Practice Exam 4 and Rationales
This chapter is from the book
This chapter is from the book
This chapter is from the book
A client with AIDS asks the nurse why he can’t have a pitcher of water at his bedside so he can drink whenever he likes. The nurse should tell the client that:
A. It would be best for him to drink tap water.- B. He should drink less water and more juice.
- C. Leaving a glass of water makes it easier to calculate his intake.
- D. He shouldn’t drink water that has been sitting longer than 15 minutes.
Quick Answers: 251
Detailed Answer: 254The mother of a male child with cystic fibrosis tells the nurse that she hopes her son’s children won’t have the disease. The nurse is aware that:
- A. There is a 25% chance that his children would have cystic fibrosis.
- B. Most of the males with cystic fibrosis are sterile.
- C. There is a 50% chance that his children would be carriers.
- D. Most males with cystic fibrosis are capable of having children, so genetic counseling is advised.
Quick Answers: 251
Detailed Answer: 254An infant is hospitalized for treatment of botulism. Which factor is associated with botulism in the infant?
- A. The infant sucks on his fingers and toes.
- B. The mother sweetens the infant’s cereal with honey.
- C. The infant was switched to soy-based formula.
- D. The infant’s older sibling has an aquarium.
Quick Answers: 251
Detailed Answer: 254A nurse is assessing a client hospitalized with peptic ulcer disease. Which finding should be reported to the charge nurse immediately?
- A. BP 82/60, pulse 120
- B. Pulse 68, respirations 24
- C. BP 110/88, pulse 56
- D. Pulse 82, respirations 16
Quick Answers: 251
Detailed Answer: 254The nurse is teaching the client with AIDS regarding proper food preparation. Which statement indicates that the client needs further teaching?
- A. “I should avoid adding pepper to food after it is cooked.”
- B. “I can still have an occasional medium-rare steak.”
- C. “Eating cheese and yogurt won’t help prevent AIDS-related diarrhea.”
- D. “I should eat fruits and vegetables that can be peeled.”
Quick Answers: 251
Detailed Answer: 254A client taking Laniazid (isoniazid) asks the nurse how long she must take the medication before her sputum cultures will return to normal. The nurse recognizes that the client should have a negative sputum culture within:
- A. 2 weeks
- B. 6 weeks
- C. 2 months
- D. 3 months
Quick Answers: 251
Detailed Answer: 254Which person is at greatest risk for developing Lyme disease?
- A. Computer technician
- B. Middle-school teacher
- C. Dog trainer
- D. Forestry worker
Quick Answers: 251
Detailed Answer: 254Following eruption of the primary teeth, the mother can promote chewing by giving the toddler:
- A. Pieces of hot dog
- B. Celery sticks
- C. Melba toast
- D. Grapes
Quick Answers: 251
Detailed Answer: 254A client scheduled for an exploratory laparotomy tells the nurse that she takes kava-kava (piper methysticum) for sleep. The nurse should notify the doctor because kava-kava:
- A. Increases the effects of anesthesia and post-operative analgesia
- B. Eliminates the need for antimicrobial therapy following surgery
- C. Increases urinary output, so a urinary catheter will be needed post-operatively
- D. Depresses the immune system, so infection is more of a problem
Quick Answers: 251
Detailed Answer: 254The nurse is teaching circumcision care to the mother of a newborn. Which statement indicates that the mother needs further teaching?
- A. “I will apply a petroleum gauze to the area once a day.”
- B. “I will clean the area carefully with each diaper change.”
- C. “I can place a heat lamp next to the area to speed up the healing process.”
- D. “I should carefully observe the area for signs of infection.”
Quick Answers: 251
Detailed Answer: 254The chart of a client hospitalized with a fractured femur reveals that the client is colonized with MRSA. The nurse knows that the client:
- A. Will not display symptoms of infection
- B. Is less likely to have an infection
- C. Can be placed in the room with others
- D. Cannot colonize others with MRSA
Quick Answers: 251
Detailed Answer: 254A client is admitted with Clostridium difficile. The nurse would expect the client to have:
- A. Diarrhea containing blood and mucus
- B. Cough, fever, and shortness of breath
- C. Anorexia, weight loss, and fever
- D. Development of deep leg ulcers
Quick Answers: 251
Detailed Answer: 255An elderly client asks the nurse how often he will need to receive immunizations against pneumonia. The nurse should tell the client that she will need an immunization against pneumonia:
- A. Every year
- B. Every 2 years
- C. Every 5 years
- D. Every 10 years
Quick Answers: 251
Detailed Answer: 255The nurse is caring for a client following a right nephrolithotomy. Post-operatively, the client should be positioned:
- A. On the right side
- B. Supine
- C. On the left side
- D. Prone
Quick Answers: 251
Detailed Answer: 255A nursing assistant is referred to the employee health office with symptoms of latex allergy. The first symptom usually noticed by those with latex allergy is:
- A. Oral itching after eating bananas
- B. Swelling of the eyes and mouth
- C. Difficulty breathing
- D. Swelling and itching of the hands
Quick Answers: 251
Detailed Answer: 255Acticoat (silver nitrate) dressings are applied to the arms and chest of a client with full-thickness burns. The nurse should:
- A. Change the dressings once per shift
- B. Moisten the dressings with sterile water
- C. Change the dressings only when they become soiled
- D. Moisten the dressings with normal saline
Quick Answers: 251
Detailed Answer: 255A client is diagnosed with stage III Hodgkin’s lymphoma. The nurse recognizes that the client has involvement:
- A. In a single lymph node or single site
- B. In more than one node or single organ on the same side of the diaphragm
- C. In lymph nodes on both sides of the diaphragm
- D. In disseminated organs and tissues
Quick Answers: 251
Detailed Answer: 255A client has been receiving Rheumatrex (methotrexate) for severe rheumatoid arthritis. The nurse should tell the client to avoid taking:
- A. Aspirin
- B. Multivitamins
- C. Omega 3 and omega 6 fish oils
- D. Acetaminophen
Quick Answers: 251
Detailed Answer: 255A suitable diet for a client with cirrhosis and abdominal ascites is one that is:
- A. High in sodium, low in calories
- B. Low in potassium, high in calories
- C. High in protein, high in calories
- D. Low in calcium, low in calories
Quick Answers: 251
Detailed Answer: 255A client with gallstones in the gall bladder is scheduled for lithotripsy. For the procedure, the client will be placed:
- A. In a prone position
- B. In a supine position
- C. In a side-lying position
- D. In a recumbent position
Quick Answers: 251
Detailed Answer: 255A client with rheumatoid arthritis is being treated with daily steroid medication. Which food should the client avoid?
- A. Raw oysters
- B. Cottage cheese
- C. Baked chicken
- D. Green beans
Quick Answers: 251
Detailed Answer: 255A client tells the nurse that she takes St. John’s wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that:
- A. St. John’s wort seldom relieves depression.
- B. She should avoid eating cold cuts and aged cheese.
- C. Skin reactions increase with the use of sunscreens.
- D. St. John’s wort will increase the amount of medication needed.
Quick Answers: 251
Detailed Answer: 256The physician has instructed the client with gout to avoid protein sources of purine. Which protein source is high in purine?
- A. Dried beans
- B. Nuts
- C. Cheese
- D. Eggs
Quick Answers: 251
Detailed Answer: 256The nurse is caring for a client with a long history of bulimia. The nurse would expect the client to have:
- A. Extreme weight loss
- B. Dental caries
- C. Hair loss
- D. Lanugo
Quick Answers: 251
Detailed Answer: 256A client with paranoid schizophrenia has an order for Thorazine (chlorpromazine) 400mg orally twice daily. Which of the following symptoms should be reported to the physician immediately?
- A. Muscle spasms of the neck, difficulty in swallowing
- B. Dry mouth, constipation, blurred vision
- C. Lethargy, slurred speech, thirst
- D. Fatigue, drowsiness, photosensitivity
Quick Answers: 251
Detailed Answer: 256The nurse is applying a Transderm Nitro (nitrogycerin) patch to a client with angina. When applying the patch, the nurse should:
- A. Shave the area before applying a new patch
- B. Remove the old patch and clean the skin with alcohol
- C. Cover the patch with plastic wrap and tape it in place
- D. Avoid cutting the patch because it will alter the dose
Quick Answers: 251
Detailed Answer: 256A client with myasthenia gravis is admitted with a diagnosis of cholinergic crisis. The nurse can expect the client to have:
- A. Decreased blood pressure and pupillary meiosis
- B. Increased heart rate and increased respirations
- C. Increased respirations and increased blood pressure
- D. Anoxia and absence of the cough reflex
Quick Answers: 251
Detailed Answer: 256The nurse is providing dietary teaching regarding low-sodium diets for a client with hypertension. Which food should be avoided by the client on a low-sodium diet?
- A. Dried beans
- B. Swiss cheese
- C. Peanut butter
- D. American cheese
Quick Answers: 251
Detailed Answer: 256A client is admitted to the emergency room with partial-thickness burns of his head and both arms. According to the Rule of Nines, the nurse calculates that the TBSA (total body surface area) involved is:
- A. 20%
- B. 27%
- C. 35%
- D. 50%
Quick Answers: 251
Detailed Answer: 256The physician has ordered a paracentesis for a client with severe ascites. Before the procedure, the nurse should:
- A. Instruct the client to void
- B. Shave the abdomen
- C. Encourage extra fluids
- D. Request an abdominal x-ray
Quick Answers: 251
Detailed Answer: 256The mother of a child with chickenpox wants to know if there is a medication that will shorten the course of the illness. Which medication is sometimes used to speed healing of the lesions and shorten the duration of fever and itching?
- A. Zovirax (acyclovir)
- B. Varivax (varicella vaccine)
- C. VZIG (varicella-zoster immune globulin)
- D. Periactin (cyproheptadine)
Quick Answers: 251
Detailed Answer: 256Which of the following clients is most likely to be a victim of elder abuse?
- A. A 62-year-old female with diverticulitis
- B. A 76-year-old female with right-sided hemiplegia
- C. A 65-year-old male with a hip replacement
- D. A 72-year-old male with diabetes mellitus
Quick Answers: 251
Detailed Answer: 257A hospitalized client with severe anemia is to receive a unit of blood. Which facet of care is most appropriate for the newly licensed practical nurse?
- A. Initiating the IV of normal saline
- B. Monitoring the client’s vital signs
- C. Initiating the blood transfusion
- D. Notifying the physician of a reaction
Quick Answers: 251
Detailed Answer: 257To reduce the possibility of having a baby with a neural tube defect, the client should be told to increase her intake of folic acid. Dietary sources of folic acid include:
- A. Meat, liver, eggs
- B. Pork, fish, chicken
- C. Oranges, cabbage, cantaloupe
- D. Dried beans, sweet potatoes, Brussels sprouts
Quick Answers: 251
Detailed Answer: 257A client is admitted for suspected bladder cancer. Which one of the following factors is most significant in the client’s diagnosis?
- A. Smoking a pack of cigarettes a day for 30 years
- B. Taking hormone-replacement therapy
- C. Eating foods with preservatives
- D. Past employment involving asbestos
Quick Answers: 251
Detailed Answer: 257The physician has prescribed nitroglycerin buccal tablets as needed for a client with angina. The nurse should tell the client to take the tablets:
- A. After engaging in strenuous activity
- B. Every 4 hours to prevent chest pain
- C. When he first feels chest discomfort
- D. At bedtime to prevent nocturnal angina
Quick Answers: 251
Detailed Answer: 257The nurse is caring for an infant who is on strict intake and output. The used diaper weighs 90.5 grams. The diaper’s dry weight was 62 grams. The infant’s urine output was:
- A. 10mL
- B. 28.5mL
- C. 10 grams
- D. 152.5 grams
Quick Answers: 251
Detailed Answer: 257The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should explain the need for:
- A. Additional calcium in the infant’s diet
- B. Careful handling to prevent fractures
- C. Providing extra sensorimotor stimulation
- D. Frequent testing of visual function
Quick Answers: 251
Detailed Answer: 257The nurse is preparing a client with gastroesophageal reflux disease (GERD) for discharge. The nurse should tell the client to:
- A. Eat a small snack before bedtime
- B. Sleep on his right side
- C. Avoid colas, tea, and coffee
- D. Increase his intake of citrus fruits
Quick Answers: 251
Detailed Answer: 257The nurse is administering Dilantin (phenytoin) via nasogastric (NG) tube. When giving the medication, the nurse should:
- A. Flush the NG tube with 2–4mL of water before giving the medication
- B. Administer the medication, flush with 5mL of water, and clamp the NG tube
- C. Flush the NG tube with 5mL of normal saline and administer the medication
- D. Flush the NG tube with 2–4oz. of water before and after giving the medication
Quick Answers: 251
Detailed Answer: 258The nurse is caring for a 3-year-old in a wet hip spica cast made from plaster of Paris. When turning the 3-year-old with a wet cast, the nurse should:
- A. Grasp the cast by the hand
- B. Use an assistive sling
- C. Use the palms of the hands
- D. Obtain a lifting device
Quick Answers: 251
Detailed Answer: 258A client has a diagnosis of discoid lupus. The primary difference in discoid lupus and systemic lupus is that discoid lupus:
- A. Produces changes in the kidneys
- B. Is confined to the skin
- C. Results in damage to the heart and lungs
- D. Affects both joints and muscles
Quick Answers: 251
Detailed Answer: 258The nurse is preparing to walk the post-operative client for the first time since surgery. Before walking the client, the nurse should:
- A. Give the client pain medication
- B. Assist the client in dangling his legs
- C. Have the client breathe deeply
- D. Provide the client with additional fluids
Quick Answers: 251
Detailed Answer: 258While performing a neurological assessment on a client with a closed head injury, the licensed practical nurse notes a positive Babinski reflex. The nurse should:
- A. Recognize that the client’s condition is improving
- B. Reposition the client and check reflexes again
- C. Do nothing because the finding is an expected one
- D. Notify the charge nurse of the finding
Quick Answers: 251
Detailed Answer: 258The physician has prescribed Gantrisin (sulfasoxazole) 1 gram in divided doses for a client with a urinary tract infection. The nurse should administer the medication:
- A. With meals or a snack
- B. 30 minutes before meals
- C. 30 minutes after meals
- D. At bedtime
Quick Answers: 251
Detailed Answer: 258A client hospitalized with renal calculi complains of severe pain in the right flank. In addition to complaints of pain, the nurse can expect to see changes in the client’s vital signs, which include:
- A. Decreased pulse rate
- B. Increased blood pressure
- C. Decreased respiratory rate
- D. Increased temperature
Quick Answers: 251
Detailed Answer: 258A 3-year-old is diagnosed with diarrhea caused by an infection with salmonella. Which of the following most likely contributed to the child’s illness?
- A. Brushing the family dog
- B. Playing with a pet turtle
- C. Taking a pony ride
- D. Feeding the family cat
Quick Answers: 251
Detailed Answer: 258The nurse is administering Pyridium (phenazopyridine) to a client with cystitis. The nurse should tell the client that:
- A. The urine will have a strong odor of ammonia.
- B. The urinary output will increase in amount.
- C. The urine will have a red–orange color.
- D. The urinary output will decrease in amount.
Quick Answers: 251
Detailed Answer: 258The nurse is caring for an infant with atopic dermatitis. An important part of the infant’s care will be:
- A. Keeping the infant warm
- B. Trimming the fingernails
- C. Using soap for bathing
- D. Applying peroxide to dry areas
Quick Answers: 251
Detailed Answer: 258The nurse is providing care for a 10-month-old infant diagnosed with a Wilms tumor. Most parents report feeling a mass when:
- A. The infant is diapered or bathed
- B. The infant raises his arms
- C. The infant has finished a bottle
- D. The infant tries to sit
Quick Answers: 251
Detailed Answer: 259The LPN is assigned to care for a client with a fractured femur. Which of the following should be reported to the charge nurse immediately?
- A. The client complains of chest pain and feelings of apprehension
- B. Ecchymosis is noted on the side of the injured leg
- C. The client’s oral temperature of 99.2°F
- D. The client complains of Level 2 pain on a scale of 1 to 5
Quick Answers: 251
Detailed Answer: 259The Joint Commission for Accreditation of Hospital Organizations (JCAHO) specifies that two client identifiers are to be used before medication administration. Which method is best for identifying patients using two patient identifiers?
- A. Take the medication administration record (MAR) to the room and compare it with the name and medical number recorded on the armband
- B. Compare the medication administration record (MAR) with the client’s room number and name on the armband
- C. Request that a family member identify the client, and then ask the client to state his name
- D. Ask the client to state his full name and then to write his full name
Quick Answers: 251
Detailed Answer: 259A nurse finds her neighbor lying unconscious in the doorway of her bathroom. After determining that the victim is unresponsive, the nurse should:
- A. Start cardiac compression
- B. Give two slow deep breaths
- C. Open the airway using the head-tilt chin-lift maneuver
- D. Call for help
Quick Answers: 251
Detailed Answer: 259A client with AIDS-related cytomegalovirus has been started on Cytovene (ganciclovir). The client asks the nurse how long he will have to take the medication. The nurse should tell the client that the medication will be needed:
- A. Until the infection clears
- B. For 6 months to a year
- C. Until the cultures are normal
- D. For the remainder of life
Quick Answers: 251
Detailed Answer: 259The nurse is caring for a client with a basal cell epithelioma. The nurse recognizes that the risk factors for basal cell carcinoma include having fair skin and:
- A. Sun exposure
- B. Smoking
- C. Ingesting alcohol
- D. Ingesting food preservatives
Quick Answers: 251
Detailed Answer: 259While caring for a client following a Whipple procedure, the LPN notices that the drainage has become bile tinged and has increased over the past hour. The LPN should:
- A. Document the finding and continue to monitor the client
- B. Irrigate the drainage tube with 10mL of normal saline
- C. Decrease the amount of intermittent suction
- D. Notify the RN regarding changes in the drainage
Quick Answers: 251
Detailed Answer: 259A client with AIDS tells the nurse that he regularly takes Echinacea to boost his immune system. The nurse should tell the client that:
- A. Herbals can interfere with the action of antiviral medication.
- B. Supplements have proven effective in prolonging life.
- C. Herbals have been shown to decrease the viral load.
- D. Supplements appear to prevent replication of the virus.
Quick Answers: 251
Detailed Answer: 259A client receiving chemotherapy has Sjogren’s syndrome. The nurse can help relieve the discomfort caused by Sjogren’s syndrome by:
- A. Providing cool, noncarbonated beverages
- B. Instilling eyedrops
- C. Administering prescribed antiemetics
- D. Providing small, frequent meals
Quick Answers: 251
Detailed Answer: 259Which one of the following symptoms is common in the client with duodenal ulcers?
- A. Vomiting shortly after eating
- B. Epigastric pain following meals
- C. Frequent bouts of diarrhea
- D. Presence of blood in the stools
Quick Answers: 251
Detailed Answer: 260The physician has prescribed a Flovent (fluticasone) inhaler two puffs twice a day for a client with chronic obstructive pulmonary disease. The nurse should tell the client to report:
- A. Increased weight
- B. A sore throat
- C. Difficulty in sleeping
- D. Changes in mood
Quick Answers: 251
Detailed Answer: 260A client treated for depression is admitted with a diagnosis of serotonin syndrome. The nurse recognizes that serotonin syndrome can be caused by:
- A. Concurrent use of two SSRIs
- B. Eating foods that are high in tyramine
- C. Drastic decrease in dopamine levels
- D. Use of medications containing pseudoephedrine
Quick Answers: 251
Detailed Answer: 260A client is admitted with suspected pernicious anemia. Which finding is common in the client with pernicious anemia?
- A. Complaints of feeling tired and listless
- B. Waxy, pale skin
- C. Loss of coordination and position sense
- D. Rapid pulse rate and heart murmur
Quick Answers: 251
Detailed Answer: 260Which finding is associated with secondary syphilis?
- A. Painless, popular lesions on the perineum, fingers, and eyelids
- B. Absence of lesions
- C. Deep asymmetrical granulomatous lesions
- D. Well-defined generalized lesions on the palms, soles, and perineum
Quick Answers: 251
Detailed Answer: 260The physician has ordered an injection of morphine for a client with post-operative pain. Before administering the medication, it is essential that the nurse assess the client’s:
- A. Heart rate
- B. Respirations
- C. Temperature
- D. Blood pressure
Quick Answers: 251
Detailed Answer: 260The nurse is assessing a client following a subtotal thyroidectomy. Part of the assessment is asking the client to state her name. The primary reason for asking the client to state her name is to check for:
- A. Post-operative bleeding
- B. Decreased calcium
- C. Laryngeal stridor
- D. Laryngeal nerve damage
Quick Answers: 251
Detailed Answer: 260A client is admitted for treatment of essential hypertension. Essential hypertension exists when the client maintains a blood pressure reading at or above:
- A. 140/90
- B. 136/72
- C. 130/70
- D. 128/68
Quick Answers: 251
Detailed Answer: 260The nurse is applying karaya powder to the skin surrounding the client’s ilestomy. The purpose of the karaya powder is to:
- A. Prevent the formation of odor
- B. Help form a seal that will protect the skin
- C. Prevent the loss of electrolytes
- D. Increase the time between bag evacuations
Quick Answers: 251
Detailed Answer: 260The nurse is caring for a 9-month-old with suspected celiac disease. Which diet is appropriate?
- A. Whole milk and oatmeal
- B. Breast milk and mixed cereal
- C. Formula and barley cereal
- D. Breast milk and rice cereal
Quick Answers: 251
Detailed Answer: 261Which lab finding would the nurse expect to find in the client with diverticulitis?
- A. Elevated red cell count
- B. Decreased serum creatinine
- C. Elevated white cell count
- D. Decreased alkaline phosphatase
Quick Answers: 251
Detailed Answer: 261A gravida two para one has just delivered a full-term infant. Which finding indicates separation of the placenta?
- A. Wavelike relaxation of the abdomen
- B. Increased length of the cord
- C. Decreased vaginal bleeding
- D. Inability to palpate the uterus
Quick Answers: 251
Detailed Answer: 261The physician has ordered a daily dose of Nexium (esomeprazole) for a client with gastric ulcers. The nurse should administer the medication:
- A. Before breakfast
- B. After breakfast
- C. At bedtime
- D. At noon
Quick Answers: 251
Detailed Answer: 261A client admitted for treatment of a duodenal ulcer complains of sudden sharp midepigastric pain. Further assessment reveals that the client has a rigid, boardlike abdomen. The nurse recognizes that the client’s symptoms most likely indicate:
- A. Ulcer perforation
- B. Increased ulcer formation
- C. Esophageal inflammation
- D. Intestinal obstruction
Quick Answers: 251
Detailed Answer: 261Which snack is best for the child following a tonsillectomy?
- A. Banana popsicle
- B. Chocolate milk
- C. Fruit punch
- D. Cola
Quick Answers: 251
Detailed Answer: 261The physician has prescribed Xanax (alprazolam) for a client with acute anxiety. The nurse should teach the client to avoid:
- A. Sun exposure
- B. Drinking beer
- C. Eating cheese
- D. Taking aspirin
Quick Answers: 251
Detailed Answer: 261The nurse is instructing a post-operative client on the use of an incentive spirometer. The nurse knows that the correct use of the incentive spirometer is directly related to:
- A. Promoting the client’s circulation
- B. Preparing the client for amubulation
- C. Strengthening the client’s muscles
- D. Increasing the client’s respiratory effort
Quick Answers: 251
Detailed Answer: 261The nurse is assisting the physician with the insertion of an esophageal tamponade. Before insertion, the nurse should:
- A. Inflate and deflate the gastric and esophageal balloons
- B. Measure from the tip of the client’s nose to the xiphoid process
- C. Explain to the client that the tube will remain in place for 5–7 days
- D. Insert a nasogastric tube for gastric suction
Quick Answers: 251
Detailed Answer: 261The physician has ordered Cephulac (lactulose) for a client with increased serum ammonia. The nurse knows the medication is having its desired effect if the client experiences:
- A. Increased urination
- B. Diarrhea
- C. Increased appetite
- D. Decreased weight
Quick Answers: 251
Detailed Answer: 262The nurse is assessing a client immediately following delivery. The nurse notes that the client’s fundus is boggy. The nurse’s next action should be to:
- A. Assess for bladder distention
- B. Notify the physician
- C. Gently massage the fundus
- D. Administer pain medication
Quick Answers: 251
Detailed Answer: 262Which breakfast selection is suitable for the client on a high‑fiber diet?
- A. Danish pastry, tomato juice, coffee, and milk
- B. Oatmeal, grapefruit wedges, coffee, and milk
- C. Cornflakes, toast and jam, and milk
- D. Scrambled eggs, bacon, toast, and coffee
Quick Answers: 251
Detailed Answer: 262A male client is admitted with a tentative diagnosis of Hodgkin’s lymphoma. The client with Hodgkin’s lymphoma commonly reports:
- A. Finding enlarged nodes in the neck while shaving
- B. Projectile vomiting upon arising
- C. Petechiae and easy bruising
- D. Frequent, painless hematuria
Quick Answers: 251
Detailed Answer: 262A client with acquired immunodeficiency syndrome has begun treatment with Pentam (pentamidine). The nurse recognizes that the medication will help to prevent:
- A. Candida albicans
- B. Pneumocystis jiroveci
- C. Cryptosporidiosis
- D. Cytomegaloretinitis
Quick Answers: 251
Detailed Answer: 262During a well baby visit, the mother asks the nurse when the “soft spot” on the front of her baby’s head will close. The nurse should tell the mother that the anterior fontanel normally closes by the time the baby is:
- A. 4–6 months of age
- B. 7–9 months of age
- C. 10–12 months of age
- D. 12–18 months of age
Quick Answers: 251
Detailed Answer: 262An elderly client with anemia has a positive Schilling test. The nurse knows that the client’s anemia is due to:
- A. Chronically low iron store
- B. Abnormal shape of the red blood cells
- C. Lack of intrinsic factor
- D. Shortened lifespan of the red blood cells
Quick Answers: 251
Detailed Answer: 262The nurse is cleaning up a blood spill that occurred during removal of a chest tube. The nurse should clean the blood spill using:
- A. Hydrogen peroxide
- B. Weak solution of bleach
- C. Isoprophyl alcohol
- D. Soap and water
Quick Answers: 251
Detailed Answer: 262A 5-month-old admitted with gastroenteritis is managed with IV fluids and is to be NPO. Which nursing intervention will provide the most comfort for the 5-month-old who is NPO?
- A. Offering a pacifier
- B. Sitting next to the crib
- C. Providing a mobile
- D. Singing a lullaby
Quick Answers: 251
Detailed Answer: 262During the admission assessment, the nurse discovers that the client has brought her medications from home. The nurse should:
- A. Tell the client that she can keep her medicines as long as she does not take them
- B. Make a list of the medications and ask a family member to take the medications home
- C. Allow the client to keep over-the-counter medications and herbal supplements
- D. Use the client’s home medications because they have already been purchased
Quick Answers: 251
Detailed Answer: 262The nurse is reviewing the preoperative checklist for a client scheduled for a cholecystectomy. Which item is not required on the client’s preoperative checklist?
- A. History of allergies
- B. Most recent vital signs
- C. Physician’s signature
- D. Preoperative medications
Quick Answers: 251
Detailed Answer: 262The nursing staff has planned a picnic for a small group of clients from the psychiatric unit. Some of the clients are taking Thorazine (chlorpromazine). The nursing staff should take extra measures to:
- A. Protect the clients from sun exposure
- B. Eliminate aged cheese from the menu
- C. Limit the amount of fluid intake by the clients
- D. Avoid chocolate desserts and treats on the menu
Quick Answers: 252
Detailed Answer: 263The nurse is caring for a client following a pneumonectomy. Which nursing intervention will help prevent an embolus?
- A. Encouraging the client to use an incentive spirometer
- B. Administering thrombolytic medication as ordered
- C. Telling the client to turn, cough, and breathe deeply
- D. Ambulating the client as soon as possible
Quick Answers: 252
Detailed Answer: 263The physician has ordered B & O (belladonna and opium) suppositories for a client following a prostatectomy. The nurse recognizes that the medication will:
- A. Help relieve pain due to bladder spasms
- B. Improve the urinary output
- C. Reduce post-operative swelling
- D. Treat nausea and vomiting
Quick Answers: 252
Detailed Answer: 263Post-operative orders have been left for a client with an above-the-knee amputation. The orders include wrapping the stump with an elastic bandage. The nurse knows that the primary reason for wrapping the stump with an elastic bandage is to:
- A. Decrease bleeding
- B. Shrink the stump
- C. Prevent phantom pain
- D. Prevent seeing the area
Quick Answers: 252
Detailed Answer: 263A client with polycythemia vera is admitted for a phlebotomy. Assessment of the client with polycythemia vera reveals:
- A. Red, sore tongue; fatigue; and paresthesia
- B. Ruddy complexion, dyspnea, and pruritis
- C. Pallor; thin, spoon-shape fingernails; and pica
- D. Nocturnal dyspnea, rales, and weight gain
Quick Answers: 252
Detailed Answer: 263The nurse is assisting a client with a total hip replacement to a chair. Which type of chair is appropriate for the client following a total hip replacement?
- A. A recliner
- B. A rocking chair
- C. A straight chair
- D. A sofa chair
Quick Answers: 252
Detailed Answer: 263The physician has ordered Cotazyme (pancrelipase) for a child with cystic fibrosis. The nurse knows that the medication is given to:
- A. Replace the fat-soluble vitamins A, D, E, and K
- B. Decrease carbohydrate metabolism
- C. Aid in the digestion and absorption of fats, carbohydrates, and protein
- D. Facilitate sodium and chloride excretion
Quick Answers: 252
Detailed Answer: 263The nurse at a local daycare center observes a group of preschool-age children playing. The children are playing in an unorganized fashion, with no obvious rules to the play activity. The type of play that is typical of preschool-age children is known as:
- A. Solitary play
- B. Parallel play
- C. Associative play
- D. Cooperative play
Quick Answers: 252
Detailed Answer: 263Which of the following is not a part of routine cord care of the newborn?
- A. Placing a petroleum gauze on the cord
- B. Applying an antibiotic to the cord
- C. Cleaning the cord with alcohol
- D. Folding diapers below the cord
Quick Answers: 252
Detailed Answer: 264A client is hospitalized with a diagnosis of antisocial personality disorder. According to Freud’s psychoanalytic theory, antisocial personality disorder arises from faulty development of the:
- A. Id
- B. Ego
- C. Superego
- D. Preconscious
Quick Answers: 252
Detailed Answer: 264The nurse is monitoring a client admitted with an overdose of Oxycontin (oxycodone). The nurse should carefully observe the client for signs of:
- A. Hyperthermia
- B. Decreased respirations
- C. Increased blood pressure
- D. Dysuria
Quick Answers: 252
Detailed Answer: 264An elderly client is admitted with a fractured left hip. Which type of traction will be used to immobilize the client’s left extremity?
- A. 90–90 traction
- B. Buck’s traction
- C. Bryant’s traction
- D. Dunlop’s traction
Quick Answers: 252
Detailed Answer: 264The physician has prescribed Zoloft (sertraline) for a client who has been taking Nardil (phenelzine). The recommended length of time between discontinuing a monoamine oxidase inhibitor and beginning therapy with a selective serotonin reuptake inhibitor is:
- A. 2 days
- B. 7 days
- C. 10 days
- D. 14 days
Quick Answers: 252
Detailed Answer: 264A post-operative client has called the nurse’s station with complaints of pain. The first action by the nurse should be to:
- A. Check to see when the client received pain medication
- B. Administer the prescribed pain medication
- C. Notify the charge nurse of the client’s complaints
- D. Assess the location and character of the client’s pain
Quick Answers: 252
Detailed Answer: 264The nurse is observing a developmental assessment of an infant. Which of the following is an example of cephalocaudal development?
- A. The infant is able to make rudimentary vocalizations before using language.
- B. The infant can control arm movements before she can control finger movements.
- C. The infant is able to raise her head before sitting.
- D. The infant responds to pain with her whole body before she can localize pain.
Quick Answers: 252
Detailed Answer: 264The physician has ordered a straight catheterization for a female client. When performing a straight catheterization on a female client, the nurse should:
- A. Use medical asepsis when doing the catheterization
- B. Insert the catheter 4–6 inches
- C. Inflate and deflate the balloon before insertion
- D. Hold the catheter in place while the bladder empties
Quick Answers: 252
Detailed Answer: 264Before moving a client up in bed, the nurse lowers the head of the bed. The purpose of lowering the head of the bed is:
- A. To avoid working against gravity as the client is moved
- B. To prevent getting wrinkles in the client’s linen
- C. To eliminate needing additional help to move the client
- D. To relieve pressure on the client’s sacrum
Quick Answers: 252
Detailed Answer: 264A client has returned from having an arteriogram. The nurse should give priority to:
- A. Checking the radial pulse
- B. Assessing the site for bleeding
- C. Offering fluids
- D. Administering pain medication
Quick Answers: 252
Detailed Answer: 265The physician has ordered Dolophine (methadone) for a client withdrawing from opiates. Which finding is associated with acute methodone toxicity?
- A. Fever
- B. Oliguria
- C. Nasal congestion
- D. Respiratory depression
Quick Answers: 252
Detailed Answer: 265A client scheduled for surgery has a preoperative order for atropine on call. The nurse should tell the client that the medication will:
- A. Make him drowsy
- B. Make his mouth dry
- C. Help him to relax
- D. Prevent infection
Quick Answers: 252
Detailed Answer: 265The nurse is assessing a primgravida 12 hours after a Caesarean section. The nurse notes that the client’s fundus is at the umbilicus and is firm. The nurse should:
- A. Prepare to catheterize the client
- B. Obtain an order for an oxytocic
- C. Chart the finding
- D. Tell the client to remain in bed
Quick Answers: 252
Detailed Answer: 265Which of the following observations in a 4-year-old suggests the possibility of child abuse?
- A. The presence of “rainbow” bruises
- B. Sucking the thumb when going to sleep
- C. Crying during painful procedures
- D. Eagerness to talk to strangers
Quick Answers: 252
Detailed Answer: 265A client with a history of alcoholism cannot remember the events of the past week even though he has receipts from various places of business. The client’s inability to recall events is known as:
- A. Alcoholic hallucinosis
- B. A hangover
- C. A blackout
- D. Sunday morning paralysis
Quick Answers: 252
Detailed Answer: 265The nurse is caring for a client with degenerative joint disease. Which finding is associated with degenerative joint disease?
- A. Joint pain that intensifies with activity and diminishes with rest
- B. Bilateral and symmetric joint involvement
- C. Involvement of the fingers and hands
- D. Complaints of early-morning stiffness
Quick Answers: 252
Detailed Answer: 265The physician has ordered an injection of Demerol (meperidine) for a client with pancreatitis. The nurse should:
- A. Administer the injection using the Z track method
- B. Hold pressure on the injection site for 3–5 minutes
- C. Administer the medication subcutaneously in the arm
- D. Prep the skin using a betadine wipe
Quick Answers: 252
Detailed Answer: 265The nurse is preparing a client with Addison’s disease for discharge. The nurse should explain that the client can help prevent complications by:
- A. Avoiding dietary sources of sodium
- B. Dressing in lightweight clothing
- C. Restricting foods rich in potassium
- D. Staying out of crowds
Quick Answers: 252
Detailed Answer: 265A 10-year-old received an injury to his face and mouth in a bicycle accident. Examination reveals that a permanent tooth has been evulsed. Emergency care following evulsion of a permanent tooth includes:
- A. Rinsing the tooth in milk before reimplantation
- B. Wiping the tooth with gauze before reimplantation
- C. Holding the tooth by the root as it is rinsed
- D. Putting the tooth underneath the child’s tongue
Quick Answers: 252
Detailed Answer: 265A 6-year-old is admitted with a diagnosis of leukemia. The most frequent presenting symptoms of leukemia include:
- A. Headache, nausea, and vomiting
- B. Pallor, easy bruising, and joint pain
- C. Delayed growth, anorexia, and alopecia
- D. Poor wound healing, polyuria, and fever
Quick Answers: 252
Detailed Answer: 266The LPN is assigning tasks to the nursing assistant. Which task is beyond the scope of practice for the nursing assistant?
- A. Collecting a stool specimen for occult blood
- B. Obtaining a urine specimen for a routine urinalysis
- C. Performing a tape test for pinworms
- D. Aspirating nasogatric secretions for occult blood
Quick Answers: 252
Detailed Answer: 266The nurse is caring for a client following an exploratory laparotomy. Which of the following assessment findings requires intervention?
- A. The abdominal dressing is clean, dry, and intact.
- B. The hourly urinary output of 20mL is dark amber in color.
- C. The nasogastric tube output of 15mL is bile colored.
- D. The IV is infusing with no signs of infiltration.
Quick Answers: 252
Detailed Answer: 266The nurse is caring for a client following a colonoscopy in which conscious sedation was used. Initial assessment of the client reveals the following: BP 128/72, temperature 97, pulse 64, respirations 14, oxygen saturation 90%, and Glascow score of 13. An IV of normal saline is infusing at 20 drops per minute. Which nursing intervention should receive priority?
- A. Administering an analgesic
- B. Administering oxygen per standing order
- C. Covering the client with a blanket
- D. Discontinuing the IV fluid
Quick Answers: 252
Detailed Answer: 266The physician has prescribed Phenergan (promethazine) with codeine for a client with pleurisy. The nurse recognizes that the medication was ordered for its:
- A. Expectorant effects
- B. Anti-inflammatory properties
- C. Antitussive effects
- D. Ability to relieve pain
Quick Answers: 252
Detailed Answer: 266The primary cause of anemia in clients with chronic renal failure is:
- A. The urinary loss of red blood cells
- B. The lack of erythropoietin
- C. Alterations in the shape of red blood cells
- D. The decrease in iron stores
Quick Answers: 252
Detailed Answer: 266The nurse is about to administer the client’s medication when the client states that the medication “looks different” than what she took before. The safest action for the nurse to take is to:
- A. Tell the client that the medication is the same
- B. Reassure the client that the doctor has prescribed correctly
- C. Explain that pharmacies make generic substitutions
- D. Recheck the MAR (medication administration record) to validate the medication’s correctness
Quick Answers: 252
Detailed Answer: 266The physician has prescribed Laradopa (levodopa) for a client with Parkinson’s disease. The nurse should:
- A. Tell the client that the medication will not be absorbed if it is taken with food
- B. Explain that monthly lab work will be needed while the client is taking the medication
- C. Tell the client that the medication will be needed only until the symptoms disappear
- D. Instruct the client to rise slowly from a sitting position
Quick Answers: 252
Detailed Answer: 266Dietary management of the client with congestive heart failure includes the restriction of:
- A. Sodium
- B. Calcium
- C. Potassium
- D. Magnesium
Quick Answers: 252
Detailed Answer: 266The physician has ordered diuretic therapy and fluid restrictions for a client admitted with a stroke. The nurse knows that diuretic therapy and fluid restrictions are ordered during the acute phase of a stroke to:
- A. Reduce cardiac output
- B. Prevent an embolus
- C. Reduce cerebral edema
- D. Minimize incontinence
Quick Answers: 252
Detailed Answer: 267The nurse is caring for a client with esophageal cancer. The client’s history will likely reveal:
- A. A diet high in fiber
- B. Presence of gastroesophageal reflux
- C. Occasional use of alcohol
- D. A diet low in fat
Quick Answers: 252
Detailed Answer: 267Which food is the best source of calcium and potassium?
- A. Broccoli
- B. Sweet potato
- C. Spinach
- D. Avocado
Quick Answers: 252
Detailed Answer: 267The physician has ordered a PSA and acid phosphatase for a client admitted with complaints of dysuria. The nurse knows that a PSA and acid phosphatase are screening tests for:
- A. Cancer of the bladder
- B. Cancer of the prostate
- C. Cancer of the vas deferens
- D. Cancer of the testes
Quick Answers: 252
Detailed Answer: 267The client’s morning lithium level is 1.2mEq/L. The nurse recognizes that:
- A. The level is too low to be therapeutic.
- B. The client can be expected to have signs of toxicity.
- C. The level is within the therapeutic range.
- D. The client needs to eat more sodium-rich foods.
Quick Answers: 252
Detailed Answer: 267Which emergency treatment is appropriate for the client who suddenly develops ventricular fibrillations?
- A. Cardioversion
- B. Intubation
- C. Defibrillation
- D. Anticonvulsant medication
Quick Answers: 252
Detailed Answer: 267The nurse is caring for a client following a stroke that left him with apraxia. The nurse knows that the client will:
- A. Be unable to communicate through speech
- B. Have difficulty swallowing
- C. Have difficulty with voluntary movements
- D. Be unable to perform previously learned skills
Quick Answers: 252
Detailed Answer: 267The nurse is positioning a client with right hemiplegia. To prevent subluxation of the client’s right shoulder, the nurse should:
- A. Use a pillow to support the client’s arm when she is sitting in a chair
- B. Elevate the arm and hand above chest level when she is lying in bed
- C. Place a pillow under the axilla to elevate the elbow when she is lying in bed
- D. Use a pillow to support the client’s hand when she is sitting in a chair
Quick Answers: 252
Detailed Answer: 267A client with thrombophlebitis is receiving Lovenox (enoxaparin). Which method is recommended for administering Lovenox?
- A. Z track in the dorsogluteal muscle
- B. Intramuscularly in the deltoid muscle
- C. Subcutaneously in the abdominal tissue
- D. Orally after breakfast
Quick Answers: 252
Detailed Answer: 267A client with angina is to be discharged with a prescription for nitroglycerin tablets. The client should be instructed to:
- A. Take one tablet daily with a glass of water
- B. Leave the medication in a dark-brown bottle
- C. Replenish the medication supply every year
- D. Leave the cotton in the bottle to protect the tablets
Quick Answers: 252
Detailed Answer: 267The physician has ordered Parnate (tranylcypromine) for a client with depression. The nurse should tell the client to avoid foods containing tryamine because it can result in:
- A. Elevations in blood pressure
- B. Decreased libido
- C. Elevations in temperature
- D. Increased depression
Quick Answers: 252
Detailed Answer: 268A client is receiving external radiation for cancer of the larynx. As a result of the treatment, the client will most likely complain of:
- A. Generalized pruritis
- B. Dyspnea
- C. Sore throat
- D. Bone pain
Quick Answers: 252
Detailed Answer: 268The nurse is caring for a client with a T4 spinal cord injury when he begins to have symptoms of autonomic dysreflexia. After placing the client in high Fowler’s position, the nurse should:
- A. Administer a prescribed analgesic
- B. Check for patency of the catheter
- C. Tell the client to breathe slowly
- D. Check the temperature
Quick Answers: 252
Detailed Answer: 268Hospital policy recommends that all children under the age of 3 years be placed in a crib. When providing care for a child in a crib, the nurse should give priority to:
- A. Keeping the side rails locked at the halfway point
- B. Maintaining one hand on the child whenever side rails are down
- C. Positioning the child farther away from the lowered side rail
- D. Telling the parent that the side rails can stay down as long as someone is in the room
Quick Answers: 252
Detailed Answer: 268An infant with respiratory synctial virus has been started on Virazole (ribavirin). When caring for the infant receiving Virazole, the nurse should:
- A. Discontinue isolation precautions while the medication is being administered
- B. Use contact precautions only when opening the mist tent
- C. Temporarily stop administration of the medication when the mist tent needs to be opened
- D. Increase the rate of medication administration when the mist tent needs to be opened
Quick Answers: 252
Detailed Answer: 268Although children can develop allergies to a variety of foods, the most common food allergens are:
- A. Fruit, eggs, and corn
- B. Wheat, oats, and grain
- C. Cow’s milk, rice, and tomatoes
- D. Eggs, cow’s milk, and peanuts
Quick Answers: 252
Detailed Answer: 268A 9-month-old is admitted with a diagnosis of eczema. The nurse would expect the 9-month-old to have eczematous lesions over:
- A. The abdomen, cheeks, and scalp
- B. The buttocks, abdomen, and back
- C. The back and flexor surfaces of the arms and legs
- D. The cheeks and extensor surfaces of arms and legs
Quick Answers: 252
Detailed Answer: 268Which one of the following factors has the greatest influence on the recovery and sobriety of a client with a chemical addiction?
- A. The family’s understanding of the client’s addiction
- B. The quality of the treatment program and follow-up
- C. The client’s own desire to become drug-free
- D. The nursing staff’s attitude toward addiction
Quick Answers: 252
Detailed Answer: 268Which symptom differentiates chronic otitis media from acute otitis media?
- A. Elevated temperature
- B. Pain in the affected ear
- C. Nausea and vomiting
- D. Feelings of fullness in the ear
Quick Answers: 252
Detailed Answer: 268A 6-year-old is admitted with suspected rheumatic fever. Which finding is associated with rheumatic fever?
- A. A history of low birth weight
- B. A case of strep throat several weeks ago
- C. Presence of sickle cell trait
- D. Inability to digest certain grains
Quick Answers: 252
Detailed Answer: 269Which of the following signs is characteristic of the child with Duchenne’s muscular dystrophy?
- A. The use of Gower’s maneuver to rise to a standing position
- B. Bilateral knee pain located at the tibial tubercle
- C. Concave curvature of the lumbar spine
- D. Aseptic necrosis of the head of the femur
Quick Answers: 252
Detailed Answer: 269An obstetrical client is admitted in active labor. When the membranes rupture, the nurse would expect to find:
- A. A large amount of bright-red discharge
- B. A moderate amount of straw-colored discharge
- C. A small amount of green-colored discharge
- D. A scant amount of dark-brown discharge
Quick Answers: 252
Detailed Answer: 269Fetal heart tones can be heard using a fetoscope as early as:
- A. 5 weeks gestation
- B. 10 weeks gestation
- C. 15 weeks gestation
- D. 18 weeks gestation
Quick Answers: 252
Detailed Answer: 269The nurse is teaching the pregnant client ways to prevent heartburn. The nurse should tell the client to:
- A. Sleep on her right side
- B. Eat dry crackers at bedtime
- C. Sleep on a small pillow
- D. Avoid caffeinated beverages
Quick Answers: 252
Detailed Answer: 269A child with cystic fibrosis takes pancreatic enzymes with each of his meals and between meal snacks. Which finding indicates that the prescribed amount of pancreatic replacement is adequate?
- A. Improved respiratory function
- B. Decreased sodium excretion
- C. Increased weight
- D. Decreased chloride excretion
Quick Answers: 252
Detailed Answer: 269The mother of a child with impetigo asks the nurse when her child will be able to return to school. The nurse’s response is based on the knowledge that the lesions of impetigo resolve in:
- A. 24 hours
- B. 5 days
- C. 1 week
- D. 2 weeks
Quick Answers: 252
Detailed Answer: 269Infants born to diabetic mothers are often described as large for gestational age. The primary reason for the infant’s large size is:
- A. Overstimulation of the thyroid
- B. Maternal hyperglycemia
- C. Improved maternal nutrition
- D. Increased production of the pituitary
Quick Answers: 252
Detailed Answer: 269The physician has ordered a Guthrie test for a newborn. The nurse recognizes that the test is ordered to detect:
- A. Cystic fibrosis
- B. Phenylketonuria
- C. Hypothyroidism
- D. Sickle cell anemia
Quick Answers: 252
Detailed Answer: 269A client with emphysema has an order for Elixophyllin (theophylline). The desired action of theophylline for a client with emphysema is:
- A. Reduction of bronchial secretions
- B. Decreased alveolar spasms
- C. Restoration of bronchial compliance
- D. Relaxation of bronchial smooth muscle
Quick Answers: 252
Detailed Answer: 269The physician has ordered a low-calorie, low-fat, low-sodium diet for a client with hypertension. Which menu selection is appropriate for the client?
- A. Mixed green salad, blue cheese dressing, crackers, tea
- B. Frankfurter and roll, baked beans, celery and carrots, cola
- C. Taco salad, tortilla chips, sour cream, tea
- D. Baked chicken, apple, angel food cake, 1% milk
Quick Answers: 252
Detailed Answer: 269A postpartal client wants to know how the nutrient value of breast milk differs from that of cow’s milk. The nurse should tell the client that breast milk is:
- A. Higher in fat
- B. Higher in iron
- C. Higher in calcium
- D. Higher in sodium
Quick Answers: 252
Detailed Answer: 270The nurse is administering medication to a client with schizophrenia. The client accepts the medication but does not place it in his mouth. The nurse should:
- A. Tell the client that if he does not take the medication, he will have to get an injection
- B. Tell the client to put the medicine in his mouth and swallow it with the water
- C. Tell a nursing assistant to remain with the client until he takes the medication
- D. Tell the client he will have to take his medication or he cannot go with the others to recreation
Quick Answers: 252
Detailed Answer: 270A client with Crohn’s disease has been started on Entocort EC (budesonide) 9mg daily. The nurse should tell the client to take the medication:
- A. With grapefruit juice
- B. On an empty stomach
- C. Between meals
- D. With meals or a snack
Quick Answers: 252
Detailed Answer: 270The nurse is teaching an obstetrical client regarding the appearance of edema in the last trimester. Which statement by the client indicates a need for further teaching?
- A. “I need to drink six to eight glasses of water a day.”
- B. “I can expect to have edema of my feet and ankles.”
- C. “Edema of my face and hands is a normal occurrence.”
- D. “It’s important for me to avoid prolonged standing.”
Quick Answers: 252
Detailed Answer: 270While reviewing the client’s lab report, the nurse notes that the client has a potassium level of 3.0 mEq/L. What is the best source of potassium?
- A. One cup of apple juice
- B. One cup of orange juice
- C. One cup of cranberry juice
- D. One cup of prune juice
Quick Answers: 252
Detailed Answer: 270A client admitted with renal calculi is experiencing severe pain in the right flank and nausea. The immediate nursing intervention is to:
- A. Administer pain medication as ordered
- B. Encourage oral fluids
- C. Administer an antiemetic as ordered
- D. Evaluate the hydration status
Quick Answers: 252
Detailed Answer: 270The physician has ordered a sterile urine specimen from a client with an in-dwelling catheter. The nurse should:
- A. Open the spout on the urine bag and allow urine to flow into a sterile specimen cup
- B. Disconnect the drainage tube from the collection bag and allow urine to drain into a sterile specimen cup
- C. Disconnect the drainage tube from the catheter and allow urine to drain from the bag into a sterile specimen cup
- D. Use a sterile syringe and needle to remove urine from the port nearest the client and place the urine into a sterile specimen cup
Quick Answers: 252
Detailed Answer: 270Otitis media occurs more frequently in infants and young children because of the unique anatomic features of the:
- A. Nasopharynx
- B. External ear canals
- C. Eustachian tubes
- D. Tympanic membranes
Quick Answers: 252
Detailed Answer: 270The nurse is admitting a newborn to the nursery. Which finding is expected in the full-term newborn?
- A. Absence of sucking pads
- B. Presence of vernix caseosa
- C. Presence of the scarf sign
- D. Absence of solar creases
Quick Answers: 252
Detailed Answer: 270A client who was admitted with a closed head injury is asked to tell the nurse today’s date. The nurse is assessing the client’s orientation to:
- A. Person
- B. Place
- C. Time
- D. Objects
Quick Answers: 252
Detailed Answer: 270Which of the following tasks is within the developmental norm for the 22-month-old child?
- A. Feeds herself with a spoon
- B. Dresses and undresses without help
- C. Shares her toys with others
- D. Speaks in 8- to 10-word sentences
Quick Answers: 252
Detailed Answer: 270A pediatric client is admitted with Munchausen’s syndrome by proxy. The nurse would expect the child to have:
- A. Extreme tooth decay
- B. Unexplained illness
- C. Dermatitis of the lips and tongue
- D. Inability to sweat
Quick Answers: 252
Detailed Answer: 271A client refuses to take the medication prescribed for her. Which action should the nurse take first?
- A. Encourage the client to take the medication
- B. Ask the client her reasons for refusing the medication
- C. Document that the client refused her medication
- D. Report the client’s refusal to take the medication to the charge nurse
Quick Answers: 252
Detailed Answer: 271A nurse complains that a client is noncompliant because she prefers to take herbs prescribed by her herbalist rather than taking “real medicine.” The nurse’s statement is an example of:
- A. Ethnicity
- B. Cultural sensitivity
- C. Ethnocentrism
- D. Cultural tolerance
Quick Answers: 252
Detailed Answer: 271The nurse is checking the fetal heart rates of a client in labor. The normal range for fetal heart rates is:
- A. 90–110 beats per minute
- B. 110–160 beats per minute
- C. 160–200 beats per minute
- D. 200–250 beats per minute
Quick Answers: 252
Detailed Answer: 271Which one of the following measures decreases abdominal discomfort when the post-operative client is asked to cough?
- A. Exhaling forcefully between coughs
- B. Splinting the incision with a pillow
- C. Maintaining muscle tension in the operative site
- D. Taking panting respirations between coughs
Quick Answers: 252
Detailed Answer: 271The nurse is caring for a client with arteriosclerotic heart disease. The nurse recognizes that a nonmodifiable risk factor in the development of arteriosclerotic heart disease is:
- A. Family history
- B. Hypertension
- C. Diet
- D. Exercise
Quick Answers: 252
Detailed Answer: 271The physician has ordered Nardil (phenelzine), an MAO inhibitor for a client who is currently taking Paxil (paroxetine). The nurse should:
- A. Give the medications together as ordered
- B. Clarify the orders with the physician
- C. Request an order for anti-Parkinsonian medication
- D. Administer the medications at different times
Quick Answers: 252
Detailed Answer: 271Which technique should the nurse use to prevent air from entering the stomach during a nasogastric tube feeding?
- A. Pour all the formula into the syringe barrel before opening the clamp
- B. Open the clamp and pour the formula in a continuous flow down the side of the syringe barrel
- C. Release the clamp before pouring all the formula into the syringe barrel
- D. Open the clamp and allow a small amount of formula to enter the stomach before adding more formula
Quick Answers: 252
Detailed Answer: 271The nurse is assessing a client who has undergone a right lobectomy. Which assessment should alert the nurse to the possibility of internal bleeding?
- A. Urinary output of 200mL during the past 3 hours
- B. Sanguineous chest tube drainage at a rate of 50mL per hour for the past 3 hours
- C. Restless and shortness of breath
- D. Decreased pulse rate and decreased respirations
Quick Answers: 252
Detailed Answer: 271A client with congestive heart failure loses 4.1kg while hospitalized. The client’s weight loss is approximately:
- A. 2 pounds
- B. 4 pounds
- C. 7 pounds
- D. 9 pounds
Quick Answers: 252
Detailed Answer: 271A 40-year-old client with a myocardial infarction tells the nurse, “My father died with a heart attack when he was in his forties, and I guess I will, too.” Which response by the nurse is most appropriate?
- A. “Tell me more about what you are feeling.”
- B. “Are you thinking you won’t recover from this?”
- C. “You have an excellent doctor, so I’m sure everything will be fine.”
- D. “I would think that’s unlikely because we have much better treatment now.”
Quick Answers: 252
Detailed Answer: 272Which nursing action is most appropriate immediately following the removal of a nasogastric tube?
- A. Providing mouth care
- B. Auscultating bowel sounds
- C. Offering fluids
- D. Checking for abdominal distention
Quick Answers: 252
Detailed Answer: 272An elderly client injured in a fall is admitted with fractures of the ribs and a closed right pneumothorax. The nurse should position the client:
- A. In modified Trendelenburg position with the lower extremities elevated
- B. In semi-Fowler’s position tilted toward the right side
- C. In dorsal recumbent position with the lower extremities flat
- D. In semi-Fowler’s position tilted toward the left side
Quick Answers: 252
Detailed Answer: 272A client develops cravings while withdrawing from alcohol. Which measure will best help the client maintain sobriety?
- A. Placing the client in seclusion for 24 hours
- B. Restricting visits from family and friends
- C. Gaining support from other recovering alcoholics
- D. Assigning a staff member to stay until the cravings pass
Quick Answers: 252
Detailed Answer: 272A client with Addison’s disease has a diagnosis of fluid volume deficit related to inadequate adrenal hormone secretion. Which fluids are most appropriate for the client with Addison’s disease?
- A. Milk and diet soda
- B. Water and tea
- C. Bouillon and juice
- D. Coffee and juice
Quick Answers: 252
Detailed Answer: 272The nurse is preparing to administer DTP, Hib, and hepatitis B immunizations to an infant. The nurse should:
- A. Administer all the immunizations in one site
- B. Administer the DTP in one leg, and the Hib and the hepatitis B in the other leg
- C. Administer the DTP in the leg, the Hib in the other leg, and the hepatitis B in the arm
- D. Administer the DTP and Hib in one leg, and the hepatitis B in the arm
Quick Answers: 252
Detailed Answer: 272Lab results indicate that a client receiving heparin has a prolonged bleeding time. Which medication is the antidote for heparin?
- A. Aquamephyton (phytonadione)
- B. Ticlid (ticlopidine)
- C. Protamine sulfate (protamine sulfate)
- D. Amicar (aminocaproic acid)
Quick Answers: 252
Detailed Answer: 272A newborn of 32 weeks gestation is diagnosed with respiratory distress syndrome 3 hours after birth. An assessment finding in the newborn with respiratory distress syndrome is:
- A. Feeding difficulties
- B. Nasal flaring
- C. Increased blood pressure
- D. Temperature instability
Quick Answers: 252
Detailed Answer: 272To reduce the risk of SIDS (sudden infant death syndrome), the nurse should tell parents to place the infant:
- A. Prone while he is sleeping
- B. Side-lying while he is awake
- C. On his back while he is sleeping
- D. Prone while he is awake
Quick Answers: 252
Detailed Answer: 272Which of the following play activities is most developmentally appropriate for the toddler?
- A. Watching cartoons
- B. Pulling a toy wagon
- C. Watching a mobile
- D. Coloring with crayons in a coloring book
Quick Answers: 253
Detailed Answer: 272The physician has discharged a client with diverticulitis with a prescription for Metamucil (psyllium). When teaching the client how to prepare the medication, the nurse should tell the client to:
- A. Dissolve the medication in gelatin or applesauce
- B. Mix the medication with water and drink it immediately
- C. Sprinkle the medication on ice cream or sherbet
- D. Take the medication with an ounce of antacid
Quick Answers: 253
Detailed Answer: 273Young children living in housing that was built before the 1970s are at risk for:
- A. Lead poisoning
- B. Pernicious anemia
- C. Iron poisoning
- D. Sprue
Quick Answers: 253
Detailed Answer: 273Which of the following findings is associated with fluid overload in the child with renal disease?
- A. Sluggish capillary refill and slow heart rate
- B. Distention of the jugular veins and pitting edema
- C. Decreased blood pressure and increased heart rate
- D. Increased blood pressure and bilateral wheezes
Quick Answers: 253
Detailed Answer: 273A client with allergic dermatitis has a prescription for a Medrol (methylprenisolone) dose pack. The client asks why the number of pills decreases each day. The nurse’s response is based on the knowledge that a gradual decreasing of the daily dose is necessary to prevent:
- A. Cushing’s syndrome
- B. Thyroid storm
- C. Cholinergic crisis
- D. Addisonian crisis
Quick Answers: 253
Detailed Answer: 273A child with beta thalassemia has developed hemosiderosis. To prevent organ damage, the child will receive chelation therapy with:
- A. Chemet (succimer)
- B. Versenate (calcium disodium versenate)
- C. Desferal (deferoxamine)
- D. EDTA (calcium disodium edetate)
Quick Answers: 253
Detailed Answer: 273The nurse is caring for a client 1 week post-burn injury. The nurse should expect the client to benefit from a diet that is:
- A. High in protein, low in sodium, and low in carbohydrates
- B. Low in fat, low in sodium, and high in calories
- C. High in protein, high in carbohydrates, and high in calories
- D. High in protein, high in fat, and low in calories
Quick Answers: 253
Detailed Answer: 273Which of the following describes a nosocomial infection?
- A. A client develops MRSA while hospitalized for treatment of a fractured hip.
- B. A client develops a kidney infection from an extended bladder infection.
- C. A client develops hepatitis A after eating in a local restaurant.
- D. A client develops pneumonia after attending a sporting event.
Quick Answers: 253
Detailed Answer: 273An 8-month-old infant has been diagnosed with iron deficiency anemia. What food should be added to the infant’s diet?
- A. Orange juice
- B. Fortified rice cereal
- C. Whole milk
- D. Strained meat
Quick Answers: 253
Detailed Answer: 273The American Cancer Society’s current recommendation is that women should have a baseline mammogram done between the ages of:
- A. 25 and 30
- B. 30 and 35
- C. 35 and 40
- D. 40 and 45
Quick Answers: 253
Detailed Answer: 273The nurse is caring for a 6-year-old following revision of a ventriculoperitoneal shunt. An expected nursing intervention is:
- A. Request for an x-ray to evaluate shunt placement
- B. Daily measurement of head circumference
- C. Frequent palpation of the fontanels
- D. Maintaining the child in a prone position
Quick Answers: 253
Detailed Answer: 273Stranger anxiety is defined as the distress that occurs when the infant is separated from the parents or caregivers. Stranger anxiety first peaks at:
- A. 1–3 months of age
- B. 3–6 months of age
- C. 7–9 months of age
- D. 12–15 months of age
Quick Answers: 253
Detailed Answer: 274The nurse is assessing an infant with coarctation of the aorta. The nurse can expect to find:
- A. Deep cyanosis
- B. Clubbing of the fingers and toes
- C. Loud cardiac murmur
- D. Diminished femoral pulses
Quick Answers: 253
Detailed Answer: 274Which client is most likely to be affected with Cooley’s anemia?
- A. A child of Mediterranean descent
- B. A child of Asian descent
- C. A child of African descent
- D. A child of European descent
Quick Answers: 253
Detailed Answer: 274The primary nursing consideration when working with a newly admitted adolescent with anorexia nervosa is:
- A. Identifying stressors that contributed to the disorder
- B. Including family members in the client’s care
- C. Establishing a trusting relationship
- D. Restoring the client’s nutritional status
Quick Answers: 253
Detailed Answer: 274The nurse is palpating the fontanels of a 2-month-old. The fontanels should feel:
- A. Tense and bulging
- B. Soft and sunken
- C. Flat and firm
- D. Flat and tense
Quick Answers: 253
Detailed Answer: 274An infant born at 25 weeks gestation was treated with prolonged oxygen therapy. Prolonged oxygen therapy places the infant at risk for:
- A. Cerebral palsy
- B. Retinitis pigmentosa
- C. Hydrocephalus
- D. Retinopathy of prematurity
Quick Answers: 253
Detailed Answer: 274
Quick Check Answer Key
D
B
B
A
B
D
D
C
A
C
A
A
C
C
D
B
C
B
C
A
A
B
A
B
A
D
A
D
B
A
A
B
B
C
A
C
B
B
C
D
C
B
B
D
B
B
B
C
B
A
A
A
D
D
A
D
A
B
D
B
A
C
D
B
D
A
B
D
C
B
A
A
A
B
D
A
B
C
B
A
B
D
C
B
A
B
C
A
D
A
B
B
A
C
C
A
A
B
B
D
D
C
D
A
B
D
B
C
A
C
A
B
D
A
B
D
B
B
C
B
D
D
A
C
B
C
B
C
C
D
A
C
B
A
C
B
B
C
D
D
C
A
B
A
B
D
D
C
D
B
B
D
D
A
B
D
C
D
A
D
C
B
C
A
B
B
C
B
B
A
B
A
C
D
A
A
B
C
C
B
C
B
C
B
B
A
B
D
C
C
A
B
C
B
C
D
A
D
C
D
