This chapter is from the book
This chapter is from the book
This chapter is from the book
Answers and Rationales
Answer D is correct. The client with AIDS should not drink water that has been sitting longer than 15 minutes because of bacterial contamination. Answer A is incorrect because tap water is not better for the client. Answer B is incorrect because juices should not replace water intake. Answer C is not an accurate statement; therefore, it is incorrect.
Answer B is correct. Approximately 99% of males with cystic fibrosis are sterile because of obstruction of the vas deferens. Answers A, C, and D are incorrect because most males with cystic fibrosis are incapable of reproduction.
Answer B is correct. Infants under the age of 2 years should not be fed honey because of the danger of infection with Clostridium botulinum. Answers A, C, and D have no relationship to the situation; therefore, they are incorrect.
Answer A is correct. Decreased blood pressure and increased pulse rate are signs of bleeding. Answers B, C, and D are within normal limits; therefore, they are incorrect.
Answer B is correct. Undercooked meat is a source of toxoplasmosis cysts. Toxoplasmosis is a major cause of encephalitis in clients with AIDS. Answers A, C, and D are accurate statements reflecting the client’s understanding of the nurse’s teaching; therefore, they are incorrect.
Answer D is correct. The client taking isoniazid should have a negative sputum culture within 3 months. Answers A, B, and C are incorrect because there has not been sufficient time for the medication to be effective.
Answer D is correct. Lyme disease is transmitted by ticks found on deer and mice in wooded areas. Answers A and B have little risk for the disease. Dog trainers are exposed to dog ticks that carry Rocky Mountain Spotted Fever but not Lyme disease; therefore, answer C is incorrect.
Answer C is correct. Melba toast promotes chewing and is easily managed by the toddler. Pieces of hot dog, celery sticks, and grapes are unsuitable for the toddler because of the risk of aspiration.
Answer A is correct. Kava-kava increases the effects of central nervous system depressants. Answers B, C, and D are not related to the use of kava-kava; therefore, they are incorrect.
Answer C is correct. The mother does not need to place an external heat source near the infant. It will not promote healing, and there is a chance that the newborn could be burned; therefore, the mother needs further teaching. Answers A, B, and D indicate correct care of the newborn who has been circumcised; therefore, they are incorrect.
Answer A is correct. The client who is colonized with MRSA will have no symptoms associated with infection. Answer B is incorrect because the client is more likely to develop an infection with MRSA following invasive procedures. Answer C is incorrect because the client should not be placed in the room with others. Answer D is incorrect because the client can colonize others, including healthcare workers, with MRSA.
Answer A is correct. Pseudomembranous colitis results from infection with Clostridium difficile. Symptoms of pseudomembranous colitis include diarrhea containing blood, mucus, and white blood cells. Answers B, C, and D are incorrect because they are not symptoms of infection with Clostridium difficile.
Answer C is correct. Immunization against pneumonia is recommended every 5 years for persons over age 65, as well as for those with a chronic illness. Answers A and B are incorrect because the client still has immunity from the vaccine. Answer D is incorrect because the client should have received the booster immunization much sooner.
Answer C is correct. Following a nephrolithotomy, the client should be positioned on the unoperative side. Answers A, B, and D are incorrect positions for the client following a nephrolithotomy.
Answer D is correct. The first sign of a latex allergy is usually contact dermatitis, which includes swelling and itching of the hands. Answers A, B, and C can also occur but are not the first signs of latex allergy; therefore, they are incorrect.
Answer B is correct. The dressings should be moistened with sterile water. Answer A is incorrect because Acticoat dressings remain in place up to 5 days. Answer C is incorrect because the dressings should be changed every 4 or 5 days. Answer D is incorrect because normal saline should not be used to moisten the dressing.
Answer C is correct. Stage III Hodgkin’s lymphoma is characterized by lymph node involvement on both sides of the diaphragm. Answer A refers to stage I Hodgkin’s lymphoma; therefore, it is incorrect. Answer B refers to stage II Hodgkin’s lymphoma; therefore, it is incorrect. Answer D refers to stage IV Hodgkin’s lymphoma; therefore, it is incorrect.
Answer B is correct. The client taking methotrexate should avoid multivitamins because they contain folic acid. Folic acid is the antidote for methotrexate. Answers A and D are incorrect because aspirin and acetaminophen are given to relieve pain and inflammation associated with rheumatoid arthritis. Answer C is incorrect because omega 3 and omega 6 fish oils have proven beneficial for the client with rheumatoid arthritis.
Answer C is correct. The client with ascites requires additional protein and calories unless the client’s condition deteriorates because of renal involvement. In that case, protein intake is restricted. Answer A is incorrect because the client needs a low-sodium diet. Answer B is incorrect because the client does not need to decrease his intake of potassium. Answer D is incorrect because the client needs adequate amounts of calcium-rich foods that are also excellent sources of protein.
Answer A is correct because it is the position used for lithotripsy for the client with gallstones in the gall bladder. Answer B is incorrect because it is the position used for lithotripsy for the client with gallstones in the common bile duct. Answers C and D are incorrect because side-lying and recumbent positions do not allow the maximum effect of therapy.
Answer A is correct. Persons receiving steroids should eat only cooked or processed foods. Raw oysters carry hepatitis A as well as E. coli. Answers B, C, and D are all suitable foods for the client taking steroid medication; therefore, they are incorrect.
Answer B is correct. St. John’s wort has properties similar to those of monoamine oxidase inhibitors (MAOI). Eating foods high in tryramine (aged cheese, chocolate, salami, liver, and so on) can result in a hypertensive crisis. Answer A is incorrect because it can relieve mild to moderate depression. Answer C is incorrect because use of a sunscreen prevents skin reactions to sun exposure. Answer D is incorrect because the use of St. John’s wort decreases the amount of medication needed.
Answer A is correct. Foods high in purine include dried beans, peas, spinach, oatmeal, poultry, fish, liver, lobster, and oysters. Answers B, C, and D are incorrect because they are low in purine. Other sources low in purine include most vegetables, milk, and gelatin.
Answer B is correct. The client with bulimia is prone to dental caries due to erosion of the tooth enamel from frequent bouts of self-induced vomiting. Answers A, C, and D are findings associated with anorexia nervosa, not bulimia; therefore, they are incorrect.
Answer A is correct. Adverse reactions to Thorazine include dystonia. Spasms of the neck and difficulty swallowing can lead to airway compromise. Answers B, C, and D are expected side effects that occur with the use of Thorazine. They do not require that the physician be notified immediately; therefore, they are incorrect.
Answer D is correct. Transderm Nitro is a reservoir patch that releases the medication via a semipermeable membrane. Cutting the patch allows too much of the drug to be released. Answer A is incorrect because the area should not be shaved because it can cause skin irritation. Answer B is incorrect because the skin is cleaned with soap and water. Answer C is incorrect because the patch is not covered with plastic wrap.
Answer A is correct. Cholinergic crisis is the result of overmedication with anticholinesterase inhibitors. Clients with cholinergic crisis have the following symptoms: nausea, vomiting, diarrhea, blurred vision, pallor, decreased blood pressure, and pupillary meiosis. Myasthenia crisis is the result of under medication with cholinesterase inhibitors. Answers B, C, and D are incorrect because they are symptoms of myasthenia crisis.
Answer D is correct. The client should avoid eating American and processed cheeses such as Colby and Cheddar because they are high in sodium. Dried beans, peanut butter, and Swiss cheese are low in sodium; therefore, answers A, B, and C are incorrect.
Answer B is correct. According to the Rule of Nines, the arms (18%) + the head (9%) = 27% TBSA burn injury. Answers A, B, and D are inaccurate percentages for the TBSA; therefore, they are incorrect.
Answer A is correct. The client should void before the paracentesis to prevent accidental trauma to the bladder. Answer B is incorrect because the abdomen is not shaved. Answer C is incorrect because the client does not need extra fluids, which would cause bladder distention. Answer D is incorrect because the physician, not the nurse, would request an x-ray, if needed.
Answer A is correct. Acyclovir shortens the course of chickenpox, but the American Academy of Pediatrics does not recommend it for healthy children because of the cost. Answer B is incorrect because it is the vaccine used to prevent chickenpox. Answer C is incorrect because it is the immune globulin given to those who have been exposed to chickenpox. Answer D is incorrect because it is an antihistamine used to control itching associated with chickenpox.
Answer B is correct. Females with chronic debilitating conditions who are dependent on others for most or all of their care are most likely to be the victims of elder abuse. Answers A, C, and D are incorrect because the clients are less likely to be dependent on others for their care; therefore, they are less likely to be victims of elder abuse. Although they might also be victims, men are less likely to report abuse than women.
Answer B is correct. The most appropriate facet of care for the newly licensed practical nurse is the monitoring of the client’s vital signs. Answers A and C are incorrect because initiation of IV fluids and administration of blood is the responsibility of the registered nurse. Answer D is incorrect because in the hospital setting, the registered nurse would be responsible for notifying the physician of a reaction.
Answer C is correct. Dark-green, leafy vegetables; the cabbage family; beets; kidney beans; cantaloupe; and oranges are good sources of folic acid (B9). Meat, liver, eggs, dried beans, sweet potatoes, and Brussels sprouts are good sources of B12; therefore, answers A and D are incorrect. Pork, fish, and chicken are good sources of B6; therefore, answer B is incorrect.
Answer A is correct. Cigarette smoking is the number-one cause of bladder cancer. Answer B is incorrect because it is associated with breast cancer, not bladder cancer. Answer C is wrong because it is a primary cause of gastric cancer. Answer D is incorrect because it is a cause of certain types of lung cancer.
Answer C is correct. Nitrogycerin tablets should be used as soon as the client first notices chest pain or discomfort. Answer A is incorrect because the medication should be used before engaging in activity. Strenuous activity should be avoided. Answer B is incorrect because the medication should be used when pain occurs, not on a regular schedule. Answer D is incorrect because the medication will not prevent nocturnal angina.
Answer B is correct. To obtain the urine output, the weight of the dry diaper (62 grams) is subtracted from the weight of the used diaper (90.5 grams), for a urine output of 28.5 grams, or 28.5mL (1 gram = 1mL). Answer A is an inaccurate amount; therefore, it is incorrect. Output is measured in milliliters, not grams; therefore, answers C and D are incorrect.
Answer B is correct. The infant with osteogenesis imperfecta (ribbon bones) should be handled with care to prevent fractures. Adding calcium to the infant’s diet will not improve the condition; therefore, answer A is incorrect. Answers C and D are not related to the disorder; therefore, they are incorrect.
Answer C is correct. The client with gastroesophageal reflux disease (GERD) should avoid beverages containing caffeine because they increase the production of hydrochloric acid, which erodes the esophagus. Answer A is incorrect because the client should not eat for 3–4 hours before going to bed. The client should sleep on his left side, not his right side; therefore, answer B is incorrect. Citrus juices are acidic, which can contribute to reflux and esophageal erosion; therefore, answer D is incorrect.
Answer D is correct. The nurse should flush the NG tube with 2–4oz. of water before and after giving the medication. Answers A and B are incorrect because they do not use sufficient amounts of water. Answer C is incorrect because water, not normal saline, is used to flush the NG tube.
Answer C is correct. The nurse should handle the cast using the palms of the hands to prevent indentations in the cast. Answer A is incorrect because grasping the cast with the hands will produce indentations that cause pressure points. Answers B and D are incorrect choices because assistive slings and lifting devices would frighten the 3-year-old and are not needed.
Answer B is correct. Discoid lupus is confined to the skin, producing “coinlike” lesions on the skin. Answers A, C, and D refer to systemic lupus; therefore, they are incorrect.
Answer B is correct. Before walking the client for the first time since surgery, the nurse should ask the client to sit on the side of the bed and dangle his legs to prevent postural hypotension. Pain medication should not be given before walking; therefore, answer A is incorrect. Answers C and D have no relationship to walking the client; therefore, they are incorrect.
Answer D is correct. A positive Babinski reflex in adults should be reported to the charge nurse because it indicates an abnormal finding. Answer A is incorrect because a positive Babinski sign in the adult is abnormal, therefore it does not indicate that the client’s condition is improving. Answer B is incorrect because changing the position will not alter the finding. Answer C is incorrect because a positive Babinski reflex is an expected finding in the infant but not in adults.
Answer B is correct. Gantrisin and other sulfa drugs should be given 30 minutes before meals to enhance absorption. Answer A is incorrect because the medication should be given before eating. Answer C is incorrect because the medication should be given on an empty stomach. Answer D is incorrect because the medication is to be given in divided doses throughout the day.
Answer B is correct. The client in pain usually has an increased blood pressure. Answers A and C are incorrect because the client in pain will have an increase in the pulse rate and respirations. Temperature is not affected by pain; therefore, answer D is incorrect.
Answer B is correct. Salmonella infection is commonly associated with turtles. Answers A, C, and D are incorrect because they are not sources of salmonella infection.
Answer C is correct. The medication will cause the urine to become red-orange in color. Answers A, B, and D are not associated with the use of Pyridium; therefore, they are incorrect.
Answer B is correct. The infant’s fingernails should be kept short to prevent scratching the skin. Keeping the infant warm will increase itching; therefore, answer A is incorrect. Soap should not be used because it dries the skin; therefore, answer C is incorrect. Peroxide is damaging to the tissues; therefore, answer D is incorrect.
Answer A is correct. A Wilms tumor is found by most parents when the infant is being diapered or bathed. Answers B, C, and D are not associated with a Wilms tumor; therefore, they are incorrect.
Answer A is correct. Complaints of chest pain and feelings of apprehension are associated with pulmonary emboli, which can occur after the fracture of long bones. These findings should be reported immediately so that interventions can begin. Answer B is incorrect because ecchymosis is common following fractures. Answer C is incorrect because a low-grade temperature is expected because of the inflammatory response. Answer D is incorrect because Level 2 pain is expected in the client with a recent fracture.
Answer A is correct. JCAHO guidelines state that at least two client identifiers should be used whenever administering medications or blood products, whenever samples or specimens are taken, and when providing treatments. Neither of the identifiers is to be the client’s room number. Answer B is incorrect because the client’s room number is not used as an identifier. Answers C and D are incorrect because the best identifiers according to JCAHO are the client’s armband, medical record number, and/or date of birth.
Answer D is correct. According to the American Heart Association, the nurse should call for help before instituting CPR. Answer A is incorrect because the nurse would first call for help. The nurse would not start cardiac compressions before evaluating the client’s carotid pulse. Answer B is incorrect because the nurse would first call for help. The nurse would not administer rescue breathing until she established that the client was not breathing on her own. Answer C is incorrect because the nurse would open the airway after calling for help.
Answer D is correct. The medication must be taken for the remainder of the client’s life to prevent the reoccurrence of CMV infection. Answers A, B, and C are inaccurate statements; therefore, they are incorrect.
Answer A is correct. Basal cell epithelioma, skin cancer, is related to sun exposure. Answers B, C, and D are incorrect because they are not associated with the development of basal cell epithelioma.
Answer D is correct. The appearance of increased drainage that is clear, colorless, or bile tinged indicates disruption or leakage at one of the anastamosis sites, which requires immediate attention. Answer A is incorrect because the client’s condition will worsen without prompt intervention. Answers B and C are incorrect choices because they cannot be performed without a physician’s order.
Answer A is correct. Herbals such as Echinacea can interfere with the action of antiviral medications; therefore, the client should discuss the use of herbals with his physician. Answer B is incorrect because supplements have not been shown to prolong life. Answer C is incorrect because herbals have not been shown to be effective in decreasing the viral load. Answer D is incorrect because supplements do not prevent replication of the virus.
Answer B is correct. The client with Sjogren’s syndrome complains of dryness of the eyes. The nurse can help relieve the client’s discomfort by instilling eyedrops. Answers A, B, and C do not relieve the symptoms of Sjogren’s syndrome; therefore, they are incorrect.
Answer D is correct. Melena, or blood in the stool, is common in the client with duodenal ulcers. Answers A and B are symptoms of gastric ulcers; therefore, they are incorrect. Diarrhea is not a symptom of duodenal ulcers; therefore, answer C is incorrect.
Answer B is correct. Clients who use steroid medications, such as fluticasone, can develop adverse side effects, including oral infections with candida albicans. Symptoms of candida albicans include sore throat and white patches on the oral mucosa. Increased weight, difficulty in sleeping, and changes in mood are expected side effects; therefore, answers A, C, and D are incorrect.
Answer A is correct. Concurrent use of two SSRIs can result in serotonin syndrome, a potentially lethal condition. Answer B is incorrect because it refers to the “Parnate-cheese” reaction or hypertension that results when the client taking an MAO inhibitor ingests sources of tyramine. Answer C is incorrect because it refers to neuroleptic malignant syndrome or elevations in temperature caused by antipsychotic medication. Answer D is incorrect because it refers to the hypertension that results when MAO inhibitors are used with cold and hayfever medications containing pseudoephedrine.
Answer C is correct. Pernicious anemia is characterized by changes in neurological function such as loss of coordination and loss of position sense. Answers A, B, and D are applicable to all types of anemia; therefore, they are incorrect.
Answer D is correct. Secondary syphilis is characterized by well-defined generalized lesions on the palms, soles, and perineum. Lesions can enlarge and erode, leaving highly contagious pink or grayish white lesions. Answer A describes the chancre associated with primary syphilis; therefore, it is incorrect. Answer B describes the latent stage of syphilis; therefore, it is incorrect. Answer C describes late syphilis; therefore, it is incorrect.
Answer B is correct. Morphine can severely depress the client’s respirations. Answer A is incorrect because the assessment of heart rate, a part of pain assessment, is not an essential assessment for administering morphine. Answer C is incorrect because temperature is not affected by the administration of morphine. Answer D is incorrect because assessment of blood pressure, a part of pain assessment, is not an essential assessment for administering morphine.
Answer D is correct. Hoarseness and weak voice are signs of laryngeal nerve damage. These would be evident when the client states her name. Answer A is incorrect because it is not assessed by having the client state her name. The nurse would check the client’s dressing and check behind the neck for signs of post-operative bleeding. Answer B is incorrect because it is not assessed by having the client state her name. Signs of decreased calcium include tingling around the mouth and muscle twitching. Answer C is incorrect because it is not assessed by having the client state her name. Signs of laryngeal stridor include harsh, high-pitched respirations.
Answer A is correct. Essential hypertension is defined as maintenance of a blood pressure reading at or above 140/90. Answers B, C, and D are incorrect because the blood pressures are lower than 140/90.
Answer B is correct. Karaya powder is applied to help form a seal that will protect the skin from the liquid stool. Answer A is incorrect because karaya powder will not prevent the formation of odor. Answer C is incorrect because karaya powder will not prevent the loss of electrolytes from the ileostomy. Answer D is incorrect because karaya powder will not increase the time between bag evaluations.
Answer D is correct. The appropriate diet for the 9-month-old with suspected celiac disease is breast milk and rice cereal. Answer A is incorrect because the 9-month-old is too young to have whole milk, and oats contain gluten, which is associated with celiac disease. Both mixed cereal and barley cereal contain gluten, which is associated with celiac disease; therefore, answers B and C are incorrect.
Answer C is correct. An elevated white cell count is expected in inflammatory conditions such as diverticulitis. Answers A, B, and D are not associated with inflammation; therefore, they are incorrect.
Answer B is correct. Increased length of the cord is a sign that the placenta has separated. Answers A, C, and D are not associated with separation of the placenta; therefore, they are incorrect.
Answer A is correct. It is recommended that a daily dose of Nexium (esomeprazole), a proton pump inhibitor, be given before breakfast. Answers B, C, and D are inaccurate times for administering proton pump inhibitors; therefore, they are incorrect.
Answer A is correct. Perforation of a duodenal ulcer is characterized by sudden sharp midepigastric pain caused by the emptying of duodenal contents into the peritoneum. The abdomen is tender, rigid, and boardlike. Answer B is not associated with the client’s sudden onset of symptoms; therefore, it is incorrect. Answer C is incorrect because the client would complain of heartburn or reflux. Answer D is incorrect because the client would have increased abdominal distention, visible peristaltic waves, and high-pitched bowel sounds.
Answer A is correct. The banana popsicle is best for the child following a tonsillectomy because it is cold and the yellow color does not allow it to be confused with any bleeding that the child might have. Answer B is incorrect because milk products form a film on the operative area and thicken saliva. Answer C is incorrect because fruit punch contains fruit juices that might cause a burning sensation in the throat following a tonsillectomy. Answer D is incorrect because the carbonation from cola causes a burning sensation in the throat following a tonsillectomy.
Answer B is correct. The client taking alprazolam should not use alcohol, which includes beer, because alcohol potentiates the effect of the medication. Answers A and D are not associated with the use of alprazolam; therefore, they are incorrect. Answer C is associated with the use of MAO inhibitors; therefore, it is incorrect.
Answer D is correct. The correct use of the incentive spirometer will increase the client’s respiratory effort and effectiveness. Answers A and B are indirectly affected by the correct use of the incentive spirometer; therefore, they are incorrect. Answer C is not affected by the use of an incentive spiromenter; therefore, it is incorrect.
Answer A is correct. Unless the manufacturer recommends otherwise, the nurse should inflate and deflate the gastric and esophageal balloons to make sure they are not defective. Answer B refers to the insertion of a standard nasogastric tube; therefore, it is incorrect. Answer C is incorrect because the esophageal tamponade is usually removed after 48 hours. Answer D is incorrect because the esophageal tamponade has a port for gastric suction.
Answer B is correct. Lactulose is given to produce diarrhea, which lowers the client’s serum ammonia levels. Answers A, C, and D are not associated with the use of lactulose; therefore, they are incorrect.
Answer C is correct. Gently massaging the fundus immediately following delivery will help it to contract. Answer A is incorrect because the uterus would be displaced to one side if the bladder was distended. Answer B is incorrect. The nurse should first massage the fundus before notifying the doctor. Answer D is incorrect because uterine relaxation is not associated with pain.
Answer B is correct. Oatmeal and grapefruit wedges are high in fiber. Answers A, C, and D are incorrect because they contain less fiber.
Answer A is correct. Many clients with Hodgkin’s lymphoma report finding enlarged nodes in the neck when shaving. Answer B is associated with brain tumors; therefore, it is incorrect. Answer C is associated with leukemia; therefore, it is incorrect. Answer D is associated with renal cancer; therefore, it is incorrect.
Answer B is correct. Pentamidine is used to prevent pneumocystis jiroveci pneumonia. Answers A, C, and D are not associated with the use of pentamidine; therefore, they are incorrect.
Answer D is correct. The anterior fontanel usually closes by the time the baby is 12–18 months of age. Answers A, B and C are incorrect because the baby is too young for the anterior fontanel to be closed.
Answer C is correct. A positive Schilling test indicates that the client has pernicious anemia, which is due to the lack of intrinsic factor. Answer A describes iron-deficiency anemia; therefore, it is incorrect. Answer B describes sickle cell anemia; therefore, it is incorrect. Answer D describes Cooley’s anemia; therefore, it is incorrect.
Answer B is correct. According to standard (universal) precautions, blood spills should be cleaned up immediately using a weak solution of bleach (1 part bleach to 10 parts water). Answers A, C, and D are not recommended for cleaning up accidental blood spills; therefore, they are incorrect.
Answer A is correct. Providing a pacifier will provide the most comfort for the 5-month-old by providing oral gratification. Answers B, C, and D will comfort the infant, but not as much as the pacifier while he is NPO.
Answer B is correct. The nurse should make a list of the medications and ask a family member to take the medications home. If no family member is available, the medication should remain locked in the medication room until the client is discharged home. Answer A is incorrect because the client might take the medication without the nurse’s knowledge, which might result in overmedication. Answer C is incorrect because over-the-counter medications and herbal supplements can interact with medications the physician might order. Answer D is incorrect because only medications supplied by the hospital pharmacy should be used while the client is hospitalized unless the physician writes an order allowing the nurse to administer medication previously purchased by the client.
Answer C is correct. The physician’s signature is not included on the preoperative checklist because it is a check sheet for the assessment and preparation of the client for surgery. The physician’s signature is required on the preoperative orders and the consent form for surgery. Answers A, B, and D are incorrect because they are required on the client’s preoperative checklist.
Answer A is correct. Thorazine (chlorpromazine) causes an increase in sun sensitivity; therefore, the nursing staff should take extra measures to protect the clients from sun exposure. Aged cheese and chocolate are eliminated from the diet of a client taking an MAO inhibitor; therefore, answers B and D are incorrect. Answer C is incorrect because the client taking Thorazine needs extra fluid because the anticholinergic effects of the medication cause dry mouth.
Answer D is correct. Ambulating the client as soon as possible prevents venous stasis and helps to prevent embolus formation. Answers A and C are measures to increase the effectiveness of respirations and help to prevent pneumonia; therefore, they are incorrect. Answer B is a treatment to break up an existing embolus; therefore, it is incorrect.
Answer A is correct. B & O suppositories relieve pain following a prostatectomy by reducing bladder spasms. The medication does not improve urinary output, does not reduce post-operative swelling, and does not treat nausea and vomiting; therefore, answers B, C, and D are incorrect.
Answer B is correct. The primary reason for wrapping the stump with an elastic bandage is to shrink the stump and get it ready for application of a prosthetic device. Answer A is incorrect because the application of an elastic bandage will not decrease bleeding. Answer C is incorrect because the application of an elastic bandage will not prevent phantom pain. Application of an elastic bandage will prevent the client from seeing the area, but this is not the primary reason for its use; therefore, answer D is incorrect.
Answer B is correct. Symptoms associated with polycythemia include ruddy complexion, spleenomegaly, headache, fatigue, dyspena, angina, and pruritis. Answer A is incorrect because it is associated with pernicious anemia. Answer C is incorrect because it is associated with anemia. Answer D is incorrect because the symptoms are associated with left-sided heart failure.
Answer A is correct. Following a total hip replacement, the nurse should assist the client to sit in a recliner, which limits the amount of hip flexion to 60° or less. Answers B, C, and D are incorrect because they allow the hip to be flexed more than 90°, which might dislocate the hip prosthesis.
Answer C is correct. Cotazyme (pancrelipase) increases the digestion and absorption of fats, carbohydrates, and proteins in the GI tract. Deficiencies in the fat-soluble vitamins (A, D, E, K) are corrected by administering the water-soluble forms of those vitamins; therefore, answer A is incorrect. Answer B is incorrect because Cotazyme increases carbohydrate metabolism. Answer D is incorrect because Cotazyme has no effect on sodium and chloride excretion.
Answer C is correct. The typical play of preschool-age children is described as associative play. In associative play, children of the same sex play together with no obvious rules for play activity and without leaders. Answer A is incorrect because it is the typical play activity of the infant. Answer B is incorrect because it is the typical play activity of the toddler. Answer D is incorrect because it is the typical play activity of the school-age child.
Answer A is correct. Petroleum gauze should not be applied to the cord, which separates by a process of drying. Answers B, C, and D are all parts of routine cord care; therefore, they are incorrect.
Answer A is correct. According to Freud’s psychoanalytic theory, antisocial personality disorder arises from faulty development of the id. Answers B, C, and D are incorrect because they are not related to the development of antisocial personality disorder.
Answer B is correct. Oxycontin (oxycodone) is a central nervous system depressant that is capable of producing decreased respirations and apnea. Answer A is associated with an overdose of aspirin; therefore, it is incorrect. Answer C is incorrect because the blood pressure would be decreased. Answer D is not associated with an overdose of Phenobarbital; therefore, it is incorrect.
Answer B is correct. Buck’s traction is a skin traction used for short-time immobilization of hip fractures before surgical correction. Answer A is incorrect because 90-90 traction is a skeletal traction used to immobilize fractures of the femur. Answer C is incorrect because Bryant’s traction is used only for children who weigh less than 30 pounds. Answer D is incorrect because Dunlop’s traction is used to treat fractures of the humerus.
Answer D is correct. Concurrent use of an SSRI and an MAO inhibitor can produce serotonin syndrome; therefore, the client should discontinue the MAO inhibitor 14 days before beginning therapy with an SSRI. Answers A, B, and C are incorrect because the time is too brief between the use of the MAO inhibitor and the beginning of therapy with an SSRI.
Answer D is correct. The nurse should first assess the client to determine the location and character of the pain. Answers A, B, and C are incorrect because they are not the first action that the nurse should take.
Answer C is correct. Cephalocaudal development refers to head-to-tail (toe) development; therefore, the infant can raise her head before she can sit. Answer A is an example of simple-to-complex development; therefore, it is incorrect. Answer B is an example of proximodistal development; therefore, it is incorrect. Answer D is an example of general-to-specific development; therefore, it is incorrect.
Answer D is correct. When performing a straight catheterization, the nurse should hold the catheter in place as the bladder empties to prevent it from slipping out. Answer A is incorrect because surgical, not medical, asepsis is used when performing a catheterization. Answer B is incorrect because the catheter should be inserted 2–3 inches. Answer C is incorrect because the straight catheter does not have a balloon for inflation.
Answer A is correct. Moving the client up in the bed is easier with the head of the bed lowered because the nurse does not have to work against the force of gravity. Answer B is incorrect because lowering the head of the bed will not prevent wrinkles in the linen. Answer C is incorrect because lowering the head of the bed will not eliminate the need for additional help to move the client. Answer D is incorrect because lowering the head of the bed will not relieve pressure on the client’s sacrum.
Answer B is correct. During an arteriogram, contrast media is injected directly into the artery. The nurse should give priority to assessing the site for bleeding. Answers A, C, and D are incorrect because they do not take priority over assessing the site for bleeding.
Answer D is correct. Methodone is an opioid agonist; therefore, it is capable of producing respiratory depression.
Answer B is correct. Atropine is given to dry secretions and lessens the likelihood of aspiration. Answers A, C, and D are inaccurate statements; therefore, they are incorrect.
Answer C is correct. The client’s assessment findings are within normal 12 hours after a Caesarean section; therefore, the nurse should chart the finding. Answer A is incorrect because the assessment does not reveal the presence of bladder distention. Answer B is incorrect because the assessment does not reveal uterine atony. Answer D is incorrect because the client needs to ambulate.
Answer A is correct. “Rainbow” bruises refer to bruises in various stages of healing. Although they are not conclusive proof of physical abuse, they do suggest the possibility. Answer B is incorrect because the 4-year-old might still suck the thumb when going to sleep. The victim of child abuse usually endures painful procedures with little expression of emotion; therefore, answer C is incorrect. Victims of child abuse are usually reluctant to talk to strangers; therefore, answer D is incorrect.
Answer C is correct. An alcoholic blackout refers to the inability to remember what occurred before or after a period of alcohol intake. Answer A is incorrect because it occurs after a period of heavy drinking or when the usual alcohol intake is reduced. Alcoholic hallucinosis is characterized by hallucinations. Answer B is incorrect because it refers to the headache and gastrointestinal symptoms experienced after drinking alcohol. Sunday morning paralysis refers to radial nerve palsy commonly observed when a stuporous person lies with his arm pressed over a projecting surface; therefore, answer D is incorrect.
Answer A is correct. Degenerative joint disease (osteoarthritis) is characterized by joint pain that intensifies with activity and diminishes with rest. Answers B, C, and D are typical findings in the client with rheumatoid arthritis; therefore, they are incorrect.
Answer B is correct. The client with pancreatitis has decreased levels of vitamin K, making him more likely to have prolonged bleeding with injections; therefore, the nurse should hold pressure on the injection site for 3–5 minutes. Answer A is incorrect because the medication is not administered using the Z track method. Answer C is incorrect because the medication is not administered subcutaneously. Answer D is incorrect because alcohol, not betadine, is used to prep the skin.
Answer D is correct. The client with Addison’s disease is treated with corticosteroid therapy that reduces the client’s immunity. The client needs to stay out of crowds to prevent complications posed by infection. Answers A and C are incorrect because the client needs additional sources of sodium and potassium in the diet. Answer B is incorrect because the client with Addison’s disease should dress in warm clothing to prevent easy chilling.
Answer A is correct. The evulsed tooth should be rinsed in milk, in saline solution, or under running water before reimplantation. Answer B is incorrect because it will disturb the adhering periodontal membrane. Answer C is incorrect because the tooth should be held by the crown, not the root. Answer D is incorrect because the child might swallow or aspirate the tooth.
Answer B is correct. Presenting symptoms of leukemia include pallor, fatigue, anorexia, petechiae, and bone or joint pain. Answers A, C, and D are incorrect because they are not associated with leukemia.
Answer D is correct. The skill of aspirating nasogastric secretions is beyond the scope of practice of the nursing assistant. Answers A, B, and C are incorrect because they are within the scope of practice of the nursing assistant.
Answer B is correct. The hourly urinary output should be maintained between 30mL and 50mL per hour. The fact that the urine is dark amber indicates that the client is not receiving adequate fluids to prevent dehydration. Answers A, C, and D do not call for any interventions; therefore, they are incorrect.
Answer B is correct. The client’s oxygen saturation is low; therefore, the nurse should give priority to administering oxygen per standing order. Answer A is incorrect because there is nothing that indicates that the client needs an analgesic. Answer C is incorrect because the client’s temperature is satisfactory. Answer D is incorrect because the Glascow score of 13 indicates that the client is not fully recovered from the effects of conscious sedation; therefore, the IV should not be discontinued.
Answer C is correct. Phenergan with codeine is an antitussive that relieves coughing and affords the client an opportunity to rest. Answers A and B are not properties of the medication; therefore, they are incorrect. Answer D is incorrect because the amount of codeine in the medication is not sufficient to relieve pain.
Answer B is correct. The primary cause of anemia in the client with chronic renal failure is the lack of erythropoietin. Answer A is incorrect because it is not the primary cause of anemia in the client with chronic renal failure. Answer C is incorrect because it refers to sickle cell anemia. Answer D is incorrect because it refers to iron-deficiency anemia.
Answer D is correct. The nurse should recheck the MAR to make sure the medication she is about to give is correct. Answers A and B are incorrect because they do not provide for the client’s safety. Answer C is incorrect because the pharmacist might or might not have made a substitution. The nurse needs to validate generic substitution before administering the medication.
Answer D is correct. A side effect of Laradopa (levodopa) is orthostatic hypotension; therefore, the nurse should tell the client to rise slowly from a sitting position. Answer A is incorrect because the medication can be given with a snack to prevent gastric irritation. Answer B is incorrect because the client does not need monthly lab work. Answer C is incorrect because the medication only controls the symptoms of Parkinson’s disease; it does not cure the disease. Therefore, the medication will be taken indefinitely.
Answer A is correct. Dietary management of the client with congestive heart failure includes a sodium-restricted diet. Answers B, C, and D are incorrect because they are not restricted in the client with congestive heart failure.
Answer C is correct. Diuretic therapy and restriction of fluids are ordered during the acute phase of a stroke to reduce cerebral edema. Answer A is incorrect because the orders are not intended to reduce cardiac output. Answer B is incorrect because the measures will not prevent an embolus. Answer D is incorrect because the measures are not intended to minimize incontinence.
Answer B is correct. Long-term exposure to gastric contents such as that caused by gastroesophageal reflux plays a role in the development of esophageal cancer. Answers A and D are incorrect because they are not associated with esophageal cancer. A history of prolonged use of alcohol and tobacco is associated with esophageal cancer; therefore, answer C is incorrect.
Answer C is correct. Spinach is an excellent source of both calcium and potassium. Broccoli is a good source of calcium but not potassium; therefore, answer A is incorrect. Sweet potato and avocado are good sources of potassium but not calcium; therefore, answers B and D are incorrect.
Answer B is correct. The PSA (prostate specific antigen) and acid phosphatase are valuable screening tests for cancer of the prostate. The PSA is not a screening test for cancers of the bladder, vas deferens, or testes; therefore, answers A, C, and D are incorrect.
Answer C is correct. The client’s lithium level is within the therapeutic range. Answer A is incorrect because the lithium level is not too low to be therapeutic. Answer B is incorrect because the client is not within the range of toxicity. Answer D is incorrect because eating more sodium-rich foods will reduce the lithium level.
Answer C is correct. The treatment for ventricular fibrillations (V-fib) is defibrillation (D-fib). Answers A, B, and D are not emergency treatments for the client who suddenly develops ventricular fibrillations.
Answer D is correct. The client with apraxia is unable to recognize the purpose of familiar objects; therefore, he is unable to perform previously learned skills such as combing his hair. Answer A is incorrect because it refers to aphasia. Answer B is incorrect because it refers to dysphagia. Answer C is incorrect because it refers to ataxia.
Answer A is correct. Using a pillow or sling to support the client’s arm while she is sitting will help prevent subluxation of the affected shoulder. Answers B, C, and D are incorrect because they do not prevent subluxation of the client’s affected shoulder.
Answer C is correct. The recommended way of administering Lovenox (enoxaparin) is subcutaneously in the abdominal tissue. Answers A and B are not recommended ways of administering Lovenox (enoxaparin); therefore, they are incorrect. Answer D is incorrect because Lovenox (enoxaprin) is not available in an oral form.
Answer B is correct. Nitroglycerin should be kept in a dark-brown bottle to protect it from light, which causes deterioration of the medication. Answer A is incorrect because the medication is placed beneath the tongue when needed, not taken daily. Answer C is incorrect because the medication supply should be replenished every 6 months, not every year. Answer D is incorrect because the cotton should be removed from the bottle because it absorbs the medication.
Answer A is correct. Ingestion of foods containing tyramine by the client taking Parnate, an MAO inhibitor, can result in elevations in blood pressure. Answers B, C, and D are not associated with the interaction of Parnate or other MAO inhibitors; therefore, they are incorrect.
Answer C is correct. Because of the location, the client receiving external radiation for cancer of the larynx will most likely complain of a sore throat. Generalized pruritis, dyspnea, and bone pain are not associated with external radiation for cancer of the larynx; therefore, answers A, B, and D are incorrect.
Answer B is correct. Symptoms of autonomic dysreflexia are often triggered by bladder distention or fecal impaction; therefore, after raising the client’s head, the nurse should check for patency of the catheter. Answer A is incorrect because administering a prescribed analgesic will not alleviate the symptoms of autonomic dysreflexia. Answer C is incorrect because breathing slowly does not alleviate autonomic dysreflexia. Answer D is incorrect because the changes in the client’s temperature are not associated with autonomic dysreflexia.
Answer B is correct. The nurse or parent should maintain one hand on the child whenever the side rails are down to prevent the child falling from the crib. Answer A is incorrect because the child can fall over rails that are locked at the halfway point. Positioning the child farther away from the lowered side rail will not prevent falls because the child can quickly move to the other side so that falls can result; therefore, answer C is incorrect. Answer D is incorrect because the child can fall from the crib.
Answer C is correct. The nurse should temporarily stop the administration of the Virazole when the mist tent needs to be opened to allow the medication particles to settle. Answer A is incorrect because contact precautions should be used even though the infant is receiving Virazole. Answer B is incorrect because contact precautions are used whether the mist tent is opened or closed. Answer D is incorrect because increasing or decreasing the rate of medication administration is not a nursing function.
Answer D is correct. The most common food allergens are proteins such as those contained in eggs, cow’s milk, and peanuts. Answers A, B, and C are incorrect because they are not the most common food allergens.
Answer D is correct. Eczematous lesions are more common on the cheeks and extensor surfaces of the arms and legs. Answer A is incorrect because the abdomen is not a common site of eczematous lesions. Answer B is incorrect because the buttocks, abdomen, and back are not common sites of eczematous lesions. Answer C is incorrect because the back and flexor surfaces of the arms and legs are not common sites of eczematous lesions.
Answer C is correct. The client’s own desire to become drug-free has the most influence on recovery and sobriety. Answers A, B, and D are important factors, but they do not have the greatest influence on the client’s recovery; therefore, they are incorrect.
Answer A is correct. Acute otitis media is characterized by elevations in temperature as high as 104°F. Pain in the affected ear, nausea and vomiting, and feelings of fullness characterize both chronic otitis media and acute otitis media; therefore, answers B, C, and D are incorrect.
Answer B is correct. Rheumatic fever is associated with a history of a sequella to strep throat. Answers A, C, and D are not associated with rheumatic fever; therefore, they are incorrect.
Answer A is correct. The child with Duchenne’s muscular dystrophy must use Gower’s maneuver to rise to a standing position. The child puts his hands on his knees and moves the hands up the legs until he is standing. Answer B is incorrect because it refers to the child with Osgood-Schlatter disease. Answer C is incorrect because it refers to the child with lordosis. Answer D is incorrect because it refers to the child with Legg-Calve-Perthes disease.
Answer B is correct. Amniotic fluid is straw colored in appearance. Answer A is incorrect because it indicates active bleeding. Answer C is incorrect because it indicates the passage of meconium, which is associated with fetal distress. Answer D is incorrect because the discharge should be straw colored, not dark brown in appearance.
Answer D is correct. Fetal heart tones can be heard using a fetoscope as early as 18 weeks gestation. Answers A, B, and C are incorrect because fetal heart tones cannot be heard using a fetoscope before 18 weeks gestation.
Answer D is correct. The client can help prevent heartburn by avoiding caffeinated beverages. Answers A and C are incorrect because the client should sleep on her left side with her head elevated on several pillows. Answer B is incorrect because eating dry crackers at bedtime can increase problems with heartburn.
Answer C is correct. Pancreatic enzyme replacement is given to facilitate the digestion of fats, proteins, and carbohydrates. Therefore, if the amount of pancreatic enzyme is adequate, the client will have an increase in weight. Answer A is incorrect because pancreatic enzyme replacement has no effect on respiratory function. Answer B is incorrect because pancreatic enzyme replacement does not decrease sodium excretion. Answer D is incorrect because pancreatic enzyme replacement does not decrease chloride excretion.
Answer D is correct. The lesions of impetigo resolve in 2 weeks, and it will be safe for the child to return to school. Answers A, B, and C are incorrect because the lesions will still be present, and the child will be contagious.
Answer B is correct. Infants born to diabetic mothers have microsomia or large bodies because of maternal hyperglycemia. Answers A, C, and D do not relate specifically to infants of diabetic mothers; therefore, they are incorrect.
Answer B is correct. The Guthrie test is a screening test for newborns to detect phenylketonuria. Cystic fibrosis is confirmed by a sweat test; therefore, answer A is incorrect. Hypothyroidsim is confirmed by a T3 and T4; therefore, answer C is incorrect. Sickle cell is confirmed by the Sickledex; therefore, answer D is incorrect.
Answer D is correct. Elixophylline (theophylline) is a bronchodilator that acts to relax bronchial smooth muscle. Answers A, B, and C are incorrect because they are not actions of theophylline.
Answer D is correct. A meal of baked chicken, apple, angel food cake, and 1% milk is low in calories, low in fat, and low in sodium. Answer A is incorrect because blue cheese dressing and crackers are high in sodium. Answer B is incorrect because frankfurters are high in calories, fat, and sodium. Answer C is incorrect because taco seasoning, meat, chips, and sour cream are high in calories, fat, and sodium.
Answer A is correct. Breast milk is higher in fat than cow’s milk. Answers B, C, and D are inaccurate statements regarding breast milk; therefore, they are incorrect.
Answer B is correct. The nurse should direct the client to put the medicine in his mouth and swallow it with some water. Answer A is incorrect because it is threatening to the client. Answer C is incorrect because medication administration and supervision is a responsibility of the nurse, not the nursing assistant. Answer D is incorrect because the nurse is threatening the client.
Answer D is correct. Entocort EC (budesonide) is a long-acting corticosteroid that should be taken with meals or a snack to prevent gastric upset. Answer A is incorrect because the medication should not be taken with grapefruit juice. Entocort EC (budesonide) should be taken with food; therefore, answers B and C are incorrect.
Answer C is correct. Edema of the face and hands is not a normal occurrence in pregnancy; therefore, the client needs further teaching. Answers A, B, and D indicate that the client understands the nurse’s teaching; therefore, they are incorrect.
Answer D is correct. One cup of prune juice provides 707mg of potassium. Answers A, B, and C are incorrect because they provide less potassium than prune juice. (One cup of apple juice provides 295mg of potassium, one cup of orange juice provides 496mg of potassium, and one cup of cranberry juice provides 152mg of potassium.)
Answer A is correct. The immediate nursing intervention is the administration of pain medication. Answers B, C, and D will be done later; therefore, they are incorrect.
Answer D is correct. The urine should be removed using a sterile syringe and needle. Removing the urine from the port nearest the client ensures that the urine is more sterile. Answer A is incorrect because urine in the bag is not sterile. Answer B is incorrect because urine in the drainage tube is not sterile. Answer C is incorrect because urine in the bag is not sterile.
Answer C is correct. In infants and young children, the Eustachian tube is shorter, straighter, and wider, making it more vulnerable to otitis media. Answers A, B, and D are incorrect because they are not related to the occurrence of otitis media.
Answer B is correct. Vernix caseosa covers the body of the full-term infant. Absence of sucking pads, presence of the scarf sign, and the absence of solar creases are expected findings in the preterm infant; therefore, answers A, C, and D are incorrect.
Answer C is correct. The nurse can assess the client’s orientation to time by asking the date, the month, the year, or the season. Asking the client to state his name or to identify family members or friends is a way of assessing the client’s orientation to person; therefore, answer A is incorrect. Answer B is incorrect because it elicits information regarding where the client is at the present time. Answer D is incorrect because it elicits information regarding the client’s recognition of familiar objects.
Answer A is correct. The 22-month-old child can be expected to feed herself with a spoon. Answers B, C, and D are developmental tasks of the older child; therefore, they are incorrect.
Answer B is correct. Munchausen’s syndrome by proxy is characterized by unexplained illness brought on by another person, usually the mother, for the purpose of gaining attention. Answer A refers to nursing bottle syndrome; therefore, it is incorrect. Answer C refers to oral allergy syndrome; therefore, it is incorrect. Answer D refers to Christ-Siemen’s Touraine syndrome; therefore, it is incorrect.
Answer B is correct. The nurse should first try to determine the client’s reason for refusing the medication so that she can decide what action needs to be taken. The nurse should not encourage the client to do anything she does not want to do; therefore, answer A is incorrect. Answers C and D are incorrect because they are not the first action the nurse should take.
Answer C is correct. The nurse believes that her way of treating illness (real medication) is superior to the client’s way of treating illness (herbals). Answer A refers to belonging to a particular ethnic group; therefore, it is incorrect. Answers B and D are incorrect choices because the nurse’s statement did not reflect cultural sensitivity or cultural tolerance.
Answer B is correct. The normal range for fetal heart tones is 110–160bpm. Answer A is incorrect because the heart rate is too slow. Answers C and D are incorrect choices because the heart rate is too rapid.
Answer B is correct. The client can decrease abdominal discomfort by splinting the incision with a pillow. Answers A and C are incorrect because they increase abdominal discomfort. Answer D is incorrect because it does not decrease abdominal discomfort.
Answer A is correct. A family history of arteriosclerotic heart disease is a nonmodifiable risk factor in the development of arteriorsclerotic heart disease. Answers B, C, and D are incorrect because the risk of developing arteriosclerotic heart disease can be modified or altered by controlling hypertension, eliminating high cholesterol and high saturated fats from the diet, and enrolling in a program of regular exercise.
Answer B is correct. The concurrent use of an MAO inhibitor such as Nardil and an SSRI such as Paxil is contraindicated because it can result in serotonin syndrome. Answers A and D are incorrect because the concurrent use of the medications is contraindicated. Answer C is incorrect because anti-Parkinsonian medication is used for the client with neuroleptic malignant syndrome, not serotonin syndrome.
Answer A is correct. To prevent air from entering the stomach, the nurse should pour all the formula into the syringe barrel before opening the clamp. Answers B, C, and D are incorrect because they do not prevent air from entering the stomach during nasogastric tube feeding.
Answer C is correct. Signs of possible internal bleeding include restlessness and shortness of breath. Answer A is incorrect because the urinary output is within normal limits. Answer B is incorrect because the color and rate of chest tube drainage is within the expected range following a lobectomy. Answer D is incorrect because the pulse rate and respiratory rate would be increased with internal bleeding.
Answer D is correct. A weight of 2.2 pounds is equal to 1kg; therefore, 4.1kg equals 9.02kg. Answers A, B, and C are inaccurate answers; therefore, they are incorrect.
Answer A is correct. Asking the client to tell more about what he is feeling gives the client an opportunity to discuss his fears and apprehensions. Answer B is incorrect because it is a closed question. Answer C is incorrect because it minimizes the client’s feelings and offers false reassurances. Answer D is incorrect because it minimizes the client’s feelings.
Answer A is correct. Providing mouth care should be done immediately after the removal of a nasogastric tube. Answers B, C, and D are incorrect because they are done later.
Answer B is correct. Positioning the client in semi-Fowler’s position tilted toward the right side will help to splint the fractured ribs and will allow the uninvolved left lung to fully inflate. Answers A and C are incorrect because they would make breathing more difficult. Answer D is incorrect because it would not allow the full expansion of the uninvolved lung.
Answer C is correct. An established means of dealing with cravings and maintaining sobriety is gaining support from other recovering alcoholics. Answers A and B are incorrect because they are punitive and will not help the client deal with his cravings. Answer D will help provide for the client’s safety during withdrawal, but it will not help the client maintain sobriety; therefore, it is incorrect.
Answer C is correct. The client with Addison’s disease needs an increased sodium intake. Bouillon and juices such as tomato juice are high in sodium. Answers A, B, and D are incorrect because they do not contain high levels of sodium.
Answer B is correct. When administering the DTP, Hib, and hepatitis B vaccines, it is recommended that the DTP be administered in one leg and the Hib and hepatitis B vaccine be administered in the other leg. Answer A is incorrect because all the immunizations are not given in one site. No immunizations are to be given in the infant’s arm; therefore, answers C and D are incorrect.
Answer C is correct. Protamine sulfate is the antidote for heparin overdose. Aquamephyton is the antidote for sodium warfarin overdose; therefore, answer A is incorrect. Ticlid is used to inhibit platelet aggregation and decrease the incidence of strokes; therefore, answer B is incorrect. Amicar is used in the management of hemorrhage caused by thrombolytic agents; therefore, answer D is incorrect.
Answer B is correct. Assessment findings in the newborn with respiratory distress syndrome include nasal flaring, grunting respirations, and retractions. Answers A, C, and D are not associated with respiratory distress syndrome; therefore, they are incorrect.
Answer C is correct. Placing the infant on his back while he is sleeping helps to reduce the risk of SIDS. Answers A, B, and D are incorrect because they have not been shown to reduce the risk of SIDS.
Answer B is correct. Pulling a toy wagon is the most developmentally appropriate play activity for the toddler. Answer A is incorrect because the toddler’s attention span is too short for watching cartoons. Watching a mobile is developmentally appropriate for the infant, not the toddler; therefore, answer C is incorrect. Answer D is incorrect because the toddler lacks the fine motor development needed for using a coloring book and crayons.
Answer B is correct. Metamucil should be mixed with the recommended amount of water and drunk immediately. Answers A, C, and D are improper ways of preparing the medication; therefore, they are incorrect.
Answer A is correct. Before the mid-1970s, lead-based paint was used extensively. Children living in housing built before that time are at risk for lead poisoning. Answer B is incorrect because it is due to a lack of intrinsic factor needed for the production of red blood cells. Answer C is incorrect because it is related to the overuse of iron supplements or vitamins containing iron. Answer D is incorrect because it is related to the ingestion of grains such as oats, barley, wheat, and rye.
Answer B is correct. Distention of the jugular veins and pitting edema are findings associated with fluid overload in the child with renal disease. Answers A, C, and D are not characteristics of fluid overload; therefore, they are incorrect.
Answer D is correct. Gradual decreasing of the daily dose of steroid medication is necessary to prevent an Addisonian crisis caused by adrenocortical hyposecretion. Cushing’s syndrome is the result of adrenocortical hypersecretion; therefore, answer A is incorrect. Answer B is incorrect because a thyroid storm is the result of untreated hyperthyroidism. Answer C is incorrect because a cholinergic crisis is the result of overmedication with anticholinesterase drugs.
Answer C is correct. Desferal (deferoxamine) is the chelating agent used to treat the child with hemosiderosis. Succimer, Versenate, and EDTA are chelating agents used to treat the child with lead poisoning; therefore, answers A, B, and D are incorrect.
Answer C is correct. The client recovering from a burn injury should have a diet that is high in protein, high in carbohydrates, and high in calories to meet the body’s requirements for tissue repair. Answer A is incorrect because the client needs additional carbohydrates. Answer B is incorrect because the client would benefit from increased fat. Answer D is incorrect because the client needs additional calories.
Answer A is correct. Nosocomial infections are infections acquired in the healthcare facility. Answer B is incorrect because the infection was not acquired in the healthcare facility. Answers C and D refer to community acquired infections; therefore, they are incorrect.
Answer B is correct. Fortified rice cereal will provide the infant with an additional source of iron. Orange juice and whole milk are poor sources of iron and should not be added to the diet until the infant is older; therefore, answers A and C are incorrect. Answer D is incorrect because strained meat should not be added until the infant is older.
Answer C is correct. According to the American Cancer Society, women should have a baseline mammogram done between the ages of 35 and 40. After age 40, women should have an annual mammogram. Answers A, B, and D are incorrect because they do not follow the recommendations of the American Cancer Society.
Answer B is correct. The nurse should measure the child’s head circumference daily to determine the effectiveness of the shunt. Answer A is incorrect because it is a medical intervention. Answer C is incorrect because the fontanels would be closed. Answer D is incorrect because it is not necessary to maintain the child in a prone position.
Answer C is correct. Stranger anxiety first peaks when the infant is 7–9 months of age. Stranger anxiety does not peak before age 7 months; therefore, answers A and B are incorrect. Answer D is incorrect because stranger anxiety first peaks before 12 months of age.
Answer D is correct. Coarctation of the aorta is an acyanotic heart defect characterized by the presence of diminished femoral pulses and bounding radial and brachial pulses. Answers A, B, and C are incorrect because they describe the child with a cyanotic heart defect.
Answer A is correct. Cooley’s anemia, also known as thalassemia major, is a genetic disease primarily affecting those of Mediterranean descent. Answers B, C, and D are incorrect because they are not likely to be affected with Cooley’s anemia.
Answer D is correct. The primary nursing consideration is restoring the client’s nutritional status. Answers A, B, and C are an important part of the client’s care but are not the primary nursing considerations of the newly admitted client with anorexia nervosa; therefore, they are incorrect.
Answer C is correct. The fontanels of a 2-month-old should feel flat and firm to the touch. Tense, bulging fontanels indicate increased intracranial pressure; therefore, answers A and D are incorrect. Soft, sunken fontanels indicate dehydration; therefore, answer B is incorrect.
Answer D is correct. Retinopathy of prematurity is caused by damage to immature blood vessels in the retina, which can be the result of high levels of oxygen. Answers A, B, and C are not associated with prolonged oxygen therapy; therefore, they are incorrect.
