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A 30-year-old client has just been admittedto the psychiatric unit with the diagnosis ofmanic episode. The client manifests anexcess of energy, and it is difficult for herto sit still. The most useful activity for thisclient that the nurse might suggest would

be to

A) Empty wastebaskets on the unit.

B) Engage in occupational therapy andgroup exercises.C) Play volleyball outside.D) Deliver linen to the rooms.

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Answer: DD) This activity would channel her

energy, but not increase the externalstimuli as the group activities would do.Competitive activities are

nontherapeutic because they are sostimulating.

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The best rationale for the nurse introducingher- or himself to a blind client and tellinghim exactly what will be administered is toA) Illustrate the principle of opencommunication.

B) Encourage and utilize clearcommunication.C) Follow steps for beginning a nurse-client

relationship.D) Decrease the client's anxiety and fear ofthe unknown.

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Answer: DD) Blind clients become anxious when

they hear someone enter the roomwithout talking.

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The priority rationale for checking a client'splatelet count following heparin therapy isto

A) Check the client's level ofanticoagulation.

B) Detect heparin-inducedthrombocytopeniaC) Determine if the client requires an

anticoagulant alternative.D) Monitor the client's heparin absorption.

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Answer: BB) Up to 10 percent of clients receiving

heparin therapy develop heparin-induced thrombocytopenia. If theplatelet count drops below 10,000/cu

mm or 40 percent below thepretreatment level, the client has thiscondition and it contraindicates the

continued use of heparin. He may thenrequire an alternate medication.

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A young client is in spinal shock and will befor a few weeks after being struck by a car.The nurse will be able to recognize that this

state is resolving when

A) His legs move.

B) Hyperreflexia occurs.C) His vital signs stabilize.D) He regains sensations but not motion in

his upper extremities.

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Answer: BB) Reflex activity begins to return

below the level of injury because ofautomatic activity inherent in nervoustissue.

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Immediately following a thoracentesis,which clinical manifestations could indicatethat a complication has occurred and the

physician should be notified?

A) Increased pulse and pallor.

B) Increased temperature and bloodpressure.C) Hypotension and hypothermia.

D) Serosanguineous drainage from thepuncture site.

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Answer: AA) Increased pulse and pallor are

symptoms associated with shock. Acompromised venous return may occurif there is a mediastinal shift as a result

of excessive fluid removal. Usually nomore than one liter of fluid is removedat one time to prevent this from

occurring.

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The nurse has orders to suction a 50-year-old client. One nursing action necessary toprevent hypoxia during the procedure is to

A) Ensure that the catheter is no more thanthree-quarters the diameter of the nares.

B) Limit suction time to 30 seconds, atintervals of three minutes.C) Hyperinflate the lungs with 100 percent

oxygen prior to and following suctioning.D) Suction no more than three consecutivetimes before administering oxygen.

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Answer: DD) Preoxygenation of the lungs

prevents hypoxia during the suctioningprocedure in a client requiring frequenttreatments. (A) The catheter should be

one-half the diameter of the nares, (B)suctioning should be limited to 5-10seconds at one time, and (D) should be

to allow the client to breathe normallyor administer oxygen between periodsof suctioning.

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A client, age 60, is admitted to thehospital for a possible low intestinal

obstruction. His preoperative work-upindicates vital signs of BP 100/70, P 88,R 18, and temperature of 96.4 degrees

F. Listening to bowel sounds, the nursewould expect to find

A) Gurgling bowel sounds.B) Hyperactive, high-pitched sounds.C) Absence of bowel sounds.

D) Tympanic, percussion sounds.

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Answer: BB) The nurse will note high-pitched

sounds with an obstruction. Paralyticileus has no bowel sounds or gurgling.Gastric distention will have tympanic

sounds.

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The first nursing action immediatelyafter a precipitous birth in the

emergency room is to

A) Remove any mucous from the

baby's mouth to clear the airway.B) Wrap the baby tightly to keep itwarm.

C) Place the baby on the mother'sabdomen to maintain warmth.D) Prepare for delivery of the placenta.

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Answer: AA) The first priority is to determine that

the infant's airway is clear. Keeping thebaby warm is also a very importantnursing intervention, but not the first

action to be done. After delivery andclearing the infant's airway, place theinfant head-down on his mother's

abdomen. This action facilitatescontraction of the uterus and provideswarmth for the baby.

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An RN's friend, who is also a nurse, is in herfirst trimester of pregnancy. While workingin the hospital, the nurse knows that her

friend should avoidA) A client who has just been diagnosed

with lupus erythematosus.B) A 3-month-old infant with a generalizedrash.

C) Any client with an infection.D) A child with a fever and upperrespiratory disorder.

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Answer: BB) German measles or rubella, if

contracted in the first trimester ofpregnancy, may result in a child withcongenital malformations of the heart,

eye and ear, as well as mentalretardation.

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A common test used to determine fetalstatus in the presence of pre-eclampsia isthe Nonstress Test (NST). If this test is

"reactive," the nurse knows that it means

A) The test was abnormal, indicating a

need for an immediate Oxytocin ChallengeTest (OCT).B) The test was normal, showing no change

in FHR with fetal movement.C) The test was normal, showing anincreased fetal heart rate (FHR) with fetalmovement.D) Ultrasound is indicated to determine

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Answer: CC) Reactive = good outcome. Increased

FHR with movement indicates normalreaction and adequate CNS integration.

d

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The nurse is assigned a client who hasjust had a nasogastric tube inserted

postoperatively. During the evaluationof his status, the nurse will check for

A) Infection.B) Ulcerative colitis.C) Electrolyte imbalance.

D) Gastric distention.

C

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Answer: CC) Nasogastric intubation can lead to

the complication of electrolyteimbalance because of removing thegastric contents by suctioning. Large

amounts of sodium and potassium arelost through the suctioning and, if notreplaced via IV fluids, can lead to

serious electrolyte imbalance.

A li t h h b f il

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A client who has been near a familymember with suspected tuberculosis hasthe Mantoux test. The results are 6 mm

induration. The nurse will recommend tothe client that

A) He begin on a drug protocol.B) The Mantoux test be repeated.C) He take the Tine test.

D) He do nothing because it is not 10 mminduration.

A B

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Answer: BB) If the reaction (area of induration) is

between 5 and 9 mm, a repeat testshould be done. If the induration is 10mm or more, it indicates that the client

has had contact with the tuberclebacillus. The Tine test is notrecommended for diagnosis and, if

positive, the Mantoux will be done.When a definitive diagnosis of TB ismade, a drug protocol will be

administered.

Th t i t t t i l d i

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The most important measure to include inthe nursing management for a child withcystic fibrosis would be to

A) Promote optimal nutrition with a high-protein, low-fat diet.

B) Administer only water-soluble vitamins.C) Administer pancreatic enzymes beforeeach meal.

D) Encourage lots of fluids, especially fruitjuices.

A C

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Answer: CC) Pancreatic enzymes should be

administered before each meal in orderto facilitate digestive processes in thechild with cystic fibrosis. The diet is

important, but without the pancreaticenzymes the nutrients will not beassimilated.

A male client is being discharged from the

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A male client is being discharged from thehospital following a short hospitalization forangina. He will be sent home on the drug

propranolol hydrochloride (Inderal). Which of thefollowing statements would indicate to the nursethat he understands the actions of the drug?

A) "I will not discontinue the drug suddenly."B) "I will monitor my blood pressure before eachdose of the drug."C) "I will need to take additional potassium

supplements."D) "I will need to have laboratory tests doneevery month."

A A

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Answer: AA) Discontinuing the drug suddenly

may result in an exacerbation of theangina and myocardial infarction.Laboratory tests are not drawn

routinely and potassium supplementsare not necessary with this drug.

A client has the diagnosis of ac te renal

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A client has the diagnosis of acute renalfailure. The nurse assesses him forhyperkalemia. Monitoring his EKG, the

nurse will observe for

A) Complete heart block.

B) Peaked T waves.C) Ventricular arrhythmias.D) Flattened T waves.

A B

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Answer: BB) When the serum potassium exceeds

5.5 mEq/l, T waves become tall, narrowand pointed. Enhanced automaticitydoes not occur, nor does heart block as

a result of hyperkalemia.

If it is suspected that a child is abused the

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If it is suspected that a child is abused, thelegal responsibility of the staff whoevaluated the case is that

A) The nurse is legally responsible forreporting a suspected child abuse.

B) Both the doctor and the nurse arelegally responsible for reporting childabuse.

C) The doctor, not the nurse, is legallyresponsible for reporting child abuse.D) Neither the doctor nor the nurse islegally responsible for reporting childabuse.

Ans er B

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Answer: BB) Both the nurse and doctor,

independently, are legally responsibleto report a suspected battered child tothe proper authorities.

A 42 year old client is admitted with

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A 42-year-old client is admitted withsuspected cholelithiasis. Making anassessment of the client, the nurse should

be alert to her complaints of

A) Fatty food intolerance several hours

after eating.B) Chronic pain in her lower right abdomen.C) Chronic pain in her lower left abdomen.

D) Fatty food intolerance while eating.

Answer: A

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Answer: AA) Pain is probably due to contraction

of the gallbladder. The gallbladderempties when fat is present in thestomach and symptoms usually occur

several hours after eating. Pain wouldlikely be present in the region of thegallbladder.

A client with acute interstitial pancreatitis

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A client with acute interstitial pancreatitishas laboratory values that show mildhypocalcemia. The nurse knows that this

condition occurs in pancreatitis due to

A) Elevated amylase.

B) Poorly digested fats.C) Vomiting.D) Decreased food intake.

Answer: B

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Answer: BB) Fats are incompletely metabolized in

pancreatitis. Because calcium ions arebound to the fats, hypocalcemia canoccur.

A 3-year-old's parents are unable to "room in"

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A 3-year-old s parents are unable to room inbecause of other responsibilities at home. Duringpainful hospital procedures, the nurse observes

that the child becomes very quiet and nevercries. Based on knowledge of growth anddevelopment, the nurse would interpret thisbehavior as evidence that he

A) Does not feel well.B) Has been taught not to misbehave in front ofstrangers.

C) Has given up fighting and has becomedespondent and hopeless.D) Was well prepared by his parents for theseparation and hospitalization.

Answer: C

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Answer: CC) A toddler who passively accepts

aggressive, painful intrusions into hisor her life has usually given up anysense of hope and is suffering from

separation anxiety. He is depressedand requires specialized care from thestaff and parents.

A client's demand pacemaker is

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A client s demand pacemaker isprogrammed for a ventricular rate of

72. When the nurse takes the client'sapical pulse, it is 84 and regular. Thenursing action is to

A) Obtain a cardiogram.B) Place the client on bedrest.

C) Report this finding immediately.D) Do nothing more at this time.

Answer: D

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Answer: DD) A demand pacemaker stimulates

cardiac contraction when the heart ratefalls below the preset rate. A regularrate that is above the demand rate and

below 100 indicates that the client'sheart is beating independently at anormal sinus rate; therefore, no action

is called for at this time.

The nurse observes another nurse enter

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The nurse observes another nurse enterthe room of a blind client withoutannouncing herself. The appropriate

intervention is to

A) Do nothing, as there is no intervention

required.B) Tell the nurse that she had alwayslearned to announce herself when entering

the room of a blind person.C) Tell the client she is sorry the othernurse may have frightened her.D) Inform the head nurse so that he can

intervene.

Answer: B

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Answer: BB) Because the nurse's behavior is not

therapeutic and may cause the clientto be frightened, explaining how sheherself learned to approach a blind

client is a way of teaching the othernurse a new approach.

A male client has just returned from a

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A male client has just returned from abronchoscopy procedure to diagnosepossible bronchogenic carcinoma. The

critical nursing assessment immediatelyfollowing the test is to assess for

A) Vital signs to compare with baselinesigns.B) The client's face and neck for edema.

C) The client's ability to deep breathe andcough.D) Signs of dyspnea or wheezing.

Answer: D

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Answer: DD) Dyspnea and wheezing are signs oflaryngeal edema or bronchospasm which

can result in respiratory distress and mustbe reported to the physician immediately.Clients are instructed to refrain from

coughing which could result inhemorrhaging. His face and neck should beassessed for subcutaneous crepitus, not

just edema. Vital signs are alwaysimportant to monitor, but at this time themost crucial assessment is to monitor forrespiratory problems.

In teaching a newly diagnosed diabetic

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In teaching a newly diagnosed diabeticclient about insulin self-injection, the nurseteaches that the injection site currently

believed to be the best, because it providesthe most rapid insulin absorption, is the

A) Arms.B) Thighs.C) Abdomen.

D) Buttocks.

Answer: C

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Answer: CC) Studies have shown that insulin is

most rapidly and consistently absorbedfrom the subcutaneous tissue of theabdomen. The current thinking,

therefore, is that insulin injectionsshould be rotated among sites on theabdomen alone (with the exception of

1 inch around the umbilicus), ratherthan among the other availableanatomic sites, i.e., arms, thighs and

buttocks.

As part of a newborn assessment the

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As part of a newborn assessment, thenurse knows that signs of

hypoglycemia in the infant include

A) Hyperactivity, high-pitched cry,

respiratory distress.B) Twitching, shrill or intermittent cry.C) Stuporlike behavior, no cry.

D) Weak, soft cry.

Answer: B

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Answer: BB) Infants with signs and symptoms ofhypoglycemia usually have a shrill orintermittent cry and may havehypertonicity. Answer (A) refers to an

infant born to a drug-addicted mother.

In which situation would gloves not

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In which situation would gloves notbe necessary when caring for an

AIDS client?A) When in contact with urine.

B) Changing an ostomy pouch.C) Monitoring an IV infusion.

D) When suctioning clients.

Answer: C

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Answer: CC) The first three situations could resultin transmission of the HIV virus.Starting an IV would require gloves, butmonitoring an infusion, a closed

system, would not.

A 39-year-old client has been admitted to the

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yhospital with clinical manifestations indicatingacute renal failure. A precipitating factor seems

to be a viral infection of the upper respiratorytract. Considering the diagnosis while completinga physical assessment, the nurse would expect toobserve

A) Anuria, bradycardia, tachypnea.B) Urine output of 400 mL/day, dyspnea, neckvein distention.

C) Urine specific gravity of 1.010, decreasedcreatinine levels, hypokalemia.D) Hypomagnesemia, nausea, vomiting,weakness.

Answer: B

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Answer: BB) These signs are indicative of fluidoverload due to decreased ability to

excrete urine. When the end products ofmetabolism cannot be excreted insufficient amounts, they will accumulate in

the body. Resultant blood samples willindicate higher levels of creatinine,potassium and magnesium, not lower

levels. When fluid overload occurs due todecreased urine output, the intravascularcompartment becomes overloaded withfluids causing tachycardia and neck vein

distention.

A 6-month-old child with cystic fibrosis is

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A 6 month old child with cystic fibrosis isbrought to the hospital with sudden onsetvomiting and abdominal distention.

Intussusception is the admitting diagnosis.The nurse will anticipate that the child willfirst be prepared for

A) Total parenteral nutrition (TPN)supplement.

B) Barium enema x-ray.C) Nasogastric (NG) tube insertion.D) Abdominal surgery.

Answer: B

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Answer: BB) A barium enema is the firsttreatment of choice because thisprocedure frequently reduces thebowel and cures the intussusception

(telescoping bowel). If this proceduredoes not work, surgery for bowelreduction will be done. The child will

probably not require TPN or an NGtube.

A client with a myocardial infarction is

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A client with a myocardial infarction istransferred to the transitional care unit ashis condition improves. The nursing care

plan will be based on knowledge that

A) It is necessary to limit visitors until his

condition has improved.B) It is therapeutic to give himexplanations of his illness as soon as

possible.C) The client must begin to accept thatchanges in lifestyle will be needed.D) It is important to eliminate stress as

much as ossible in his dail routine.

Answer: D

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Answer: DD) The first priority will be to minimizestress by orienting the daily routines tohis needs. This may include his havingvisitors immediately, rather than

limiting them.

When a male client returns from the

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recovery room following a lumbarlaminectomy, the most important

postoperative assessment is toA) Auscultate lung sounds.

B) Check the client's temperature for signsof infection.C) Check for sensation in the lowerextremities.D) Observe the dressing for any drainage.

Answer: C

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Answer: CC) All of the interventions areimportant and will be carried outduring the postoperative period;however, the most important

intervention is to check for sensation.The ability to wiggle toes and move hisfeet indicate there is not a complication

from the surgical site.

After removing the fecal impaction, the

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g p ,client complains of feeling light-headed andthe pulse rate is 44. The priority

intervention is to

A) Place in shock position.

B) Call the physician.C) Begin CPR.D) Monitor vital signs.

Answer: A

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Answer: AA) The client requires treatment forshock. Vital signs are monitored afterplacing the client in the shock position;then the physician is called for orders.

The nursing behavior of sitting down at the

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g gclient's bedside to talk with the client willconvey a sense of

A) Communication.B) Empathy.

C) Sympathy.D) Encouragement.

Answer: B

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B) Nonverbal action conveysacceptance, openness to listen, andempathy. It assists the client toverbalize feelings.

Which nursing diagnosis should receive the

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g ghighest priority in a client with acute renalfailure?

A) Altered nutrition: less than bodyrequirements related to anorexia.

B) Activity intolerance related to fatigueand muscle cramps.C) Fluid volume excess related to oliguria.D) Risk for trauma related to decreasedalertness.

Answer: C

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C) The oliguria associated with acuterenal failure results in fluid volumeexcess. The increase in fluid volumemay produce life-threatening effects

such as heart failure, hypertension, andcerebral edema. The other nursingdiagnoses would have lower priority.

A client with cystic fibrosis is receiving

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y gdornase-alfa (Pulmozyme). To assess fordesired therapeutic effect, the nurse would

monitor the client's

A) Weight.

B) Cardiac rhythm.C) Lung sounds.D) Serum chloride.

Answer: C

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C) Dornase-alfa reduces the viscosity ofthe sputum in clients with cysticfibrosis. Pulmonary function isimproved and the incidence of

respiratory tract infections is lessened.Lung sounds reflect the presence orabsence of lung congestion which may

indicate infection and are, therefore,monitored closely as an indicator of thetherapeutic effect of this drug.

A client is brought to the hospital by her husband

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who says she is highly anxious and spends halfthe morning doing rituals. As part of her

treatment plan, the client will join a daily grouptherapy session at 10:30 in the morning. Therationale for choosing this time of day is

A) Anxious clients are more relaxed in themorning.B) Most groups are planned for the morning whenphysicians are on the unit.

C) Mornings are better for group therapy becauseclients have the rest of the day to work throughproblems that come up during the sessions.D) The client will have just completed her

ritualistic activit .

Answer: D

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D) It is best to plan any activity,particularly therapy, to follow thecompulsive activity because anxiety islowest at this time.

Following gall bladder surgery, a client has

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orders for an IV of D5W to run 100 ml/hour.When the nurse checks at the beginning of

the evening shift, she observes that the IVis one hour behind. The appropriate actionwould be to

A) Increase the flow so that the loss ismade up over the remaining hours in theshift.B) Continue the IV flow at the same rate.C) Double the rate of drops/minute for onehour to make up for the loss.

D) S eed u the IV to make u for the loss

Answer: A

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A) The IV needs to be infused equallyover the time ordered. When the IV isbehind, it should be recalculated. Thecalculation is completed by taking theamount of solution remaining to beinfused and dividing by the remaininghours.

The development of anti-Rh antibodies

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within the mother could have beenprevented with the administration of

RhoGAM for previous pregnancies. Thenurse's knowledge of RhoGAM is that it

A) Must be given on the sixth daypostdelivery.B) Should be given to an unsensitizedmother after each pregnancy or abortion.C) May be given to the infant in the uterus.D) May be given even after sensitizationoccurs.

Answer: B

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B) RhoGAM should be given after eachpregnancy including an abortion,because fetal blood may enter themother's circulation and set up asensitization process.

The nurse will know that a client with

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chronic renal failure adheres to dietaryphosphorus modification when he

A) Increases milk products.B) Increases red meats.C) Decreases whole grain products.D) Decreases red vegetables.

Answer: C

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C) Whole grain breads and cerealsprovide high sources of phosphate.Other sources include milk, meat,poultry, fish, and legumes.Hyperphosphatemia results fromdecreased renal clearance. Calciumantacids are often given to bind

phosphate in the GI tract.

When evaluating the client's understanding

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of a low potassium diet, the nurse will knowhe understands if he says that he will avoid

A) Pasta.B) Raw apples.

C) French bread.D) Dry cereal.

Answer: B

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B) Raw apples are high in potassium,while white-enriched and French bread,dry cereal, and pasta are foods low inpotassium.

After an automobile accident in which theli i d h d i j i

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client sustained a head injury, a craniotomyhas been scheduled. Analyzing the client's

immediate postoperative needs, thenursing care plan includes

A) Maintaining fluid and electrolyte balanceby administering at least 3000 mL D5Lactated Ringer's every 24 hours.B) Keeping his temperature below 97degrees F to decrease metabolic needs.C) Obtaining serial blood and urinesamples.

D) Placin him in su ine osition. Answer: CC) S i l bl d d i l

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C) Serial blood and urine samples arecollected because sodium regulation

disturbances frequently accompany headinjury. The temperature should be keptnormal to avoid increasing metabolic

needs. At 97 degrees F, the client wouldprobably shiver, causing not only increasedintracranial pressure but also increasedmetabolic rate. Fluids are kept at aminimum to prevent overhydration, whichcan lead to cerebral edema.

As the nurse is diluting an NG feeding for aCVA li t h h b d "Sh '

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CVA client, her husband says, "She'sgetting better, isn't she?" The best nursing

response at this time is

A) "Why do you ask? Does she appear

different to you?"B) "The doctor could better tell you that."C) "No. She is just about the same; but onlytime will tell."D) "Her condition is stable and she is veryill."

Answer: A

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A) The appropriate response is anassessment question to determinewhether the husband has observed achange. All the other responses closeoff communication, thus arenontherapeutic.

A client has an arteriovenous fistula as

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an access site for hemodialysis. Whichassessment finding indicates that thefistula is patent?

A) Normal capillary refill distal to thefistula.B) Palpation of a pulse distal to the

fistula.C) Absence of edema or redness overthe fistula.

D) Auscultation of a bruit over the Answer: D

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D) The flow of blood through a patentarteriovenous fistula producesturbulence manifested by a bruitaudible when the fistula is auscultated.

Following a client's total hip replacement,i di t l t ti l th ill

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immediately postoperatively the nurse willformulate a goal that states

A) Turn on operative side only immediatelypostoperatively.

B) Operative leg maintained in abduction.C) Head of bed elevated to 45-degreeangle.D) Buck's traction until hip can be putthrough range of motion.

Answer: Bb bd

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B) The leg must be kept in abduction.This position prevents dislocation of thenew hip until range of motion can beinstituted. Buck's traction is no longerused following total hip replacement.Physicians now order that the clientmay be turned on either side postop.

A client, age 32, is married and has nochildren He has been e periencing

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children. He has been experiencingabdominal pain for several months and his

physician suspects a duodenal ulcer.Assessing the symptoms described by theclient, the nurse will chart that the pain is

A) Constant over the epigastric area wheneating.B) Intermittent with no correlation betweenfood intake and when the pain occurs.C) Experienced about 30 minutes aftereating regardless of the diet.

D) Ex erienced about 2 to 3 hours after Answer: DD) P i i d d i h

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D) Pain is reduced upon eating whenthe client has a duodenal ulcer. Whenthe duodenum is empty, about 2 to 3hours after eating, the pain recurs.

A client with COPD has orders for oxygenadministration The method that delivers

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administration. The method that deliversthe appropriate liter flow and concentration

of oxygen would be

A) A venturi mask.

B) An oxygen catheter.C) Nasal prongs.D) A mask with reservoir bag.

Answer: AA) Th t i k d li fi d

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A) The venturi mask delivers a fixedFIO2, usually 24 to 35% at a liter flowof 2 to 8 l. The COPD client must havean accurate and predictable FIO2 and alow liter flow (less than 6 l/minute) toprevent hypoxemia. A liter flow of 8 to10 will provide an FIO2 of 70 to 100%.The reservoir bag contains the highestlevel of oxygen. As the client inhales,oxygen is taken in from the bag.

A hypothyroid client has orders for all ofthe following medications The nurse would

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the following medications. The nurse wouldevaluate the client most closely following

administration of which medication?

A) Meperidine (Demerol).

B) Levothyroxine (Synthroid).C) Digoxin (Lanoxin).D) Ibuprofen (Motrin).

Answer: AA) H th idi d th

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A) Hypothyroidism reduces themetabolic rate and prolongs thesedative effects of medications.Narcotics, such as meperidine, areespecially dangerous and should begiven in smaller doses. The client mustbe closely monitored for signs ofoversedation and respiratorydepression.

The nurse is assigned to a client with acentral vein IV infusing hyperalimentation

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central vein IV infusing hyperalimentationsolution. The most important nursing

intervention isA) Checking urine specific gravity, sugar,

and acetone every 4 hours.B) Preparing the next bottle of solutionprior to use.C) Changing the IV filter and tubing witheach bottle change.D) Maintaining the exact amount ofsolution administered hourly by adjusting

the flow rate.

Answer: AA) Ch ki th i f l d

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A) Checking the urine for glucose andacetone is essential to prevent ahyperosmolar condition. Insulin mayhave to be administered according torainbow coverage. Notify physician forurine glucose over 2+ and positiveacetone.

The nurse is counseling a woman who has justlearned she is pregnant She says she does not

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learned she is pregnant. She says she does notwant to gain too much weight because herhusband likes her "thin." The most appropriateresponse isA) "Why don't you have your husband come to

the clinic next time, and we can all talk aboutnutrition."B) "If you are careful about the foods you eat,especially those high in calories, you will not gain

too much."C) "It's best for the baby if you don't try to staytoo thin."D) "Let's talk about the importance of good

nutrition and wei ht ain in re nanc ."

Answer: DD) Ad t t iti d i ht i

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D) Adequate nutrition and weight gainin pregnancy are directly related todecreased mortality and morbidity inthe newborn. Helping the clientunderstand the role of nutrition andweight gain will help her then explorethe best way to talk to her husbandabout his concerns.

Adequate nutrition is essential during earlypregnancy for optimum fetal development

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pregnancy for optimum fetal development.The nurse, in counseling a client, would

recommend a daily diet that would include

A) 1500 calories

B) One fruit or vegetable high in vitamin C.C) Low roughage foods.D) A low sodium diet.

Answer: BB) The diet must include at least one

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B) The diet must include at least onefruit or vegetable high in vitamin C,and should include a total of four fruitsand vegetables. Pregnancy requiresthe addition of 300 calories a day overregular caloric intake, and 1500calories a day would be inadequate.The recommended calories forsomeone age 28 are 2300 a day.Research indicates that sodium is

essential during pregnancy A client in her 37th week of pregnancy isshowing early signs of pre-eclampsia The

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showing early signs of pre-eclampsia. Thenursing care plan will include assessment

for further signs of this condition.Indications of progression of pre-eclampsiato a more severe state would be the

presence ofA) Severe hypertension, glycosuria,polyuria.B) Hypertension, weight loss, diuresis.C) Hyperreflexia, oliguria, epigastric pain.D) Hypertension, convulsions, polyuria.

Answer: CC) Hyperreflexia occurs with increased

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C) Hyperreflexia occurs with increasedCNS irritation. Epigastric pain is usuallydue to edema or bleeding into the livercapsule and oliguria. Other signsinclude edema and hypertension.

When a client with a diagnosis of manicepisode returns to the clinic to have lithium

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episode returns to the clinic to have lithiumblood levels checked, her lithium level is

only slightly higher than the previous weekbut she complains of blurred vision andataxia. The first intervention is to

A) Withhold the next dose.B) Suggest she drink more fluid.C) Instruct her to watch for signs oftoxicity.D) Notify the physician.

Answer: AA) These are symptoms of toxicity and

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A) These are symptoms of toxicity andthe nurse must withhold the next dose.The nurse would then notify thephysician. The client needs to maintaina normal fluid level to prevent toxicity,but this may not be the cause of hersymptoms.

A nursing intervention to increase thenutritional status of a client on

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nutritional status of a client onchemotherapy is to

A) Encourage the intake of fluids withmeals.

B) Provide the highest amount of proteinwith the morning meal.C) Provide three meals a day and highprotein supplement fluids at least twice aday.D) Use high protein supplement fluids asthe major source of protein during the

chemothera

Answer: BB) The highest amount of protein

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B) The highest amount of proteinshould be ingested in the morningbecause this is usually when theappetite is better. The client shouldconsume at least one-third of the dailyprotein requirement with this meal. It isbest to offer frequent small meals orsnacks throughout the day to promoteadequate protein consumption. Fluidsshould be taken between rather than

with meals to prevent the client from A schizophrenic client has been takingThorazine for 2 days and is beginning

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Thorazine for 2 days and is beginningto develop extrapyramidal effects. The

nurse would expect the physician toorderA) Xanax.B) Cogentin.C) L-dopa.D) The drug to be discontinued.

Answer: BB) Cogentin is an antiparkinson drug

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B) Cogentin is an antiparkinson drugand will reduce these side effects.

Xanax is an antianxiety drug. L-dopa isgiven to clients with Parkinson'sdisease but is not useful for dystoniceffects; answer (D) is not the treatmentof choice, because the client needsThorazine to control her symptoms.

The toy most suitable to provide for a21 1/2 year old hospitalized for

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21 1/2 year old hospitalized fordiarrhea is

A) A stuffed animal.B) A mobile.C) Play -doh.D) A box of jacks.

Answer: AA) A stuffed animal would not be

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A) A stuffed animal would not beharmful and it would be comforting.

Play-doh is more appropriate for olderchildren. Jacks are not safe for aninfant; they will go immediately intothe infant's mouth.

A young male client has had a castplaced on his right leg While caring for

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placed on his right leg. While caring forthe client, the nurse identifies a "hot

spot" or area on the cast that feelswarm. The nurse reports to thephysician the signs of

A) Infection.B) Uneven cast drying.C) Poor circulation.D) The cast being too tight.

Answer: AA) Infection can be identified by "hot

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A) Infection can be identified by hotspots," or areas on the cast that feel

warm to the touch. A hot spot is notevidence of poor circulation or too tighta cast.

The nursing staff should encourage clientswith senile dementia to participate in

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with senile dementia to participate inactivities that provide him a chance to

A) Learn something new.B) Compete with others for stimulation.

C) Get a sense of continuity.D) Complete a task and feel successful.

Answer: DD) It is essential that the client

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D) It is essential that the clientparticipate in activities that he can

complete and that will increase his self-esteem. His diagnosis indicates he willhave difficulty learning anything new(A) and competition would be toothreatening (B). If his diagnosis isdementia, continuity will not be anissue.

Assisting the physician to establish a CVPline in a client, the nurse instructs the

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line in a client, the nurse instructs theclient to exhale against a closed glottis

(perform Valsalva's maneuver). Thepurpose of this procedure is to

A) Decrease intrathoracic pressure.B) Establish equal pressure in the line.C) Prevent an air embolism.D) Assist in catheter insertion.

Answer: CC) Valsalva's maneuver--the attempt to

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C) Valsalva s maneuver the attempt toforcibly exhale with the glottis, nose

and mouth closed--produces increasedintrathoracic pressure and lessens thechance of an air embolism as the CVPcatheter is inserted.

The nurse is monitoring the followingcardiac rhythms on the central cardiac

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cardiac rhythms on the central cardiacmonitoring console on the unit. Which

client would the nurse assess first?A) Complete heart block.B) Ventricular tachycardia.C) Sinus arrhythmia.D) Atrial fibrillation.

Answer: BB) Ventricular tachycardia is a life-

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B) Ventricular tachycardia is a lifethreatening arrhythmia because it

severely limits cardiac output and candegenerate quickly into ventricularfibrillation. Although atrial fibrillationand complete heart block can limitcardiac output, they are not asimmediately life-threatening as isventricular tachycardia. Sinusarrhythmia is not life-threatening.

The physician has ordered acholecystogram for a client. The

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y gintervention most important as a part of

the preparation for this procedure isA) Giving the client a high-fat meal.

B) Assessing for shellfish allergy.C) Administering an enema.D) Allowing a light breakfast.

Answer: BB) If the client is allergic to shellfish he

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B) If the client is allergic to shellfish, hemost likely will be allergic to the dye

used for the cholecystogram. Answers(C) and (D) might be carried out, butthey are not the most important.

A client is receiving the drug flecainide(Tambocor). Which nursing intervention

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( ) gshould be implemented?

A) Assess blood glucose by finger-stick ACand HS.

B) Give the medication with meals.C) Monitor apical pulse rate and rhythm.D) Restrict intake of high sodium foods.

Answer: CC) Flecainide is an antiarrhythmic used

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C) Flecainide is an antiarrhythmic usedfor the treatment of certain life-

threatening arrhythmias. The apicalpulse is monitored to evaluate thetherapeutic response to the drug andto detect any new arrhythmias whichmay represent a side effect or toxiceffect of this potent drug.

When a child has had one poison ingestion,statistically he is nine times more likely to

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y yhave another poisoning episode within the

year. To prevent further poisoningincidents, the most important informationto tell the mother is to

A) Keep purses out of the child's reach.B) Never give medications to others in frontof the child.

C) Keep all cabinets locked at all times.D) If poisoning occurs, do as the label onthe bottle recommends.

Answer: CC) Answers (A) and (B) are also

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C) Answers (A) and (B) are alsonecessary information but keeping

cabinets locked is critical. Not all labelsinclude sufficient information. Thechild's mother should be given thetelephone number of a poison controlcenter.

A client complains of nausea and loss of appetite.The monitor reveals she is now in a slow atrialfib ill ti ith l t f 72 Th Di i

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fibrillation with a pulse rate of 72. The Digoxindose is 0.25 mg PO daily with Valium and

Compazine ordered prn. The initial nursingintervention will be to

A) Administer the Compazine ordered prn fornausea.B) Call the physician because the client isprobably having an allergic reaction to Digoxin.

C) Administer the Valium ordered prn for anxiety.D) Hold the drug as the client is probably Digoxin-toxic.

Answer: DD) One of the first signs of Digoxin

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D) One of the first signs of Digoxintoxicity is nausea. The drug should not

be given until the cause of the client'snausea is determined. Neither Valiumnor Compazine is indicated until thesource of the nausea is determined.

A female client is placed on digoxin(Lanoxin) 0.25 mg daily. Two weeks later,

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she comes to the clinic for a check-up. If

the medication is effective, the nurse willassess a

A) Lowered blood pressure.B) Decreased pulse rate.C) Decreased urine output.D) Decreased respiratory rate.

Answer: BB) The pulse rate should decrease with

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B) The pulse rate should decrease withdigoxin due to strengthened

myocardial contraction. Urine outputshould increase. Blood pressure andrespirations will be unaffected.

[Chapter 1] Topic: Physiological IntegrityA 6-week-old infant with a diagnosis of a

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fever of unknown origin is admitted to the

unit. The nurse enters the room and findshim sleeping. A priority assessment onadmission is to obtain his vital signs. The

nurse would begin this assessment byA) Taking his axillary temperature.B) Counting his respirations.

C) Taking his rectal temperature.D) Taking his apical pulse.

Answer: BB) Counting respirations before

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) g pdisturbing the child will give the most

accurate number. As soon as a child istouched (or even approached, ifawake) his respiratory and apical rate

will increase. Take respirations first,apical pulse next, and rectaltemperature last.

As the nurse is changing an abdominaldressing, the client suddenly coughs and

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an evisceration of the wound occurs. The

priority intervention is to

A) Obtain vital signs.B) Keep the client in a supine position.C) Apply an abdominal binder to theincision.D) Apply butterfly tape to the wound

edges.

Answer: BB) The client's wound opens and the

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) pbowel contents protrude when an

evisceration occurs. Intra-abdominalpressure changes creating a shockstate; thus the supine position is

required. In addition, the bowelcontents should be prevented fromprotruding any further.

A client is to receive IV heparin at a rate of1200 units per hour. Available is a bag

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containing 25,000 units of Heparin in 500

mL of D5W. The nurse would set the IVcontroller to deliverA) 48 mL per hour.B) 24 mL per hour.C) 82 mL per hour.D) 12 mL per hour.

Answer: BB) This computation can be done using

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) p gthe formula of D divided by H

multiplied by V. 1200 divided by25,000 multiplied by 500 equals 24 mL.

A client has been admitted to aninpatient psychiatric unit. Her initial

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p p ydiagnosis is schizophrenia--

undifferentiated type. When the nurseis sitting with the client, she saysslowly, "My blue sky moves to arm."

This statement is most clearly anexample of

A) Hallucinatory experience.B) Associative looseness.C) Neologism.

Answer: BB) Schizophrenics often evidence loose

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passociations or disordered thoughts.

This is manifested by words that don'tmake sense, word salad, andneologisms (made up words). Flight of

ideas is found with manic disorders.

A client in acute intoxication or DTs isadmitted to the emergency room.

di d d d h ill

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According to standard orders, the nurse will

probably add which specific supplement tothe IV glucose?

A) Calcium gluconate.B) Vitamin B, thiamine.C) Vitamin C.D) Magnesium sulfate.

Answer: BB) The most critical supplement is

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ppvitamin B, specifically thiamine,

although often a B complex (mixturethat contains all B vitamins) is given.This vitamin deficiency is at least

partially responsible for causing theclient to develop Delirium Tremens.None of the other answers is relevant.

Paralytic ileus is a frequent complication ofpostoperative abdominal surgery.A di t th h i i ' d d th

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According to the physician's orders and the

nurse's assessment, a planned interventionwould be toA) Administer PO fluids only.B) Insert a nasogastric tube.C) Listen for bowel sounds.D) Insert a rectal tube.

Answer: CC) The client will not be fed until bowel

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sounds are present, abdominal

distention relieved, and flatus ispassed. Answer (C) would be the firstintervention followed by (B) and (D) if

necessary.

While assessing a client in skeletal traction,the nurse observes the distal extremity tob l ith l ill fill d

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be pale with slow capillary refill and

palpated at a 1+ pulse. The initialintervention is to

A) Assess the client every 15 minutes forchanges.B) Remove the traction.C) Observe for ecchymosis or signs of

infection.D) Notify the physician.

Answer: DD) There is a circulatory compromise

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and thus the physician needs to be

notified immediately. The otheractions, except removing traction, willbe carried out later.

When a client has the diagnosis ofschizophrenia, the most conspicuous signsf t di d ki i

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of tardive dyskinesia are

A) Muscular spasms of the extremities.B) Drowsiness and lethargy.C) Spastic movements of the eyelids.D) Oral movements and drooling.

Answer: DD) Drooling, shuffling gait, and general

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dystonic symptoms are characteristic

of tardive dyskinesia, a conditionassociated with long-term use ofantipsychotic drugs. This is usually a

permanent form of an extrapyramidaleffect. Muscular spasms most oftenoccur with dystonia, a side effect thatoccurs early in the use ofantipsychotics.

When taking the history from the mother ofa baby who has pyloric stenosis, the nurse

o ld e pect her to sa that the bab

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would expect her to say that the baby

vomits

A) When new foods are introduced.B) Between feedings.C) Immediately after feedings.D) Continuously.

Answer: CC) Stenosis of the pyloric sphincter

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impedes gastric emptying; therefore,

feedings are vomited when thestomach is full.

Following abdominal surgery it is importantthat the nurse assess the client fornegative nitrogen balance The clinical

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negative nitrogen balance. The clinical

manifestation most indicative of negativenitrogen balance is

A) Dehydration.B) Generalized edema.C) Diarrhea.D) Pale color to skin.

Answer: BB) When there is insufficient nitrogen

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for synthesis, there is a change in the

body's osmotic pressure resulting inthe oozing of fluids out of the vascularspace. This phenomena results in the

formation of edema in the abdomenand flanks.

The RN responsible for administering athiazide medication to a client evaluateshis recent lab reports which are K+ 3 0

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his recent lab reports, which are K+ 3.0

and NA+ 140. The correct intervention is toA) Administer the thiazide drug.B) Withhold the drug and report both labresults to the physician.C) Notify the physician.D) Withhold the drug and report K+ level to

the physician.

Answer: DD) The appropriate intervention is to

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withhold the thiazide medication until

the nurse receives further orders andreport K+ level to the physician.Normal K+ is 3.5 to 5.5 mEq/l. His NA+

level is normal (range 135 to 145mEq/l).