatient clinic is caring for a client with an acute attack of gout. The client states, “It feels excruciating whenever I start to walk.” Which instruction by the nurse is most appropriate in decreasing the client’s pain? A. You need to perform range of motion exercises before you get up and walk B. Don’t put all your weight on your foot if it hurts.” C. Don’t move your feet when resting.” D. You need to pace yourself. You need to limit the distance and time you walk

Answer 59

Explanation A is incorrect. The range of motion exercises aggravates the pain in the client with gout. B is correct. The nurse should instruct the client of partial weight bearing on the affected extremity to relieve weight, stress, and pressure on the affected leg. C is incorrect. Immobilizing the feet would increase stiffness in the client with gout. D is incorrect. Limiting the amount of activity of the client would aggravate pain and inflammation in his affected extremity. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 60

The nurse is implementing orders for a client to undergo a barium enema. Aside from the radiology department, which hospital department should be notified of the procedure? A. The cardiac catheterization department. B. The dietary department. C. The nuclear medicine department. D. The hospital laboratory department.

Answer 60

Explanation A is incorrect. The procedure is performed in the radiology department, not the cardiac catheterization department. Therefore the cardiac catheterization department does not need to be informed. B is correct. As part of preparations for a barium enema, the client needs to be on NPO for 8 – 10 hours. The dietary department needs to be informed about withholding meals within the NPO period. C is incorrect. The procedure does not contain any nuclear material; therefore, the nuclear medicine department does not need to be informed. D is incorrect. The laboratory should not be informed as it does not involve the laboratory. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Question 61

The husband of a client diagnosed with a brain tumor tells the nurse, “I don’t know how I will make it if something happens to my wife. I love her so much.” What is the most appropriate reply to the nurse? A. “Let me call the chaplain to come and talk to you.” B. “Do you have any family support to be with you?” C. “You don’t know how you will make it if something happens.” D. “Do not worry, everything will be all right. You are a strong man.”

Answer 61

Explanation A is incorrect. The nurse should not pass the responsibility to the chaplain. The nurse should address the comment. B is incorrect. The nurse is not needed to problem-solve at the moment. The nurse just needs to address the comments of the husband. C is correct. This is an appropriate response and encourages the client to ventilate her feelings. D is incorrect. This is offering false reassurance. This is a non-therapeutic response. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Question 62

Prednisone is to be given to a 4-year-old child with nephrotic syndrome. Which symptom would the nurse be alert for as a sign of a serious side effect of the medication? A. Respiratory rate of 12 breaths per minute B. Weight gain and increased hair growth C. Metabolic acidosis D. Decreased ACTH levels; stomach, muscle weakness, muscle pains

Answer 62

Explanation A is incorrect. Decreased respirations are a common side effect of prednisone in children; however, this is not a life-threatening side effect. B is incorrect. Prednisone can result in Cushingoid appearance; however, it is not a severe side effect of the medication. C is incorrect. Prednisone does not have metabolic acidosis as a side effect. D is correct. Prednisone can lead to adrenal suppression, which is a potentially life-threatening side effect of the drug. Reference Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4thEdition; Lippincott, Williams & Wilkins, 2003 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6thEdition. Saunders-Elsevier 2014

Question 63

After taking the health history of a client who admits to binge eating, which health concern should the nurse delve further with this client? A. Disorganized behavior B. Emotional hunger C. Adolescent turmoil D. Extreme restlessness

Answer 63

Explanation Rationale When a client continues to eat when already feeling full, he/she is into binge eating. This is a way to cope with emotions that aren’t being handled effectively or met. Adolescent turmoil isn’t necessarily associated with binge eating, while disorganized behavior and extreme restlessness are associated with bipolar disorder, not binge eating. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Question 64

A client in the maternity ward is about to be discharged after having a Dilatation and Curettage as elective abortion. The nurse is instructing her on complications that would warrant her to seek medical attention. Which statement by the client indicates a need for further teaching? A. “If I have stomach pain and tenderness, I can take a tablet of Tylenol.” B. “There will be instances that I will feel a sense of loss.” C. “I expect to have minimal vaginal bleeding for 10 - 14 days.” D. “I need to see a doctor if my temperature reaches 101 degrees Fahrenheit.”

Answer 64

Explanation A is correct. Abdominal tenderness and pain may indicate uterine infection. The client should report this to a physician. B is incorrect. Having an abortion would entail a sense of loss in the client. This is a regular occurrence, even if it is a blighted ovum. C is incorrect. There will be vaginal bleeding due to uterine changes in the client. The bleeding can last from 2 weeks up to a month. D is incorrect. Client’s that have undergone need to have a temperature of 101 degrees Fahrenheit to be classified as feverish. Reference Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6th Edition. Saunders-Elsevier 2014

Question 65

Due to the influx of patients at a local hospital because of a cholera outbreak, the charge nurse was asked by the nurse manager in which patients can be transferred to their rehabilitation ward to free up some space in the medical ward. Which client can be assigned? A. A client with diabetic foot. B. A client with right hemiparesis due to a TIA four days ago. C. A post Myocardial infarction patient with PVCs D. A client with pneumonia with a respiratory rate of 25

Answer 65

Explanation A is incorrect. This patient is still unstable and will need the care provided for in the acute care setting. B is correct. The client with hemiparesis is the most stable of all patients. The client will also benefit the most from the rehabilitation ward. C is incorrect. A client that suffered an MI and is having PVCs is at high risk for developing cardiac arrest. This patient is still unstable and will need the care provided for in the acute care setting. D is incorrect. The patient needs to be monitored in case he gets into respiratory arrest. This patient is still unstable and will need the care provided for in the acute care setting. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 66

Which of the following clients is at greatest risk for experiencing impaired vascular perfusion? A. A 76-year-old female client with a history of alcohol abuse. B. A 76-year-old female client with a history of radon gas exposure. C. A 64-year-old male client with a history of cigarette smoking. D. A 64-year-old male client with hypotension.

Answer 66

Explanation Choice D is correct. Perfusion refers to the continuous supply of blood through the blood vessels to vital organs. The client with hypotension is at the highest risk for impaired vascular perfusion. Hypotension can result from various causes such as adrenal insufficiency, dehydration, hemorrhage, septic shock, obstructive shock, and cardiogenic shock. A Mean Arterial Pressure (MAP) greater than 65 mm Hg is essential to maintain perfusion to vital organs. Prolonged hypoperfusion may lead to end-organ damage, such as renal failure and ischemic hepatitis. Therefore, the cause of hypotension must be identified and treated right away. Choices A, B, and C are incorrect. Alcohol abuse, cigarette smoking, and exposure to radon place people at risk for cancer. Prolonged cigarette smoking hastens atherosclerosis, leads to peripheral vascular disease and thereby, impairs perfusion. However, among the listed options, the patient at the greatest risk for impaired perfusion is the one with hypotension. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Reduction of Risk Potential Reference: Fundamentals of Nursing (Wilkinson and Barnett); Chapter20: Measuring Vital Signs

Question 67

A client who has a gastrostomy tube in place is being discharged. Enteral feedings will be continued at home. While doing client and family education, which statement made by a family member indicates the need for further teaching? A. “If he gets diarrhea for 2-3 days, I will call the doctor or nurse.” B. “I should expect a weight gain of about 1 lb/day now that he is on continuous feedings.” C. “When feeding, I should keep the head of his bed elevated or sit him in the chair.” D. “Prepared or open formula should be used within 24 hours and unused portions should be stored in the fridge.”

Answer 67

Explanation Rationale: Enteral feedings are best administered with the client’s head elevated to prevent reflux and aspiration pneumonia. The unused formula should be placed in the refrigerator to avoid the bacterial proliferation that can lead to gastroenteritis and even sepsis. Diarrhea is a common complication of tube feedings that may be a result of hypertonic formulas that draw fluid into the bowel. Other causes may be bacterial contamination, fecal impaction, medications, and low albumin. This can lead to dehydration and should be reported. A consistent weight gain of more than 0.5lb/day over several days should be reported promptly so that the client may be evaluated for fluid volume excess. The correct answer is option B. Options A, C, and D are incorrect. Reference: Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 68

Which of the following statements best describes the cardiovascular system? A. It has a heart with six chambers, strong vessels, and valves. B. It is a double-pump circulating blood out to the lungs and the body. C. It includes concepts of precontractility, postcontractility, and load. D. It functions with a conduction system and starts in the ventricles.

Answer 68

Explanation Choice B is correct. This statement is correct. The heart is a double pump with four chambers, four valves, and a conduction system with a pacemaker originating in the atrium. Choice A, C, and D are incorrect. These are incorrect statements about the cardiovascular system. The heart has four chambers, not six. These chambers include two atria ( right and left) and two ventricles ( right and left). Blood from the entire body returns to the heart's right atrium through superior and inferior ven cavae. Blood circulates through the right atrium, then to the right ventricle, gets oxygenated in the lungs, moves on to the left atrium, then left ventricle, and is pumped back to the systemic circulation via. the aorta. The conduction system of the heart begins in the right atrium, not the ventricle. The heart's conduction system includes pacemaker cells ( SA node, AV node, Bundle of His, bundle branches, and Purkinje fibers) plus contractile cells. The sinoatrial node ( SA node), located in the right atrium, is the pacemaker that sets the heart rate and is the starting point of the conduction system. The effectiveness of the pumping action of the heart is described in concepts of preload, afterload, and contractility. Preload ( end-diastolic volume) is the amount of initial stretching of the ventricles before the contraction ( systole) begins. Preload is determined by the venous return to the heart and is directly related to ventricular filling. Afterload refers to the resistance/ load against which the left ventricle pumps out the blood. Afterload is directly determined by aortic pressure ( systemic vascular resistance, SVR). Finally, contractility (inotropy) refers to the innate ability of heart muscle to contract at a given afterload and preload. Preload, afterload, and contractility determine the stroke volume and ejection fraction. Therefore, understanding these concepts is important to understand the pathophysiology of heart failure and the rationale for using certain medications in heart failure. Several medications are used in heart failure, and they work by different methods. Diuretics and nitrates reduce the preload. Anti-hypertensive medications such as angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARBs) work by reducing both the preload and afterload. ACEI/ ARBs are the drugs of choice in the long-term management of congestive heart failure. Positive inotropic drugs such as digoxin, dopamine, dobutamine, and milrinone directly increase contractility and are often used in acute heart failure. NCSBN Client Need - Topic: Physiological Integrity; Subtopic: Physiological Adaptation

Question 69

The nurse at the gynecology clinic is talking to a client who wishes to have a prescription of oral contraceptives. The nurse finds out that the client has also been prescribed tetracycline 500mg PO. What is the most appropriate nursing intervention? A. Provide the prescription for oral contraceptives. B. Offer other forms of contraception until the antibiotics are finished. C. Contact the prescribing physician of the antibiotic. D. Tell the client to discontinue taking the antibiotics.

Answer 69

Explanation A is incorrect. The nurse cannot give the oral contraceptive prescription to the client right away as the doctor needs to change the order of the antibiotic. B is incorrect. It is not for the nurse to decide which medication the physician will change. That is why the nurse needs to contact the physician first before initiating some action. C is correct. The nurse should be aware that tetracyclines decrease the effectiveness of oral contraceptives. The physician will need to decide whether to prescribe an equally effective antibiotic or to suggest another form of birth control for the client. The nurse must inform the physician. D is incorrect. The nurse should not tell the client to stop taking antibiotics unless the physician makes an order to prevent it. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 70

The nurse is caring for a 4-day post-abdominal surgery client. The nurse notes a temperature of 37 °C, no complaints of pain at the incision site, dry wound dressing, and hypoactive bowel sounds on all quadrants. Which conclusion can the nurse make based on all the assessment data? A. The client’s wound is getting infected. B. The nurse should implement pain relief measures. C. There are no present problems for the client. D. The nurse should perform additional GI assessment.

Answer 70

xplanation A is incorrect. The client’s wound dressing is dry and intact, and the client is not hysterical. There is no sign of infection. B is incorrect. The client states that he is not in pain; there is no need for pain relief. C is incorrect. The client is four days post-op; the client is already expected to have normoactive bowel sounds. However, the client is exhibiting hypoactive bowel sounds. That signifies a problem. D is correct. The nurse should use all the data he has gathered to analyze the situation. The client has had abdominal surgery, and he has hypoactive bowel sounds. The nurse needs to do a further assessment to determine if there are any impending GI problems for the client and for any treatments to be initiated. Reference Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013 Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 71

A client is at the clinic for hypersensitivity testing with the intradermal technique. The proper technique of administering the allergen would be to position the needle: A. at 0 degrees against the skin B. at 15 degrees insertion C. at 45 degrees D. at 90 degrees with a dart-like motion

Answer 71

Explanation Rationale: The proper angle for intradermal injections is at 15 degrees. A 45-degree perspective is used for subcutaneous injections, while a 90-degree angle is used for intramuscular injections. There are no injections administered at a 0-degree angle. The correct answer is option B, while options A, C, and D are incorrect. Reference: Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 72

The healthcare provider has prescribed 50,000-units of Heparin via SC injection for a client with pulmonary emboli. The vial on hand contains 20,000 units per ml. The nurse calculates that the drug volume to be administered should be 2.5ml. The nurse verifies that the client understands the action of the medication when the client states: “This medication will help prevent blood clots.” After double-checking the dosage, the nurse decides to: A. Hold administration and contact the healthcare provider first to clarify the dosage calculation B. Administer 0.2ml of the medication instead of the calculated volume of 2.5ml C. Go ahead and administer the prescribed dose while monitoring the client for signs of bleeding D. Administer the medication as prescribed and institute bleeding precautions and instruct the client to stay on bed to prevent injury

Answer 72

Explanation Rationale: The therapeutic dosage for Heparin is 5000 U. The prescribed dosage of 50,000 U is unsafe and would put the client at high risk for bleeding. The nurse should verify the dose with the healthcare provider. The nurse must never alter the prescribed dosage of any medication without consulting the physician. Medication administration is a collaborative action with the client’s healthcare provider. There is no need to reinforce teaching as the client already understands the action of the medication. The correct answer is therefore option A. Options B, C, and D are incorrect. Reference Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Question 73

A client is hospitalized for acute exacerbation of his COPD. The nurse taking care of him would expect to find which assessment finding? A. A Carbon dioxide level of 31 mm hg from his ABGs. B. An overinflated chest on the chest x-ray. C. Improving oxygen saturation upon exercise. D. A wide diaphragm on the chest x-ray.

Answer 73

Explanation A is incorrect. In clients with COPD, carbon dioxide is trapped in the lungs resulting in an increased carbon dioxide level. B is correct. In clients with COPD, there is a loss of elasticity in the lungs leading to congestion and hyperelasticity of the lungs, as seen on the chest X-ray. C is incorrect. Clients with COPD display a decrease in oxygen saturation during exercise due to airflow limitation. D is incorrect. Clients with COPD display a flattened diaphragm, not a full diaphragm. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 74

A middle-aged African American is being treated in the emergency room for sickle cell crisis. Which position should the nurse place the patient? A. Side-lying with flexed knees B. Fetal position C. Semi-Fowler’s position with knees and hips bent D. Semi-Fowler’s with legs extended on the bed

Answer 74

Explanation A is incorrect. The nurse should facilitate oxygenation and adequate circulation for the client. Knee flexion impedes the flow of the client. B is incorrect. In a fetal position, the client’s knees and hips are flexed. Knee and hip flexion impede circulation in the patient. The nurse should ensure that flow is optimal when positioning the client. C is incorrect. Semi-Fowler’s position facilitates lung expansion; however, the bent knees and hips impede the client’s circulation. The nurse should not place the client in this position. D is correct. The client in sickle cell crisis should be positioned to optimize circulation and oxygenation. The nurse should place the client in Semi-Fowler’s position with his extremities relaxed and straightened. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013 Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 75

A pregnant woman is admitted to the ER with an initial diagnosis of placenta previa. The nurse carries out orders to start an IV infusion, administer oxygen, and extract blood for laboratory tests. The client is getting anxious and asks the nurse what is happening. The nurse tells her not to worry and that everything is under control. What is the best description of the nurse’s statement? A. Incorrect, the doctor should be the one to offer information and assurances. B. Questionable, because the patient has the right to understand the type of treatment and the reason for the treatment. C. Effective, because the response lowers the client’s anxieties. D. Adequate, because the preparations are routine and need no explanation.

Answer 75

Explanation A is incorrect. In the Patients’ Bill of Rights, the patient has the right to be informed by healthcare staff about any procedure that will be done to her. B is correct. There was a violation of the client’s rights. The client has the right to accurate and complete explanations about any procedures to be performed. C is incorrect. The nurse has the responsibility to inform the client regarding the procedure that is going to be performed to her. D is incorrect. The procedure may be routine work for the nurse, but it is not routine for the client and should be explained to her. Reference Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012

Question 76

A client with Alzheimer’s disease is being cared for by the nurse. Which nursing problem for the client would be the nurse’s primary concern? A. Inability to do activities of daily living. B. Increased risk for injury. C. Potential for constipation. D. Ineffective family coping.

Answer 76

Explanation A is incorrect. Alzheimer’s patients have difficulty completing activities of daily living. However, the nurse should prioritize client safety over other problems. B is correct. Safety should be the highest priority for the client. Clients with Alzheimer’s disease are unaware of their surroundings and tend to wander. The nurse should implement safety measures. C is incorrect. Older clients have an increased risk for constipation; however, their safety should take priority for other concerns. D is incorrect. It is understandable for the family to be troubled regarding their loved one’s condition. However, the nurse should always prioritize the client’s safety over other problems. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013. Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 77

A child with Pulmonary tuberculosis is to be admitted to the pediatric unit. The charge nurse finds out that there are no more private rooms available in the unit, and there are no patients with tuberculosis admitted as well. What is the most appropriate action by the charge nurse? A. Inform the infection control nurse B. Room the client with another uninfected child 6 feet apart C. Room the client with another infected child 6 feet apart D. Refuse to admit the child

Answer 77

Explanation A is correct. The nurse should consult the infection control nurse for alternatives for patient placement. B is incorrect. The disease is transmittable through airborne droplets. The uninfected child can acquire the infection through the airborne droplets. C is incorrect. The infected child can be infected by the TB through the airborne droplets. D is incorrect. The staff should consult someone first before refusing to accept the child for admission.

Question 78

The nurse is caring for a client receiving total parenteral nutrition for 2 weeks. Which action by the nurse is the most important? A. Determining weight changes in the client. B. Monitoring laboratory results. C. Maintaining strict asepsis during dressing changes in the IV line. D. Monitoring of blood glucose levels.

Answer 78

Explanation A is incorrect. Obtaining the client’s weight is essential to assess the client’s nutritional status. However, this is not the nurse’s priority intervention. B is incorrect. The nurse should monitor laboratory results to monitor changes in electrolytes. However, this is not a priority action. C is correct. TPN has high glucose content making it an ideal medium for bacterial growth. The nurse should perform strict asepsis during dressing changes in the TPN line. D is incorrect. TPN may cause an increase in blood sugar levels in the first 48 hours of administration as the client has not yet adjusted to the glucose load of the patient. However, since it is already two weeks of administering the solution, the client should have already changed to the TPN solution. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 79

A nasogastric tube has been inserted into a client with bowel obstruction for gastric decompression. The nurse should set the suction on which setting? A. Intermittent suction at 70 mm Hg B. Intermittent suction at 100 mm Hg C. Continuous suction at 100 mm Hg D. Continuous suction at 70 mm Hg

Answer 79

A is correct. Gastric decompression should always intermittent and at low suction pressure. A suction pressure below 80 mm Hg is considered low suction. B is incorrect. Continuous and high suction pressure for gastric decompression should be avoided as this predisposes the gastric mucosa to injury and ulceration. C is incorrect. Continuous and high suction pressure for gastric decompression should be avoided as this predisposes the gastric mucosa to injury and ulceration. D is incorrect. Continuous and high suction pressure for gastric decompression should be avoided as this predisposes the gastric mucosa to injury and ulceration. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013. Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 80

A 3-month-old infant is in the emergency room for acute abdominal pain. The nurse suspects intussusception. Which assessment data would further support the nurse’s suspicion? A. black tarry stool B. ribbon-like stool C. red, currant jelly like stool D. frothy, foul smelling stool

Answer 80

Explanation A is incorrect. Black tarry stools indicate upper GI bleeding in a patient. B is incorrect. Ribbon-like stools are a characteristic of Hirschsprung’s disease. C is correct. Red currant jelly-like stools are a characteristic of intussusception. D is incorrect. Frothy foul-smelling stools are a characteristic stool pattern for cystic fibrosis. Reference Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4thEdition; Lippincott, Williams & Wilkins, 2003 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6thEdition. Saunders-Elsevier 2014

Question 81

A patient is rushed to the ER following a near-drowning episode at a local beach. Does the nurse anticipate which conditions to be present in the patient? A. Hypoxia, hypercarbia, acidosis B. Coma, hyperthermia, alkalosis C. Hypothermia, hypocapnia, alkalosis D. Hyperthermia, hyperoxia, acidosis

Answer 81

Explanation A is correct. Following a near-drowning incident, the patient will most likely exhibit symptoms of hypoxia (decreased oxygen levels in the blood), hypercarbia (increased carbon dioxide levels in the blood), and acidosis (respiratory) due to a prolonged period of having a lack of oxygen. B is incorrect. Although the patient may be in a coma after near-drowning, hyperthermia and alkalosis are least likely. There would be a high chance of acquiring hypothermia, mainly if the patient stayed in the water for too long before being rescued. Alkalosis will not result from a lack of oxygen in the body; instead, acidosis will occur. C is incorrect. Although hypothermia is a possibility in near-drowning situations, lack of oxygen for long periods will produce hypercapnia/hypercarbia and acidosis. D is incorrect. Hypoxia will result from long periods without oxygen, not hyperoxia. Hyperthermia is least likely to occur in near-drowning incidents. References Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012

Question 82

The nurse is working at a women’s health clinic. A patient comes in suspected of having Trichomoniasis. Upon physical examination of the perineal region, the nurse should expect which type of sign? A. White “cheesy” discharge B. Malodorous, thin, yellow discharge C. Grayish-white discharge; malodorous D. No vaginal discharge

Answer 82

Explanation A is incorrect. A white “cheesy” discharge is indicative of moniliasis or candidiasis, which is caused by Candida albicans. B is correct. Trichomoniasis patients would yield a malodorous, thin, yellow discharge. Trichomoniasis is caused by a protozoon, Trichomonas vaginalis. C is incorrect. Grayish-white malodorous discharges would indicate bacterial vaginosis. D is incorrect. Patients with trichomoniasis yield a malodorous, thin, yellow discharge. Reference Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012

Question 83

A 32-year-old man comes into the emergency department after being hit by a baseball bat in his chest. The nurse would suspect a pneumothorax because of which sign? A. Decreased respiratory rate B. Diminished breath sounds C. Presence of a barrel chest D. A sucking sound at the injury site

Answer 83

Explanation A is incorrect. The client who has a pneumothorax would display tachypnea, or an increase in respiratory rate, not a decrease in respiratory rate. B is correct. A client who experiences a pneumothorax may initially experience shortness of breath and chest pain. When the pneumothorax increases in size the client will display an increased respiratory rate, cyanosis, diminished breath sounds, and subcutaneous emphysema. C is incorrect. A barrel chest would indicate emphysema, a form of COPD. Patients with pneumothorax do not exhibit a barrel chest. D is incorrect. The client’s injuries are from a blunt object; therefore, the resulting pneumothorax would be a closed one. A sucking sound at the site of injury would denote an open chest injury. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 84

A woman comes into the ER with a laceration on the forehead and a broken nose. The nurse asks the accompanying man to leave the examination room, however, the man refuses. What is the most appropriate action of the nurse? A. Tell the man that the client needs to go the x-ray department. B. Call hospital security and have the man escorted from the room. C. Explain to the man that the nurse needs to examine the client and he must provide privacy. D. Hand the client a leaflet about domestic abuse.

Answer 84

Explanation A is correct. The nurse needs to be alone with the client so that she can talk to her about possible abuse. Taking the client to the x-ray department does not arouse suspicion from the man and may allow the client to talk about the situation. B is incorrect. This may cause problems in the ER and may cause more problems for the client when she goes home with the man. C is incorrect. This action may provoke the man even more and cause his anger to escalate. This is an inappropriate action of the nurse. D is incorrect. The man may see the leaflet and may escalate the problems for the client. The nurse should not do this. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Question 85

A client brought into the Emergency Department from a vehicular accident has sustained excessive blood loss and is in need of blood transfusion. The blood typing test returned a result of AB negative. From the blood types at hand, which is the safest type for the nurse to administer? A. AB positive B. O positive C. B negative D. A positive

Answer 85

Explanation Rationale: Individuals with AB negative blood type (AB type, Rh-negative) can receive A negative, B negative, and AB negative blood only. It is unsafe to administer Rh-positive blood to an Rh-negative person. Reference: Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Question 86

The client is receiving instructions from the nurse in a clinic about interventions that help alleviate symptoms of gastroesophageal reflux disease. Which statement from the client indicates an accurate understanding of the instructions given? A. “It’s much better for me to wear loose fitting clothes right now.” B. “Thank goodness, I can still eat burger and fries.” C. “A glass of wine before bedtime can help me sleep better.” D. “I need to take my medication, Omeprazole, after meals.”

Answer 86

Explanation A is correct. The client with GERD is advised to avoid tight clothing and wear loose-fitting clothing. B is incorrect. The client with GERD is encouraged to eat a low fat, high fiber diet. Burger and fries have high-fat content and may stimulate excess gastric acid production. C is incorrect. Clients are instructed to avoid eating and drinking 2 hours before bedtime; they also need to avoid alcohol. D is incorrect. Omeprazole is a proton pump inhibitor; it needs to be taken 20 – 30 minutes before meals to achieve its desired effect. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013. Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 87

A 15-year-old admitted for status asthmaticus has been stabilized. Which activity would be most appropriate for the client? A. Completing a jigsaw puzzle B. Talking with friends on the phone C. Watching basketball on television D. Putting together a necklace

Answer 87

Explanation A is incorrect. Teenagers need an opportunity to interact with peers during their times of sickness to have an outlet to express their concerns. Completing a jigsaw puzzle does not give the teenager an opportunity to achieve this. B is correct. Teenagers need an opportunity to interact with peers during their times of sickness to have an outlet to express their concerns. Talking to friends over the phone enables the client to achieve this. C is incorrect. Teenagers need an opportunity to interact with peers during their times of sickness to have an outlet to express their concerns. Watching television does not give the teenager an opportunity to achieve this. D is incorrect. Teenagers need an opportunity to interact with peers during their times of sickness to have an outlet to express their concerns. Arts and crafts do not give the teenager an opportunity to achieve this. Reference Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4thEdition; Lippincott, Williams & Wilkins, 2003 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6thEdition. Saunders-Elsevier 2014

Question 88

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse was about to attach the distal end of the IV tubing to a needleless device, the exposed tubing drops and hits the top of the medication cart. Which of the following is the most appropriate action by the nurse? A. Get a new IV tubing B. Discard the old needleless device and attach a new one C. Wipe the distal end of the tubing with Betadine to render is sterile D. Scrub the needleless device with an alcohol swab

Answer 88

Explanation Rationale: The nurse should change the IV tubing as it has been contaminated and may cause a systemic infection to the client. It must not be wiped with Betadine since it will be attached to a cannula that is directly inside the client’s vein. There is no need to change the needleless device because it has not been contaminated. The correct answer is, therefore, option A. Options B, C, and D are incorrect. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6th Edition. Saunders-Elsevier 2014

Question 89

A widower has been complaining that he could not sleep, he is short of breath, extremely anxious, and has been having a sense of impending doom. Which response by the nurse is most appropriate? A. “Just relax. You’re in a safe place now. You have nothing to worry about.” B. “Has anything happened recently, or is there anything in the past that could have triggered these feelings?” C. “The medication I have given you will help decrease these feelings of anxiety.” D. “Why don’t you take some deep breaths to help you calm down?”

Answer 89

Explanation Rationale: Option B reassures the client and provides an opportunity to gain insight into the root of the client’s anxiety. Telling the client she has nothing to worry about dismisses the client’s feelings and only gives her false reassurance. Simply giving her medications and instructing her to calm down doesn’t allow the client to verbalize her feelings, which is necessary for her to understand and resolve the cause of anxiety. Options A, C, and D are therefore incorrect. Reference: Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Halter, MJ. Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 7th Ed. St. Louis, MO: Mosby Elsevier; 2014:14

Question 90

mother brings her toddler to the GP. Her child is on digoxin for congestive heart failure. The nurse tells the mother about signs of digoxin toxicity. Which statement by the mother would indicate an understanding of the topic? A. “I will have my son checked if his respirations are less than 20” B. “I will stop digoxin if my son does not gain any weight after 6 months.” C. “I will avoid feeding him potassium rich food.” D. “I will have the doctor see my son if he vomits.”

Answer 90

Explanation A is incorrect. A decreased respiratory rate is not associated with digitalis toxicity. A reduced heart rate is a sign associated with digitalis toxicity. B is incorrect. Failure to thrive is commonly associated with congestive heart failure. However, it is not associated with digitalis toxicity. The mother should also not discontinue any medications unless told by a doctor. C is incorrect. The mother needs to serve high potassium food to her child as a low potassium level will aggravate digitalis toxicity. D is correct. Vomiting is an early sign of increased digoxin levels in the blood. The mother should bring her son to the doctor immediately to have his serum digoxin levels checked so that appropriate intervention can be initiated. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Question 91

Which of the following clients is at greatest risk for experiencing impaired vascular perfusion? A. A 76-year-old female client with a history of alcohol abuse. B. A 76-year-old female client with a history of radon gas exposure. C. A 64-year-old male client with a history of cigarette smoking. D. A 64-year-old male client with hypotension.

Answer 91

Explanation Choice D is correct. Perfusion refers to the continuous supply of blood through the blood vessels to vital organs. The client with hypotension is at the highest risk for impaired vascular perfusion. Hypotension can result from various causes such as adrenal insufficiency, dehydration, hemorrhage, septic shock, obstructive shock, and cardiogenic shock. A Mean Arterial Pressure (MAP) greater than 65 mm Hg is essential to maintain perfusion to vital organs. Prolonged hypoperfusion may lead to end-organ damage, such as renal failure and ischemic hepatitis. Therefore, the cause of hypotension must be identified and treated right away. Choices A, B, and C are incorrect. Alcohol abuse, cigarette smoking, and exposure to radon place people at risk for cancer. Prolonged cigarette smoking hastens atherosclerosis, leads to peripheral vascular disease and thereby, impairs perfusion. However, among the listed options, the patient at the greatest risk for impaired perfusion is the one with hypotension. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Reduction of Risk Potential Reference: Fundamentals of Nursing (Wilkinson and Barnett); Chapter20: Measuring Vital Signs

Question 92

The nurse is working in the emergency department when an elderly man is rushed in with complaints of dizziness, weakness, headache, and nausea. The patient’s shirt is drenched in sweat. His son who accompanied him to the ER tells the nurse that they were watching his 10-year-old grandson’s baseball game when suddenly his dad complained of a severe headache and weakness. The nurse understands that based on the client’s presentation and history, he is most likely suffering from: A. Myocardial infarction B. Left sided Heart failure C. Pulmonary embolism D. Heat exhaustion

Answer 92

Explanation A is incorrect. Although profuse sweating is one sign of myocardial infarction, all signs and symptoms point to heat exhaustion/heat stroke since the client has been out in the open and had been under the sun. There is also no complaint of chest pain from the client which is indicative of myocardial infarction. B is incorrect. All signs and symptoms point to heat exhaustion/heat stroke since the client has been out in the open and had been under the sun. Signs of heart failure include respiratory symptoms from pulmonary edema; namely cough, crackles, shortness of breath. All of which was not manifested by the client. C is incorrect. Signs and symptoms of pulmonary embolism are tachypnea, dyspnea, anxiety, and chest pain. The client did not display any of these signs or symptoms. D is correct. Signs and symptoms of heat exhaustion include headache, dizziness, nausea, and weakness. Because of excessive sweating, hyponatremia can also be present. Reference Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 93

client was brought into the emergency department by his wife because he has been vomiting for three days. The wife is worried because he has grown weak and seems to be having a hard time breathing. The nurse notes that he is hypoventilating and has a respiratory rate of 10 breaths/min. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/min. Consequently, arterial blood gases are drawn, and the nurse reviews the results, expecting to note which of the following? A. A decreased pH and an elevated CO2 B. An elevated pH and a decreased CO2 C. A decreased pH and a decreased HCO3_ D. An increased pH with an increased HCO3_

Answer 93

Explanation Rationale: Persistent nausea and vomiting would most likely lead to metabolic alkalosis because of the loss of gastric acid, thus causing the pH and HCO3_to increase. Hypoventilation and tachycardia are some symptoms the patient may experience. Option A reflects a respiratory acidotic condition. Option B reflects a respiratory alkalotic status. Option C reflects a metabolic acidotic status. Therefore, option D is the correct answer. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6thEdition. Saunders-Elsevier 2014

Question 94

The husband of a client diagnosed with a brain tumor tells the nurse, “I don’t know how I will make it if something happens to my wife. I love her so much.” What is the most appropriate reply to the nurse? A. “Let me call the chaplain to come and talk to you.” B. “Do you have any family support to be with you?” C. “You don’t know how you will make it if something happens.” D. “Do not worry, everything will be all right. You are a strong man.”

Answer 94

Explanation A is incorrect. The nurse should not pass the responsibility to the chaplain. The nurse should address the comment. B is incorrect. The nurse is not needed to problem-solve at the moment. The nurse just needs to address the comments of the husband. C is correct. This is an appropriate response and encourages the client to ventilate her feelings. D is incorrect. This is offering false reassurance. This is a non-therapeutic response. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013.

Question 95

The client with a diagnosis of Diabetes Mellitus is being discharged with Novolog insulin. The nurse is instructing him about the effects of Novolog, particularly its peak effects. Which statement by the nurse indicates client understanding? A. “I need to eat breakfast within 10 minutes of taking my insulin.” B. “I must have some candy or any form of sugar with me all the time.” C. “I need to eat some snacks early in the afternoon.” D. “I need to eat something sweet before bedtime.“

Answer 95

Explanation A is correct. Novolog has a very quick onset and peak action. Its onset is 15 minutes from administration and peaks at 1-2 hours after administration. The client should understand that he needs to eat within 10-15 minutes of drug administration to prevent hypoglycemia. B is incorrect. This is true in all patients that receive any medication that lowers blood sugar levels. This however, does not apply particularly Novolog insulin. C is incorrect. NPH insulin peaks at 8-12 hours after administration (around 2-3 pm in the afternoon if taken in the morning before breakfast). However, Novolog is rapid-acting insulin whose peak is at 1-2 hours after administration. D is incorrect. There is no need to eat something sweet at bedtime is not necessary. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013. Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 96

A client with hyperthyroidism is scheduled to have a thyroidectomy. The physician prescribes Logul’s solution, and the nurse is about to administer it to the client. The client asks the nurse what the purpose of the medication is. The nurse’s most appropriate response would be: A. to prevent hypocalcemia B. to decrease the client’s anxiety during surgery C. to reduce the size of the thyroid and reduce bleeding D. to increase the effects of anesthesia

Answer 96

Explanation A is incorrect. Lugol’s solution does not increase calcium levels. It does not act to prevent hypocalcemia. B is incorrect. Anxiolytics reduce anxiety during surgery, not Lugol’s solution. C is correct. Lugol’s solution is also known as the Iodine solution. The client may receive Lugol’s solution for 10 to 14 days before surgery to decrease vascularity of the thyroid and thus prevent excess bleeding. D is incorrect. Lugol’s solution does not increase the effects of anesthesia. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 97

A. Notify the physician. B. Wait until the IV fluid is consumed and start the blood transfusion. C. Stop the IV infusion, flush the line with normal saline then transfuse the blood. D. Insert a new IV line and start the blood transfusion there.

Answer 97

Explanation A is incorrect. Administering a blood transfusion does not necessitate informing the physician. As long as the order for the blood is valid, and there are no pressing issues with the client, there is no need for the nurse to contact the physician. B is incorrect. There is no need to wait for the IV fluid to be finished to start the blood transfusion unless specifically instructed by the physician. The nurse can interrupt the IV, administer the blood, and resume it after the bleeding is finished. C is correct. The nurse should interrupt the IV fluid and flush the line with normal saline to prevent any blood from hemolytic. Once the line is flushed, the nurse may now transfuse the blood. D is incorrect. The nurse does not need to insert a new IV line to transfuse the blood unless there are specific contraindications to administering the blood on the site. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013. Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 98

The nurse educator is giving a lecture on the different types of arthritis. Does the nurse educator emphasize which findings that distinguish rheumatoid arthritis from gouty arthritis and osteoarthritis? A. Crepitus with range of motion B. Symmetry of joint involvement C. Elevated serum uric acid levels D. Dominance in weight bearing joints

Answer 98

Explanation Rationale: The distinguishing factor in all three types of arthritis is the symmetry of joint involvement. Rheumatoid arthritis is symmetrical and bilateral, while osteoarthritis and gout are unilateral. Osteoarthritis is characterized by crepitus. Gout is manifested by elevated serum uric acid levels, while Osteoarthritis is characterized by the involvement of dominant weight-bearing joints. Reference: Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013. Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 99

The client in the delivery room has just delivered her third child. The physician ordered methylergonovine (Methergine) to the client and was promptly administered. Which manifestation would indicate to the nurse that the medication is having its intended effect? A. The client reports a decrease in pain. B. The nurse palpates a firm uterus on the client. C. The client states that she wants to empty her bladder. D. The client’s blood pressure increases.

Answer 99

Explanation A is incorrect. Methylergonovine does not control pain. It is an ergot alkaloid that promotes vasoconstriction and uterine muscle constriction. B is correct. Methylergonovine promotes vasoconstriction and uterine contraction. A firm and contracted uterus is a sign that the medication is having its desired effect. C is incorrect. Methylergonovine does not promote urine production nor stimulate urination. D is incorrect. An increase in blood pressure is a side effect of methylergonovine. Its primary indication and effect is uterine contraction and vasoconstriction, which leads to a rise in blood pressure. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006 Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Question 100

The nurse is preparing to administer Prednisone 5 mg to a client with Hyperparathyroidism. The nurse understands that Prednisone is given to the client because: A. Prednisone increases the clients’ immune function B. Prednisone increases the clients’ Vitamin D levels C. Prednisone decreases GI absorption of calcium D. Prednisone decreases the release of Calcium by the bones

Answer 100

Explanation A is incorrect. Prednisone is an immunosuppressant. It does not promote immune function. B is incorrect. Prednisone does not have any effect on Vitamin D levels. C is correct. Prednisone decreases the absorption of Calcium in the gastrointestinal system thereby reducing serum calcium levels in the patient with hyperparathyroidism D is incorrect. Etidronate (Didronel) and Calcitonin are drugs that prevent the release of calcium from the bones, not Prednisone. Reference: Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 101

The nurse is caring for a one week post-operative right below-the-knee amputation client with peripheral arterial occlusive disease. The nurse cannot palpate a pedal pulse in the client’s left foot. What is the nurse’s next action? A. Ask the client if he feels numbness on the left foot and ask him to move his left foot. B. Check the pulse using a Doppler device. C. Lower the client’s leg and check for a pulse again. D. Apply warm compress to the client’s leg.

Answer 101

Explanation A is correct. It is common for clients with arterial occlusive disease to have absent pedal pulses. Absent or diminished pedal pulses alone does not warrant immediate action. However, if there are any other signs or symptoms of arterial occlusion or signs of impending gangrene, the nurse must notify the physician. Signs of acute occlusion include pain, pallor, paralysis ( loss of function), numbness, and paresthesis. The nurses should first assess the client for numbness in his toes, and whether he can move them. If no other symptoms, there is no need for immediate intervention. B is incorrect. The nurse can use a Doppler device to locate a pulse if it cannot be palpated. The nurse should first check for compromised oxygenation in the left foot before using the Doppler. C is incorrect. Lowering the foot can increase blood flow and help the nurse in palpating for a pulse. This is not, however, the priority action. D is incorrect. Warming the extremity also helps in palpating for a pulse. However, this is not the first action of the nurse. Reference Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier

Question 102

n infant has just been diagnosed with cystic fibrosis. The nurse understands that the priority nursing goal for the family is to A. stabilize the child B. provide emotional support C. arrange for financial assistance D. formulate long range plans

Answer 102

Explanation A is incorrect. The infant has already been stabilized, so there is no longer a need to maintain the infant. B is correct. The family needs emotional support when a chronic condition is newly diagnosed in a family. The parents need to follow up on genetic counseling, treatment options, prognosis, and resources. C is incorrect. This is a long term goal for the family. D is incorrect. This is a long term goal for the family. Reference Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4thEdition; Lippincott, Williams & Wilkins, 2003 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination, 6thEdition. Saunders-Elsevier 2014

Question 103

The nurse is caring for an 18-month-old toddler with cough and fever. Which is the most appropriate play activity for the nurse to give to the toddler? A. Toy puzzles B. Miniature cars C. Finger painting D. Comic book reading

Answer 103

Explanation A is incorrect. Puzzles may be too difficult to manipulate, and some pieces may be small enough to be aspirated. B is incorrect. Miniature cars have a high potential for aspiration. C is correct. Toddlers enjoy feeling different textures. They are sensorimotor learners at this point. Finger paints would be an appropriate toy choice. D is incorrect. Comic books are too advanced for toddlers. Although they are enjoyable to watch because of the pictures, the toddler cannot fully appreciate the comic book yet. Reference Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 104

The nurse is having her shift in the nursery. Which of the following newborns would warrant further investigation and intervention from the nurse? A. An hour old newborn with lanugo B. A 6 hour old newborn with a respiratory rate of 50 C. A crying 12 hour old newborn that is turning red D. A day old newborn that has not passed meconium

Answer 104

Explanation A is incorrect. A newborn with lanugo is typical. This would not warrant immediate intervention. B is incorrect. A standard respiratory rate for a newborn is 30 - 60; this would not warrant immediate intervention. C is incorrect. A new turning red when crying is ordinary; this would not warrant immediate intervention. D is correct. A newborn who has not passed meconium 24 hours after birth must be assessed for intestinal obstruction or congenital abnormalities. This may be caused by an imperforate anus and several other possibilities. This newborn must be evaluated immediately. Reference Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003 Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 105

A 30-year-old male client in the medical ward for admitted for hiatal hernia is being discharged today. The nurse talks to him regarding methods to prevent and reduce pain associated with his condition. Which of the following statements from the client indicate that teaching is successful? A. “I need to wear loose-fitting clothes.” B. “After a meal, I must lie down to avoid dumping syndrome.” C. “I need to eat three large meals a day.” D. “I can go to my favorite Indian restaurant anytime of the week.”

Answer 105

Explanation A is correct. The nurse should teach the client measures that reduce gastric acid reflux in the patient. The nurse should instruct the patient to wear loose-fitting clothes to prevent pressure in the stomach that might cause reflux. B is incorrect. The client should not lie down after a meal. Instead, the client should remain in an upright position for 2 hours after eating. Dumping syndrome in a hiatal hernia does not exist. C is incorrect. The nurse should instruct the client to have frequent small feedings rather than three large meals to avoid gastric reflux. D is incorrect. Spicy food and caffeine trigger acid reflux and should be avoided. Indian food is full of spices, and clients should avoid eating tasty food. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014 Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013. Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 106

A client admitted in the medical ward convulsions is receiving intravenous magnesium sulfate. The nurse taking care of her must be alert for which sign is indicating an expected side effect of the drug. A. Less frequency of urination B. Frequent sleepiness C. Absence of a knee jerk reflex D. Decreased respirations

Answer 106

Explanation A is incorrect. Magnesium prevents or controls convulsions by blocking neuromuscular transmission and decreasing the amount of acetylcholine liberated at the endplate by the motor nerve impulse. Magnesium sulfate does not affect urine production. B is correct. Clients taking Magnesium sulfate are expected to become sleepy during the daytime, have hot flashes, and be lethargic. C is incorrect. The absence of deep tendon reflexes indicates elevated magnesium levels. As plasma Magnesium rises above four mEq/liter, the deep tendon reflexes are decreased. D is incorrect. This indicates magnesium toxicity. As the plasma level approaches ten mEq/liter, respiratory paralysis may occur. A decrease in respiratory rate initially manifests this. Reference Silvestri, L. Saunders Comprehensive Review for the NCLEX-RN Examination,6th Edition. Saunders-Elsevier 2014

Question 107

Which of the following educational points are appropriate for a client with chronic stable angina? Select all that apply. A. Eat only three large meals per day. B. Try to exercise every morning after breakfast. C. Avoid isometric exercises D. Wear a jacket when it is cold outside.

Answer 107

Explanation Correct Answers: C and D. C is correct. Isometric exercises are contractions of a particular muscle or group of muscles. Examples include planks or wall sits where the patient is holding still and contracting a muscle. This should be avoided in clients with chronic stable angina as it can temporarily increase the workload on the heart, decrease blood flow to the myocardium, and therefore precipitate an attack. Better exercises to recommend are aerobic exercises such as walking, swimming, or cycling. D is correct. This may seem obvious, but it is a vital teaching point for patients with chronic stable angina. Sudden changes in temperature and temperature extremes of either hot or cold are common triggers for an attack. By educating the client about these risk factors and encouraging them always to wear a jacket when going outside in the cold, you will hopefully help them to avoid unnecessary attacks. A is incorrect. It is essential to teach a client with chronic stable angina not to overeat. It would be better for them to eat several small meals throughout the day rather than three large meals. This is because overeating can precipitate an attack, and we need to teach them how to avoid attacks prophylactically. B is incorrect. While it is essential to promote healthy exercise habits, for a patient with chronic stable angina, we should encourage them to wait at least 2 hours after eating before they exercise. If they do too much activity on a full stomach, they may have an attack and end up needing to take their sublingual nitroglycerin. NCSBN Client Need: Topic: Health Promotion and Maintenance Reference: DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: Concepts & practice. Elsevier Health Sciences. Subject: Adult health Lesson: Cardiac

Question 108

The client is upset because she just found out that she has syphilis. She tells the nurse, “This is so upsetting. Does everyone need to know?” What would be the nurse’s best response? A. “We need to report this case to the Public Health Department and they will call your past partners.” B. “According to the Health Insurance Portability and Accountability Act (HIPAA), I can’t tell anyone without your permission.” C. “You really should contact your sexual partners, so they can be treated too.” D. “I understand you’re upset. Would you like to talk about it?”

Answer 108

Explanation A is incorrect. The Public Health Department will attempt to notify any sexual partners of the client reports. B is incorrect. This is a false statement. HIPAA does not apply to this situation. C is incorrect. The client should contact all her sexual partners so that they could get treated. The response, however, is not therapeutic. D is correct. This response provides facts but still encourages verbalization of feelings to the client. Reference Nugent, P., et al., Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination. 20th Edition, Elsevier 2012

Question 109

15-month-old infant is brought to the well-baby clinic for immunizations. On assessment, he was found to have a “runny” nose, and his mother tells the nurse that he has had it for over a week. Overall assessment findings indicate that the baby is well, except for a mild upper respiratory infection. According to his immunization card, his last immunization was at nine months old when he received DPT 2, OPV 2, and HIB 2 vaccines. The plan of care for this infant would be: A. Administer DPT 3, OPV3, HIB 3 and Hepatitis B vaccines B. Administer DPT 3, OPV 3, HIB 3, hepatitis and MMR vaccines C. refer the infant to the physician for mild upper respiratory tract infection D. Do not administer any vaccine and schedule a return visit in 2 weeks to see if the URI has resolved

Answer 109

Explanation At 15 months, the recommended vaccines are DPT 3, OPV 3, HIB 3, Hepatitis B, and MMR. A mild URI is not a contraindication to the administration of any vaccine. It is not necessary to refer the child to a physician at the moment. The correct answer is option B. Options A, C, and D are incorrect. Reference: Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins

Question 110

One nurse is assigned to do dressing changes to all patients in their unit for the entire shift. Another nurse is assigned to give medications while another one is assigned to monitor the vital signs for the entire unit. Which nursing delivery system does this exemplify? A. Case management B. Team C. Functional D. Primary

Answer 110

Explanation Rationale: Case management covers all aspects of care. Team nursing involves a group of nurses or staff being assigned to a limited number or group of patients. Functional nursing involves assigning each nurse with a specific task to perform for the shift. Primary nursing requires a nurse to take care of all nursing care needs of a patient. The correct answer, therefore, is option C, while options A, B, and D are incorrect. Reference: Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013. Kelly, P; Marthaler, M; Nursing Delegation, Setting Priorities, and Making Patient Care Assignments, 2nd Edition; Cengage Learning, 2010