Actualtests nclex rn p1 pdf

Actualtests
NCLEX-RN
828q
Number: NCLEX
Passing Score: 800
Time Limit: 120 min
File Version: 12.5
NCLEX-RN
National Council Licensure Examination
Passed on 2-02-15 with an 890. Dump still valid in US. 1 or 2 new questions. You must know the material as answers are worded differently at times.
NCLEX-RN
QUESTION 1
A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of
her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Nägele’s rule
is:
A. March 27
B. February 1
C. February 27
D. January 3
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A)March 27 is a miscalculation. (B) February 1 is a miscalculation. (C) February 27 is the correct answer. To calculate the estimated date of confinement using
Nagele’s rule, subtract 3 months from the date that the last menstrual cycle began and then add 7 days to the result. (D) January 3 is a miscalculation.
QUESTION 2
The nurse practitioner determines that a client is approximately 9 weeks’ gestation. During the visit, the practitioner informs the client about symptoms of physical
changes that she will experience during her first trimester, such as:
A. Nausea and vomiting
B. Quickening
C. A 68 lb weight gain
D. Abdominal enlargement
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Nausea and vomiting are experienced by almost half of all pregnant women during the first 3 months of pregnancy as a result of elevated human chorionic
gonadotropin levels and changed carbohydrate metabolism. (B) Quickening is the mother’s perception of fetal movement and generally does not occur until 1820
weeks after the last menstrual period in primigravidas, but it may occur as early as 16 weeks in multigravidas. (C) During the first trimester there should be only a
modest weight gain of 24 lb. It is not uncommon for women to lose weight during the first trimester owing to nausea and/or vomiting. (D) Physical changes are not
apparent until the second trimester, when the uterus rises out of the pelvis.
QUESTION 3
A 38-year-old pregnant woman visits her nurse practitioner for her regular prenatal checkup. She is 30 weeks’ gestation. The nurse should be alert to which
condition related to her age?
A. Iron-deficiency anemia
B. Sexually transmitted disease (STD)
C. Intrauterine growth retardation
D. Pregnancy-induced hypertension (PIH)
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Iron-deficiency anemia can occur throughout pregnancy and is not age related. (B) STDs can occur prior to or during pregnancy and are not age related. (C)
Intrauterine growth retardation is an abnormal process where fetal development and maturation are delayed. It is not age related. (D) Physical risks for the pregnant
client older than 35 include increased risk for PIH, cesarean delivery, fetal and neonatal mortality, and trisomy.
QUESTION 4
A client returns for her 6-month prenatal checkup and has gained 10 lb in 2 months. The results of her physical examination are normal. How does the nurse
interpret the effectiveness of the instruction about diet and weight control?
A. She is compliant with her diet as previously taught.
B. She needs further instruction and reinforcement.
C. She needs to increase her caloric intake.
D. She needs to be placed on a restrictive diet immediately.
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) She is probably not compliant with her diet and exercise program. Recommended weight gain during second and third trimesters is approximately 12 lb. (B)
Because of her excessive weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits and reinforcement of proper dietary habits for pregnancy. A
2200-calorie diet is recommended for most pregnant women with a weight gain of 2730 lb over the 9-month period. With rapid and excessive weightgain, PIH
should also be suspected. (C) She does not need to increase her caloric intake, but she does need to re-evaluate dietary habits. Ten pounds in 2 months is
excessive weight gain during pregnancy, and health teaching is warranted. (D) Restrictive dieting is not recommended during pregnancy.
QUESTION 5
Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality. When evaluating the pregnant client, the nurse knows
the recommended serum glucose range during pregnancy is:
A. 70 mg/dL and 120 mg/dL
B. 100 mg/dL and 200 mg/dL
C. 40 mg/dL and 130 mg/dL
D. 90 mg/dL and 200 mg/dL
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) The recommended range is 70120 mg/dL to reduce the risk of perinatal mortality. (B, C, D) These levels are not recommended. The higher the blood glucose,
the worse the prognosis for the fetus. Hypoglycemia can also have detrimental effects on the fetus.
QUESTION 6
When assessing fetal heart rate status during labor, the monitor displays late decelerations with tachycardia and decreasing variability. What action should the
nurse take?
A. Continue monitoring because this is a normal occurrence.
B. Turn client on right side.
C. Decrease IV fluids.
D. Report to physician or midwife.
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) This is not a normal occurrence. Late decelerations need prompt intervention for immediate infant recovery. (B) To increase O2 perfusion to the unborn infant,
the mother should be placed on her left side. (C) IV fluids should be increased, not decreased. (D) Immediate action is warranted, such as reporting findings,
turning mother on left side, administering O2, discontinuing oxytocin (Pitocin), assessing maternal blood pressure and the labor process, preparing for immediate
cesarean delivery, and explaining plan of action to client.
QUESTION 7
The predominant purpose of the first Apgar scoring of a newborn is to:
A. Determine gross abnormal motor function
B. Obtain a baseline for comparison with the infant’s future adaptation to the environment
C. Evaluate the infant’s vital functions
D. Determine the extent of congenital malformations
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Apgar scores are not related to the infant’s care, but to the infant’s physical condition. (B) Apgar scores assess the current physical condition of the infant and
are not related to future environmental adaptation. (C) The purpose of the Apgar system is to evaluate the physical condition of the newborn at birth and to
determine if there is an immediate need for resuscitation. (D) Congenital malformations are not one of the areas assessed with Apgar scores.
QUESTION 8
A pregnant woman at 36 weeks’ gestation is followed for PIH and develops proteinuria. To increase protein in her diet, which of the following foods will provide the
greatest amount of protein when added to her intake of 100 mL of milk?
A. Fifty milliliters light cream and 2 tbsp corn syrup
B. Thirty grams powdered skim milk and 1 egg
C. One small scoop (90 g) vanilla ice cream and 1 tbsp chocolate syrup
D. One package vitamin-fortified gelatin drink
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) This choice would provide more unwanted fat and sugar than protein. (B) Skim milk would add protein. Eggs are good sources of protein while low in fat and
calories. (C) The benefit of protein from ice cream would be outweighed by the fat content. Chocolate syrup has caffeine, which is contraindicated or limited in
pregnancy. (D) Although most animal proteins are higher in protein than plant proteins, gelatin is not. It loses protein during the processing for food consumption.
QUESTION 9
Which of the following findings would be abnormal in a postpartal woman?
A. Chills shortly after delivery
B. Pulse rate of 60 bpm in morning on first postdelivery day
C. Urinary output of 3000 mL on the second day after delivery
D. An oral temperature of 101F (38.3C) on the third day after delivery
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Frequently the mother experiences a shaking chill immediately after delivery, which is related to a nervous response or to vasomotor changes. If not followed by
a fever, it is clinically innocuous. (B) The pulse rate during the immediate postpartal period may be low but presents no cause for alarm. The body attempts to adapt
to the decreased pressures intra-abdominally as well as from the reduction of blood flow to the vascular bed. (C) Urinary output increases during the early
postpartal period (1224 hours) owing to diuresis. The kidneys must eliminate an estimated 20003000 mL of extracellular fluid associated with a normal pregnancy.
(D) A temperature of 100.4F (38C) may occur after delivery as a result of exertion and dehydration of labor. However, any temperature greater than 100.4F needs
further investigation to identify any infectious process.
QUESTION 10
What is the most effective method to identify early breast cancer lumps?
A. Mammograms every 3 years
B. Yearly checkups performed by physician
C. Ultrasounds every 3 years
D. Monthly breast self-examination
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Mammograms are less effective than breast self-examination for the diagnosis of abnormalities in younger women, who have denser breast tissue. They are
more effective forwomen older than 40. (B) Up to 15% of early-stage breast cancers are detected by physical examination; however, 95% are detected by women
doing breast self-examination. (C) Ultrasound is used primarily to determine the location of cysts and to distinguish cysts from solid masses. (D) Monthly breast
self-examination has been shown to be the most effective method for early detection of breast cancer. Approximately 95% of lumps are detected by women
themselves.
QUESTION 11
Which of the following risk factors associated with breast cancer would a nurse consider most significant in a client’s history?
A. Menarche after age 13
B. Nulliparity
C. Maternal family history of breast cancer
D. Early menopause
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Women who begin menarche late (after 13 years old) have a lower risk of developing breast cancer than women who have begun earlier. Average age for
menarche is 12.5 years. (B) Women who have never been pregnant have an increased risk for breast cancer, but a positive family history poses an even greater
risk. (C) A positive family history puts a woman at an increased risk of developing breast cancer. It is recommended that mammography screening begin 5 years
before the age at which an immediate female relative was diagnosed with breast cancer. (D) Early menopause decreases the risk of developing breast cancer.
QUESTION 12
The nurse should know that according to current thinking, the most important prognostic factor for a client with breast cancer is:
A. Tumor size
B. Axillary node status
C. Client’s previous history of disease
D. Client’s level of estrogen-progesterone receptor assays
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Although tumor size is a factor in classification of cancer growth, it is not an indicator of lymph node spread. (B) Axillary node status is the most important
indicator for predicting how far the cancer has spread. If the lymph nodes are positive for cancer cells, the prognosis is poorer. (C) The client’s previous history of
cancer puts her at an increased risk for breast cancer recurrence, especially if the cancer occurred in the other breast. It does not predict prognosis, however. (D)
The estrogen-progesterone assay test is used to identify present tumors being fedfrom an estrogen site within the body. Some breast cancers grow rapidly as long
as there is an estrogen supply such as from the ovaries. The estrogen-progesterone assay test does not indicate the prognosis.
QUESTION 13
A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, his family describes him as being “on the
move,” sleeping 34 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment with the client, the nurse would expect him
to exhibit which of the following?
A. Short, polite responses to interview questions
B. Introspection related to his present situation
C. Exaggerated self-importance
D. Feelings of helplessness and hopelessness
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) During the manic phase of bipolar disorder, clients have short attention spans and may be abusive toward authority figures. (B) Introspection requires focusing
and concentration; clients with mania experience flight of ideas, which prevents concentration. (C) Grandiosity and an inflated sense of self-worth are characteristic
of this disorder. (D) Feelings of helplessness and hopelessness are symptoms of the depressive stage of bipolar disorder.
QUESTION 14
A client with bipolar disorder taking lithium tells the nurse that he has ringing in his ears, blurred vision, and diarrhea. The nurse notices a slight tremor in his left
hand and a slurring pattern to his speech. Which of the following actions by the nurse is appropriate?
A. Administer a stat dose of lithium as necessary.
B. Recognize this as an expected response to lithium.
C. Request an order for a stat blood lithium level.
D. Give an oral dose of lithium antidote.
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) These symptoms are indicative of lithium toxicity. A stat dose of lithium could be fatal. (B) These are toxic effects of lithium therapy. (C) The client is exhibiting
symptoms of lithium toxicity, which may be validated by lab studies. (D) There is no known lithium antidote.
QUESTION 15
Which of the following activities would be most appropriate during occupational therapy for a client with bipolar disorder?
A. Playing cards with other clients
B. Working crossword puzzles
C. Playing tennis with a staff member
D. Sewing beads on a leather belt
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) This activity is too competitive, and the manic client might become abusive toward the other clients. (B) During mania, the client’s attention span is too short to
accomplish this task. (C) This activity uses gross motor skills, eases tension, and expands excess energy. A staff member is better equipped to interact
therapeutically with clients. (D) This activity requires the use of fine motor skills and is very tedious.
QUESTION 16
Three weeks following discharge, a male client is readmitted to the psychiatric unit for depression. His wife stated that he had threatened to kill himself with a
handgun. As the nurse admits him to the unit, he says, “I wish I were dead because I am worthless to everyone; I guess I am just no good.” Which response by the
nurse is most appropriate at this time?
A. “I don’t think you are worthless. I’m glad to see you, and we will help you.”
B. “Don’t you think this is a sign of your illness?”
C. “I know with your wife and new baby that you do have a lot to live for.”
D. “You’ve been feeling sad and alone for some time now?”
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) This response does not acknowledge the client’s feelings. (B) This is a closed question and does not encourage communication. (C) This response negates the
client’s feelings and does not require a response from the client. (D) This acknowledges the client’s implied thoughts and feelings and encourages a response.
QUESTION 17
Which of the following statements relevant to a suicidal client is correct?
A. The more specific a client’s plan, the more likely he or she is to attempt suicide.
B. A client who is unsuccessful at a first suicide attempt is not likely to make future attempts.
C. A client who threatens suicide is just seeking attention and is not likely to attempt suicide.
D. Nurses who care for a client who has attempted suicide should not make any reference to the word “suicide” in order to protect the client’s ego.
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) This is a high-risk factor for potential suicide. (B) A previous suicide attempt is a definite risk factor for subsequent attempts. (C) Every threat of suicide should
be taken seriously. (D) The client should be asked directly about his or her intent to do bodily harm. The client is never hurt by direct, respectful questions.
QUESTION 18
The day following his admission, the nurse sits down by a male client on the sofa in the dayroom. He was admitted for depression and thoughts of suicide. He looks
at the nurse and says, “My life is so bad no one can do anything to help me.” The most helpful initial response by the nurse would be:
A. “It concerns me that you feel so badly when you have so many positive things in your life.”
B. “It will take a few weeks for you to feel better, so you need to be patient.”
C. “You are telling me that you are feeling hopeless at this point?”
D. “Let’s play cards with some of the other clients to get your mind off your problems for now.”
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) This response does not acknowledge the client’s feelings and may increase his feelings of guilt. (B) This response denotes false reassurance. (C) This
response acknowledges the client’s feelings and invites a response. (D) This response changes the subject and does not allow the client to talk about his feelings.
QUESTION 19
A long-term goal for the nurse in planning care for a depressed, suicidal client would be to:
A. Provide him with a safe and structured environment.
B. Assist him to develop more effective coping mechanisms.
C. Have him sign a “no-suicide” contract.
D. Isolate him from stressful situations that may precipitate a depressive episode.
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) This statement represents a short-term goal. (B) Long-term therapy should be directed toward assisting the client to cope effectively with stress. (C) Suicide
contracts represent short- term interventions. (D) This statement represents an unrealistic goal. Stressful situations cannot be avoided in reality.
QUESTION 20
After 3 weeks of treatment, a severely depressed client suddenly begins to feel better and starts interacting appropriately with other clients and staff. The nurse
knows that this client has an increased risk for:
A. Suicide
B. Exacerbation of depressive symptoms
C. Violence toward others
D. Psychotic behavior
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) When the severely depressed client suddenly begins to feel better, it often indicates that the client has made the decision to kill himself or herself and has
developed a plan to do so. (B) Improvement in behavior is not indicative of an exacerbation of depressive symptoms. (C) Thedepressed client has a tendency for
self-violence, not violence toward others. (D) Depressive behavior is not always accompanied by psychotic behavior.
QUESTION 21
Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:
A. Maintaining seizure precautions
B. Restricting fluid intake
C. Increasing sensory stimuli
D. Applying ankle and wrist restraints
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. (B) Fluid intake should be increased to prevent dehydration. (C)
Environmental stimuli should be decreased to prevent precipitation of seizures. (D) Application of restraints may cause the client to increase his or her physical
activity and may eventually lead to exhaustion.
QUESTION 22
A psychotic client who believes that he is God and rules all the universe is experiencing which type of delusion?
A. Somatic
B. Grandiose
C. Persecutory
D. Nihilistic
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) These delusions are related to the belief that an individual has an incurable illness. (B) These delusions are related to feelings of self-importance and
uniqueness. (C) These delusions are related to feelings of being conspired against. (D) These delusions are related to denial of self- existence.
QUESTION 23
A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination?
A. Auditory
B. Gustatory
C. Olfactory
D. Visceral
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Auditory hallucinations involve sensory perceptions of hearing. (B) Gustatory hallucinations involve sensory perceptions of taste. (C) Olfactory hallucinations
involve sensory perceptions of smell. (D) Visceral hallucinations involve sensory perceptions of sensation.
QUESTION 24
A schizophrenic client has made sexual overtures toward her physician on numerous occasions. During lunch, the client tells the nurse, “My doctor is in love with
me and wants to marry me.” This client is using which of the following defense mechanisms?
A. Displacement
B. Projection
C. Reaction formation
D. Suppression
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Displacement involves transferring feelings to a more acceptable object. (B) Projection involves attributing one’s thoughts or feelings to another person. (C)
Reaction formation involves transforming an unacceptable impulse into the opposite behavior. (D) Suppression involves the intentional exclusion of unpleasant
thoughts or experiences.
QUESTION 25
Hypoxia is the primary problem related to near-drowning victims. The first organ that sustains irreversible damage after submersion in water is the:
A. Kidney (urinary system)
B. Brain (nervous system)
C. Heart (circulatory system)
D. Lungs (respiratory system)
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) The kidney can survive after 30 minutes of water submersion. (B) The cerebral neurons sustain irreversible damage after 46 minutes of water submersion. (C)
The heart can survive up to 30 minutes of water submersion. (D) The lungs can survive up to 30 minutes of water submersion.
QUESTION 26
One of the most dramatic and serious complications associated with bacterial meningitis is Waterhouse- Friderichsen syndrome, which is:
A. Peripheral circulatory collapse
B. Syndrome of inappropriate antiduretic hormone
C. Cerebral edema resulting in hydrocephalus
D. Auditory nerve damage resulting in permanent hearing loss
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Waterhouse-Friderichsen syndrome is peripheral circulatory collapse, which may result in extensive and diffuse intravascular coagulation and thrombocytopenia
resulting in death. (B) Syndrome of inappropriate antidiuretic hormone is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. (C) Cerebral
edema resulting in hydrocephalus is a complication of meningitis, but it is not Waterhouse-Friderichsen syndrome. (D) Auditory nerve damage resulting in
permanent hearing loss is a complication of meningitis, but it is not Waterhouse- Friderichsen syndrome.
QUESTION 27
An 8-year-old child comes to the physician’s office complaining of swelling and pain in the knees. His mother says, “The swelling occurred for no reason, and it
keeps getting worse.” The initial diagnosis is Lyme disease. When talking to the mother and child, questions related to which of the following would be important to
include in the initial history?
A. A decreased urinary output and flank pain
B. A fever of over 103F occurring over the last 23 weeks
C. Rashes covering the palms of the hands and the soles of the feet
D. Headaches, malaise, or sore throat
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Urinary tract symptoms are not commonly associated with Lyme disease. (B) A fever of 103F is not characteristic of Lyme disease. (C) The rash that is
associated with Lyme diseasedoes not appear on the palms of the hands and the soles of the feet. (D) Classic symptoms of Lyme disease include headache,
malaise, fatigue, anorexia, stiff neck, generalized lymphadenopathy, splenomegaly, conjunctivitis, sore throat, abdominal pain, and cough.
QUESTION 28
The most commonly known vectors of Lyme disease are:
A. Mites
B. Fleas
C. Ticks
D. Mosquitoes
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Mites are not the common vector of Lyme disease. (B) Fleas are not the common vector of Lyme disease. (C) Ticks are the common vector of Lyme disease.
(D) Mosquitoes are not the common vector of Lyme disease.
QUESTION 29
A laboratory technique specific for diagnosing Lyme disease is:
A. Polymerase chain reaction
B. Heterophil antibody test
C. Decreased serum calcium level
D. Increased serum potassium level
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Polymerase chain reaction is the laboratory technique specific for Lyme disease. (B) Heterophil antibody test is used to diagnose mononucleosis. (C) Lyme
disease does not decrease the serum calcium level. (D) Lyme disease does not increase the serum potassium level.
QUESTION 30
The nurse would expect to include which of the following when planning the management of the client with Lyme disease?
A. Complete bed rest for 68 weeks
B. Tetracycline treatment
C. IV amphotericin B
D. High-protein diet with limited fluids
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) The client is not placed on complete bed rest for 6 weeks. (B) Tetracycline is the treatment of choice for children with Lyme disease who are over the age of 9.
(C) IV amphotericin B is the treatment for histoplasmosis. (D) The client is not restricted to a high-protein diet with limited fluids.
QUESTION 31
A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid
resuscitation in the burned child?
A. Blood pressure
B. Serum potassium level
C. Urine output
D. Pulse rate
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Blood pressure can remain normotensive even in a state of hypovolemia. (B) Serum potassium is not reliable for determining adequacy of fluid resuscitation.
(C) Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. (D) Pulse rate may vary for
many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation.
QUESTION 32
Proper positioning for the child who is in Bryant’s traction is:
A. Both hips flexed at a 90-degree angle with the knees extended and the buttocks elevated off the bed
B. Both legs extended, and the hips are not flexed
C. The affected leg extended with slight hip flexion
D. Both hips and knees maintained at a 90-degree flexion angle, and the back flat on the bed
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) The child’s weight supplies the countertraction for Bryant’s traction; the buttocks are slightly elevated off the bed, and the hips are flexed at a 90-degree angle.
Both legs are suspended by skin traction. (B) The child in Buck’s extension traction maintains the legs extended and parallel to the bed. (C) The child in Russell
traction maintains hip flexion of the affected leg at the prescribed angle with the leg extended. (D) The child in “9090” traction maintains both hips and knees at a
90-degree flexion angle and the back is flat on the bed.
QUESTION 33
A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:
A. Bleeding, bruising, and hemorrhage
B. Increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase
C. Pain, pallor, pulselessness, paresthesia, and paralysis
D. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemia. (B) An increase in serum levels of creatinine, alkaline
phosphatase, and aspartate transaminase is related to the disruption of muscle integrity. (C) Classic signs of ischemia related to vascular injury secondary to long
bone fractures include the five “P’s”: pain, pallor, pulselessness, paresthesia, and paralysis. (D) Generalized swelling, pain, and diminished functional use with
muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia.
QUESTION 34
When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is:
A. Stephens-Johnson syndrome
B. Folate deficiency
C. Leukopenic aplastic anemia
D. Granulocytosis and nephrosis
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Stephens-Johnson syndrome is a toxic effect of phenytoin. (B) Folate deficiency is a side effect of phenytoin, but not a toxic effect. (C) Leukopenic aplastic
anemia is a toxic effect of carbamazepine (Tegretol). (D) Granulocytosis and nephrosis are toxic effects of trimethadione (Tridione).
QUESTION 35
A six-month-old infant has been admitted to the emergency room with febrile seizures. In the teaching of the parents, the nurse states that:
A. Sustained temperature elevation over 103F is generally related to febrile seizures
B. Febrile seizures do not usually recur
C. There is little risk of neurological deficit and mental retardation as sequelae to febrile seizures
D. Febrile seizures are associated with diseases of the central nervous system
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) The temperature elevation related to febrile seizures generally exceeds 101F, and seizures occur during the temperature rise rather than after a prolonged
elevation. (B) Febrile seizures may recur and are more likely to do so when the first seizure occurs in the 1st year of life. (C) There is little risk of neurological
deficit, mental retardation, or altered behavior secondary to febrile seizures. (D) Febrile seizures are associated with disease of the central nervous system.
QUESTION 36
A child is admitted to the emergency room with her mother. Her mother states that she has been exposed to chickenpox. During the assessment, the nurse would
note a characteristic rash:
A. That is covered with vesicular scabs all in the macular stage
B. That appears profusely on the trunk and sparsely on the extremities
C. That first appears on the neck and spreads downward
D. That appears especially on the cheeks, which gives a”slapped-cheek” appearance
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) A rash with vesicular scabs in all stages (macule, papule, vesicle, and crusts). (B) A rash that appears profusely on the trunk and sparsely on the extremities.
(C) A rash that first appears on the neck and spreads downward is characteristic of rubeola and rubella. (D) A rash, especially on the cheeks, that gives a “slappedcheek” appearance is characteristic of roseola.
QUESTION 37
The priority nursing goal when working with an autistic child is:
A. To establish trust with the child
B. To maintain communication with the family
C. To promote involvement in school activities
D. To maintain nutritional requirements
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) The priority nursing goal when working with an autistic child is establishing a trusting relationship. (B) Maintaining a relationship with the family is important but
having the trust of the child is a priority. (C) To promote involvement in school activities is inappropriate for a child who is autistic. (D) Maintaining nutritional
requirements is not the primary problem of the autistic child.
QUESTION 38
The child with iron poisoning is given IV deforoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticaria. The
initial nursing intervention would be to:
A. Discontinue the IV
B. Stop the medication, and begin a normal saline infusion
C. Take all vital signs, and report to the physician
D. Assess urinary output, and if it is 30 mL an hour, maintain current treatment
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) The IV line should not be discontinued because other IV medications will be needed. (B) Stop the medication and begin a normal saline infusion. The child is
exhibiting signs of an allergic reaction and could go into shock if the medication is not stopped. The line should be kept opened for other medication. (C) Taking
vital signs and reporting to the physician is not an adequate intervention because the IV medication continues to flow. (D) Assessing urinary output and, if it is 30
mL an hour, maintaining current treatment is an inappropriate intervention owing to the child’s obvious allergic reaction.
QUESTION 39
When teaching a mother of a 4-month-old with diarrhea about the importance of preventing dehydration, the nurse would inform the mother about the importance
of feeding her child:
A. Fruit juices
B. Diluted carbonated drinks
C. Soy-based, lactose-free formula
D. Regular formulas mixed with electrolyte solutions
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Diluted fruit juices are not recommended for rehydration because they tend to aggravate the diarrhea. (B) Diluted soft drinks have a high-carbohydrate content,
which aggravates the diarrhea. (C) Soy-based, lactose-free formula reduces stool output and duration of diarrhea in most infants. (D) Regular formulas contain
lactose, which can increase diarrhea.
QUESTION 40
To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the
following?
A. Positive inotropic therapy
B. Negative chronotropic therapy
C. Increase in balance of myocardial O2 supply and demand
D. Afterload reduction therapy
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Inotropic therapy will increase contractility, which will increase myocardial O2 demand. (B) Decreased heart rate to the point of bradycardia will increase
coronary artery filling time. This should be used cautiously because tachycardia may be a compensatory mechanism to increase cardiac output. (C) The goal in the
care of the MI client with angina is to maintain a balance between myocardial O2 supply and demand. (D) Decrease in systemic vascular resistance by drug
therapy, such as IV nitroglycerin or nitroprusside, or intra-aortic balloon pump therapy, would decrease myocardial work and O2 demand.
QUESTION 41
Which of the following medications requires close observation for bronchospasm in the client with chronic obstructive pulmonary disease or asthma?
A. Verapamil (Isoptin)
B. Amrinone (Inocor)
C. Epinephrine (Adrenalin)
D. Propranolol (Inderal)
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Verapamil has the respiratory side effect of nasal or chest congestion, dyspnea, shortness of breath (SOB), and wheezing. (B) Amrinone has the effect of
increased contractility and dilation of the vascular smooth muscle. It has no noted respiratory side effects. (C) Epinephrine has the effect of bronchodilation through
stimulation. (D) Propranolol, esmolol, and labetalol are all – blocking agents, which can increase airway resistance and cause bronchospasms.
QUESTION 42
In the client with a diagnosis of coronary artery disease, the nurse would anticipate the complication of bradycardia with occlusion of which coronary artery?
A. Right coronary artery
B. Left main coronary artery
C. Circumflex coronary artery
D. Left anterior descending coronary artery
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Sinus bradycardia and atrioventricular (AV) heart block are usually a result of right coronary artery occlusion. The right coronary artery perfuses the sinoatrial
and AV nodes in mostindividuals. (B) Occlusion of the left main coronary artery causes bundle branch blocks and premature ventricular contractions. (C) Occlusion
of the circumflex artery does not cause bradycardia. (D) Sinus tachycardia occurs primarily with left anterior descending coronary artery occlusion because this
form of occlusion impairs left ventricular function.
QUESTION 43
When a client questions the nurse as to the purpose of exercise electrocardiography (ECG) in the diagnosis of cardiovascular disorders, the nurse’s response
should be based on the fact that:
A. The test provides a baseline for further tests
B. The procedure simulates usual daily activity and myocardial performance
C. The client can be monitored while cardiac conditioning and heart toning are done
D. Ischemia can be diagnosed because exercise increasesO2 consumption and demand
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) The purpose of the study is not to provide a baseline for further tests. (B) The test causes an increase in O2 demand beyond that required to perform usual
daily activities. (C) Monitoring does occur, but the test is not for the purpose of cardiac toning and conditioning. (D) Exercise ECG, or stress testing, is designed to
elevate the peripheral and myocardial needs for O2 to evaluate the ability of the myocardium and coronary arteries to meet the additional demands.
QUESTION 44
The cardiac client who exhibits the symptoms of disorientation, lethargy, and seizures may be exhibiting a toxic reaction to:
A. Digoxin (Lanoxin)
B. Lidocaine (Xylocaine)
C. Quinidine gluconate or sulfate (Quinaglute,Quinidex)
D. Nitroglycerin IV (Tridil)
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Side effects of digoxin include headache, hypotension, AV block, blurred vision, and yellow-green halos. (B) Side effects of lidocaine include heart block,
headache, dizziness, confusion, tremor, lethargy, and convulsions. (C) Side effects of quinidine include heart block, hepatotoxicity, thrombocytopenia, and
respiratory depression. (D) Side effects of nitroglycerin include postural hypotension, headache, dizziness, and flushing.
QUESTION 45
Which of the following ECG changes would be seen as a positive myocardial stress test response?
A. Hyperacute T wave
B. Prolongation of the PR interval
C. ST-segment depression
D. Pathological Q wave
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Hyperacute T waves occur with hyperkalemia. (B) Prolongation of the P R interval occurs with first-degree AV block. (C) Horizontal ST-segment depression
of>1 mm during exercise isdefinitely a positive criterion on the exercise ECG test. (D) Patho-logical Q waves occur with MI.
QUESTION 46
Clinical manifestations seen in left-sided rather than in right-sided heart failure are:
A. Elevated central venous pressure and peripheral edema
B. Dyspnea and jaundice
C. Hypotension and hepatomegaly
D. Decreased peripheral perfusion and rales
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A, B, C) Clinical manifestations of right-sided heart failure are weakness, peripheral edema, jugular venous distention, hepatomegaly, jaundice, and elevated
central venous pressure. (D) Clinical manifestations of left-sided heart failure are left ventricular dysfunction, decreased cardiac output, hypotension, and the
backward failure as a result of increased left atrium and pulmonary artery pressures, pulmonary edema, and rales.
QUESTION 47
To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expect which of the following responses with administration?
A. Stinging, burning when placed under the tongue
B. Temporary blurring of vision
C. Generalized urticaria with prolonged use
D. Urinary frequency
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Stinging or burning when nitroglycerin is placed under the tongue is to be expected. This effect indicates that the medication is potent and effective for use.
Failure to have this response means that the client needs to get a new bottle of nitroglycerin. (B, C, D) The other responses are not expected in this situation and
are not even side effects.
QUESTION 48
Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client?
A. Increased PaCO2
B. Decreased PaO2
C. Increased HCO3
D. Decreased base excess
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Increased CO2 will occur in both acute and chronic respiratory acidosis. (B) Hypoxia does not determine acid-base status. (C) Elevation of HCO3 is a
compensatory mechanism in acidosis that occurs almost immediately, but it takes hours to show any effect and days to reach maximum compensation. Renal
disease and diuretic therapy may impair the ability of the kidneys to compensate. (D) Base excess is a nonrespiratory contributor to acid-base balance. It would
increase to compensate for acidosis.
QUESTION 49
Hematotympanum and otorrhea are associated with which of the following head injuries?
A. Basilar skull fracture
B. Subdural hematoma
C. Epidural hematoma
D. Frontal lobe fracture
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Basilar skull fractures are fractures of the base of the skull. Blood behind the eardrum or blood or cerebrospinal fluid (CSF) leaking from the ear are indicative of
a dural laceration. Basilar skull fractures are the only type with these symptoms. (B, C, D) These do not typically cause dural lacerations and CSF leakage.
QUESTION 50
A client with a C-34 fracture has just arrived in the emergency room. The primary nursing intervention is:
A. Stabilization of the cervical spine
B. Airway assessment and stabilization
C. Confirmation of spinal cord injury
D. Normalization of intravascular volume
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) If cervical spine injury is suspected, the airway should be maintained using the jaw thrust method that also protects the cervical spine. (B) Primary intervention
is protection of the airway and adequate ventilation. (C, D) All other interventions are secondary to adequate ventilation.
QUESTION 51
In a client with chest trauma, the nurse needs to evaluate mediastinal position. This can best be done by:
A. Auscultating bilateral breath sounds
B. Palpating for presence of crepitus
C. Palpating for trachial deviation
D. Auscultating heart sounds
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) No change in the breath sounds occurs as a direct result of the mediastinal shift. (B) Crepitus can occur owing to the primary disorder, not to the mediastinal
shift. (C) Mediastinal shift occurs primarily with tension pneumothorax, but it can occur with very large hemothorax or pneumothorax. Mediastinal shift causes
trachial deviation and deviation of the heart’s point of maximum impulse. (D) No change in the heart sounds occurs as a result of the mediastinal shift.
QUESTION 52
Priapism may be a sign of:
A. Altered neurological function
B. Imminent death
C. Urinary incontinence
D. Reproductive dysfunction
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Priapism in the trauma client is due to the neurological dysfunction seen in spinal cord injury. Priapism is an abnormal erection of the penis; it may be
accompanied by pain and tenderness. This may disappear as spinal cord edema is relieved. (B) Priapism is not associated with death. (C) Urinary retention, rather
than incontinence, may occur. (D) Reproductive dysfunction may be a secondary problem.
QUESTION 53
When evaluating a client with symptoms of shock, it is important for the nurse to differentiate between neurogenic and hypovolemic shock. The symptoms of
neurogenic shock differ from hypovolemic shock in that:
A. In neurogenic shock, the skin is warm and dry
B. In hypovolemic shock, there is a bradycardia
C. In hypovolemic shock, capillary refill is less than 2 seconds
D. In neurogenic shock, there is delayed capillary refill
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Neurogenic shock is caused by injury to the cervical region, which leads to loss of sympathetic control. This loss leads to vasodilation of the vascular beds,
bradycardia resulting from the lack of sympathetic balance to parasympathetic stimuli from the vagus nerve, and the loss of the ability to sweat below the level of
injury. In neurogenic shock, the client is hypotensive but bradycardiac with warm, dry skin. (B) In hypovolemic shock, the client ishypotensive and tachycardiac with
cool skin. (C) In hypovolemic shock, the capillary refill would be>5 seconds. (D) In neurogenic shock, there is no capillary delay, the vascular beds are dilated, and
peripheral flow is good.
QUESTION 54
Which of the following would have the physiological effect of decreasing intracranial pressure (ICP)?
A. Increased core body temperature
B. Decreased serum osmolality
C. Administration of hypo-osmolar fluids
D. Decreased PaCO2
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) An increase in core body temperature increases metabolism and results in an increase in ICP. (B) Decreased serum osmolality indicates a fluid overload and
may result in an increase in ICP. (C) Hypo-osmolar fluids are generally voided in the neurologically compromised. Using IV fluids such as D5W results in the
dextrose being metabolized, releasing free water that is absorbed by the brain cells, leading to cerebral edema. (D) Hypercapnia and hypoventilation, which cause
retention of CO2 and lead to respiratory acidosis, both increase ICP. CO2 is the most potent vasodilator known.
QUESTION 55
A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental O2,
and establishing IV access, the next nursing intervention would be to:
A. Pass a nasogastric tube through the left nostril
B. Place a 4 X 4 gauze in the nares to impede the flow
C. Gently suction the nasal drainage to protect the airway
D. Perform a halo test and glucose level on the drainage
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Basilar skull fracture may cause dural lacerations, which result in CSF leaking from the ears or nose. Insertion of a tube could lead to CSF going into the brain
tissue or sinuses. (B) Tamponading flow could worsen the problem and increase ICP. (C) Suction could increase brain damage and dislocate tissue. (D) Testing
the fluid from the nares would determine the presence of CSF. Elevation of the head, notification of the medical staff, and prophylactic antibiotics are appropriate
therapy.
QUESTION 56
A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family
should be instructed to assess for and report:
A. Dizziness and tachypnea
B. Circumoral pallor and lightheadedness
C. Headache and facial flushing
D. Pallor and itching of the face and neck
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Tachypnea is not a symptom. (B) Circumoral pallor is not a symptom. (C) Autonomic dysreflexia is an uninhibited and exaggerated reflex of the autonomic
nervous system to stimulation, which results in vasoconstriction and elevated blood pressure. (D) Pallor and itching are not symptoms.
QUESTION 57
The initial treatment for a client with a liquid chemical burn injury is to:
A. Irrigate the area with neutralizing solutions
B. Flush the exposed area with large amounts of water
C. Inject calcium chloride into the burned area
D. Apply lanolin ointment to the area
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) In the past, neutralizing solutions were recommended, but presently there is concern that these solutions extend the depth of burn area. (B) The use of large
amounts of water to flush the area is recommended for chemical burns. (C) Calcium chloride is not recommended therapy and would likely worsen the problem. (D)
Lanolin is of no benefit in the initial treatment of a chemical injury and may actually extend a thermal injury.
QUESTION 58
The most important reason to closely assess circumferential burns at least every hour is that they may result in:
A. Hypovolemia
B. Renal damage
C. Ventricular arrhythmias
D. Loss of peripheral pulses
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Hypovolemia could be a result of fluid loss from thermal injury, but not as a result of the circumferential injury. (B) Renal damage is typically seen because of
prolonged hypovolemia or myoglobinuria. (C) Electrical injuries and electrolyte changes typically cause arrhythmias in the burn client. (D) Full-thickness
circumferential burns are nonelastic and result in an internal tourniquet effect that compromises distal blood flow when the area involved is an
extremity.Circumferential full-thickness torso burns compromise respiratory motion and, when extreme, cardiac return.
QUESTION 59
During burn therapy, morphine is primarily administered IV for pain management because this route:
A. Delays absorption to provide continuous pain relief
B. Facilitates absorption because absorption from muscles is not dependable
C. Allows for discontinuance of the medication if respiratory depression develops
D. Avoids causing additional pain from IM injections
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Absorption would be increased, not decreased. (B) IM injections should not be used until the client is hemodynamically stable and has adequate tissue
perfusion. Medications will remain in the subcutaneous tissue with the fluid that is present in the interstitial spaces in the acute phase of the thermal injury. The
client will have a poor response to the medication administered, and a “dumping” of the medication can occur when the medication and fluid are shifted back into
the intravascular spaces in the next phase of healing. (C) IV administration of the medication would hasten respiratory compromise, if present. (D) The desire to
avoid causing the client additional pain is not a primary reason for this route of administration.
QUESTION 60
The medication that best penetrates eschar is:
A. Mafenide acetate (Sulfamylon)
B. Silver sulfadiazine (Silvadene)
C. Neomycin sulfate (Neosporin)
D. Povidone-iodine (Betadine)
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Mafenide acetate is bacteriostatic against gram-positive and gram-negative organisms and is the agent that best penetrates eschar. (B) Silver sulfadiazine
poorly penetrates eschar. (C) Neomycin sulfate does not penetrate eschar. (D) Povidoneiodine does not penetrate eschar.
QUESTION 61
When the nurse is evaluating lab data for a client 1824 hours after a major thermal burn, the expected physiological changes would include which of the following?
A. Elevated serum sodium
B. Elevated serum calcium
C. Elevated serum protein
D. Elevated hematocrit
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Sodium enters the edema fluid in the burned area, lowering the sodium content of the vascular fluid. Hyponatremia may continue for days to several weeks
because of sodium loss to edema, sodium shifting into the cells, and later, diuresis. (B) Hypocalcemia occurs because of calcium loss to edema fluid at the burned
site (third space fluid). (C) Protein loss occurs at the burn site owing to increased capillary permeability. Serum protein levels remain low until healing occurs. (D)
Hematocrit level is elevated owing to hemoconcentration from hypovolemia. Anemia is present in the postburn stage owing to blood loss and hemolysis, but it
cannot be assessed until the client is adequately hydrated.
QUESTION 62
The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large
amounts?
A. Neosporin sulfate
B. Mafenide acetate
C. Silver sulfadiazine
D. Povidone-iodine
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) The side effects of neomycin sulfate include rash, urticaria, nephrotoxicity, and ototoxicity. (B) The side effects of mafenide acetate include bone marrow
suppression, hemolytic anemia, eosinophilia, and metabolic acidosis. The hyperventilation is a compensatory response to the metabolic acidosis. (C) The side
effects of silver sulfadiazine include rash, itching, leukopenia, and decreased renal function. (D) The primary side effect of povidone- iodine is decreased renal
function.
QUESTION 63
The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, is that the garment:
A. Decreases hypertrophic scar formation
B. Assists with ambulation
C. Covers burn scars and decreases the psychological impact during recovery
D. Increases venous return and cardiac output by normalizing fluid status
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Tubular support, such as that received with a Jobst garment, applies tension of 1020 mm Hg. This amount of uniform pressure is necessary to prevent or
reduce hypertrophic scarring. Clients typically wear a pressure garment for 612 months during the recovery phase of their care. (B) Pressure garments have no
ambulatory assistive properties. (C) Pressure garments can worsen the psychological impact of burn injury, especially if worn on the face. (D) Pressure garments
do not normalize fluid status.
QUESTION 64
A client with emphysema is placed on diuretics. In order to avoid potassium depletion as a side effect of the drug therapy, which of the following foods should be
included in his diet?
A. Celery
B. Potatoes
C. Tomatoes
D. Liver
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Celery is high in sodium. (B) Potatoes are high in potassium. (C) Tomatoes are high in sodium. (D) Liver is high in iron.
QUESTION 65
Which of the following would the nurse expect to find following respiratory assessment of a client with advanced emphysema?
A. Distant breath sounds
B. Increased heart sounds
C. Decreased anteroposterior chest diameter
D. Collapsed neck veins
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Distant breath sounds are found in clients with emphysema owing to increased anteroposterior chest diameter, overdistention, and air trapping. (B) Deceased
heart sounds arepresent because of the increased anteroposterior chest diameter. (C) A barrel- shaped chest is characteristic of emphysema. (D) Increased
distention of neck veins is found owing to right- sided heart failure, which may be present in advanced emphysema.
QUESTION 66
The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should:
A. Increase his nasal O2 to 6 L/min
B. Place him in a lateral Sims’ position
C. Encourage pursed-lip breathing
D. Have him breathe into a paper bag
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Giving too high a concentration of O2 to a client with em-physema may remove his stimulus to breathe. (B) The client should sit forward with his hands on his
knees or an overbed table and with shoulders elevated. (C) Pursed-lip breathing helps the client to blow off CO2 and to keep air passages open. (D) Covering the
face of a client extremely short of breath may cause anxiety and further increase dyspnea.
QUESTION 67
Signs and symptoms of an allergy attack include which of the following?
A. Wheezing on inspiration
B. Increased respiratory rate
C. Circumoral cyanosis
D. Prolonged expiration
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Wheezing occurs during expiration when air movement is impaired because of constricted edematous bronchial lumina. (B) Respirations are difficult, but the
rate is frequently normal. (C) The circumoral area is usually pale. Cyanosis is not an early sign of hypoxia. (D) Expiration is prolonged because the alveoli are
greatly distended and air trapping occurs.
QUESTION 68
A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and clay-colored stools. His admitting diagnosis is “rule out hepatitis.”
Laboratory studies reveal elevated liver enzymes and bilirubin. In obtaining his health history, the nurse should assess his potential for exposure to hepatitis.
Which of the following represents a high-risk group for contracting this disease?
A. Heterosexual males
B. Oncology nurses
C. American Indians
D. Jehovah’s Witnesses
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Homosexual males, not heterosexual males, are at high risk for contracting hepatitis. (B) Oncology nurses are employed in high-risk areas and perform
invasive procedures that expose them to potential sources of infection. (C) The literature does not support the idea that any ethnic groups are at higher risk. (D)
There is no evidence that any religious groups are at higher risk.
QUESTION 69
A diagnosis of hepatitis C is confirmed by a male client’s physician. The nurse should be knowledgeable of the differences between hepatitis A, B, and C. Which of
the following are characteristics of hepatitis C?
A. The potential for chronic liver disease is minimal.
B. The onset of symptoms is abrupt.
C. The incubation period is 226 weeks.
D. There is an effective vaccine for hepatitis B, but not for hepatitis C.
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Hepatitis C and B may result in chronic liver disease. Hepatitis A has a low potential for chronic liver disease. (B) Hepatitis C and B have insidious onsets.
Hepatitis A has an abrupt onset. (C) Incubation periods are as follows: hepatitis C is 226 weeks, hepatitis B is 620 weeks, and hepatitis A is 26 weeks. (D) Only
hepatitis B has an effective vaccine.
QUESTION 70
The nurse is aware that nutrition is an important aspect of care for a client with hepatitis. Which of the following diets would be most therapeutic?
A. High protein and low carbohydrate
B. Low calorie and low protein
C. High carbohydrate and high calorie
D. Low carbohydrate and high calorie
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Protein increases the workload of the liver. Increased carbohydrates provide needed calories and promote palatability. (B) Dietary intake should be adequate to
ensure wound healing. (C) Increased carbohydrates provide needed calories. (D) A highcalorie diet is best obtained from carbohydrates because of their
palatability. Fats increase the workload of the liver.
QUESTION 71
Which of the following nursing orders should be included in the plan of care for a client with hepatitis C?
A. The nurse should use universal precautions when obtaining blood samples.
B. Total bed rest should be maintained until the client is asymptomatic.
C. The client should be instructed to maintain a low semi-Fowler position when eating meals.
D. The nurse should administer an alcohol backrub at bedtime.
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) The source of infection with hepatitis C is contaminated blood products. (B) Modified bed rest should be maintained while the client is symptomatic. Routine
activities can be slowly resumed once the client is asymptomatic. (C) Nausea and vomiting occur frequently with hepatitis C. A high Fowler position may decrease
the tendency to vomit. (D) The buildup of bilirubin in the client’s skin may cause pruritus. Alcohol is a drying agent.
QUESTION 72
A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is
admitted to the hospital with a slight elevation of temperature and vague complaints of “not feeling well.” At 4:30 PM on the day of his admission, his blood glucose
level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to:
A. Give him 3 tbsp of sugar dissolved in 4 oz of grape juice to drink
B. Ask him to dissolve three pieces of hard candy in his mouth
C. Have him drink 4 oz of orange juice
D. Monitor him closely until dinner arrives
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) The combination of sugar and juice will increase the blood sugar beyond the normal range. (B) Concentrated sweets are not absorbed as fast as juice;
consequently, they elevate the blood sugar beyond the normal limit. (C) Four ounces of orange juice will act immediately to raise the blood sugar to a normal level
and sustain it for 30 minutes until supper is served. (D) There is an increased potential for the client’s blood sugar to decrease even further, resulting in diabetic
coma.
QUESTION 73
A male client receives 10 U of regular human insulin SC at 9:00 AM. The nurse would expect peak action from this injection to occur at:
A. 9:30 AM
B. 10:30 AM
C. 12 noon
D. 4:00 PM
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) This is too early for peak action to occur. (B) This is too early for peak action to occur. (C) Regular insulin peak action occurs 24 hours after administration. (D)
This is too late for peak action to occur.
QUESTION 74
The physician has ordered that a daily exercise program be instituted by a client with type I diabetes following his discharge from the hospital. Discharge
instructions about exercise should include which of the following?
A. Exercise should be performed 30 minutes before meals.
B. A snack may be needed before and/or during exercise.
C. Hyperglycemia may occur 24 hours after exercise.
D. The blood glucose level should be 100 mg or below before exercise is begun.
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Exercise should not be performed before meals because the blood sugar is usually lower just prior to eating; therefore, there is an increased risk for
hypoglycemia. (B) Exercise lowers blood sugar levels; therefore, a snack may be needed to maintain the appropriate glucose level. (C) Exercise lowers blood sugar
levels. (D) Exercise lowers blood sugar levels. If the blood glucose level is 100 mg or below at the start of exercise, the potential for hypoglycemia is greater.
QUESTION 75
A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states,
“Oh dear, I feel like I have to urinate again!” Which of the following is the most appropriate initial nursing response?
A. Assure her that this is most likely the result of bladder spasms.
B. Check the collection bag and tubing to verify that the catheter is draining properly.
C. Instruct her to do Kegel exercises to diminish the urge to void.
D. Ask her if she has felt this way before.
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Although this may be an appropriate response, the initial response would be to assure the patency of the catheter. (B) The most frequent reason for an urge to
void with an indwelling catheter is blocked tubing. This response would be the best initial response. (C) Kegel exercises while a retention catheter is in place would
not help to prevent a voiding urge and could irritate the urethral sphincter. (D) Though the nurse would want to ascertain whether the client has felt the same urge
to void before, the initial response should be to assure the patency of the catheter.
QUESTION 76
Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include:
A. Cleanse area around the meatus twice a day
B. Empty the catheter drainage bag at least daily
C. Change the catheter tubing and bag every 48 hours
D. Maintain fluid intake of 12001500 mL every day
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Catheter site care is to be done at least twice daily to prevent pathogen growth at the catheter insertion site. (B) Catheter drainage bags are usually emptied
every 8 hours to prevent urine stasis and pathogen growth. (C) Tubing and collection bags are not changed this often, because research studies have not
demonstrated the efficacy of this practice. (D) Fluid intake needs to be in the 20002500 mL range if possible to help irrigate the bladder and prevent infection.
QUESTION 77
A client tells the nurse that she has had a history of urinary tract infections. The nurse would do further health teaching if she verbalizes she will:
A. Drink at least 8 oz of cranberry juice daily
B. Maintain a fluid intake of at least 2000 mL daily
C. Wash her hands before and after voiding
D. Limit her fluid intake after 6 PM so that there is not a great deal of urine in her bladder while she sleeps
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Cranberry juice helps to maintain urine acidity, thereby retarding bacterial growth. (B) A generous fluid intake will help to irrigate the bladder and to prevent
bacterial growth within the bladder. (C) Hand washing is an effective means of preventing pathogen transmission. (D) Restricting fluid intake would contribute to
urinary stasis, which in turn would contribute to bacterial growth.
QUESTION 78
The nurse provides a male client with diet teaching so that he can help prevent constipation in the future. Which food choices indicate that this teaching has been
understood?
A. Omelette and hash browns
B. Pancakes and syrup
C. Bagel with cream cheese
D. Cooked oatmeal and grapefruit half
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Eggs and hash browns do not provide much fiber and bulk, so they do not effectively prevent constipation. (B) Pancakes and syrup also have little fiber and
bulk, so they do not effectively prevent constipation. (C) Bagel and cream cheese do not provide intestinal bulk. (D) A combination of oatmeal and fresh fruit will
provide fiber and intestinal bulk.
QUESTION 79
The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the following indicates that he understands this teaching?
A. “I’ll be sure to rise slowly and sit for a few minutes after lying down.”
B. “I’ll be sure to walk at least 23 blocks every day.”
C. “I’ll be sure to restrict my fluid intake to four or five glasses a day.”
D. “I’ll be sure not to take any more aspirin while I amon this drug.”
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) This response will help to prevent the occurrence of postural hypotension, a common side effect of this drug and a common reason for falls. (B) Although
walking is an excellent exercise, it is not specific to the reduction of risks associated with diuretic therapy. (C) Clients on diuretic therapy are generally taught to
ensure that their fluid intake is at least 20003000 mL daily, unless contraindicated. (D) Aspirin is a safe drug to take along with furosemide.
QUESTION 80
The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage. These signs and symptoms would include:
A. Blurred vision and dizziness
B. Eye pain and itching
C. Feeling of eye pressure and headache
D. Eye discharge and hemoptysis
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Although blurred vision may occur, dizziness would not be associated with an infection or hemorrhage. (B) Eye pain is a symptom of hemorrhage within the eye,
and itching is associated with infection. (C) Nausea and headache would not be usual symptoms of eye hemorrhage or infection. (D) Some eye discharge might be
anticipated if an infection is present; hemoptysis would not.
QUESTION 81
With a geriatric client, the nurse should also assess whether he has been obtaining a yearly vaccination against influenza. Why is this assessment important?
A. Influenza is growing in our society.
B. Older clients generally are sicker than others when stricken with flu.
C. Older clients have less effective immune systems.
D. Older clients have more exposure to the causative agents.
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Although influenza is common, the elderly are more at risk because of decreased effectiveness of their immune system, not because the incidence is
increasing. (B) Older clients have the same degree of illness when stricken as other populations. (C) As people age, their immune system becomes less effective,
increasing their risk for influenza. (D) Older clients have no more exposure to the causative agents than do school-age children, for example.
QUESTION 82
Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels?
A. Broiled fish with rice
B. Bran flakes with fresh peaches
C. Lasagna with garlic bread
D. Cauliflower and lettuce salad
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Broiled fish and rice are both excellent sources of protein. (B) Fresh fruits are not a good source of protein. (C) Foods in the bread group are not high in protein.
(D) Most vegetables are not high in protein; peas and beans are the major vegetables higher in protein.
QUESTION 83
The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include:
A. Ordering a full liquid diet for her
B. Ordering five small meals for her
C. Ordering a mechanical soft diet for her
D. Ordering a puréed diet for her
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Full liquids would be difficult to swallow if the muscle control of the swallowing act is affected; this is a probable reason for her difficulties, given her medical
diagnosis of multiple sclerosis. (B) Five small meals would do little if anything to decrease her swallowing difficulties, other than assure that she tires less easily. (C)
A mechanical soft diet should be easier to chew and swallow, because foods would be more evenly consistent. (D) A pureed diet would cause her to regress more
than might be needed; the mechanical soft diet should be tried first.
QUESTION 84
When a client with pancreatitis is discharged, the nurse needs to teach him how to prevent another occurrence of acute pancreatitis. Which of the following
statements would indicate he has an understanding of his disease?
A. “I will not eat any raw or uncooked vegetables.”
B. “I will limit my alcohol to one cocktail per day.”
C. “I will look into attending Alcoholics Anonymous meetings.”
D. “I will report any changes in bowel movements to my doctor.”
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Raw or uncooked vegetables are all right to eat postdischarge. (B) This client must avoid any alcohol intake. (C) The client displays awareness of the need to
avoid alcohol. (D) This action would be pertinent only if fatty stools associated with chronic hepatitis were the problem.
QUESTION 85
A 54-year-old client is admitted to the hospital with a possible gastric ulcer. He is a heavy smoker. When discussing his smoking habits with him, the nurse should
advise him to:
A. Smoke low-tar, filtered cigarettes
B. Smoke cigars instead
C. Smoke only right after meals
D. Chew gum instead
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A, B, D) Cigarettes, cigars, and chewing gum would stimulate gastric acid secretion. (C) Smoking on a full stomach minimizes effect of nicotine on gastric acid.
QUESTION 86
Iron dextran (Imferon) is a parenteral iron preparation.
The nurse should know that it:
A. Is also called intrinsic factor
B. Must be given in the abdomen
C. Requires use of the Z-track method
D. Should be given SC
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Intrinsic factor is needed to absorb vitamin B12.(B) Iron dextran is given parenterally, but Z- track in a large muscle. (C) A Ztrack method of injection is required
to prevent staining and irritation of the tissue. (D) An SC injection is not deep enough and may cause subcutaneous fat abscess formation.
QUESTION 87
A nasogastric (NG) tube inserted preoperatively is attached to low, intermittent suctions. A client with an NG tube exhibits these symptoms: He is restless; serum
electrolytes are Na 138, K 4.0, blood pH 7.53. This client is most likely experiencing:
A. Hyperkalemia
B. Hyponatremia
C. Metabolic acidosis
D. Metabolic alkalosis
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Sodium level is within normal limits. (B) Sodium level is within normal limits. (C) pH level is consistent with alkalosis. (D) With an NG tube attached to low,
intermittent suction, acids are removed and a client will develop metabolic alkalosis.
QUESTION 88
A client is experiencing muscle weakness and lethargy. His serum K+is 3.2. What other symptoms might he exhibit?
A. Tetany
B. Dysrhythmias
C. Numbness of extremities
D. Headache
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Tetany is seen with low calcium. (B) Low potassium causes dysrhythmias because potassium is responsible for cardiac muscle activity. (C) Numbness of
extremities is seen with high potassium. (D) Headache is not associated with potassium excess or deficiency.
QUESTION 89
Following a gastric resection, which of the following actions would the nurse reinforce with the client in order to alleviate the distress from dumping syndrome?
A. Eating three large meals a day
B. Drinking small amounts of liquids with meals
C. Taking a long walk after meals
D. Eating a low-carbohydrate diet
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Six small meals are recommended. (B) Liquids after meals increase the time food empties from the stomach. (C) Lying down after meals is recommended to
prevent gravity from producing dumping. (D) A low-carbohydrate diet will prevent a hypertonic bolus, which causes dumping.
QUESTION 90
Azulfidine (Sulfasalazine) may be ordered for a client who has ulcerative colitis. Which of the following is a nursing implication for this drug?
A. Limit fluids to 500 mL/day.
B. Administer 2 hours before meals.
C. Observe for skin rash and diarrhea.
D. Monitor blood pressure, pulse.
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Fluids up to 25003000 mL/day are needed to prevent kidney stones. (B) The client should be instructed to take oral preparations with meals or snacks to lessen
gastric irritation. (C) Sulfasalazine causes skin rash and diarrhea. (D) Blood pressure and pulse are not altered by sulfasalazine.
QUESTION 91
Other drugs may be ordered to manage a client’s ulcerative colitis. Which of the following medications, if ordered, would the nurse question?
A. Methylprednisolone sodium succinate (Solu-Medrol)
B. Loperamide (Imodium)
C. Psyllium
D. 6-Mercaptopurine
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Methylprednisolone sodium succinate is used for its anti-inflammatory effects. (B) Loperamide would be used to control diarrhea. (C) Psyllium may improve
consistency of stools by providing bulk. (D) An immunosuppressant such as 6-mercaptopurine is used for chronic unrelenting Crohn’s disease.
QUESTION 92
A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:
A. Explain that he will be kept NPO for 24 hours before the exam
B. Practice with him so he will be able to hold his breath for 1 minute
C. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver
D. Explain that his vital signs will be checked frequently after the test
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) There is no NPO restriction prior to a liver biopsy. (B) The client would need to hold his breath for 510 seconds. (C) There is no pretest laxative given. (D)
Following the test, the client is watched for hemorrhage and shock.
QUESTION 93
After a liver biopsy, the best position for the client is:
A. High Fowler
B. Prone
C. Supine
D. Right lateral
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) This position does not help to prevent bleeding. (B) This position does not help to prevent bleeding. (C) This position does not help to prevent bleeding. (D) The
right lateral position would allow pressure on the liver to prevent bleeding.
QUESTION 94
A complication for which the nurse should be alert following a liver biopsy is:
A. Hepatic coma
B. Jaundice
C. Ascites
D. Shock
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Hepatic coma may occur in liver disease due to the increased NH3levels, not due to liver biopsy. (B) Jaundice may occur due to increased bilirubin levels, not
due to liver biopsy. (C) Ascites would occur due to portal hypertension, not due to liver biopsy. (D) Hemorrhage and shock are the most likely complications after
liver biopsy because of already existing bleeding tendencies in the vascular makeup of the liver.
QUESTION 95
Which nursing implication is appropriate for a client undergoing a paracentesis?
A. Have the client void before the procedure.
B. Keep the client NPO.
C. Observe the client for hypertension following the procedure.
D. Place the client on the right side following the procedure.
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) A full bladder would impede withdrawal of ascitic fluid. (B) Keeping the client NPO is not necessary. (C) The client may exhibit signs and symptoms of shock
and hypertension. (D) No position change is needed after the procedure.
QUESTION 96
The nurse would assess the client’s correct understanding of the fertility awareness methods that enhance conception, if the client stated that:
A. “My sexual partner and I should have intercourse when my cervical mucosa is thick and cloudy.”
B. “At ovulation, my basal body temperature should rise about 0.5F.”
C. “I should douche immediately after intercourse.”
D. “My sexual partner and I should have sexual intercourse on day 14 of my cycle regardless of the length of the cycle.”
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) At ovulation, the cervical mucus is increased, stretchable, and watery clear. (B) Under the influence of progesterone, the basal body temperature increases
slightly after ovulation. (C) To enhance fertility, measures should be taken that promote retention of sperm rather than removal. (D) Ovulation, the optimal time for
conception, occurs 14+2 days before the next menses; therefore, the date of ovulation is directly related to the length of the menstrual cycle.
QUESTION 97
A couple is planning the conception of their first child. The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that she is most
likely to ovulate if she states that ovulation should occur on day:
A. 14+2 days
B. 16+2 days
C. 20+2 days
D. 22+2 days
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Ovulation is dependent on average length of menstrual cycle, not standard 14 days. (B) Ovulation occurs 14+2 days before next menses (34 minus 14 does not
equal 16). (C) Ovulation occurs 14+2 days before next menses (34 minus 14 equals 20). (D) Ovulation occurs 14+2 days before next menses (34 minus 14 does
not equal 22).
QUESTION 98
A client is pregnant with her second child. Her last menstrual period began on January 15. Her expected date of delivery would be:
A. October 8
B. October 15
C. October 22
D. October 29
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Incorrect application of Nägele’s rule: correctly subtracted 3 months but subtracted 7 days rather than added. (B) Incorrect application of Nägele’s rule: correctly
subtracted 3 months but did not add 7 days. (C) Correct application of Nägele’s rule: correctly subtracted 3 months and added 7 days. (D) Incorrect application of
Nägele’s rule: correctly subtracted 3 months but added 14 days instead of 7 days.
QUESTION 99
The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on her back. The nurse explains that this is to avoid “vena caval
syndrome,” a condition which:
A. Occurs when blood pressure increases sharply with changes in position
B. Results when blood flow from the extremities is blocked or slowed
C. Is seen mainly in first pregnancies
D. May require medication if positioning does not help
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Blood pressure changes are predominantly due to pressure of the gravid uterus. (B) Pressure of the gravid uterus on the inferior vena cava decreases blood
return from lower extremities. (C) Inferior vena cava syndrome is experienced in the latter months of pregnancy regardless of parity. (D) There are no medications
useful in the treatment of interior vena cava syndrome; alleviating pressure by position changes is effective.
QUESTION 100
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby
girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL
system to record her obstetrical history, the nurse should record:
http://www.gratisexam.com/
A. 3-2-0-0-2
B. 2-2-0-2-2
C. 3-1-1-0-2
D. 2-1-1-0-2
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) This answer is an incorrect application of the GTPAL method. One prior pregnancy was a preterm birth at 36 weeks (T =1, P= 1; not T = 2). (B) This answer is
an incorrect application of the GTPAL method. The client is currently pregnant for the third time (G = 3, not 2), one prior pregnancy was preterm (T= 1, P= 1; not T=
2), and she has had no prior abortions (A =0). (C) This answer is the correct application of GTPAL method. The client is currently pregnant for the third time (G =3),
her first pregnancy ended at term (>37 weeks) (T =
1), her second pregnancy ended preterm 2033 weeks) (P = 1), she has no history of abortion (A=0), and she has two living children (L = 2). (D) This answer is an
incorrect application of the GTPAL method. The client is currently pregnant for the third time (G =3, not 2).
QUESTION 101
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby
girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the gravida and
para system to record the client’s obstetrical history, the nurse should record:
A. Gravida 3 para 1
B. Gravida 3 para 2
C. Gravida 2 para 1
D. Gravida 2 para 2
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) This answer is an incorrect application of gravida and para. The client has had two prior deliveries of more than 20 weeks’ gestation; therefore, para equals 2,
not 1. (B) This answer is the correct application of gravida and para. The client is currently pregnant for the third time (G = 3), regardless of the length of the
pregnancy, and has had two prior pregnancies with birth after the 20th week (P = 2), whether infant was alive or dead. (C) This answer is an incorrect application of
gravida and para. The client is currently pregnant for the third time (G = 3, not 2); prior pregnancies lasted longer than 20 weeks (therefore, P = 2, not 1). (D) This is
an incorrect application of gravida and para. Client is currently pregnant for third time (G = 3, not 2).
QUESTION 102
A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate
(MgSO4) therapy, the nurse knows it is safe to repeat the dosage if:
A. Deep tendon reflexes are absent
B. Urine output is 20 mL/hr
C. MgSO4serum levels are>15 mg/dL
D. Respirations are>16 breaths/min
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) MgSO4is a central nervous system depressant. Loss of reflexes is often the first sign of developing toxicity. (B) Urinary output at 16 breaths/min indicate that toxic levels of magnesium have not been reached. Medication administration would be safe.
QUESTION 103
Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension (PIH). For the prenatal client, which of the following blood pressure
changes from baseline would be most significant for the nurse to report as indicative of PIH?
A. 136/88 to 144/93
B. 132/78 to 124/76
C. 114/70 to 140/88
D. 140/90 to 148/98
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) These blood pressure changes reflect only an 8 mm Hg systolic and a 5 mm Hg diastolic increase, which is insufficient for blood pressure changes indicating
PIH. (B) These blood pressure changes reflect a decrease in systolic pressure of 8 mm Hg and diastolic pressure of 2 mm Hg; these values are not indicative of
blood pressure increases reflecting PIH. (C) The definition of PIH is an increase in systolic blood pressure of 30 mm Hg and/or diastolic blood pressure of 15 mm
Hg. These blood pressures reflect a change of 26 mm Hg systolically and 18mm Hg diastolically. (D) These blood pressures reflect a change of only 8 mm Hg
systolically and 8 mm Hg diastolically, which is insufficient for blood pressure changes indicating PIH.
QUESTION 104
In assisting preconceptual clients, the nurse should teach that the corpus luteum secretes progesterone, which thickens the endometrial lining in which of the
phases of the menstrual cycle?
A. Menstrual phase
B. Proliferative phase
C. Secretory phase
D. Ischemic phase
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Menses occurs during the menstrual phase, during which levels of both estrogen and progesterone are decreased. (B) The ovarian hormone responsible for the
proliferative phase, during which the uterine endometrium enlarges, is estrogen. (C) The ovarian hormone responsible for the secretory phase is progesterone,
which is secreted by the corpus luteum and causes marked swelling in the uterine endometrium. (D) The corpus luteum begins to degenerate in the ischemic
phase, causing a fall in both estrogen and progesterone.
QUESTION 105
A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal, full-term girl and is now progressing toward the establishment of
successful lactation. To remove the baby from her breast, she should be instructed to:
A. Gently pull the infant away
B. Withdraw the breast from the infant’s mouth
C. Compress the areolar tissue until the infant drops the nipple from her mouth
D. Insert a clean finger into the baby’s mouth beside the nipple
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) In pulling the infant away from the breast without breaking suction, nipple trauma is likely to occur. (B) In pulling the breast away from the infant without breaking
suction, nipple trauma is likely to occur. (C) Compressing the maternal tissue does not break the suction of the infant on the breast and can cause nipple trauma.
(D) By inserting a finger into the infant’s mouth beside the nipple, the lactating mother can break the suction and the nipple can be removed without trauma.
QUESTION 106
A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate
nursing action is to:
A. Notify the physician
B. Place the client on a pad count
C. Massage the uterus and re-evaluate in 30 minutes
D. Have the client void and then re-evaluate the fundus
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) The nurse should initiate actions to remove the most frequent cause of uterine displacement, which involves emptying the bladder. Notifying the physician is an
inappropriate nursing action. (B) The pad count gives an estimate of blood loss, which is likely to increase with a boggy uterus; but this action does not remove the
most frequent cause of uterine displacement, which is a full bladder. (C) Massage may firm the uterus temporarily, but if a full bladder is not emptied, the uterus will
remain displaced and is likely to relax again. (D) The most common cause of uterine displacement is a full bladder.
QUESTION 107
A client delivered her first-born son 4 hours ago. She asks the nurse what the white cheeselike substance is under the baby’s arms. The nurse should respond:
A. “This is a normal skin variation in newborns. It will go away in a few days.”
B. “Let me have a closer look at it. The baby may have an infection.”
C. “This material, called vernix, covered the baby before it was born. It will disappear in a few days.”
D. “Babies sometimes have sebaceous glands that get plugged at birth. This substance is an example of that condition.”
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) This response identifies the fact that vernix is a normal neonatal variation, but it does not teach the client medical terms that may be useful in understanding
other healthcare personnel. (B) This response may raise maternal anxiety and incorrectly identifies a normal neonatal variation. (C) This response correctly
identifies this neonatal variation and helps the client to understand medical terms as well as the characteristics of her newborn. (D) Blocked sebaceous glands
produce milia, particularly present on the nose.
QUESTION 108
A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best auscultated just:
A. Below the umbilicus toward left side of mother’s abdomen
B. Below the umbilicus toward right side of mother’s abdomen
C. At the umbilicus
D. Above the umbilicus to the left side of mother’s abdomen
Correct Answer: A
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) LOA identifies a fetus whose back is on its mother’s left side, whose head is the presenting part, and whose back is toward its mother’s anterior. It is easiest to
auscultate fetal heart tones (FHTs) through the fetus’s back. (B) The identified fetus’s back is on its mother’s left side, not right side. It is easiest to auscultate FHTs
through the fetus’s back. (C) In an LOA position, the fetus’s head is presenting with the back to the left anterior side of the mother. The umbilicus is too high of a
landmark for auscultating the fetus’s heart rate through its back. (D) This is the correct auscultation point for a fetus in the left sacroanterior position, where the
sacrum is presenting, not LOA.
QUESTION 109
In performing the initial nursing assessment on a client at the prenatal clinic, the nurse will know that which of the following alterations is abnormal during
pregnancy?
A. Striae gravidarum
B. Chloasma
C. Dysuria
D. Colostrum
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Striae gravidarum are the normal stretch marks that frequently occur on the breasts, abdomen, and thighs as pregnancy progresses. (B) Chloasma is the
“mask of pregnancy” that normally occurs in many pregnant women. (C) Dysuria is an abnormal danger sign during pregnancy and may indicate a urinary tract
infection. (D) Colostrum is a yellow breast secretion that is normally present during the last trimester of pregnancy.
QUESTION 110
A 35-weeks-pregnant client is undergoing a nonstress test (NST). During the 20-minute examination, the nurse notes three fetal movements accompanied by
accelerations of the fetal heart rate, each 15 bpm, lasting
15 seconds. The nurse interprets this test to be:
A. Nonreactive
B. Reactive
C. Positive
D. Negative
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) In a nonreactive NST, the criteria for reactivity are not met. (B) A reactive NST shows at least two accelerations of FHR with fetal movements, each 15 bpm,
lasting 15 seconds or more, over 20 minutes. (C, D) This term is used to interpret a contraction stress test (CST), or oxytocin challenge test, not an NST.
QUESTION 111
The nurse is caring for a laboring client. Assessment data include cervical dilation 9 cm; contractions every 12 minutes; strong, large amount of “bloody show.” The
most appropriate nursing goal for this client would be:
A. Maintain client’s privacy.
B. Assist with assessment procedures.
C. Provide strategies to maintain client control.
D. Enlist additional caregiver support to ensure client’s safety.
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Privacy may help the laboring client feel safer, but measures that enhance coping take priority. (B) The frequency of assessments do increase in transition, but
helping the client to maintain control and cope with this phase of labor takes on importance. (C) This laboring client is in transition, the most difficult part of the first
stage of labor because of decreased frequency, increased duration and intensity, and decreased resting phase of the uterine contraction. The client’s ability to cope
is most threatened during this phase of labor, and nursing actions aredirected toward helping the client to maintain control. (D) Safety is a concern throughout labor,
but helping the client to cope takes on importance in transition.
QUESTION 112
A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station 12 means that the:
A. Presenting part is 2 cm above the level of the ischial spines
B. Biparietal diameter is at the level of the ischial spines
C. Presenting part is 2 cm below the level of the ischial spines
D. Biparietal diameter is 5 cm above the ischial spines
Correct Answer: C
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is above the ischial spines, the
station is negative. (B) When the biparietal diameter is at the level of the ischial spines, the presenting part is generally at a +4 or +5 station. (C) Station is the
relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is below the ischial spines, the station is positive.
Thus, 2 cm below the ischial spines is the station +2. (D) When the biparietal diameter is above the ischial spines by 5 cm, the presenting part is usually engaged
or at station 0.
QUESTION 113
A pregnant client is at the clinic for a third trimester prenatal visit. During this examination, it has been determined that her fetus is in a vertex presentation with the
occiput located in her right anterior quadrant. On her chart this would be noted as:
A. Right occipitoposterior
B. Right occipitoanterior
C. Right sacroanterior
D. LOA
Correct Answer: B
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) The fetus in the right occipitoposterior position would be presenting with the occiput in the maternal right posterior quadrant. (B) Fetal position is defined by the
location of the fetal presenting part in the four quadrants of the maternal pelvis. The right occipitoanterior is a fetus presenting with the occiput in mother’s right
anterior quadrant. (C) The fetus in right sacroanterior position would be presenting a sacrum, not an occiput. (D) The fetus in left occipitoanterior position would be
presenting with the occiput in the mother’s left anterior quadrant.
QUESTION 114
Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency
and intensity. Marked molding of the presenting fetal head is described. The physician orders, “Begin oxytocin induction at 1 mU/min.” The nurse should:
A. Begin the oxytocin induction as ordered
B. Increase the dosage by 2 mU/min increments at15-minute intervals
C. Maintain the dosage when duration of contractions is 4060 seconds and frequency is at 21/2 4 minute intervals
D. Question the order
Correct Answer: D
Section: (none)
Explanation
Explanation/Reference:
Explanation:
(A) Oxytocin stimulates labor but should not be used until CPD (cephalopelvic disproportion) is ruled out in a dysfunctional labor. (B) This answer is the correct
protocol for oxytocin administration, but the medication should not be used until CPD is ruled out. (C) This answer is the correct manner to interpret effective
stimulation, but oxytocin should not be used until CPD is ruled out. (D) This answer is the appropriate nursing action because the scenario presents adysfunctional
labor pattern that may be caused by CPD. Oxytocin administration is contraindicated in CPD.
QUESTION 115
A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the
following is the best response by the nurse?
A. “Keep breathing with your abdominal muscles as long as you can.”
B. “Make sure you take a deep cleansing breath as the contractions start, focus on an object, and breathe about 1620 times a minute with shallow chest breaths.”
C. “Find a comfortable position before you start a contraction. Once the contraction has started, take slow breaths using your abdominal muscles.”
D. “If a woman in labor listens to her body and takes rapid, deep breath…